Dual Special Needs Plan Resources

For more information about Dual Special Needs Plan Documents and Forms, please select from the resources below.

• Plan Documents
• General Forms
• Medical Forms

2024 Plan Documents

	Summary of Benefits (PDF) English | Spanish
	Annual Notice of Change (PDF) English | Spanish
	Evidence of Coverage (PDF) English | Spanish
	Medicare Plan Ratings (PDF) English | Spanish
	Formulary/Drug List (PDF) English | Spanish
	Prior Authorization Criteria (PDF) English | Spanish
	Step-Therapy Criteria (PDF) English | Spanish
	Formulary/Drug List Changes (PDF) English | Spanish
	Pharmacy Directory (PDF) English | Spanish
	Provider Directory (PDF) English | Spanish
	LIS Premium Summary Chart (PDF) English | Spanish
	Healthy Rewards Booklet (PDF) English | Spanish
	Over-The-Counter Catalog (PDF) English | Spanish
	Flex Benefit FAQs (PDF)

General Forms

	2024 Enrollment Form (PDF) English | Spanish
	Electronic Funds Transfer (EFT) Form (PDF) 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 Attention: Premium Billing PO Box 915 Owings Mills, MD 21117
	Social Security & Railroad Retirement Board Premium Deduction Authorization (PDF) 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 Attention: Enrollment PO Box 915 Owings Mills, MD 21117
	Notice of Privacy Practices (PDF) English | Spanish 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.
	Designation of Personal Representative Form (PDF) 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) (PDF) 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 Attention: Appeals & Grievance Department PO Box 915 Owings Mills, MD 21117

Medical Forms

	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.
	Member Medical Reimbursement Form (PDF) Return the completed form and applicable receipts to the address for your health plan listed in the attached document.
	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
	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