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Claims & Reimbursements

Prescription Drug Claim Form

Prescription Drug Claim Form - Spanish

Medical Reimbursement Form

Medical Reimbursement Form (Spanish)

Enrollment

How to enroll in an Innovation Health Medicare plan

Give another person permission to help manage your care

Let someone else talk to us about your health or coverage

One-time only: You can give us your permission by phone. We can speak with that person during that call.
On an ongoing basis: You may want someone to speak with us more often. If so, you’ll need to mail us an Authorization for Release of Protected Health Information (PHI) form. It lets this person access your personal health information. They can also speak with us on your behalf.

Open and print the PHI form

Let someone file a grievance (complaint), ask for coverage or make an appeal for you

You can choose someone to do all of the above. This person is your appointed representative. An appointment is good for one year from the date that you and your representative sign an Appointment of Representative form.
Fill out this form below and mail it to us. Any time your representative makes a request for you, they should send us a signed copy. You'll leave Innovation Health Medicare and go to the CMS website if you link to the form.

Appointment of Representative CMS Form

Appointment of Representative CMS Form (Spanish)

Prescription drugs

Medication Order Form for Aetna Rx Home Delivery

Medication Order Form for Aetna Rx Home Delivery - Spanish

Medication Action Plan

Medication Action Plan (Spanish)

Personal Medication List

Personal Medication List (Spanish)

Member exceptions, appeals and grievances

Learn more about requesting an exception or filing a grievance or appeal:
Access forms and learn what steps to take

Man working on laptop near fireplace

Man working on laptop near fireplace

We're here to help

Email us or call Member Services at the number on your ID card.

Don’t have your ID card handy?
Find a phone number

We speak your language: We have free interpreter services to answer questions you may have about our health or drug plan.
Get help from an interpreter

¿Habla español?
Visite nuestro sitio en español

Disclaimers

Innovation Health is a HMO, PPO plan with a Medicare contract. Enrollment in our plans depends on contract renewal.

See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area.

Innovation Health Medicare’s pharmacy network includes limited lower cost, preferred pharmacies in: rural Maine, rural Missouri and rural South Dakota. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use.

For up-to-date information about our network pharmacies, including pharmacies with preferred cost sharing, members please call the number on your ID card, non-members please call 1-866-471-9374 (TTY: 711) or consult the online pharmacy directory at http://www.innovationhealthmedicare.com/pharmacyhelp.

Y0123_4006_10831 Approved 12/7/2017

Page last updated: May 30, 2018

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