Forms

We want you to easily find the forms you need for your 丝瓜短视频 plan. Listed below are forms you may need as a 丝瓜短视频 member.

Explanations of when and why you may need to use a form are also provided below. Look for instructions on each form. The instructions will tell you where you need to return each form, who to contact if you have questions and any next steps to take. Forms may be downloaded for printing.

NAME OF THE FORM

WHEN TO USE

Use this form when you would like to send us a question or request online.

2023 Enrollment Form (Updated 10/1/2022)   

2024 Enrollment Form (Updated 10/1/2023)

Use this form to enroll in a 丝瓜短视频 Dual Advantage plan.

Use this form to contact your Care Management representative for a personalized approach to your health care needs.

Navigate Member Claim Form (10/09/2023) Last updated on 10/09/2023

Use this form to request to be reimbursed if you paid for medical expenses that should have been covered under your 丝瓜短视频 Medicare Advantage benefits.

Prescription Reimbursement Claim Form (Updated 10/21/2019) 

Use this form to request to be reimbursed if you paid for a prescription that should have been covered under your 丝瓜短视频 Medicare Advantage drug benefits.

Use this form to give your consent to share your health information with your providers and/or release health information to someone you name.

Or download this hard-copy version (Updated 7/27/2021) and mail or fax the completed form to us. Please allow up to 10 days to process the hard-copy form.

Coverage Determination Request Form  or hard copy (Updated 3/01/2021)

If you believe you are entitled to payment or benefits on a certain drug, you can request a coverage determination by completing this form.

Coverage Redetermination Request Form  or hard copy (Updated 3/01/2021

If you are unsatisfied with the outcome of a coverage determination request, you can file an appeal using the redetermination form.

An appointed representative is a relative, friend, advocate, provider or other person authorized to act on your behalf in filing a grievance, coverage determination or appeal. Those not authorized under State law to act for you will need to sign this form and mail it to the addresses below:

    • For medical coverage: 丝瓜短视频, P.O. Box 1947, Dayton, OH 45401-1947
    • For prescription drug coverage: Express Scripts, c/o Medicare Clinical Appeals, PO Box 66588, St. Louis, MO 63166-6588.

Prior Authorization Request Form (Updated 3/02/2021)

Some services require that your doctor or health care provider get approval from 丝瓜短视频 before you can get the service. Your provider can submit a request for a prior authorization using this form. A list of services that require Prior Authorization is available on the Plan Documents page.

丝瓜短视频 works with certain doctors and providers to get you care. We call these in-network providers. To have your health care services covered by your 丝瓜短视频 plan, go to an in-network provider. Neither Medicare nor 丝瓜短视频 will be responsible for the costs unless you get approval from 丝瓜短视频. Use an in-network pharmacy to get your prescriptions unless there is a situation where you can’t use one. The Comprehensive Formulary, pharmacy network and/or provider network may change at any time. You will be notified when necessary.