Medicare Advantage Dual Prime
(HMO-SNP) Plan Forms/Documents
For more information about your CareFirst BlueCross BlueShield Medicare Advantage Dual Prime (HMO-SNP) plan or appropriate forms, explore the resources below:
Plan documents for members
For specific information on your benefits, services, cost shares and health plan operations please review the plan documents linked below. You can also download a PDF to save on your computer or print out a copy for your records.
The Summary of Benefits is an easy-to-understand list of selected plan benefits, services and costs.
The Annual Notice of Change tells you how your benefits and costs will change for the new year (to be effective in January).
The Evidence of Coverage gives you details about what the plan covers, how much you pay, how to use the health plan services and much more.
2021 | |
 |
Summary of Benefits (PDF) |
|
Annual Notice of Change (PDF) |
|
Evidence of Coverage (PDF) |
Pharmacy forms
| Click the name of the form to view each document. | |
|---|---|
| Appointment of Representative Form(PDF) | Use this form to appoint any individual (such as a relative, friend, advocate, attorney, physician or other prescriber, or an employee of a pharmacy, charity, state pharmaceutical assistance program, or other secondary payer) to act as your representative for Coverage Decisions and/or Appeals. |
| Prescription Drug Claim Form(PDF) | Request reimbursement for prescription drugs by completing this form. |
| Prescription Drug Mail Order Form(PDF) | Request your maintenance prescription drugs to be mailed to you through our ReadyFill at Mail® 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. |
| Request for a Medicare Prescription Drug Coverage Determination(PDF) – Mail-In or Fax | 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. |
| 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. |
| Request for a Redetermination of a Denial of Prescription Drug Coverage(PDF) (Appeal for Part D Prescription Drug Services) – Mail-In or Fax | 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. |
| Over-The-Counter Medications and Products(PDF) |
Use this form to place orders for your Over-The-Counter Medications and Products. Mail your completed forms to: Please mail this completed form to the following address: NationsOTC |
General forms
| Click the name of the form to view each document. | |
|---|---|
| Electronic Funds Transfer (EFT) Form |
Use this form to allow your plan to withdraw your monthly plan premium payment from your checking account on the 15th of each month. Please return the EFT form to the following address: CareFirst BlueCross BlueShield Medicare Advantage |
| Social Security & Railroad Retirement Board Premium Deduction Authorization |
Use this form to sign-up to have your monthly plan premium automatically deducted from your Social Security or Railroad Retirement Board check. Please return the Social Security & Railroad Retirement Board Premium Deduction Authorization Form to the following address: CareFirst BlueCross BlueShield Medicare Advantage |
| Notice of Privacy Practices | This notice that tells you how we may use and share your health information and how you can exercise your health privacy rights. You should have received this notice in your Evidence of Coverage. You can either download this copy or call Member Services at the telephone number on the back of your membership ID card to obtain a copy at any time. We cannot use or disclose information in a way that is not consistent with our notice. |
| HIPAA Consent and Authorization Form | This consent form allows CareFirst Medicare Advantage to use and disclose information about you protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) with the individual(s) you list on the form for the purpose(s) of administering your healthcare benefit plan and providing you with Case Management and other services as deemed appropriate. Furthermore it allows you to designate specific individuals to act as your authorized representative for specific purposes you designate on the form until such time as you revoke your authorization. |
| Waiver of Liability Statement (For Non-Contracted Providers) |
This form is for non-contracted providers to use when filing an appeal with CareFirst Medicare Advantage. This form must accompany a non-contracted provider's request for an appeal and must be received by the Plan within 60 calendar days of receipt of the Plan's initial decision to deny a service and/or payment of services previously rendered. Non-Contracted Provider appeals should be mailed to: CareFirst BlueCross BlueShield Medicare Advantage |
| Request for Access to Protected Health Information Form | Use this form when you want CareFirst Medicare Advantage to provide you with access to your protected health information (PHI) that is maintained by CareFirst Medicare Advantage Simply click on the link to the left to open the form, complete it, print it out and mail it to CareFirst Medicare Advantage at the address designated on the form. |
| Request for Accounting of Protected Health Information Disclosures | Use this form when you want CareFirst Medicare Advantage to provide you with an accounting of how it has used and disclosed your protected health information (PHI). Simply click on the link to the left to open the form, complete it, print it out and mail it to CareFirst Medicare Advantage at the address designated on the form. |
| Request to Amend or Change Your Protected Health Information | Use this form when you want CareFirst Medicare Advantage to change or amend the protected health information (PHI) it maintains on you. Simply click on the link to the left to open the form, complete it, print it out, and mail it to CareFirst Medicare Advantage at the address designated on the form |
| Request to Restrict the Use and/or Disclosure of Your Protected Health Information | Use this form when you want CareFirst Medicare Advantage to restrict the use and/or disclosure of your protected health information. Simply click on the link to the left to open the form, complete it, print it out and mail it to CareFirst Medicare Advantage at the address designated on the form. |
Medical forms
| Click the name of the form to view each document. | |
|---|---|
| Appointment of Representative Form | Use this form to appoint any individual (such as a relative, friend, advocate, attorney, physician or other prescriber, or an employee of a pharmacy, charity, state pharmaceutical assistance program, or other secondary payer) to act as your representative for Coverage Decisions and/or Appeals. |
| Member Medical Reimbursement Form | Return the completed form and applicable receipts to the address for your health plan listed in the attached document. |
| PCP Change Request Form |
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 |
| Request for a Reconsideration (Appeal) | Use this form to request an appeal of CareFirst Medicare Advantage’s denial of coverage and/or payment of medical and/or hospital services |