Additional Forms
Additional Forms and Documents
Click on the links below to find the correct form you need.
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 representative 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 1-866-430-7452.
Exception and Prior Authorization Forms
If you have a Tribute
plan with prescription drug coverage, you can request a Formulary Exception or Prior Authorization using one of our Exceptions 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
If you have a Tribute
plan with prescription drug coverage, you or an appointed representative may use
this form
(PDF) to request a coverage determination from the plan.
Your physician or healthcare provider may 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
If you have a Tribute
plan with prescription drug coverage, 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
If you have a Tribute
plan with prescription drug coverage, 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 Tribute performs in different categories (for example, detecting and preventing illness, rating from patients, patient safety and customer service). The information provided here (PDF) is a summary rating of our plan's overall performance. You also may visit www.medicare.gov for more information (by clicking on this link you are leaving our website).
Provider Payment Dispute Resolution Instructions for Non-Contracting Providers and Provider Payment Dispute Resolution Form
If you’re a Tribute
provider, please view the Provider Payment Dispute Resolution Instructions for Non-Contracting Providers (PDF) and the Provider Payment Dispute Resolution Form (PDF) for provider payment disputes.
A health plan with a Medicare contract.
Tribute® HMO SNP is offered by the following organization that contracts with the Federal government: SelectCare of Oklahoma, Inc., a member of the Universal American family of companies.