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

Plan Forms

• Information Update Form
• Reimbursement Form
• Tier Exception Request Form
• Medication Exception Request Form
• Medicare Part D Coverage Determination Request Form
• Part B vs Part D Prior Authorization List
• Prior Authorization Form
• Prior Authorization Form: Aranesp, Epogen, and Procrit
• Orchard Mail Order Enrollment Form
• Orchard Mail Order Brochure

To request a Part D Coverage Determination via secure web form click here.

To request Part D Coverage Re-determination via secure web form click here.

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