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Appeals, Exceptions & Grievances Forms
  • Physician Documentation for Exception
  • Appointment of Representative
  • Your Appeal Rights
  • Appeals & Grievances Instructions
  • Physician Documentation for a Non-Preferred
       Formulary Drug Exception
  • Request for a Medicare Prescription Drug
       Coverage Determination
  • Annual Notice of Change / LIS Charts
    2010 Annual Notice of Change
    2009 Low Income Subsidy (LIS) Chart

    Authorization / Release Form

    Information Release Authorization
    Revocation of Info Release Authorization
    Prior Authorization Criteria
    Quantity Limits 
    Benefits Guides & Summaries
  • 2010 UPREHS Prime Medicare Plan Benefit Guide Book
  • 2009 Summary of Benefits
  • Company Brochures & Newsletters
    UPREHS Company Brochure
    Preventing Fraud
    Medicare & You 2009
    Formularies
    2009 Formularies
    Medicare Preferred Drug Formulary
    Medicare Non-Preferred Drug Formulary

    Earlier Formularies
    2008 Medicare Preferred Drug Formulary
    2008 Medicare Non-Preferred Drug Formulary

    HIPPA
    HIPAA Privacy Notice
    Pharmacy Forms
  • Prescription Claim Form
  • Prior Authorization for Compound Drugs
       Policies & Procedures
  • Coordination of Benefits Form
  • Physician Prescription Fax Form

  • Policies
    Privacy Policies
    Legal Disclaimers
    Privacy Notice
    Quality Assurance
    Report of Personal Injury (Form 560-A)
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    Last Updated: 02/8/2010
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