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DOCUMENTS & FORMS

Forms you may need

We've put together the most common documents and forms you might need for things like filing claims or reviewing your coverage.

  • Shared Health Dual Plus
    (HMO D-SNP)
  • Shared Health Dual Freedom
    (PPO D-SNP)
<   Back

Shared Health Dual Plus (HMO D-SNP)

Enrollment

Use these resources to help you enroll in a plan.

PDF icon2024 Enrollment Form

Benefits & Coverage

These documents contain information about your benefits, network and coverage.

PDF icon2024 Shared Health Plan Rating Sheet (Star Rating)(Updated 10/24/2023)

PDF icon2024 Low Income Subsidy (LIS) Premium Summary Chart

PDF icon2024 Annual Notice of Changes(Updated: 10/1/2023)

PDF icon 2024 Summary of Benefits (Updated: 10/1/2023)

PDF icon2024 Evidence of Coverage (EOC)(Updated: 10/1/2023)

PDF icon2024 Dental Benefits Guide

Find a Doctor

PDF iconHealth Incentives

PDF iconHow It Works: Benefits Card Guide

Pharmacies & Prescriptions

PDF icon 2024 Dual Plus Covered Drug List (Formulary)(Updated: 7/1/2024)

Pharmacy Directory

Over-the-Counter Catalog

PDF iconPart D Prescription Drug Claim Form

PDF iconRequest for Medicare Prescription Drug Coverage Determination Form(Updated: 12/1/2023)

PDF iconRequest for Redetermination of Medicare Prescription Drug Denial Form(Updated: 12/1/2023)

PDF iconPart D Prescription Home Delivery Form

PDF iconPart D Out of Network Coverage

PDF icon2024 Medicare Part D Prior Authorization Criteria(Updated: 7/1/2024)

PDF iconMedicare Part B Step Therapy Guide(Updated: 5/1/2024)

PDF iconProvider-Administered Specialty Medication List(Updated: 7/1/2024)

PDF iconProvider-Administered Medication Authorization Form

PDF icon2024 Medicare Part B Prior Authorization Criteria(Updated: 7/1/2024)

PDF iconPart D Quality Assurance Policy

PDF iconPart D Transition Supply Policy

PDF iconOne Touch® Free Blood Glucose Monitor Voucher

PDF iconFree Contour Blood Glucose Monitor Coupon

PDF iconBlank Medication List

PDF iconDrug Disposal Information

Your Rights

You'll find notices and forms in this section that’ll help you understand your rights and responsibilities and make requests related to those rights.

PDF iconAppointment of Representative Form

PDF iconHIPAA Form

PDF iconPersonal Representative Request Form

PDF iconNotice of Privacy Practices

PDF iconConfidential Communication Request Form

PDF iconDisclosure Accounting Form

PDF iconAccess Request Form

PDF iconRestriction Request Form

PDF iconRequest to Amend Records Form

PDF iconPrivacy Complaint Form

Grievances & Appeals

Use these forms to file an appeal about coverage or payment decisions or to file a grievance if you have concerns about your plan, providers or quality of care.

PDF iconMember Appeal Form

PDF iconMember Grievance Form

PDF iconDiscrimination Grievance Form

<   Back

Shared Health Dual Freedom (PPO D-SNP)

Enrollment

Use these resources to help you enroll in a plan.

PDF icon2024 Enrollment Form

Benefits & Coverage

These documents contain information about your benefits, network and coverage.

PDF icon2024 Low Income Subsidy (LIS) Premium Summary Chart

PDF icon 2024 Summary of Benefits (Updated: 10/1/2023)

PDF icon2024 Evidence of Coverage (EOC)(Updated: 10/1/2023)

PDF icon2024 Dental Benefits Guide

Find a Doctor

PDF iconHealth Incentives

PDF iconHow It Works: Benefits Card Guide

Pharmacies & Prescriptions

PDF icon2024 Dual Freedom Covered Drug List (Formulary)(Updated: 7/1/2024))

Over-the-Counter Catalog

PDF iconPart D Prescription Drug Claim Form

PDF iconRequest for Medicare Prescription Drug Coverage Determination Form(Updated: 12/1/2023)

PDF iconRequest for Redetermination of Medicare Prescription Drug Denial Form(Updated: 12/1/2023)

PDF iconPart D Prescription Home Delivery Form

PDF iconPart D Out of Network Coverage

PDF icon2024 Medicare Part D Prior Authorization Criteria(Updated: 7/1/2024)

PDF iconMedicare Part B Step Therapy Guide(Updated: 5/1/2024)

PDF iconProvider-Administered Specialty Medication List(Updated: 7/1/2024)

PDF iconProvider-Administered Medication Authorization Form

PDF icon2024 Medicare Part B Prior Authorization Criteria(Updated: 7/1/2024)

Pharmacy Directory

PDF iconPart D Quality Assurance Policy

PDF iconPart D Transition Supply Policy

PDF iconOne Touch® Free Blood Glucose Monitor Voucher

PDF iconFree Contour Blood Glucose Monitor Coupon

PDF icon Blank Medication List

PDF iconDrug Disposal Information

Your Rights

You'll find notices and forms in this section that’ll help you understand your rights and responsibilities and make requests related to those rights.

PDF iconAppointment of Representative Form

PDF iconHIPAA Form

PDF iconPersonal Representative Request Form

PDF iconNotice of Privacy Practices

PDF iconConfidential Communication Request Form

PDF iconDisclosure Accounting Form

PDF iconAccess Request Form

PDF iconRestriction Request Form

PDF iconRequest to Amend Records Form

PDF iconPrivacy Complaint Form

Grievances & Appeals

Use these forms to file an appeal about coverage or payment decisions or to file a grievance if you have concerns about your plan, providers or quality of care.

PDF iconMember Appeal Form

PDF iconMember Grievance Form

PDF iconDiscrimination Grievance Form