Dual Special Needs Plan Resources
For more information about our Dual Special Needs Plan Documents and Forms, please select from the resources below.
Plan Documents
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Summary of Benefits (PDF) English | Spanish |
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Annual Notice of Change (PDF) English | Spanish |
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Evidence of Coverage (PDF) English | Spanish |
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PreEnrollment Book (PDF) English | Spanish |
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Medicare Plan Ratings (PDF) English | Spanish |
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Formulary/Drug List (PDF) English | Spanish |
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Prior Authorization Criteria (PDF) English | Spanish |
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Step-Therapy Criteria (PDF) English | Spanish |
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Formulary/Drug List Changes (PDF) English | Spanish |
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Pharmacy Directory (PDF) English | Spanish |
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Provider Directory (PDF) English | Spanish |
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LIS Premium Summary Chart (PDF) English | Spanish |
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Healthy Rewards Booklet (PDF) English | Spanish |
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Prepaid Card Grocery List (PDF) |
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Over-The-Counter Catalog (PDF) English | Spanish |
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Flex Benefit FAQs (PDF) English | Spanish |
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Prior Authorization Quick Reference Guide HMO-SNP (PDF) |
Medical Forms
Utilization Management Forms |
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Member Medical Reimbursement Form (PDF) Return the completed form and applicable receipts to the address for your health plan listed in the attached document. |
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PCP Change Request Form (PDF) You can use this form to request a change in your Primary Care Physician (PCP) Fax to: 1-844-329-1085 Mail to: CareFirst BlueCross BlueShield Medicare Advantage Attention: Enrollment Department PO Box 915 Owings Mills, MD 21117 |
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Request for a Reconsideration (Appeal) (PDF) Use this form to request an appeal of CareFirst Medicare Advantage’s denial of coverage and/or payment of medical and/or hospital services |
Forms for Appointing a RepresentativeA member can choose someone else—such as a family member, doctor or attorney—to represent you when interacting with CareFirst BlueCross BlueShield Medicare Advantage. To appoint a representative, you must fill out one of these two forms. Please note the differences between them and choose the one that best suits your needs. |
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CareFirst Designation of Personal Representative Form (PDF) Using this form allows your designated representative to act on your behalf in all matters regarding CareFirst BlueCross BlueShield Medicare Advantage. It grants your representative the ability to make decisions related to your healthcare with the same rights and privileges afforded to you as a plan member. This form has no set time limit. It’s valid until you revoke your representative’s authority. Once completed, send the form to: CareFirst BlueCross BlueShield Privacy Office P.O. Box 14858 Lexington, KY 40512 Email:privacy.office@carefirst.com Fax to: 410-505-6692 |
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CMS Appointment of Representative Form (PDF) Using this form gives your appointed representative a limited ability to act as your representative with CareFirst BlueCross BlueShield Medicare Advantage. Your representative’s authority is limited to claims, coverage decisions, appeals and grievances. In addition, the form is only valid for one year. Once completed, send the form to: CareFirst BlueCross BlueShield Privacy Office P.O. Box 14858 Lexington, KY 40512 Email:privacy.office@carefirst.com Fax to: 410-505-6692 |
Pharmacy Forms
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Prescription Drug Claim Form (PDF) Request reimbursement for prescription drugs by completing this form. |
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Prescription Drug Mail Order Form (PDF) Request your maintenance prescription drugs to be mailed to you through our CVS Caremark Mail Service Pharmacy® mail order program. |
| Request for a Medicare Prescription Drug Coverage Determination - Online Speed up your request for a prior authorization, tiering exception or to request coverage for a drug not on our formulary by using this “online” form to electronically request a coverage determination for a prescription drug. |
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Request for a Medicare Prescription Drug Coverage Determination – Mail-In or Fax (PDF) If you prefer, download our Request for a Medicare Prescription Drug Coverage Determination to request a prior authorization, tiering exception, or to request coverage for a drug not on our formulary. Click to download the form, complete it and mail or fax it to us. |
| Request for a Redetermination of a Denial of Prescription Drug Coverage (Appeal for Part D Prescription Drugs) – CMS Use CMS’s form to request an appeal of CareFirst Medicare Advantage’s denial of coverage and/or payment of Prescription Drugs. |
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| Request for a Redetermination of a Denial of Prescription Drug Coverage (Appeal for Prescription Drug Services) – Online Speed up your request to appeal our denial of coverage and/or payment of a Prescription Drug by using our “online” form to electronically request your appeal. |
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Request for a Redetermination of a Denial of Prescription Drug Coverage (Appeal for Part D Prescription Drug Services) – Mail-In or Fax (PDF) If you prefer to download our Request for Redetermination of a Denial of Prescription Drug Coverage, just click on the form to download, complete and mail or fax it to us. |
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Request for Reconsideration of Medicare Prescription Drug Denial (PDF) If you prefer to download our Request for Reconsideration Form for an independent review of your drug plan’s Denial of Prescription Drug Coverage, just click on the form to download, complete and mail or fax it to us. |
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Over-The-Counter Medications and Products Use this form to place orders for your Over-The-Counter Medications and Products. Please mail this completed form to the address at the bottom of the form. |