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Prescription (Rx) Drugs and Pharmacy Forms
Complete this form to help organize and track your medications. Keeping it up to date will ensure you have a list of your current medications which can be shared with doctors, caregivers and loved ones as needed.
This form is used to submit a request for coverage, or payment, of a prescription drug through a CarePartners of Connecticut HMO plan. This form can be used as the Exception Request Forms for physicians, Prior Authorization Form for Physicians and Enrollees and the Utilization Management Form for Physicians and Enrollees.
This form allows physicians to submit information to CarePartners of Connecticut to help determine drug coverage for CarePartners of Connecticut and proper payment under Medicare Part B versus Part D per the Centers for Medicare and Medicaid Services(CMS).
This form allows CarePartners of Connecticut plan members to request delivery of prescription drugs through the CVS/Caremark mail order service.
This form allows you to file a Medicare Part D claim through CVS Caremark.
Financial and Payment Forms
This form allows you to sign up for Electronic Funds Transfer (EFT) payments. When you sign up for EFT payments, your CarePartners of Connecticut Plan premium payment is automatically deducted from your checking or savings account each month.
Appeals and Grievances Forms
This form is used to submit a redetermination (appeal) of a previously declined request for coverage or payment of a prescription drug through a CarePartners of Connecticut HMO plan. Please note that you have 60 days from the date of the initial Notice of Denial of Medicare Prescription Drug Coverage to request a redetermination.
This form allows CarePartners of Connecticut plan members to earn the Healthy Behavior Reward for the contract year 2020. Simply complete this form showing proof of your healthy behavior related to diabetes care. Then mail or fax it to CarePartners of Connecticut by 11/30/2020.
Use this form to request the Wellness Allowance Reimbursement. This benefit applies to the CarePartners of Connecticut CareAdvantage Preferred (HMO) plan only.
This form allows CarePartners of Connecticut plan members to request reimbursement for any health care services you have received that were not initially covered by CarePartners of Connecticut (including out-of-country health care services).
This form is used to request the $150* Weight Management Reimbursement offered by CarePartners of Connecticut. This benefit will cover up to $150 toward program fees for weight loss programs including Weight Watchers®, Jenny Craig®, or a hospital-based weight loss program. This benefit does not cover costs for pre-packaged meals/foods, books, videos, scales, or other items or supplies.
This form is used if you are visiting a provider that is not a participating provider in the EyeMed Network. Not all plans have out-of-network benefits, so please consult your CarePartners of Connecticut Evidence of Coverage to ensure coverage of services.
Enrollment and Disenrollment Forms
This form is used to apply for enrollment in a CarePartners of Connecticut HMO plan. Please note, this form is intended for new enrollments. If you are a current member and need to switch your plan, please use the CarePartners of Connecticut HMO plan HMO Short Enrollment Form.
This form helps you better understand the enrollment process, plan benefits and rules prior to enrolling.
This form is used to disenroll from CarePartners of Connecticut Medicare plans. Please note that you must continue to get all medical care from CarePartners of Connecticut until the effective date of disenrollment.