Additional Forms and Documents

Click on the links below to find the correct form you need.

• Appointment of Representative Form
• Exception and Prior Authorization Forms
• Request for a Medicare Prescription Drug Coverage Determination Form
• Request for Medicare Prescription Drug Redetermination Form
• Direct Claims Form
• Vaccine and Administration (Injection) Claim Form
• Medicare Five-Star Quality Ratings System

Appointment of Representative Form

Our members can appoint a representative to act on their behalf. To do so, we must have written authorization signed by both the caregiver and the member.

A representative who is appointed by the court or who is acting in accordance with state law may also file a request on your behalf after sending us the legal representative document. You will not need to complete an Appointment of Representative Form if you provide another legal representation document with your request.

Download an Appointment of Representative form (PDF). Once the form is filled out in its entirety, fax it to us at 1-877-907-2982.

Forms for Medicare Advantage plans with Prescription Drug Coverage (MA-PD):

• Exception and Prior Authorization Forms:
• Print Exception and Prior Authorization forms
• Or, use our easy Drug Search Tool to find the forms you need. Learn more about Exceptions and Prior Authorizations.
• Request for a Medicare Prescription Drug Coverage Determination Form:
• Use this form (PDF) to request a coverage determination from the plan. Learn more about Exceptions and Prior Authorizations.
• Request for Medicare Prescription Drug Redetermination Form:
• Use this form (PDF) to request a redetermination (appeal) from the plan.
• Direct Claims Form
• Use this form (PDF) to submit a request for reimbursement of your covered Part D Drugs that may have been paid for out-of-pocket.
• Vaccine and Administration (Injection) Claim Form
• Use this form (PDF) to request for reimbursement of your covered Part D vaccines and their administration (injection) fees.

Medicare Five-Star Quality Rating System

The Medicare Program rates how well TexanPlus performs in different categories (for example, detecting and preventing illness, rating from patients, patient safety and customer service). The information provided in the document(s) is a summary rating of our plan's overall performance:

• H4506: TexanPlus Medicare Plan Ratings (PDF)

You also may visit www.medicare.gov  for more information (by clicking on this link you are leaving our website).