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Hearing, vision, and dental included plus over-the-counter benefits and more.
General Medicare Forms
Center for Medicare and Medicaid Services Disaster Tip Sheet Getting medical care and prescription drugs in a disaster or emergency area.
Multi-Language Non-Discrimination Interpreter Services Insert Access to interpreter services for non-English language speakers.
Appointment of Representative Form - Instructions Instructions on how to complete the Appointment of Representative form.
Appointment of Representative Form CDPHP Medicare Advantage members may appoint any individual (friend, relative, lawyer) as a representative to assist them with understanding and following coverage determinations, exceptions, appeals, or grievances.
Medicare Coordination of Benefits Questionnaire Keeping CDPHP up-to-date about other insurance coverage can help avoid claim payment delays.
Medicare Health Survey Filling out this brief survey can help CDPHP better understand your individual health care needs.
Medicare Advantage Disenrollment Form Complete and mail in this form to disenroll from an individual CDPHP Medicare plan.
2021 Medicare Advantage Formularies and Part D Coverage Documents
2021 Formulary The list of covered drugs for all individual members of CDPHP Medicare Advantage plans with Part D prescription drug coverage.
Medicare: Notice of Formulary Updates List of updates and changes to the 2021 Formulary.
Medicare Vaccine Coverage Guide: Part B Versus Part D This tip sheet explains how certain vaccinations are covered.
Medicare Part D Mail Order Pharmacy Overview
Medicare Part D Mail Order Pharmacy Order Form By ordering your maintenance drugs through the mail, you can obtain up to a three (3)-month supply of drugs at a discounted rate, depending on your drug coverage.
Medicare Prescription Claim Form Medicare Advantage Drug Plan members should use this form to request direct reimbursement for covered prescription drugs you’ve purchased.
Medicare Part B vs. Part D Mail Service Tip Sheet
Medicare Part D Prior Authorization Guidelines Grid This grid outlines which drugs require prior authorization through the CDPHP pharmacy department.
Medicare Part D Prior Authorization Criteria This document outlines the criteria for the drugs that require prior authorization through the CDPHP pharmacy department.
Medicare Prior Authorization Drugs (Part B versus Part D) Drugs on this list may be covered under Medicare Part B or Part D depending on the circumstances.
Coverage Determination Request Form
Medical Exception Request and Prior Authorization Form
Pharmacy Directory, Medicare
Appeals and Grievances Overview for CDPHP Medicare Advantage Plan Members
Request for Redetermination of Medicare Prescription Drug Denial
Medicare Advantage Part D Step Therapy Drug List
Medicare Advantage Part D High-Risk Medications List A list of medications that require prior authorization due to increased risks.
$0 Medicare Rx
Summary of Benefits - $0 Medicare Rx
Annual Notice of Changes - $0 Medicare Rx
Evidence of Coverage - $0 Medicare Rx
Basic Rx (HMO) Documents
Summary of Benefits - Basic Rx
Annual Notice of Changes - Basic Rx
Evidence of Coverage - Basic Rx
Value Rx (HMO) Documents
Summary of Benefits - Value Rx
Annual Notice of Changes - Value Rx
Evidence of Coverage - Value Rx
Choice (HMO) Documents
Summary of Benefits - Choice
Annual Notice of Changes - Choice
Evidence of Coverage - Choice
Choice Rx (HMO) Documents
Summary of Benefits - Choice Rx
Annual Notice of Changes - Choice Rx
Evidence of Coverage - Choice Rx
Vital Rx (PPO) Documents
Summary of Benefits - Vital Rx
Annual Notice of Changes - Vital Rx
Evidence of Coverage - Vital Rx
Flex (PPO) Documents
Summary of Benefits - Flex
Annual Notice of Changes - Flex
Evidence of Coverage - Flex
Flex Rx (PPO) Documents
Summary of Benefits - Flex Rx
Annual Notice of Changes - Flex Rx
Evidence of Coverage - Flex Rx
CDPHP Medicare Advantage is an HMO and PPO plan with a Medicare contract. Enrollment in CDPHP Medicare Advantage depends on contract renewal.
Y0019_21_13605 - last updated 10/29/2020
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