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Member materials
2024 Annual Notice of Change — English (PDF) | Español (PDF)
2024 Evidence of Coverage — English (PDF) | Español (PDF)
2024 Summary of Benefits — English (PDF) | Español (PDF)
2024 Enrollment form — English (PDF) | Español (PDF)
2024 Privacy notice — English (PDF) | Español (PDF)
2023 OTC Catalog — English (PDF) | Español (PDF)
Printable forms
Prior authorization-related forms
Medical Prior authorization form (PDF)
Part D Coverage determination form — English (PDF) | Spanish (PDF)
Pharmacy- and prescription-related forms
Sample personal medication list — English (PDF) | Español (PDF)
Sample recommendation to do list — English (PDF) | Español (PDF)
Complaint- and appeal-related forms
Appointment of representative (PDF)
Part D coverage redetermination form — English (PDF) | Spanish (PDF)
Information- and privacy-related forms
Authorization to release protected health information (PDF)
Request for an accounting of disclosures of protected health information (PDF)
Interactive forms
File a complaint or appeal online.
Report suspected cases of fraud, waste and abuse online.
Use this form to request drug coverage.
You can ask for an appeal if we denied your request for coverage, or payment, for a drug. An appeal can be made within 60 days of getting your Notice of Denial of Medicare Prescription Drug Coverage letter.
You can send us a message here.