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Ohio Medicare Assured® Member Forms

Forms Relating to Pharmacy (Part D) Services
1
Use this form to request an exception to the drug formulary:
Request for Medicare Prescription Drug Coverage Determination Form
Use these instructions to complete the Request for Medicare Prescription Drug Coverage Determination Form:
Instructions
In addition, your doctor will need to fill out the following form:
Medicare Assured® Nonformulary Drug Exception Form
2
Use this form if you disagree with an adverse Coverage Determination and want to request Gateway Health Plan Medicare AssuredSM conduct a redetermination review:
Part D Standard Redetermination Request Form
Use these instructions to complete the Part D Standard Redetermination Request Form: Instructions
3 Use this form if you want to request Gateway Health Plan Medicare AssuredSM for Pharmacy reimbursement:
Phamacy Direct Reimbursement Form
Forms Relating to Medical Services
4
Use this form if you disagree with an adverse Organization Determination and want to request Gateway Health Plan Medicare AssuredSM conduct a reconsideration review:
Standard Request for Reconsideration Form
Use these instructions to complete the Standard Request for Reconsideration Form: Instructions
Forms Relating to both Medical and Pharmacy (Part D) Services
5
Use this form if you would like to submit a grievance to Gateway Health Plan Medicare AssuredSM:
Member Grievance Form
Use these instructions to complete the Member Grievance Form: Instructions
6 Use this form if someone is helping you fill out the Standard Reconsideration Form or Standard Redetermination Form:
Appointment of Representative Form

Forms require the Adobe Acrobat Reader installed on your system. Most computers have this program installed. If it is not installed on your computer, you can download it for free from Adobe.

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