Member Forms

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

H5932_432 CMS Approval 12/18/2009