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
• Pharmacy 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)

2025 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

	2025 Enrollment Form (PDF) English | Spanish
	2024 Enrollment Form (PDF) English | Spanish

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

Pharmacy 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.
	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 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.
	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.
	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 (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.
	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.
	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.