Medicare Forms and Documents

Find the Medicare forms and documents you need

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.

2018 Medicare Advantage Formularies and Part D Coverage Documents

• 2018 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 2018 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 2018
  This grid outlines which drugs require prior authorization through the CDPHP pharmacy department.

• Medicare Part D Prior Authorization Criteria 2018
  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) 2018
  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 2018
  

• 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
  Information about medications on the step therapy list for 2017.

• Medicare Advantage Part D High-Risk Medications List
  A list of medications that require prior authorization due to increased risks.

$0 Plan Documents

• Summary of Benefits
  

• Evidence of Coverage
  

Basic Rx Documents

• Summary of Benefits
  

• Annual Notice of Changes and Evidence of Coverage (Basic Rx)
  

Value Rx Documents

• Summary of Benefits
  

• Annual Notice of Changes and Evidence of Coverage
  

Choice/Choice Rx Documents

• Summary of Benefits
  

• Annual Notice of Changes and Evidence of Coverage (Choice)
  

• Annual Notice of Changes and Evidence of Coverage (Choice Rx)