Below you will find the forms necessary to enroll in Care N‘ Care as well as additional forms you may find helpful. More information on policies and forms regarding coverage determinations, appeals and appointment of representatives can be found in the Care N’ Care Evidence of Coverage (EOC) or on the Your Rights page.

All forms are in PDF format. If you cannot open these files you will need to download Adobe Acrobat Reader.*

2009 Enrollment

2009 Enrollment Form
If you would like to enroll in Care N’ Care you can download the Care N’ Care enrollment form and instructions now.

For Members

Appointment of Representative Form (AOR)
If you would like to appoint a representative, you may use this Appointment of Representation (AOR) form. 

Request for Medicare Prescription Drug Coverage Form
If you would like to request Prescription Drug Coverage you may use the prescription drug coverage request form which is located on the CMS website

For Providers

Medicare Part D Formulary Exception/Prior Authorization Form
To request a coverage determination, providers should complete this form.

CMS Medicare Part D Coverage Determination Form
To request a coverage determination, physicians may also use this form which is located on the CMS website at www.cms.hhs.gov.

Care N’ Care materials are available in alternative formats, please contact customer services for details.