- To access the Senior Preferred enrollment application, please visit the enrollment page.
Prescription (Part D) forms
- To request an initial Part D coverage determination or exception, please use this form:
- To request a Part D redetermination, first-level appeal, please use this form:
- Accident Questionnaire
- Authorization for Disclosure of Protected Health Information Form
- Member Claim Form
- Payment Change Form
- Appointment of Representative Statement Form (If you would like to appoint a representative to act on your behalf in requesting a coverage determination, appeal or grievance, please refer to this form).
Completed forms can be mailed or faxed to:
Mail Stop: NCA2-01
1900 South Avenue
La Crosse, WI 54601
Fax: (608) 775-8091
This web page was updated on November 15, 2017.