Plan Documents

Here, you’ll find additional details about Clover’s plans.

• Plan Details (2017 Summary of Benefits and Evidence of Coverage)
• 2017 Welcome Booklet ( English | Español )

Forms

• Authorization for Disclosure of Protected Health Information ( English | Español )
• Appointment of Representative Form
• Enrollment Form ( English | Español )
• EFT/ACH Form for Premium Billing ( English | Spanish )

Appeals and Grievances

• Organization Determinations (Pre-authorizations), Grievances, and Appeals

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

Reference

• Privacy Practices for Protected Health Information (PHI)
• How to Disenroll from Clover
• Multi-language Interpreter Services
• 2017 Medicare Plan Ratings ( English | Español )
• Pre-Authorizations
• Provider Directory ( Search | PDF )
• Out-of-network Coverage Rules
• Utilization Management
• Member claims submission