Medicare Part D
Medicare Prescription Drug (Part D) Resources & Links
Plan Premiums, Deductibles, and Cost Sharing
To find out more about our benefits, please click here to review our
Summary of Benefits. The document highlights applicable premiums, co-payments, co-insurance, and deductibles. Please refer to the
Evidence of Coverage for a complete explanation of our benefits.
Information about Out of Network Coverage including limits and financial responsibility.
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APPOINTMENT OF REPRESENTATIVE FORM
Appointment of Representative Form (AOR) - (CMS-1696).
Click here
GRIEVANCE, COVERAGE DETERMINATION OR APPEAL
The process for coverage decisions and appeals can be found in Chapter 9 of your evidence of coverage (EOC). This is the process you use for issues such as whether something is covered or not and the way in which something is covered. Please refer to Chapter 9 of your EOC for a full description of the process. Evidence of Coverage
You can also access this information by downloading Chapter 9 here.
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DRUG COVERAGE DETERMINATION FORM
REDETERMINATION REQUEST FORM
MEDICATION THERAPY MANAGEMENT PROGRAM (MTMP)
Part B Prescription Drugs
Prior Authorization Criteria
PRIOR AUTHORIZATION REQUEST FORM
LOW INCOME SUBSIDY (LIS) LEVELS
Page last updated on 5/21/2020 | Y0141_20095EN