X
We use cookies to ensure you get the best experience on our website. Cookie Policy 
OK

Forms

For Medica Advantage Solution and Medica Prime Solution (Cost) Members

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)

2023 Medica Prime Solution Plan Change (writeable PDF)

Medicare Plan Materials Order Form

Y0088_1001143_M
Last Updated: January 2023