Beneficiary Forms

Important update about Exemplar Health PDP

Summary of Benefits

Resumen de beneficios

Evidence of Coverage

Appointment of Representative Form – CMS 1696 – located on Fill out this form is you are appointing a representative for an appeal, redetermination or grievance.


Exception Request Form for Physicians and Enrollees

Privacy Notice Under the HIPAA Privacy Rule

Prior Authorization Forms for Enrollees

LIS Premium Summary Chart

Prescription Drug Transition Policy

Disenrollment Form

Coverage Determination Request Form

Coverage Redetermination Request Form

Last Updated on October 15, 2021 by marketing