Medicare Part D Plan Medicare Part D Premiums Medicare Part D Forms & Publications Pharmacy Information Pharmacy Directory Order Rx Refills Annual Notice of Change Enrollment Contract Termination MTMP Service Area Grievances, Exceptions, Coverage Determination & Appeal Proceedures Member Rights & Responsibilities Privacy Notice Medicare Website All forms and publications are Acrobat PDF documents. If you do not have Acrobat Reader, please download it now. Appeals, Exceptions & Grievances Forms Appointment of Representative Your Appeal Rights Appeals & Grievances Instructions Request for Medicare Prescription Drug    Coverage Determination Request for Redetermination of Medicare    Prescription Drug Denial Annual Notice of Change / LIS Charts 2012 Annual Notice of Change 2011 Annual Notice of Change 2012 Low Income Subsidy (LIS) Chart 2011 Low Income Subsidy (LIS) Chart Authorization / Release Form Information Release Authorization Revocation of Info Release Authorization Benefits Guides & Summaries 2012 UPREHS Prime Medicare Plan Benefit Guide Book 2012 Summary of Benefits 2011 UPREHS Prime Medicare Plan Benefit Guide Book 2011 Summary of Benefits Company Brochures & Newsletters UPREHS Company Brochure Preventing Fraud Medicare & You 2012 B vs D and Quantity Limits Medicare D Prior Authorization Criteria Quantity Limits "Part B" vs "Part D" Criteria  Formularies 2012 Formularies 2012 Preferred Part D Formulary 2012 Comprehensive Part D Formulary 2011 Formularies 2011 Preferred Part D Formulary 2011 Non-Preferred Part D Formulary HIPPA HIPAA Privacy Notice Health Information & Tips Traveling with Insulin Pharmacy Forms Prescription Claim Form Physician Prescription Fax Form Compound Drug Claim Form Policies Privacy Policies Legal Disclaimers Privacy Notice Quality Assurance Report of Personal Injury (Form 560-A) English Last Updated: 12/21/2011 Provider Login     |     Medicare Plans     |     Find A Physician     |     Member Login Home  |  About UPREHS  |  UPREHS Members  |  Plans & Coverage  |  Health & Wellness  |  Forms  |  Contact Us Legal Disclaimers | HIPAA | Privacy Policy UPREHS. Plan for Life.™              © 1995-2009 UPREHS. All rights reserved.