Find A Form
Elderplan makes it easy to find the information you need. Please use the links below to access helpful forms.
2014 Plan Forms
- Information Update Form English
- Member Reimbursement Form English /Spanish
- Tier Exception Request Form English/Spanish
- Medication Exception Request Form For Non-Formulary Drug, Quantity Limit and Step Therapy English/Spanish
- Medicare Part D Coverage Determination Request Form English/Spanish
- Part B vs Part D Prior Authorization List English/Spanish
- Prior Authorization Request List English/Spanish
- Prior Authorization Request Form: Aranesp, Epogen and Procrit English/Spanish
To request a Part D Coverage Determination for Elderplan Members Only via secure Web form click here.
To request Part D Coverage Re-determination for Elderplan Members Only via secure Web form click here.
To activate your OTC debit card, to check your card balance or for a complete list of participating retailers, please visit www.otcmember.com.
The following forms are also available on the Centers for Medicare and Medicaid Services (CMS) website:
Appointment of Representative: