Documents for 2024 Georgia Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Sharing Health Information Forms
Click below to access the forms that authorize the sharing of your health information.
Authorization for Disclosure of Protected Health Information Form
Appointment of Representative Form
Setting up a My Clover Account
The My Clover member portal is where you can manage your healthcare and health information. You can access your ID cards, find a doctor, explore your benefits, and manage data sharing settings with third-party applications that have access to your health information.
Enrollment/Membership Forms
Click below to access enrollment and membership related forms.
2024 Getting To Know You (Health Assessment Survey) - PDF
2024 Getting to Know You (Health Assessment Survey)
2024 Enrollment Attestation Eligibility Form
EFT/ACH Form for Premium Billing
Late Enrollment Penalty (LEP) Reconsideration Request Form
Low-Income Subsidy for Medicare Prescription Drug Coverage
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
Organization Determinations (Prior Authorizations), Grievances, and Appeals
Part D Coverage Determinations, Exceptions, Grievances, and Appeals
Medicare STAR Ratings
PPO - 2023 Medicare Plan Ratings
PPO- 2024 Medicare Plan Ratings
Reimbursement Forms
Click below to access forms for reimbursements.
Direct Member Reimbursement (DMR) Form
Prescription Reimbursement Forms
Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Policies
Read Clover Health policies and other information here.
Prescription Drug Transition Policy
Out-of-Network Coverage Policy
Quality Assurance and Drug Management Programs
Confidential Communications Request
Request for Access to Protected Health Information
Request for Accounting Disclosures
Request for Amendment of Protected Health Information
Request for Restriction of Protected Health Information
Consent for Recurring Mailing of Prescriptions Follow Up Call
Documents for 2024 Pennsylvania Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Sharing Health Information Forms
Click below to access the forms that authorize the sharing of your health information.
Authorization for Disclosure of Protected Health Information Form
Appointment of Representative Form
Setting up a My Clover Account
The My Clover member portal is where you can manage your healthcare and health information. You can access your ID cards, find a doctor, explore your benefits, and manage data sharing settings with third-party applications that have access to your health information.
Enrollment/Membership Forms
Click below to access enrollment and membership related forms.
2024 Getting To Know You (Health Assessment Survey) - PDF
2024 Getting to Know You (Health Assessment Survey)
2024 Enrollment Attestation Eligibility Form
EFT/ACH Form for Premium Billing
Late Enrollment Penalty (LEP) Reconsideration Request Form
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
Organization Determinations (Prior Authorizations), Grievances, and Appeals
Part D Coverage Determinations, Exceptions, Grievances, and Appeals
Medicare STAR Ratings
PPO - 2023 Medicare Plan Ratings
PPO- 2024 Medicare Plan Ratings
Reimbursement Forms
Click below to access forms for reimbursements.
Direct Member Reimbursement (DMR) Form
Prescription Reimbursement Forms
Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Policies
Read Clover Health policies and other information here.
Prescription Drug Transition Policy
Out-of-Network Coverage Policy
Quality Assurance and Drug Management Programs
Confidential Communications Request
Request for Access to Protected Health Information
Request for Accounting Disclosures
Request for Amendment of Protected Health Information
Request for Restriction of Protected Health Information
Consent for Recurring Mailing of Prescriptions Follow Up Call
Documents for 2024 South Carolina Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Sharing Health Information Forms
Click below to access the forms that authorize the sharing of your health information.
Authorization for Disclosure of Protected Health Information Form
Appointment of Representative Form
Setting up a My Clover Account
The My Clover member portal is where you can manage your healthcare and health information. You can access your ID cards, find a doctor, explore your benefits, and manage data sharing settings with third-party applications that have access to your health information.
Enrollment/Membership Forms
Click below to access enrollment and membership related forms.
2024 Getting To Know You (Health Assessment Survey) - PDF
2024 Getting to Know You (Health Assessment Survey)
2024 Enrollment Attestation Eligibility Form
EFT/ACH Form for Premium Billing
Late Enrollment Penalty (LEP) Reconsideration Request Form
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
Organization Determinations (Prior Authorizations), Grievances, and Appeals
Part D Coverage Determinations, Exceptions, Grievances, and Appeals
Medicare STAR Ratings
PPO - 2023 Medicare Plan Ratings
PPO- 2024 Medicare Plan Ratings
Reimbursement Forms
Click below to access forms for reimbursements.
Direct Member Reimbursement (DMR) Form
Prescription Reimbursement Forms
Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Policies
Read Clover Health policies and other information here.
Prescription Drug Transition Policy
Out-of-Network Coverage Policy
Quality Assurance and Drug Management Programs
Confidential Communications Request
Request for Access to Protected Health Information
Request for Accounting Disclosures
Request for Amendment of Protected Health Information
Request for Restriction of Protected Health Information
Consent for Recurring Mailing of Prescriptions Follow Up Call
Documents for 2024 New Jersey Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Sharing Health Information Forms
Click below to access the forms that authorize the sharing of your health information.
Authorization for Disclosure of Protected Health Information Form
Appointment of Representative Form
Setting up a My Clover Account
The My Clover member portal is where you can manage your healthcare and health information. You can access your ID cards, find a doctor, explore your benefits, and manage data sharing settings with third-party applications that have access to your health information.
Enrollment/Membership Forms
Click below to access enrollment and membership related forms.
2024 Getting To Know You (Health Assessment Survey) - PDF
2024 Getting to Know You (Health Assessment Survey)
2024 Enrollment Attestation Eligibility Form
EFT/ACH Form for Premium Billing
Late Enrollment Penalty (LEP) Reconsideration Request Form
Low-Income Subsidy for Medicare Prescription Drug Coverage
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
Organization Determinations (Prior Authorizations), Grievances, and Appeals
Part D Coverage Determinations, Exceptions, Grievances, and Appeals
Medicare STAR Ratings
PPO - 2023 Medicare Plan Ratings
HMO - 2023 Medicare Plan Ratings
PPO- 2024 Medicare Plan Ratings
HMO - 2024 Medicare Plan Ratings
Reimbursement Forms
Click below to access forms for reimbursements.
Direct Member Reimbursement (DMR) Form
Prescription Reimbursement Forms
Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Policies
Read Clover Health policies and other information here.
Prescription Drug Transition Policy
Out-of-Network Coverage Policy
Quality Assurance and Drug Management Programs
Confidential Communications Request
Request for Access to Protected Health Information
Request for Accounting Disclosures
Request for Amendment of Protected Health Information
Request for Restriction of Protected Health Information
Consent for Recurring Mailing of Prescriptions Follow Up Call
Documents for 2024 Texas Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Sharing Health Information Forms
Click below to access the forms that authorize the sharing of your health information.
Authorization for Disclosure of Protected Health Information Form
Appointment of Representative Form
Setting up a My Clover Account
The My Clover member portal is where you can manage your healthcare and health information. You can access your ID cards, find a doctor, explore your benefits, and manage data sharing settings with third-party applications that have access to your health information.
Enrollment/Membership Forms
Click below to access enrollment and membership related forms.
2024 Getting To Know You (Health Assessment Survey) - PDF
2024 Getting to Know You (Health Assessment Survey)
2024 Enrollment Attestation Eligibility Form
EFT/ACH Form for Premium Billing
Late Enrollment Penalty (LEP) Reconsideration Request Form
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
Organization Determinations (Prior Authorizations), Grievances, and Appeals
Part D Coverage Determinations, Exceptions, Grievances, and Appeals
Medicare STAR Ratings
PPO - 2023 Medicare Plan Ratings
PPO- 2024 Medicare Plan Ratings
Reimbursement Forms
Click below to access forms for reimbursements.
Direct Member Reimbursement (DMR) Form
Prescription Reimbursement Forms
Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Policies
Read Clover Health policies and other information here.
Prescription Drug Transition Policy
Out-of-Network Coverage Policy
Quality Assurance and Drug Management Programs
Confidential Communications Request
Request for Access to Protected Health Information
Request for Accounting Disclosures
Request for Amendment of Protected Health Information
Request for Restriction of Protected Health Information
Consent for Recurring Mailing of Prescriptions Follow Up Call
Documents for 2025 Georgia Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Sharing Health Information Forms
Click below to access the forms that authorize the sharing of your health information.
Authorization for Disclosure of Protected Health Information Form
Appointment of Representative Form
Setting up a My Clover Account
The My Clover member portal is where you can manage your healthcare and health information. You can access your ID cards, find a doctor, explore your benefits, and manage data sharing settings with third-party applications that have access to your health information.
Enrollment/Membership Forms
Click below to access enrollment and membership related forms.
2025 Getting To Know You (Health Assessment Survey) - PDF
2025 Getting to Know You (Health Assessment Survey)
2025 Enrollment Attestation Eligibility Form
EFT/ACH Form for Premium Billing
Late Enrollment Penalty (LEP) Reconsideration Request Form
Low-Income Subsidy for Medicare Prescription Drug Coverage
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
Organization Determinations (Prior Authorizations), Grievances, and Appeals
Part D Coverage Determinations, Exceptions, Grievances, and Appeals
Medicare STAR Ratings
PPO - 2025 Medicare Plan Ratings
Reimbursement Forms
Click below to access forms for reimbursements.
Direct Member Reimbursement (DMR) Form
Prescription Reimbursement Forms
Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Policies
Read Clover Health policies and other information here.
Prescription Drug Transition Policy
Out-of-Network Coverage Policy
Quality Assurance and Drug Management Programs
Confidential Communications Request
Request for Access to Protected Health Information
Request for Accounting Disclosures
Request for Amendment of Protected Health Information
Request for Restriction of Protected Health Information
Consent for Recurring Mailing of Prescriptions Follow Up Call
Documents for 2025 New Jersey Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Sharing Health Information Forms
Click below to access the forms that authorize the sharing of your health information.
Authorization for Disclosure of Protected Health Information Form
Appointment of Representative Form
Setting up a My Clover Account
The My Clover member portal is where you can manage your healthcare and health information. You can access your ID cards, find a doctor, explore your benefits, and manage data sharing settings with third-party applications that have access to your health information.
Enrollment/Membership Forms
Click below to access enrollment and membership related forms.
2025 Getting To Know You (Health Assessment Survey) - PDF
2025 Getting to Know You (Health Assessment Survey)
2025 Enrollment Attestation Eligibility Form
EFT/ACH Form for Premium Billing
Late Enrollment Penalty (LEP) Reconsideration Request Form
Low-Income Subsidy for Medicare Prescription Drug Coverage
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
Organization Determinations (Prior Authorizations), Grievances, and Appeals
Part D Coverage Determinations, Exceptions, Grievances, and Appeals
Medicare STAR Ratings
PPO - 2025 Medicare Plan Ratings
HMO - 2025 Medicare Plan Ratings
Reimbursement Forms
Click below to access forms for reimbursements.
Direct Member Reimbursement (DMR) Form
Prescription Reimbursement Forms
Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Policies
Read Clover Health policies and other information here.
Prescription Drug Transition Policy
Out-of-Network Coverage Policy
Quality Assurance and Drug Management Programs
Confidential Communications Request
Request for Access to Protected Health Information
Request for Accounting Disclosures
Request for Amendment of Protected Health Information
Request for Restriction of Protected Health Information
Consent for Recurring Mailing of Prescriptions Follow Up Call
Documents for 2025 Pennsylvania Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Sharing Health Information Forms
Click below to access the forms that authorize the sharing of your health information.
Authorization for Disclosure of Protected Health Information Form
Appointment of Representative Form
Setting up a My Clover Account
The My Clover member portal is where you can manage your healthcare and health information. You can access your ID cards, find a doctor, explore your benefits, and manage data sharing settings with third-party applications that have access to your health information.
Enrollment/Membership Forms
Click below to access enrollment and membership related forms.
2025 Getting To Know You (Health Assessment Survey) - PDF
2025 Getting to Know You (Health Assessment Survey)
2025 Enrollment Attestation Eligibility Form
EFT/ACH Form for Premium Billing
Late Enrollment Penalty (LEP) Reconsideration Request Form
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
Organization Determinations (Prior Authorizations), Grievances, and Appeals
Part D Coverage Determinations, Exceptions, Grievances, and Appeals
Medicare STAR Ratings
PPO - 2025 Medicare Plan Ratings
Reimbursement Forms
Click below to access forms for reimbursements.
Direct Member Reimbursement (DMR) Form
Prescription Reimbursement Forms
Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Policies
Read Clover Health policies and other information here.
Prescription Drug Transition Policy
Out-of-Network Coverage Policy
Quality Assurance and Drug Management Programs
Confidential Communications Request
Request for Access to Protected Health Information
Request for Accounting Disclosures
Request for Amendment of Protected Health Information
Request for Restriction of Protected Health Information
Consent for Recurring Mailing of Prescriptions Follow Up Call
Documents for 2025 South Carolina Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Sharing Health Information Forms
Click below to access the forms that authorize the sharing of your health information.
Authorization for Disclosure of Protected Health Information Form
Appointment of Representative Form
Setting up a My Clover Account
The My Clover member portal is where you can manage your healthcare and health information. You can access your ID cards, find a doctor, explore your benefits, and manage data sharing settings with third-party applications that have access to your health information.
Enrollment/Membership Forms
Click below to access enrollment and membership related forms.
2025 Getting To Know You (Health Assessment Survey) - PDF
2025 Getting to Know You (Health Assessment Survey)
2025 Enrollment Attestation Eligibility Form
EFT/ACH Form for Premium Billing
Late Enrollment Penalty (LEP) Reconsideration Request Form
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
Organization Determinations (Prior Authorizations), Grievances, and Appeals
Part D Coverage Determinations, Exceptions, Grievances, and Appeals
Medicare STAR Ratings
PPO - 2025 Medicare Plan Ratings
Reimbursement Forms
Click below to access forms for reimbursements.
Direct Member Reimbursement (DMR) Form
Prescription Reimbursement Forms
Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Policies
Read Clover Health policies and other information here.
Prescription Drug Transition Policy
Out-of-Network Coverage Policy
Quality Assurance and Drug Management Programs
Confidential Communications Request
Request for Access to Protected Health Information
Request for Accounting Disclosures
Request for Amendment of Protected Health Information
Request for Restriction of Protected Health Information
Consent for Recurring Mailing of Prescriptions Follow Up Call
Documents for 2025 Texas Plans
Plan Details (Summary of Benefits, Evidence of Coverage, and Annual Notice of Change)
Sharing Health Information Forms
Click below to access the forms that authorize the sharing of your health information.
Authorization for Disclosure of Protected Health Information Form
Appointment of Representative Form
Setting up a My Clover Account
The My Clover member portal is where you can manage your healthcare and health information. You can access your ID cards, find a doctor, explore your benefits, and manage data sharing settings with third-party applications that have access to your health information.
Enrollment/Membership Forms
Click below to access enrollment and membership related forms.
2025 Getting To Know You (Health Assessment Survey) - PDF
2025 Getting to Know You (Health Assessment Survey)
2025 Enrollment Attestation Eligibility Form
EFT/ACH Form for Premium Billing
Late Enrollment Penalty (LEP) Reconsideration Request Form
Appeals and Grievances
Use these forms and instructions if you need to appeal a decision or make a complaint.
Organization Determinations (Prior Authorizations), Grievances, and Appeals
Part D Coverage Determinations, Exceptions, Grievances, and Appeals
Medicare STAR Ratings
PPO - 2025 Medicare Plan Ratings
Reimbursement Forms
Click below to access forms for reimbursements.
Direct Member Reimbursement (DMR) Form
Prescription Reimbursement Forms
Quick tip: For an easy claim submission process and a faster claim decision turnaround time submit requests for reimbursement of member-paid prescriptions online via Caremark web portal (Caremark.com) and the Caremark mobile app (available for Android and Apple).
Policies
Read Clover Health policies and other information here.
Prescription Drug Transition Policy
Out-of-Network Coverage Policy
Quality Assurance and Drug Management Programs
Confidential Communications Request
Request for Access to Protected Health Information
Request for Accounting Disclosures
Request for Amendment of Protected Health Information
Request for Restriction of Protected Health Information
Consent for Recurring Mailing of Prescriptions Follow Up Call
Contact Us
We want to make sure you always have the forms and information you need. If you have questions, please don’t hesitate to reach out to Member Services at:
1-888-778-1478 (TTY/TDD 711)*
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Original Medicare
Traditional Medicare covers hospitals (Part A) and doctors (Part B), and you pay standard rates for services. You can go to any doctor, hospital or other provider that accepts Medicare patients anywhere in the country.
You can add drug coverage (Part D) by enrolling in a private "stand-alone" drug plan for an additional premium. You can buy separate Medigap insurance to cover some or most of the out-of-pocket costs of hospitals (Part A) and doctors (Part B).
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