Following are links to commonly used forms for our Medicare Advantage and prescription drug plans (requires Adobe Reader).

Appointment of Representative Form
Appoint a doctor, lawyer or family member to file a Coverage Determination request on your behalf.

Authorization for Disclosure of Protected Health Information Form
Appoint a doctor, lawyer or family member to file a Grievance on your behalf.

Coverage Determination Request Form (for Enrollees)
Request a drug coverage rule exception.

Direct Member Reimbursement Forms
Request reimbursement for out-of-pocket payment of covered drugs

• Alliance Medicare Rx Form
• Alliance Medicare PPO reimbursement request
• HAP Senior Plus reimbursement request

Mail Order Pharmacy Forms

• Pharmacy Advantage Enrollment and Mail Order Form
• Walgreens Mail Order Form for:
  • HAP Senior Plus members
  • Alliance Medicare PPO members
  • Alliance Medicare Rx members

Medicare Part D Coverage Determination Request Form (for Providers) Request prior authorization for a formulary drug, a formulary exception or a tiering exception.

Medication Request Form
Request prior authorization for a formulary drug, a formulary exception (coverage for a non-formulary drug) or a tiering exception.

Plan Enrollment Forms

• Alliance Medicare Supplement
• Alliance Medicare Rx
• Alliance Medicare PPO
• HAP Senior Plus