Medica Advantage Solution
Plan management forms
2023 Automatic Payment (writeable PDF)
Appoint a Representative (writeable PDF)
Medicare Part D Prescription Claim (writeable PDF)
Reimbursement Instructions for Prescription Part D Costs (writeable PDF)
Claim reimbursement forms for Medica Advantage Solution members
If your plan includes reimbursement for claims, you can find your claim reimbursement forms below. At the top of each form, information about plan eligibility is included. If reimbursement for a service doesn't apply to your plan, your form won't be processed.
Dental, Eyewear, Hearing Claim Reimbursement Form (PDF)
Medical Services Claim Reimbursement Form (PDF)
Travel (for transplant) Claim Reimbursement Form (PDF)
Determinations, appeals, and grievances
Advantage Solution Determinations, Appeals, and Grievances
Enrollment forms
Review Medicare Advantage Solution Plan Benefits and Materials
Enroll Online or Contact Your Broker
2023 Advantage Solution Pre-Enrollment Checklist (writeable PDF)
2023 Advantage Solution Enrollment Application IA NE (writeable PDF)
2023 Advantage Solution Enrollment Application Central & North MN (writeable PDF)
2023 Advantage Solution Enrollment Application Metro MN (writeable PDF)
2023 Advantage Solution Enrollment Application South MN (writeable PDF)
Medica Prime Solution (Cost)
Plan management forms
Online Medicare Enrollment Change for Prime Solution Members
2023 Automatic Payment (writeable PDF)
Appoint a Representative (writeable PDF)
Medicare Part D Prescription Claim (writeable PDF)
Reimbursement Instructions for Prescription Part D Costs (writeable PDF)
Claim Reimbursement Forms for Medica Prime Solution members
If your plan includes reimbursement for claims, you can find your claim reimbursement forms below. At the top of each form, information about plan eligibility is included. If reimbursement for a service doesn't apply to your plan, your form won't be processed.
Dental, Eyewear, Hearing Claim Reimbursement Form (PDF)
Travel (for transplant) Claim Reimbursement Form (PDF)
Determinations, appeals and grievances
Prime Solution Determinations, Appeals, and Grievances
Enrollment and change forms
Review Medica Prime Solution Plan Benefits and Materials
Enroll Online or Contact Your Broker
2023 Medica Prime Solution Pre-Enrollment Checklist (writeable PDF)
Medica Prime Solution Plan Request for Disenrollment (writeable PDF)
Iowa
2023 Medica Prime Solution Enrollment Application (writeable PDF)
2023 Medica Prime Solution Plan Change (writeable PDF)
Kansas
2023 Medica Prime Solution Enrollment Application (writeable PDF)
2023 Medica Prime Solution Plan Change (writeable PDF)
Minnesota
2023 Medica Prime Solution Enrollment Application (writeable PDF)
2023 Medica Prime Solution Plan Change (writeable PDF)
2023 Medica Prime Solution Plan with Part D Change (writeable PDF)
Missouri
2023 Medica Prime Solution Enrollment Application (writeable PDF)
2023 Medica Prime Solution Plan Change (writeable PDF)
Nebraska
2023 Medica Prime Solution Enrollment Application (writeable PDF)
2023 Medica Prime Solution Plan Change (writeable PDF)
North Dakota and South Dakota
2023 Medica Prime Solution Enrollment Application (writeable PDF)
2023 Medica Prime Solution Plan Change (writeable PDF)
2023 Medica Prime Solution Plan with Part D Change (writeable PDF)
Oklahoma
2023 Medica Prime Solution Enrollment Application (writeable PDF)
2023 Medica Prime Solution Plan Change (writeable PDF)
Wisconsin
2023 Medica Prime Solution Enrollment Application (writeable PDF)
2023 Medica Prime Solution Plan Application Supplement (writeable PDF)
2023 Medica Prime Solution Plan with Part D Change (writeable PDF)
2023 Medica Prime Solution Plan Change (writeable PDF)
2023 Medica Rider Prime Solution Enrollment Application (writeable PDF)
2023 Wisconsin Notice to Applicants (writeable PDF)
Wyoming
2023 Medica Prime Solution Enrollment Application (writeable PDF)
Last Updated: January 2023