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Care Improvement Plus

2012 Forms

Provider Preauthorization Form
To download a copy of the Provider Preauthorization Form, click here.
(Revised 12/2011)

Waiver of Liability Statement
Per CMS guidance, a non-contracted provider requesting an appeal must sign a Waiver of Liability Statement before the appeal will be considered by the Health Plan. If the Waiver of Liability Statement is not executed by the non-contracted provider, the Health Plan will close the appeal request and submit the appeal case to CMS? Independent Review Entity (Maximus) for dismissal.

Coverage Determination
For prescription drug coverage determinations and exception requests for members: Coverage Determination Request Form. For instructions on how to fill out the Coverage Determination Request form Click here.

Instructions: 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)

Drug Determination
For appeals related to prescription drug coverage you may submit a letter or use the following form: Request for Medicare Prescription Drug Redetermination Form

Authorized Representative
For authorizing a family member or a friend to represent you, use the following form: Appointment of Representative 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.

Paper Claim
For filing a claim to request payment, use the following form: Rx Claim Paper Claim Form.

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 HCFA 1500 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 Form For obtaining prescription drugs by mail, use the following form: Mail Order Form.

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: 12/22/2011 10:58:29 AM
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Copyright © 2006 - 2012 Care Improvement Plus
Y0072_OE12_4511 CMS Approved 11/15/2011

Care Improvement Plus is a Medicare Advantage organization with a Medicare contract. The Care Improvement Plus contract with CMS is renewed annually and coverage availability beyond the end of the current contract year is not guaranteed. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2013.

The benefit information provided herein is a brief summary, but not a comprehensive description of available benefits. For more information contact the plan. To be eligible for a Care Improvement Plus plan you must be a Medicare beneficiary living in Arkansas, Georgia, Missouri, South Carolina, Texas and select counties in Illinois, Iowa, Indiana, Maryland, New Mexico, New York, Wisconsin and have both Medicare Part A and Part B to enroll.

To be eligible for a Care Improvement Plus Chronic Conditions Special Needs Plan, you must have diabetes and/or heart failure. To be eligible for Care Improvement Plus Dual Advantage, you must be enrolled in state Medicaid and be a dual eligible beneficiary whom the State holds harmless for Part A and Part B cost sharing.

Members may enroll in the plan only during specific times of the year. Contact Care Improvement Plus for more information. If you have diabetes, heart failure, or Medicaid/Low Income Subsidy, you may qualify to enroll in a Care Improvement Plus Special Needs Plan ANYTIME of the year by exercising a “Special Election Period.

You must continue to pay your Medicare Part B premium. If you are a full benefit dual beneficiary and your Part B premium is paid for by the State, you will not be responsible for paying your Part B premium. Premiums, copays, coinsurance and deductibles may vary based on the level of help received. Limitations, copayments and restrictions may apply.

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

  • 1–800–MEDICARE (1–800–633–4227). TTY users should call 1–877–486–2048, 24 hours a day/7 days a week;
  • The Social Security Office at 1–800–772–1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1–800–325–0778; or
  • Your State Medicaid Office.

People with limited incomes may qualify for extra help to pay their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1–800–772–1213.TTY users should call 1–800–325–0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a part of this premium, we will bill you for the amount that Medicare doesn’t cover.

Premiums, copays, coinsurance, and deductibles may vary based on the level of help that beneficiaries may receive. Contact the plan for further details. Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under nonroutine circumstances, and quantity and restrictions may apply. It may cost more to get care from out–of–network providers, except in an emergency. If there isn’t a network provider available for you to see, you can go to an out–of–network provider but still pay the in–network amounts except for members who live in our Maryland service areas. Those members can only use doctors, specialists, or hospitals in–network. The health providers in our network can change at any time.