Your Source for Medicare Forms
There are many forms to keep track of as part of your Medicare Advantage coverage. We’ve gathered them here
for your convenience.
Drug Coverage and Pharmacy
Find the forms you need regarding orders, claims and coverage determinations for Medicare Find the forms you need regarding orders, claims and coverage determinations for Medicare prescription drug coverage:
- CVS Caremark Mail Service Order Form (PDF)
- CVS Caremark Medicare Part D Prescription Claim Form (PDF)
- Coverage Determination Form
- Request for Redetermination of Medicare Prescription Drug Denial (PDF)
2023 Plan Formularies
The following are formularies that are part of our 2023 Medicare Advantage Plans:
- 2023 Medicare Part D Comprehensive Formulary (PDF) (list of covered drugs) (updated 4/2023)
- Monthly Medicare Formulary Updates (PDF) (updated 4/2023)
- 2023 UVM Health Advantage Medicare Part D Comprehensive Formulary (PDF) (list of covered drugs) (updated 4/2023)
- Monthly UVM Health Advantage Formulary Updates (PDF) (updated 4/2023)
- 2023 Formulario Comprensivo (PDF) (actualizado 4/2023)
Advance Directives/Advance Care Planning
Find the forms you need regarding New York State and Vermont advance directives, as well as other advance care planning:
Claims and Reimbursement Forms
Find the forms you need regarding filing claims and requesting reimbursements:
Enrollment and Disenrollment Forms
Find the forms you need to enroll in one of our Medicare Advantage plans :
- 2023 Individual Enrollment Application—Capital District, Southern Tier, Central New York (PDF)
- 2023 Individual Enrollment Application—Hudson Valley Region (PDF)
- 2023 Individual Enrollment Application—Rochester/Buffalo Region (PDF)
- 2023 Individual Enrollment Application—Vermont Region (PDF)
- 2023 Individual Enrollment Application—MVP DualAccess (PDF)
- 2023 Individual Enrollment Application—UVM Health Advantage (PDF)
Below are the forms you need to disenroll from one of our plans:
Government and Medicare Links
The following are resources outside the MVP website that can provide guidance on your Medicare questions:
- View Medicare’s official government site
- Get help with Medicare complaints, grievances and information (Medicare Beneficiary Ombudsman)
- Submit feedback about your plan via the Medicare Complaint Form
- View the official Medicare Coverage Database (National Coverage Determinations)
- Visit the official Social Security website
- Visit the website for the U.S. Department of Health and Human Services
- Get help paying for prescription drugs with New York’s Elderly Pharmaceutical Insurance Coverage (EPIC) program or Vermont Pharmaceutical Assistance (VPharm)
- Find programs and services for the elderly at the New York State Office for the Aging
- Help protect your Medicare rights
Find the forms you need to allow us to release information to other people on your behalf:
- Authorization to Disclose Information (ADI) Form (PDF)
- Autorización para Revelar Información (Spanish) (PDF)
- Actively Employed Information Form (PDF)
“Appointment of Representative” form (PDF) — 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 MVP 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.
Find information you need related to special situations, such as filing a grievance or appeal of our policies, decisions, etc., or getting the care you need during disasters:
Other physicians/providers are available in the MVP Health Care network. MVP virtual care services through Gia are available at no cost-share for most members. In-person visits and referrals are subject to cost-share per plan. Members enrolled in a Medicare Rx plan without additional MVP medical coverage do not have access to MVP virtual care services through Gia. SilverSneakers is a registered trademark of Tivity Health, Inc. SilverSneakers On-Demand is a trademark of Tivity Health, Inc. ©2023 Tivity Health, Inc. All rights reserved. GetSetUp is a third-party provider and is not owned or operated by Tivity Health, Inc. (“Tivity”) or its affiliates. Users must have internet service to access online services. Internet service charges are responsibility of user.
TruHearing® and (RE)TM are trademarks of TruHearing, Inc. All other trademarks, product names, and company names are the property of their respective owners. Retail pricing based on prices for comparable aids. Follow-up provider visits included for one year following hearing aid purchase. Free battery offer is not applicable to the purchase of rechargeable hearing aid models. Three-year warranty includes repairs and one-time loss and damage replacement. Hearing aid repairs and replacements are subject to provider and manufacturer fees. For questions regarding fees, contact a TruHearing hearing consultant.
Y0051_8263_M | Last Updated: 4/13/2023
Speak to a Representative
To shop for a plan, contact an MVP Medicare Advisor at 1-800-324-3899 (TTY 711)
For questions about your plan, contact the MVP Medicare Customer Care Center at 1-800-665-7924 (TTY 711). If you have an MVP DualAccess plan, call 1-866-954-1872 (TTY 711).
From April 1-September 30, reach us Monday-Friday, 8 am-8 pm.
From October 1-March 31, reach us seven days a week, 8 am-8 pm.