Medicare Forms and Documents
Find Medicare Advantage formularies and pharmacy documents here.
Enrollment Application Forms
Enrollment Application
Medicare Advantage Special Needs Enrollment Application
Optional Supplemental Dental Benefit
Medicare Advantage Plan Documents
2025 ConnectiCare Choice Plan 3 (HMO-POS)
Annual Notice of Changes (ANOC)
Evidence of Coverage (EOC)
Last Updated: 05/12/2025
Pharmacy Directory
Last Updated: 07/18/2025
Provider Directory
Last Updated: 08/01/2025
Summary of Benefits
2025 ConnectiCare Choice Plan 2 (HMO-POS) No RX
Annual Notice of Changes (ANOC)
Evidence of Coverage (EOC)
Last Updated: 10/08/2024
Provider Directory
Last Updated: 08/01/2025
Summary of Benefits
2025 ConnectiCare Choice Plan 1 (HMO-POS)
Annual Notice of Changes (ANOC)
Evidence of Coverage (EOC)
Last Updated: 05/12/2025
Pharmacy Directory
Last Updated: 05/23/2025
Provider Directory
Last Updated: 06/01/2025
Summary of Benefits
2025 ConnectiCare Flex Plan 3 (HMO-POS)
Annual Notice of Changes (ANOC)
If you live in Hartford, Litchfield, Middlesex or Tolland County
Annual Notice of Changes (ANOC)
If you live in Fairfield, New Haven, New London or Windham County
Evidence of Coverage (EOC)
Last Updated: 05/12/2025
Pharmacy Directory
Last Updated: 07/18/2025
Provider Directory
Last Updated: 08/01/2025
Summary of Benefits
2025 ConnectiCare Flex Plan 2 (HMO-POS)
Annual Notice of Changes (ANOC)
Evidence of Coverage (EOC)
Last Updated: 05/12/2025
Pharmacy Directory
Last Updated: 07/18/2025
Provider Directory
Last Updated: 08/01/2025
Summary of Benefits
2025 ConnectiCare Passage Plan 1 (HMO-POS)
Annual Notice of Changes (ANOC)
Evidence of Coverage (EOC)
Last Updated: 05/12/2025
Pharmacy Directory
Last Updated: 07/18/2025
Provider Directory
Last Updated: 08/01/2025
Summary of Benefits
2025 ConnectiCare Choice Dual (HMO-POS D-SNP)
Annual Notice of Changes (ANOC)
Annual Notice of Changes (ANOC)
Formerly known as ConnectiCare Choice Dual Vista (HMO-POS D-SNP)
Evidence of Coverage (EOC)
Last Updated: 05/12/2025
Pharmacy Directory
Last Updated: 07/18/2025
Provider Directory
Last Updated: 08/01/2025
Summary of Benefits
2025 ConnectiCare Employer Group Plan (HMO and HMO-POS)
Evidence of Coverage (EOC)
Last Updated: 05/12/2025
Forms
Find forms for reimbursement, coverage determination, and more.
Vision, Hearing Aid Allowance and/or Over the Counter (OTC) Reimbursement Form
Use this form to file a claim for reimbursement of out of pocket costs of covered eyewear, hearing aids and/or OTC plan benefits (if applicable). Do not use this form for post-cataract eyewear reimbursement requests. Y0026_200572_C
Dental Reimbursement Form
Use this form to send a claim for reimbursement of out-of-pocket costs for covered dental services. Y0026_203951_C Last Updated: 11/02/2023
Authorization of Representative (AOR)
An enrollee may appoint any individual to act as his or her representative. To be appointed by an enrollee, both the enrollee making the appointment and the representative accepting the appointment must sign, date, and complete an authorization form.
Clinical Review Preauthorization Request Form
Last updated: 7/06/2021 If you are seeking to obtain authorization of services or procedures included under ConnectiCare's preauthorization requirements.
Coverage Determination Form
An exception is a type of coverage determination. You may ask for an exception if you need a drug that is not on our list of covered drugs. You may also ask for an exception to rules, such as a limit on the quantity of a drug. Y0026_201899_C
If not currently enrolled call 877-224-8221 (TTY: 711)
From Oct. 1 to March 31, you can call us from 8 a.m. to 8 p.m., seven days a week. From April 1 to Sept. 30, you can call us from 8 a.m. to 8 p.m., Monday through Friday.
Medicare members call 800-224-2273 (TTY: 711)
From Oct. 1 to March 31, you can call us from 8 a.m. to 8 p.m., seven days a week. From April 1 to Sept. 30, you can call us from 8 a.m. to 8 p.m., Monday through Saturday.
