Elderplan makes it easy to find the information you need. Please use the links below to access helpful forms.

2013 Plan Forms

• Information Update Form
• Member Reimbursement Form
• 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
• Prior Authorization Request Form English/Spanish
• Prior Authorization Request Form: Aranesp, Epogen and Procrit English/Spanish
• Orchard Mail Order Enrollment Form
• Orchard Mail Order Catalog
• OTC Mail Order Form 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.

Authorization For Release of Health Information to HIPAA

The following forms are also available on the Centers for Medicare and Medicaid Services (CMS) website:

Appointment of Representative:
http://www.cms.gov/cmsforms/downloads/cms1696.pdf

Coverage Determination:
http://www.cms.gov/MedPrescriptDrugApplGriev/Downloads/ModelCoverageDeterminationRequestForm.pdf