1. To find documents related to your coverage, start by selecting
your Medicare plan.
2. Select the state you reside in.
5. Download Plan Documents
General Documents
- CSNP Enrollment Form - 2025
- CSNP Enrollment Application - 2025
- MAPD Attestation & Enrollment Form - 2024
- MAPD Attestation & Enrollment Form - 2025
- MAPD Enrollment Application - 2025
- MAPD Scope of Appointment
- MAPD Enrollment Form - 2025
- Over-the-Counter (OTC) Product Catalog - 2024
- Over-the-Counter (OTC) Product Catalog - 2025
- List of Covered Dental Procedures
- Admissions Form
- Appeal Form
- Appointment of Representative Form
- Coverage Determination Request Form
- Disenrollment Form
- Grievance Form
- Health Risk Assessment
- Health Risk Assessment (Spanish)
- Mail Order Drug Form
- Medical Reimbursement Claim Form
- Medication Therapy Management (MTM) Overview
- Medication Therapy Management (MTM) - Personal Rx List
- Prescription Drug Claim Form
- Privacy (HIPAA) Authorization Form
2. Select a state.
4. Download Plan Documents
General Documents
- LIS Premium Summary
- Pharmacy Directory
- Appointment of Representative Form
- Coverage Determination Request Form
- Disenrollment Form
- Mail Order Drug Form
- Medication Therapy Management (MTM) Overview