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Medicare Advantage Plan Documents
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Vision, Hearing Aid Allowance and/or Over the Counter (OTC) Reimbursement Form
Use this form to file a claim for reimbursement of out of pocket costs of covered eyewear, hearing aids and/or OTC plan benefits (if applicable). Do not use this form for post-cataract eyewear reimbursement requests. Y0026_200572_C
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Dental Reimbursement Form
Use this form to send a claim for reimbursement of out-of-pocket costs for covered dental services. Y0026_203951_C
Last Updated: 11/02/2023 -
Authorization of Representative (AOR)
An enrollee may appoint any individual to act as his or her representative. To be appointed by an enrollee, both the enrollee making the appointment and the representative accepting the appointment must sign, date, and complete an authorization form. -
Clinical Review Preauthorization Request Form
Last updated: 7/06/2021 If you are seeking to obtain authorization of services or procedures included under ConnectiCare's preauthorization requirements.
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Coverage Determination Form
An exception is a type of coverage determination. You may ask for an exception if you need a drug that is not on our list of covered drugs. You may also ask for an exception to rules, such as a limit on the quantity of a drug. Y0026_201899_C
Last Update: 10/08/2024
Y0026_203647_M