Documents and Forms

DOCUMENTS AND FORMS

DOCUMENTS AND FORMS

Assign Your Care Decisions

Advance Directives


Advance Directives are legal records. They are used when you are very sick and cannot explain the kind of care you want. They let your family, friends and doctors know about your end-of-life choices ahead of time.

 

This document provides information about advanced directives such as a living will and durable power of attorney for health care.

 

Advance Directives Form

Directivas de salud anticipadas

 

Appointment of Representative Form (CMS-1696) 


An appointed representative is a relative, friend, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal.

 

Use this form to appoint a representative to act on your behalf. Once you have completed and signed this form, please mail to the following address:

 

Meridian Complete
1 Campus Martius, Suite 700

Detroit, MI 48226

 

Appointment of Representative Form 1696

Greivance & Coverage Decisions

Part C

 

 

To file a request for a standard Medicare Part C appeal please call

MeridianComplete

Member Services at

1-855-580-1689

 

(TTY 711), Monday - Sunday from 8 a.m. – 8 p.m.

 


Medicare Grievance Form

Use this form if you have concerns or problems with covered services or the quality of care you receive as a member of our plan.

 

 

Part D

 

Member Request for Reimbursement

Use this form to request reimbursement for a prescription/medication that you paid out of pocket for but believe should have been covered by the plan.

 

Medicare Grievance Form

Use this form if you have concerns or problems with covered services or the quality of care you receive as a member of our plan.

 

Part D Coverage Determination Request Form

Use this form to ask us to make a coverage determination and/or prior authorization. Once you have completed and signed this form, please mail to the address below.

 

MeridianComplete

Attn: Coverage Determination/Appeals

1 Campus Martius, Suite 750

Detroit, MI 48226

 

 

Part D Redetermination Request Form

If Meridian denied your request for coverage of (or payment for) a prescription drug, use this form to ask us for a redetermination (appeal) of our decision. Once you have completed and signed this form, please mail to the address below.

 

MeridianComplete

Attn: Coverage Determination/Appeals

1 Campus Martius, Suite 750

Detroit, MI 48226

MEDICARE DISCLAIMER

MeridianComplete is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees.

 

You can get this document in Spanish, or speak with someone about this information in other languages for free. Call

1-855-580-1689 (TTY users should call 711)

,

Monday - Sunday, 8 a.m. to 8 p.m.

  The call is free.

 

Usted puede obtener gratuitamente este documento en español o hablar con alguien sobre esta información en otros idiomas. Llame al

1-855-580-1689

(los usuarios de TTY deben llamar al 711), lunes a domingo, de 8 a.m. a 8 p.m. La llamada es gratuita.

 

Limitations, copays, and restrictions may apply. For more information, call MeridianComplete Member Services or read the MeridianComplete Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year

The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.

 

Copays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details.

 

For certain kinds of drugs, you can use the plan’s network mail-order services. We also have an optional automatic mail-order delivery program under which we will automatically fill all new prescriptions your health care provider sends to us, as well as refills for prescriptions that have already been filled but are running out. Usually a mail-order pharmacy order will get to you in no more than 5 days. If you experience any problems receiving your mail order prescription, call Member Services at

1-855-580-1689 (TTY users should call 711)

.

Page Last Modified: 11/20/2017 2:43:27 PM