Forms

Use this form to request the Wellness Allowance Reimbursement. This benefit applies to the CarePartners of Connecticut CareAdvantage Preferred plans.

This form is used to request reimbursement for covered in- or out-of-network dental services that were not originally covered by CarePartners of Connecticut at point of service.

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 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.

This form is used to request the Weight Management Reimbursement offered by CarePartners of Connecticut.

This form allows you to request a reimbursement for a prescription that was not initially covered by CarePartners of Connecticut.

This form helps you better understand the enrollment process, plan benefits and rules prior to enrolling.

This form is used to disenroll from Carpartners of Connecticut plans. Please note that you must continue to get all medical care from Carepartners of Connecticut until the effective date of disenrollment.

The Medicare Prescription Payment Plan is a voluntary payment option that works with your current drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). This payment option might help you manage your expenses, but it doesn’t save you money or lower your drug costs.

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 or PPO plan.

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).

Use this form to request Hepatitis C medication.

This form is used to document medications as part of the MTM programming.

This form allows CarePartners of Connecticut Medicare Advantage HMO and PPO plan members to request home delivery of prescription drugs through the OptumRx mail order service.

This form allows you to request a reimbursement for a prescription that was not initially covered by CarePartners of Connecticut.

This form is used to submit a request for reconsideration to eliminate your Part D late enrollment penalty.

This document allows you to learn about your right to ask Medicare to review your Medicare Part D late enrollment penalty.

This form allows you to authorize CarePartners of Connecticut to disclose your protected health information to a person or entity. This form should be used for member enrolled in a CarePartners of Connecticut plan.

This form is used by Medicare/Medicaid members to appoint a representative to act on their behalf in filing a grievance, requesting an initial determination, or in dealing with any of the levels of the appeal.

This form is used to designate a representative to act on a member’s behalf and authorize CarePartners of Connecticut to disclose the member’s protected health information to the representative.

This form is used as a cover sheet to submit with your legal personal representative documents.

This form allows member to terminate an existing authorization or restriction.

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.

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.