2017 Forms, Policies and Resources

Medicare Advantage Resources

Forms
Appointment of Representative Form (PDF)
Online Member Appeals Request Form
Medicare Complaints Form
Drug Coverage Determination Form (PDF)

Plan Information
Disenrollment Rights and Responsibilities
Medicare National Coverage Determinations (NCD)
Out of Network Coverage Rules
Part C Medical Care (Organization Determinations, Appeals, Grievances)
Multi Language Interpreter Services (PDF)
Privacy Notice
Preferred Durable Medical Equipment (DME) List (PDF)
Medicare Star Ratings (PDF)
Medicare Advantage HMO Service Area (PDF)
Plans for a Healthier You: Puget Sound Region (PDF)
Plans for a Healthier You: Northwest Counties (PDF)
Plans for a Healthier You: Spokane County (PDF)

Policies
Contract Term or Service Area Reduction (PDF)
Medicare Part C Standard and Expedited Reconsiderations (Appeals) Policy (PDF)
Medicare Part D Standard and Expedited Redeterminations (Appeals) Policy (PDF)
Medicare Part C and D Grievance Policy (PDF)
How to Obtain Information on Grievances, Appeals, and Exceptions
CMS Best Available Evidence Guidelines

Pharmacy Resources

Forms
Prescription Transfer Form (PDF)
Request for Prescription Information or Change (PDF)
Request for Medicare Prescription Drug Coverage Determination Form & Instructions (PDF)
Request for Redetermination of Medicare Prescription Drug Denial Form & Instructions (PDF)
Online Member Appeals Request Form
Drug Formulary Exception Request Form
Member Reimbursement Form for Prescription Drugs: For Members With Medicare Part D Coverage for Fill Dates in 2016 (PDF)
Member Reimbursement Form for Prescription Drugs: For Members With Medicare Part D Coverage for Fill Dates in 2017 (PDF)
Member Reimbursement Form for Prescription Drugs: For Members With Medicare But No Part D Coverage (PDF)
Also see: Prescription drug reimbursement process

Plan Information
Part D Drug Formulary: Exceptions, Appeals, and Grievances
HMO Low Income Document (PDF)
Prior Authorization Drug List (PDF)
Step Therapy Requirements (PDF)
Quantity Limit Drug List (PDF)

Policies
Medicare Part D Grievance Policy (PDF)
Prescription Drug Transition Policy
Medication Therapy Management (MTM) Program Policy
Medicare Standard Appeals (PDF)
Out-of-Network Prescription Drug Access Policy (PDF)
Formulary Change Policy (PDF)
Formulary Exception Policy
Drug Utilization Mgmt: Current and Retrospective (PDF)