Documents & Forms Center

Medicare

2019 Retiree Advantage Formulary

PDF icon 2019 Retiree Advantage Formulary 06202019.pdf

Medicare

2019 Advantage Plus Annual Notice of Changes

PDF icon 2019-anoc-advantage-plus.pdf

Medicare

2019 Advantage Plus Preferred Advantage Formulary

PDF icon 2019 Advantage Plus Preferred Advantage Formulary 06202019.pdf

Medicare

2019 CHP Advantage Plus Evidence of Coverage

PDF icon H5938_DP1419_C 2019 AP EOC.pdf

Medicare

2019 CHP Preferred Advantage Evidence of Coverage

PDF icon H5938_DP1428_C 2019 PA EOC.pdf

Medicare

2019 CHP Retiree Advantage Enrollment Application

PDF icon H5938_RA380_M 2019 RA Enrollment Application_ORIG.PDF

Medicare

2019 CHP Retiree Advantage Evidence of Coverage

PDF icon H5938_RA383_C 2019 RA EOC.pdf

Medicare

2019 CHP State of Florida Retiree Advantage Evidence of Coverage

PDF icon H5938_RA384_C 2019 SOF EOC.PDF

Medicare

2019 Request for Medicare Prescription Drug Coverage Determination Form

PDF icon 2019-coverage-determination-fax-form.pdf

Medicare

2019 Request for Redetermination of Medicare Prescription Drug Denial

PDF icon 2019-redetermination-fax-form.pdf

Members

2019 SOF Benefit Summary

PDF icon H5938_RA391M2019 2019 SOF Benefits Summary.pdf

Members

2019-FEHB-Brochure-10-4-2018.pdf

PDF icon 2019-FEHB-Brochure-10-4-2018.pdf

Medicare

2019-retiree-advantage-summary-of-benefits.pdf

PDF icon 2019-Retiree-Advantage-Summary-of-Benefits.pdf

Medicare

2019.09.005-medicare-made-easy.pdf

PDF icon 2019.09.005-medicare-made-easy.pdf

Agents, Employers

3101 - Platinum 153050 - 2018

PDF icon SBC 2018 3101 - Platinum 153050.pdf

Agents

Agent Appointment Application

PDF icon Agent Appointment Application.pdf

Agents

Agent Partner Guide

PDF icon 2019_01_004_agent_guide_final_web.pdf

Agents - 2018 Large Employer Group Census

File 2018 Large Group Census.xlsx

Agents, Employers, Members

Amwell Frequently Asked Questions

PDF icon Amwell FAQ General.pdf

Agents, Employers, Members

Amwell Quick Start Guide

PDF icon Amwell Quick Start Guide.pdf

Medicare, Providers

Anesthesia and Facility Charges for Dental Services MCR

PDF icon Anesthesia and Facility MCR 8-18.pdf

Medicare

Appa Enrollment Checklist

PDF icon APPA Enrollment Checklist.pdf

Application Form

PDF icon Application Form.pdf

Application Process Guidelines

PDF icon Application Process Guidelines.pdf