Find a Form
Elderplan makes it easy to find the information you need. Please use the links below to access helpful forms.
2016 Plan Forms
- Information Update Form
- Member Reimbursement Form
- Part D Reimbursement Form
- Tier Exception Request Form
- Medication Exception Request Form For Non-Formulary Drug
- Medication Exception Request Form For Quantity Limits
- Medication Exception Request Form For Step Therapy
- Medicare Part D Coverage Determination Request Form
- Tier 1 Prior Authorization Approval List
- Tier 5 Prior Authorization Approval List
- Prior Authorization Request Form: Aranesp 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: