Medicare Forms

Medicare Forms

Paperwork Made Easy

For your convenience, all the forms you need to participate in the CDPHP network can easily be downloaded to your computer.

If you have any questions or need additional assistance, please contact CDPHP Member Services.

Also view the member forms page.

• General Forms
• Center for Medicare and Medicaid Services Disaster Tip Sheet
  Getting Medical Care and Prescription Drugs in a Disaster or Emergency Area.
• Medicare Appointment of Representative
  CDPHP Medicare plan members may appoint any individual (e.g., a friend, relative, lawyer) as your representative to assist with you with understanding and following coverage determinations, exceptions, appeals or grievances.
• Medicare Coordination of Benefits Questionnaire
  Keeping CDPHP up-to-date about other insurance coverage can help avoid claim payment delays.
• Medicare Health Survey
  Filling out this brief survey can help CDPHP better understand your individual health care needs.

• Medicare Prescription Forms & Lists
• Medicare Choices Drug Plans - 2009 Formulary (6-Tier)
  The 6-tier list of covered drugs for all individual members and some employer group members of CDPHP Medicare Choices plans with Part D prescription drug coverage. Also see the 6-tier Notice of Formulary Updates.
• Medicare Choices Group Drug Plans - 2009 Formulary (4-Tier)
  The 4-tier list of covered drugs for some employer group members of CDPHP Medicare Choices Group Drug Plans. Also see the 4-tier Notice of Formulary Updates.
• Medicare Choices Group Drug Plans -
  2009 Enhanced Formulary (6-Tier)
  The 6-tier list of additional covered non-Part D prescription drugs for some employer group members of CDPHP Medicare Choices Group Drug Plans.
• Medicare Choices Group Drug Plans -
  2009 Enhanced Formulary (4-Tier)
  The 4-tier list of additional covered non-Part D prescription drugs for some employer group members of CDPHP Medicare Choices Group Drug Plans.
• Medicare: Notice of Formulary Updates (6-Tier)
  List of updates and changes to the 6-Tier CDPHP Medicare Choices Drug Plans 2009 Formulary.
• Medicare: Notice of Formulary Updates (4-Tier)
  List of updates and changes to the 4-Tier CDPHP Medicare Choices Group Drug Plans 2009 Formulary.
• Medicare Choices: Prior Authorization Drugs -
  Part B versus Part D 2009
  Drugs on this list may be covered under Medicare Part B or Part D depending on the circumstances
• Medicare Choices: Prior Authorization Guidelines 2009
  This guideline outlines those services that require prior authorization through the CDPHP pharmacy department.
• Medicare: Prescriptions by Mail—Overview Brochure
  Medicare Choices Drug Plan members can save money by using Caremark’s Prescription by Mail Service.
• Medicare: Prescriptions by Mail—Order Form
  By ordering your maintenance drugs through the mail, you can obtain up to a three (3)-month supply of drugs at a discounted rate, depending on your drug coverage.
• Medicare: Prescription Claim Form
  Medicare Choices Drug Plan members should use this form to request direct reimbursement for covered prescription drugs you’ve purchased.

PDF downloads require Adobe® Acrobat® Reader. If you don't have this plug-in installed on your computer, get it here.