Plan Documents
Here, you’ll find additional details about Clover’s plans.
- Plan Details (Summary of Benefits and Evidence of Coverage)
- 2018 Welcome Booklet
Forms
- Authorization for Disclosure of Protected Health Information ( English | Español )
- Appointment of Representative Form
- 2018 Enrollment Form
- EFT/ACH Form for Premium Billing ( English | Spanish )
- Health Assessment ( English | Spanish )
Appeals and Grievances
Drug Coverage
- Part D Coverage Determinations, Exceptions, Grievances, and Appeals
- Prescription Drug Transition Policy
- Monthly Plan Premiums for Those Receiving Extra Help from Medicare to Pay for Prescription Drugs
- Request for Medicare Prescription Drug Coverage Determination
- Request For Redetermination Of Medicare Prescription Drug Denial
