Forms and Policies

Plans

• 2027 Enrollment Form
• 2026 Enrollment Form
• 2027 Dental Reimbursement Form
• 2026 Dental Reimbursement Form
• 2027 Medical Claim Reimbursement Form
• 2026 Medical Claim Reimbursement Form
• Request for Disenrollment Form
• Low-Income Subsidy Information
• Out of Network and Emergency Care Policy
• Medical Prior Authorization Request Form
• International Claims Reimbursement Form
• Medicare Advantage Procedures
• MCG Health Client Log In
  

  If you do not have log in credentials or are requesting coverage criteria, please reach out to umanagement@P3hp.org

Prescription Drug

• Part D Coverage Determination and Redetermination
• Medication Therapy Management Program
• Part D Prior Authorization
• Part D Step Therapy
• 2027 Transition Period Drug Benefits
• 2026 Transition Period Drug Benefits
• Medicare Part B Diabetic Testing Supplies Prescriber Fax Form
• Medicare Drug Claim Form
• Part B Drug Requiring Prior Authorization
• Information on Safe Disposal of Drugs

Payments and Assistance

• CMS Best Available Evidence Policy
• Medicare Prescription Payment Plan

Confidential and Representative

• Notice of Privacy Practices
• Appointing a Representative
  

  You may choose someone to act on your behalf in filing a grievance, in requesting a coverage determination and in requesting a redetermination. You may choose someone such as a relative, friend, sponsor, lawyer or a doctor. A court may also appoint someone.

• Release of Protected Health Information (PHI)
  

  You may choose someone such as a family member of friend to share your Protected Health Information(PHI) with.

• Filing a Grievance or Complaint
  • Plan Specific Procedures for Filing a Grievance, Complaint, Coverage Decision or Appeal
  • How to File with the Federal Government
  • Request a Report or Have Questions
• Rights and Responsibilities When You End Your Plan
• Non-discrimination
• Notice of Availability
• Part C Appeal Request