<%@ Page MaintainScrollPositionOnPostback="true" AutoEventWireup="true" Codebehind="current_member_useful_forms.aspx.cs" Inherits="UAMedicarePartD.current_member_useful_forms" Language="C#" MasterPageFile="~/UAMedicarePartD.Master" %> <asp:content id="MetaContent" contentplaceholderid="MetaContent" runat="server"> <meta http-equiv="Content-Type" content="text/html; charset=UTF-16" /> <title>United American Part D Prescription Drug Plans</title> </asp:content> <asp:content id="TitleContent" contentplaceholderid="TitleContent" runat="server"> </asp:content> <asp:content id="CSSContent" contentplaceholderid="CSSContent" runat="server"> <link href="css/ua_individual/styles_structure.css" rel="stylesheet" type="text/css" title="styles_structure"/> </asp:content> <asp:content id="JSContent" contentplaceholderid="JSContent" runat="server"> <script type="text/javascript" src="js/styleswitcher.js"></script> <script type="text/javascript" src="js/rollover.js"></script> </asp:content> <asp:content id="PageContent" contentplaceholderid="PageContent" runat="server"> <div id="sub_header" class="sub_header_007"></div> <p><!--sub_header_index--> </p> <div id="zone1" class="zone1_main"> <h2>Current Members</h2> </div><!--index_zone1--> <div id="BreadCrumbBar"> <p><a href="default.aspx">Home</a> &gt; <a href="current_member.aspx">Current Members</a> &gt; <strong class="SubTitle">Useful Forms</strong></p> </div> <!--BreadCrumbBar--> <div id="content_main" class="layoutTwo"> <div id="ContentLeft"><!---ContentLeft---> <ul> <li><a href="http://www.medcoonline.com/medco/consumer/medicare/home.jsp?partner=PDPCUAIC">Are my drugs covered?</a></li> <li><a href="plan_resources_find_pharmacy.aspx" title="Find A Pharmacy">Find a Pharmacy</a></li> <li><a href="current_member_useful_forms.aspx">Useful Forms</a></li> <li><a href="current_member_exceptions_appeals.aspx">Exceptions &amp; Appeals</a></li> <li><a href="current_member_other_plans.aspx">Other Plans* UA offers</a></li> </ul> <a href="get_started_need_medsupp_plan.aspx" target="_blank"><img src="images/ua_individual/medsuppbanner.gif" alt="Need A Medicare Supplement Plan?" width="207" height="158" border="0" /></a> </div> <div id="ContentRight"> <h3>Useful Forms</h3> <p>Click on form name to access and download.</p> <p><strong>Direct Claim Form</strong><br /> Submit claims for medications dispensed at a nonparticipating pharmacy due to an emergency. You must submit claims within 12 months of date of purchase.<br /> <a href="http://www.unitedamerican.com/Compliance/Compliance Sheets V2/Library/Part D/2012/Medco_Forms/F9617_Medco_claim_Order_Form.pdf" title="Download" target="_blank">Download Direct Claim Form (PDF file)</a></p> <p><strong>Medco Mail Order</strong><br /> Receive your drug prescriptions through the mail.<br /> <a href="http://www.unitedamerican.com/Compliance/Compliance Sheets V2/Library/Part D/2012/Medco_Forms/HN4492A_Medco_Pharmacy_Order_Form.pdf" title="Download" target="_blank">Download Medco Mail Order (PDF file)</a></p> <p><strong>Health &amp; Allergy Questionnaire</strong><br /> <a href="http://www.unitedamerican.com/medicarepartd/2010%20Part%20D/UseFul_Forms/QN0UAA0A.pdf" title="Download" target="_blank">Download Health &amp; Allergy Questionnaire (PDF file)</a></p> <p><strong>Request for Medicare Prescription Drug Coverage Determination Form</strong><br /> Request formulary or tiering exception, prior authorization for a drug, or file an appeal.</p> <p class="odd"><strong><em>Note:</em></strong> Drugs are added or removed from our formulary during the year. You are notified at least 60 days before the date that the change becomes effective.</p> <p> <a href="http://www.unitedamerican.com/Compliance/Compliance Sheets V2/Library/Part D/2012/Medco_Forms/UA_Model_Coverage_Determination_Request_Form_2012.pdf" target="_blank">Download Medicare Prescription Drug Coverage Determination Form</a></p> <p><strong>Coverage Review Fax Form</strong><br /> If a patient or pharmacist requests help completing a coverage review, start the process via fax, using the <a href="http://www.unitedamerican.com/medicarepartd/United_American/misc//CoverageReviewFaxForm.pdf" title="Coverage Review Fax Form">Coverage Review Fax Form</a>.</p> <p>To initiate the review by phone, contact Medco at: 1-800-753-2851</p> <p><strong>Appointing a Representative Form</strong><br /> If you wish to appoint someone to act on your behalf when requesting a coverage determination, use the Appointing a Representative Form. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Other persons may already be authorized under state law to act for you. If you want someone to act for you, then you and that person must sign and date this form.<br /> </p> <p> <a href="https://www.cms.gov/CMSForms/CMSForms/itemdetail.asp?filterType=dual,keyword&filterValue=1696&filterByDID=0&sortByDID=1&sortOrder=ascending&itemID=CMS012207&intNumPerPage=10">Download Appointing a Representative Form</a></p> <p><strong>Mail completed form to:</strong><br /> Attn: Part D Member Services<br /> P.O. Box 8080<br /> McKinney, TX 75070</p> <p><strong>Vaccine and Administration Form</strong><br /> For reimbursement of covered Part D vaccines and their administration (injection).<br /> <a href="http://www.unitedamerican.com/Compliance/Compliance Sheets V2/Library/Part D/2012/Medco_Forms/VAC4496A_Medco_Vaccine_Claim_Form.pdf" title="Download" target="_blank">Download Vaccine and Administration Form (PDF file)</a></p> <p>For your Medicare Part D questions and needs, please let us know how we can assist you. <a href="contact_us.aspx">Contact Us</a>.</p> <p><strong><em>Note:</em></strong> You must have Adobe Reader version 5.0 or higher installed on your computer in order to view and print the above file properly. <a href="http://get.adobe.com/reader/" title="Adobe Reader" target="_blank">Click here to download a FREE COPY of Adobe Reader.</a></p> <p>Updated 10/01/11</p> </div> <!---ContentRight---> <div id="clearfloat"></div><!--clearfloat--> </div><!--content_main--> </asp:content>