Forms and Prior Authorization

Appoint a Representative

Medicare’s privacy policy ensures that personal information is only shared with the covered beneficiary and no one else. However, we know that when navigating your Medicare Part D Plan, you may need assistance.

Appointing a representative allows you to designate someone you trust to make decisions and handle
your Medicare Part D matters on your behalf. By filling out the Medicare Appointment of Representative (AOR) Form, caregivers can more easily help you navigate your Medicare coverage, file claims, and address any issues that may arise, giving both you and your loved ones peace of mind. This authorization can be set for a specific period or up to one year and can be revoked by you at any time.

To appoint a representative to assist you with your Medicare Part D matters, please complete the Medicare Appointment of Representative (AOR) Form and submit it using one of the following methods:

Click below to access the Medicare Appointment of Representative Form.

Retiree RxCare Customer Care Department
50 Whitecap Drive
North Kingstown, RI 02852

Medicare Appointment of Representative Form

Prior Authorization

Sometimes prescription drugs require a prior authorization. Prior authorization ensures that the medications you receive are safe, effective, and covered by your plan. Here, we’ve made it easy to understand the process and get started with your request.

How do I request a prior authorization?

To request a prior authorization you, your authorized representative, or physician can call our customer service line 24 hours a day, 7 days week. Prior authorization forms may also be submitted by mail or fax.

A prior authorization decision will be made within 72 hours, and your request will either be approved or denied.

Approved

If your request is approved by the Plan, the pharmacy you are using will be notified immediately and your prescription will be filled. An override and expiration date of the approval will be entered into the Plan’s adjudication system so you will be able to fill that particular prescription without delay until the approval's expiration date.

Denied

The prescribing physician will be notified by phone and by written letter with the Appeals Process information. The plan will also notify you (the insured) in writing within 72 hours explaining the reason for the denial and will provide information on your rights to appeal any decision about your Medicare Part D Plan benefits.

Exceptions

Members have the option to request an exception for drug coverage or tier cost sharing. For more detailed information regarding the criteria for exceptions, please call the Retiree RxCare Customer Care Department at 1-855-693-3921, 24 Hours, 7 days a week.

How do I request an appeal?

Prior Authorization Appeal Form

How do I file a grievance?

Click Here