Plan Forms (2012)
General
Authorized Representative - Requests may be made by a family member, friend, or other party if the individual demonstrates
legal authority, such as a medical power of attorney. Another way to be delegated this authority is by submitting to the plan a
signed Appointment of Representative form.
General information about a claim can be provided to family members or other authorized representatives to
solve a question or complaint, but specific diagnostic information can only be discussed with your written permission.
Click here to print out the Authorization to Release form.
For prescription drug determinations, physicians may act on behalf of the beneficiary and do not need the authority just described.
Part B Reimbursement Form
For filing a claim to request payment, use the following form:
Reimbursement Claim Form
Electronic Funds Transfer (EFT) Form
If you would like to have your monthly plan premium automatically deducted from either your checking or savings account,
complete the Electronic Funds Transfer (EFT)Form.
Pharmacy
Coverage Determination Request Form
For prescription drug coverage determinations and exception requests by members:
Coverage Determination Request Form.
For instructions on how to fill out the Coverage Determination Request form Click here.
Please fill in all the requested information.
- fill in your identifying information (including your Medicare number and Plan ID number)
- provide the name of the drug being requested and other known information such as dosage amount
- fill in your doctor's name, contact information, and specialty (such as internal medicine or cardiology)
- check the appropriate box that specifies the nature of your request
- provide any other pertinent information
- check the box provided if you need the medication in less than 24 hours and waiting longer could jeopardize your health
- sign and date the form
- fax or mail to Medco (see Contact Information)
Request for Medicare Prescription Drug Redetermination Form
For appeals related to prescription drug coverage you may submit a letter or use the following form:
Request for Medicare Prescription Drug Redetermination Form
Prescription Claim Form
For filing a claim to request payment, use the following form:
Rx Claim Form
Part D Vaccine
If you have been prescribed a vaccine that is covered under Medicare and was administered by your physician,
your physician may submit the claim to Medco for reimbursement and collect only your copay by submitting the
Vaccine Claim form to:
Medco Health Solutions, Inc.
PO BOX 14718
Lexington, KY 40512
Upon receipt of the HCFA 1500 from the physician, Medco will process the paper claim and return reimbursement to the
physician's office with an explanation of payment including the beneficiary's cost share for collection.
Mail Order
For obtaining prescription drugs by mail, use the following Mail Order Form, and include a completed
Health, Allergy, and Medication Questionnaire.
As a Care Improvement Plus member, you may request:
-
Additional information from the Centers for Medicare and Medicaid Services by calling
1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048), which is the national Medicare help line, 24 hours a day, 7 days a week.
- The aggregate number of Care Improvement Plus grievances, appeals and exceptions, by calling Member Services.
This page was last updated on: 12/8/2011 11:58:30 AM
