Retiree Advantage - More Information & Forms

Medicare Made Easy

This brochure explains the different Medicare options. 

Download the Medicare Made Easy Brochure to explore the different Medicare options.

Forms

• Advance Directives - Information on Advance Directives including the Living Will and Health Care Surrogate
• Appointment of Representative Form
• Authorization to Disclose Protected Health Information
• Communication Directive Form - Specify who can communicate with your health care team using the Communication Directive Form.
• These forms can be used to request an exception to your drug coverage: 
  • Request for Medicare Prescription Drug Coverage Determination Form is for member and healthcare doctor/provider use.
  • Request for Redetermination of Medicare Prescription Drug Denial Form
• Enrollment Application - 2018 Capital Health Plan Advantage Plus and Capital Health Plan Preferred Advantage.
• Enrollment Application - 2018 Capital Health Plan Retiree Advantage.
• Health and Fitness Reimbursement Form
• Medicare Complaint Form - You are now able to submit feedback about your Medicare health plan or other non-urgent issues directly to Medicare using the Medicare Complaint Form.

Medicare Complaint Form

You are now able to submit feedback about your Medicare health plan or other non-urgent issues directly to Medicare using the Medicare Complaint Form. 

View the Medicare Complaint Form. By clicking on this link you will be leaving the Capital Health Plan Medicare Retiree Advantage (HMO) information.

The Office of the Medicare Ombudsman

• The Office of the Medicare Ombudsman - The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests. By clicking on this link you will be leaving the Capital Health Plan Medicare Retiree Advantage (HMO) information.

Out-of-Network Coverage

The services we cover when you are outside our service area or network are care for a medical emergency, urgently needed care, renal dialysis, and care that Capital Health Plan has approved in advance.

A "medical emergency" is when you, or a prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb.  The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.  Members are covered for medical emergencies anywhere in the world.

If you have a medical emergency:

• Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital.  Call for an ambulance if you need it.  You do not need to get approval or a referral first from your PCP.
• As soon as possible, make sure that our plan has been notified about your emergency.  We need to follow up on your emergency care.  You or someone else should call to tell us about your emergency care, usually within 48 hours.  Member Services can assist you if you call the number located on your plan membership card.

"Urgently needed care" is a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care.  Urgently needed care may be furnished by in-network doctor/providers or by out-of-network doctor/providers when network doctor/providers are temporarily unavailable or inaccessible.  The unforseen condition could, for example, be an unforeseen flare-up of a known condition that you have.  Members are covered for urgently needed care anywhere in the world.

Privacy Notice

• Privacy Notice - We believe our members have the right to privacy and that their non-public personal, financial and health information should be kept confidential.

Prescription Drug Coverage

• Medication Therapy Management Program
• Prescription Drug Transition Process

  • Sometimes you are taking a drug that is not on our formulary. Please click the link to review the 2018 Prime Medicare Transition Policy. During the time when you are getting a temporary supply of a drug, you should talk with your doctor or provider to decide what to do when your temporary supply runs out.  You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To ask for a temporary supply, call Member Services.

• Part D Exceptions
• Pharmacy Search Tool
• Formulary Search Tool

Appointment of a Representative Instructions and Form

• Appointment of Representative Form - Assign someone to represent you in accordance with HIPAA regulations using an Appointment of Representative form.
• Appointment of Representative Form Instructions

Determinations, Grievances, and Appeals

• Medical Care & Services
• Prescription Drug Coverage
• Request for Medicare Prescription Drug Coverage Redetermination
  • Download the Request for Medicare Prescription Drug Coverage Determination Form to request an exception.
  • Download the Request for Redetermination of Medicare Prescription Drug Denial Form to request a redetermination. 
• Appointment of Representative Form
  • For instructions on how to use the form to appoint a representative, visit Appointment of Representative Form Instructions. 

Utilization Management

Capital Health Plan makes health care decisions to ensure quality treatment and efficient use of resources. View more information about utilization management.

• Referrals and Authorizations