Find A Form
Elderplan makes it easy to find the information you need. Please use the links below to access helpful forms.
2015 Plan Forms
- Information Update Form
- Member Reimbursement Form
- Tier Exception Request Form
- Medication Exception Request Form For Non-Formulary Drug, Quantity Limit and Step Therapy
- Medicare Part D Coverage Determination Request Form
- Part B vs Part D Prior Authorization List
- Prior Authorization Request List Tier 1: For the following plans: Elderplan for Medicaid Beneficiaries (HMO SNP) | Elderplan Extra Help (HMO) | Elderplan Plus Long-Term Care (HMO SNP) | Elderplan Advantage for Nursing Home Residents (HMO SNP)
- Prior Authorization Request List Tier 4: For the following plans:Elderplan Classic Zero Premium (HMO) | Elderplan Diabetes Care (HMO SNP) | Elderplan Healthy Balance (HMO)
- Prior Authorization Request Form: Aranesp, Epogen and Procrit
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: