Plan Forms & Documents 

Automatic Premium Payment Form

Download [PDF] — Sign up for automatic monthly premium payments by Social Security/RRB, bank account (ACH), or credit/debit card. 

Medical Services Reimbursement Form

Download [PDF] — For covered medical services rendered by a provider or facility, such as flu vaccines and eyewear purchased after cataract surgery.

Prescription Drug Reimbursement Form

Download [PDF] — For out-of-pocket payments of Part D formulary prescription drugs. Do not use any other forms for prescription drug claims.

Wellness Wallet & Eyewear Reimbursement Form

2026 Plan Year [PDF] | 2027 Plan Year [PDF] (coming soon) — Get reimbursed for purchases made under your Wellness Wallet or Eyewear benefit.

Direct Deposit Guide

Download [PDF] — How to set up direct deposit for reimbursements for Wellness Wallet and Eyewear.

Reimbursement Guide

2026 Plan Year [PDF] — A guide to submitting reimbursement requests for Wellness Wallet and Eyewear purchases.

Wellness Wallet/Eyewear Balance Guide

Download [PDF] — A guide to help find your Wellness Wallet or Eyewear allowance balance.

Mail-Order Prescription Form

Download [PDF] — Start or manage prescriptions by mail through CVS Caremark.

Medicare Prescription Payment Plan Request Form

2026 Plan Year [PDF] | 2027 Plan Year [PDF] (coming soon) — This optional program helps you manage your prescription payments. Learn More

Prescription Drug Coverage Determination Form

Download [PDF] — Ask for coverage of a prescription drug, including exceptions, prior authorization, quantity limits, or tiering.

Prescription Drug Redetermination Form (Appeal)

Download [PDF] — Appeal a denied Medicare Part D prescription drug coverage request.

Part D Benefits Guide

2026 Plan Year [PDF] | 2027 Plan Year [PDF] — Includes details about your Medicare Part D drug coverage, including drug tiers, preferred pharmacies, formularies, and more.

Part D Coverage Phases Guide

2026 Plan Year [PDF] | 2027 Plan Year [PDF] — Explains the three drug coverage phases for Generations Advantage members, including deductible, initial coverage, and catastrophic coverage.

Low-Income Subsidy (LIS) Premium Summary

2026 Plan Year [PDF] | 2027 Plan Year [PDF] (coming soon) — Plan premium information for those who get extra help from Medicare to pay for their prescription drug costs. Learn More

Medicare Prescription Payment Program Fact Sheet

2026 Plan Year [PDF] | 2027 Plan Year [PDF] (coming soon) — A guide to the Medicare Prescription Payment Program (MPPP), which can help you manage your prescription costs.

Medication Tracker Checklist

Download [PDF] — Track and share your medications with your health care providers and caregivers.

Change of Address Form

Download [PDF] — Verify your permanent residence address to confirm plan eligibility and service area.

Continuity of Care Form

Download [PDF] — Request a 90-day continuity of care period to help avoid interruptions in ongoing treatment.

Dental Plus Enrollment Form

2026 Plan Year [PDF] | 2027 Plan Year [PDF] — For Essential members who want to add dental coverage to their plan. Learn More

Generations Advantage Enrollment Form

2026 Plan Year [PDF] | 2027 Plan Year [PDF] — Enroll in a Generations Advantage plan. Explore Plans

In-Home Health Assessment

Download [PDF] — Request an in-home visit by a nurse practitioner to review health history, medications, and safety needs.

Other Health Insurance (OHI) Form

Download [PDF] — Report or update other health coverage to ensure accurate coordination of benefits.

Plan Change Form

2026 Plan Year [PDF] | 2027 Plan Year [PDF] — For Generations Advantage members who want to switch from one plan to another. 

Primary Care Provider (PCP) Selection Form

Download [PDF] — Use this form to update your Generations Advantage Primary Care Provider (PCP).

Medical Services Prior Authorization List

Download [PDF] — Use this list to review Generations Advantage medical services that may require prior authorization before care is provided.

Provider Attestation for Supplemental Benefits

Download [PDF] — Have your provider confirm a qualifying diagnosis to access diagnosis-based supplemental benefits.

Medicare Appointment of Representative (CMS-1696)

Download [PDF] — Authorize a representative to act on your behalf for Medicare claims, appeals, or grievances. Learn where to send this form

Permission for Member Services to Discuss My Health Information

Download [PDF] — Allow Member Services to speak with family members or friends about your care.

Veterans Affairs Record Release Form

Download [PDF] — Authorize the Department of Veterans Affairs to release specific health information to designated individuals or organizations.

Code of Ethics

Download [PDF] — As a not-for-profit organization, our commitment to our patients, members, and communities defines us. Learn More

Medicare Star Ratings

Learn how our plan’s service ratings compare and what they mean for your care. Learn More

2027 Plan Year — Prime  |  Select  |  Essential  |  Alliance  (coming soon)
2026 Plan Year — Prime  |  Select  |  Essential  |  Alliance

Member Rights & Responsibilities

Download [PDF] — Outlines member rights, responsibilities, privacy protections, and the grievance and appeals process. Learn More

Multi-Language Interpreter Services

Download [PDF] — Information about free interpreter services available in multiple languages. Learn More

Notice of Privacy Practices

Download [PDF] — Review privacy rights, disclosures, and how to access your records. Learn More

Extra Benefit Guide

2026 Plan Year [PDF] | 2027 Plan Year [PDF] — Details about extra benefits including Wellness Wallet, dental, vision/eyewear, hearing, and OTC. 

Hearing Benefit Guide—Amplifon®

An outline of hearing aid benefits provided in partnership with Amplifon. 

2027 Plan Year — Prime  |  Select  |  Essential  |  Alliance
2026 Plan Year — Prime  |  Select  |  Essential  |  Alliance 

Generations Advantage Welcome Kit

2026 Plan Year [PDF] | 2027 Plan Year [PDF] — Comprehensive welcome book for Generations Advantage plan members. Digital Welcome Kit

Over-the-Counter Catalog

2026 Plan Year [PDF] | 2027 Plan Year [PDF] (coming soon) — Lists covered health/wellness items that can be purchased under the OTC benefit. 

Pre-Enrollment Checklist

2026 Plan Year [PDF] | 2027 Plan Year [PDF] — Outlines key eligibility requirements, key information, and plan details such as provider networks and prescription coverage.

Preventive Care Checklist

Download [PDF] — Track recommended preventive care services and bring it to your next primary care visit.

Supplemental Eyewear List

2026 Plan Year [PDF] | 2027 Plan Year [PDF] (coming soon) — Outlines coverage details for frames, lenses, and contacts under your Eyewear benefit.

Wellness Wallet Covered Items List

2026 Plan Year [PDF] | 2027 Plan Year [PDF] — Lists covered items and services that can be purchased under the Wellness Wallet benefit.