Forms & Documents
Now Available
Instructions on How to Get Covered Services During a Disaster.
Medical Plans
MediSun Plus (HMO D-SNP) Plan 015
MediSun Plus (HMO D-SNP) Plan 016
HealthAdvantage Plus (HMO) 017
HealthAdvantage Plus (HMO) 018
MediSun Extra (HMO D-SNP) 019
Plan Changes and Disenrollment Information
Plan Changes and Disenrollment
Prescription Drug Benefits
Prescription Drug Benefits
- 2021 B vs. D Coverage Determination Request Form
- 2021 Grievances/Appeal Form
- 2021 Hospice PA and Plan of Care Form
- 2021 Lost, Damaged, or Stolen Medication Form
- 2021 Medication Sync Request Form
- 2021 Medication Therapy Management (MTM) Program
- 2021 Part D Reimbursement Request Form
- 2021 Part D Transition Policy
- 2021 Personal Medication List Form
- 2021 Prescription Coverage Determination Request Form
- 2021 Prescription Drug Formulary - Updated 09/16/2021
- 2021 Prior Authorization Criteria - Updated 09/16/2021
- 2021 Redetermination of Medicare Prescription Drug Denial Request Form
- 2021 Step Therapy Criteria - Updated 09/16/2021
- 2021 Vacation Supply Form
- 2022 D-SNP Prescription Drug Formulary – Updated 09/24/2021
- 2022 Medication Therapy Management (MTM) Program
- 2022 Non-SNP Prescription Drug Formulary – Updated 09/24/2021
- 2022 Over The Counter (OTC) Catalog
- 2022 Part D Transition Policy
- 2022 Prior Authorization Criteria – Updated 09/24/2021
- 2022 Step Therapy Criteria – Updated 09/24/2021
- 2022 Step Therapy Criteria Part B Drugs only – effective 01/01/2022
- Appointment of Representative Form
- CMS Medicare Prescription Drug Coverage Determination Request Form
