Member Resources

Plan Documents

Summary of Benefits: This document shows you a list of benefits covered by our plans.

 

Evidence of Coverage: This document provides detailed plan benefit information, how much you pay, and covers your rights and responsibilities as a member of the plan.

 

Over-the-Counter Products & Essential Food Pantry Items Catalog: Members of Alterwood Advantage Choice and Alterwood Advantage Dual Secure have a quarterly allowance to order products and items through this catalog.

Low Income Subsidy (LIS) Premium Summary Chart: If you get extra help from Medicare, your monthly premium will be lower than what it would be if you did not get extra help from Medicare.

Provider & Pharmacy Directory


Plan Forms

Electronic Funds Transfer (EFT) Form: this allows Alterwood Advantage to withdraw your monthly plan premium from your bank account each month.

Social Security & Railroad Retirement Board Premium Deduction Authorization: use this form to have your monthly plan premium automatically deducted from your Social Security & Railroad Retirement Board check.

PCP Change Request Form: use this form to change the PCP currently listed on your Alterwood Advantage ID card

Alterwood Advantage Appointment of Representative Form: this forms allows you to appoint an individual to act as your representative for Coverage Decisions and/or Appeals.

CMS Appointment of Representative Form: this forms allows you to appoint an individual to act as your representative for Coverage Decisions and/or Appeals.

Waiver of Liability: this form is for providers that are not in the Alterwood Advantage provider network to complete when filing an appeal with Alterwood Advantage.

Request for Access to PHI: complete this form to request access to your PHI maintained by the plan

Request to Amend or Change PHI: complete this form to amend or change your PHI

Request to Restrict Use & Disclosure of PHI: complete this form to restrict how the plan uses and/or discloses your PHI

Request for Accounting of PHI: complete this form to request for an accounting of how the plan uses and/or discloses your PHI


Part D Forms

Personal Medication List: use this to keep track of all the medications you take, including over-the-counter drugs, herbals, vitamins, and minerals, and to share it with you provider(s)

Prescription Drug Mail Order Form: request your maintenance prescription drugs through our mail order program and have them conveniently shipped directly to your home. (click here for the Spanish version)

Prescription Claim Form: request a reimbursement for prescription drugs that you paid out-of-pocket

Request for Prescription Drug Coverage Determination: use this form to request a prior authorization, tiering exception, or to request coverage for a drug not on our formulary.

Request for a Redetermination of Prescription Drug Denialif the plan denied your request for coverage of a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision.

Request for Reconsideration of Prescription Drug Denial: if the plan denies your request for coverage or payment of a prescription drug and it was also denied (upheld) upon appeal, you have the right to ask for an independent review of the plan’s decision. (Alterwood Advantage Choice form, Alterwood Advantage Choice Plus form, Alterwood Advantage Dual Secure form)