Medicare forms and resources

CVS Caremark Mail Service Order Form (PDF)

CVS Caremark Medicare Part D Prescription Claim Form (PDF)

Coverage Determination Request Form (PDF)
Solicitud de determinación de cobertura de medicamentos recetados de Medicare (PDF)

Part B Medical Drugs Requiring Prior Authorization (PDF)
Prior authorization is required for the drugs listed within this document when being administered using the member’s medical Part B benefit. Requests for the drugs in this document should be submitted to Novologix.

Part B Prescription Medical Drug Organization Determination Request Form (PDF)
Solicitud de determinación de la organización de medicamentos recetados de la parte B de Medicare (PDF)

Part B Medical Service Drugs Requiring Prior Authorization (PDF)
These drug requests are submitted to Mass General Brigham Health Plan.

Individual Enrollment Application — Mass General Brigham Health Plan (PDF)

Disenrollment Rights & Responsibilities (PDF)

Information release

If you would like a friend, relative, doctor, or other person to act for you as your “representative” to ask for a coverage decision (such as whether a service is covered) or make an appeal, you may need to appoint them as your representative. If that person is already legally authorized to act as your representative under State law, you do not need to appoint them to represent you. If you want to appoint someone to be your representative, complete the “Appointment of Representative” form. The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give Mass General Brigham Health Plan a copy of the signed form. You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or to appeal a decision.

Authorizations

Request For Medicare Service Coverage Determination (PDF)
This form can be used to submit information to Mass General Brigham Health Plan to help determine if a service or Part B Medical service drug is covered.

Grievances and Appeals (PDF) (Updated 10/1/2022)

Extra Help Subsidy (PDF)
Getting Care During a Disaster (PDF)