Documents & Forms

RELEASE MAPD NON RENEWAL NOTICE

• Summary of Benefits
• Annual Notice of Change - Central Tennessee
• Annual Notice of Change - Knoxville Tennessee
• Annual Notice of Change - Tri-Cities Tennessee
• Evidence of Coverage - Central Tennessee (Updated 3/11/24)
• Evidence of Coverage - Knoxville Tennessee (Updated 3/11/24)
• Evidence of Coverage - Tri-Cities Tennessee (Updated 3/11/24)
• Provider Directory - Central Tennessee (Updated 10/30/24)
• Provider Directory - Knoxville Tennessee (Updated 10/30/24)
• Provider Directory - Tri-Cities Tennessee (Updated 10/30/24)
• Pharmacy Directory (Updated 10/30/24)
• Comprehensive Formulary (Updated 12/1/24)
• Comprehensive Formulary - Large Print (Updated 12/1/24)
• Medical - Prior Authorization Procedure Codes (Updated 10/2/24)
• Prescription Drug - Prior Authorization Criteria (Updated 12/1/24)
• Step Therapy Criteria (Updated 12/1/24)
• Quantity Limits Criteria (Updated 12/1/24)
• CMS Star Ratings
• Pre-enrollment checklist
• Enrollment Form
• Sales Kit

• Member Reimbursement Drug Claim Form
• Appointment of Representative Form
• Coverage Determination/Prior Authorization Request Form – Drugs
• MAPD - List of Drug Changes
• Request for Redetermination
• Request for Redetermination - Drugs
• SSA Extra Help Information 
• Scope of Appointment
• Authorization for Release of Protected Health Information
• Coverage Determination/Prior Authorization Request Form – Medical 
• Medicare Advantage Member Health Care Claim Form
• Disenrollment Form
• Supplemental Benefits Guide
• Supplemental Benefits Contacts
• Personal Medication List
• Appeals Form
• MTMP Enrollment Mailer
• Recommended To-Do-List
• Prescription Drug Home Delivery Form and FAQ’s
• OTC Catalog

Late Enrollment Penalty (LEP) Premium - Billing FAQ

Bank Withdrawal Form

RRB Withhold Form