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Important Member Forms

If you personally paid for a covered medical service or OTC item, fill out this form to receive timely reimbursement:

 

Member Reimbursement Form (last updated 11/8/16)

Medicare Transition Drug Policy Overview – Last Updated 07/06/2015

Prescription Drug Transition Policy  – Last updated 04/18/2014

 

In the event that you need to appoint a representative regarding a claim the following form is also available on the Medicare and Medicaid Services (CMS) website. CMS Appointment of Representative Form  – Last updated 10/20/2014

CMS Electronic Complaint Form – Last updated 11/19/2014

Best Available Evidence (BAE) – Last updated 11/19/2014

 

Medicare Disclaimers

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