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Member materials
- 2025 Annual Notice of Change – English (PDF)
- 2025 Annual Notice of Change – Spanish (PDF)
- 2025 Evidence of Coverage – English (PDF)
- 2025 Evidence of Coverage – Spanish (PDF)
- 2025 Summary of Benefits – English (PDF)
- 2025 Summary of Benefits – Spanish (PDF)
- 2025 Enrollment form – English (PDF)
- 2025 Enrollment form – Spanish (PDF)
- Privacy notice – English (PDF)
- Privacy notice – Spanish (PDF)
Printable forms
Prior authorization-related forms
- Medical Prior authorization form (PDF)
- Hospice exception form (PDF)
- Part D Coverage determination form – English (PDF)
- Part D Coverage determination form – Spanish (PDF)
Pharmacy- and prescription-related forms
- Sample personal medication list – English (PDF)
- Sample personal medication list – Spanish (PDF)
- Sample recommendation to do list – English (PDF)
- Sample recommendation to do list – Spanish(PDF)
Complaint- and appeal-related forms
- Appointment of representative (PDF)
- Part D coverage redetermination form – English (PDF)
- Part D coverage redetermination form – Spanish (PDF)
Information- and privacy-related forms
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 65 days of getting your Notice of Denial of Medicare Prescription Drug Coverage letter.
You can send us a message here.
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