Find a Form
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.
The following forms are also available on the Centers for Medicare and Medicaid Services (CMS) website:
Appointment of Representative: