Forms

AvMed makes it easy to manage your account by providing forms and other tools for making requests. Simply print and fill out one of our pre-composed forms for quick, easy service. Certain requests can be submitted directly online.

AvMed Medicare Pre-Enrollment Checklist

AvMed Medicare Choice Enrollment Form

AvMed Medicare Choice Formulario para Inscripción

Appointment of Representative (Medicare members)

Designated Record Set (DRS) Request Form

Medicare Rx Mail Order Form

​Medicare Rx Formulario para Ordenar

Medication Exception Request Form

Model CMS Drug Determination Request Forms

Medicare Complaint Form

Member Disclosure Form

Request for Reimbursement Form

Quality Assurance Drug Management Programs

Utilization Management

Drug Utilization Review

Medication Therapy Management (MTM)

Personal Medication List

Coverage Determination

2017 Part D Prior Authorization Criteria (Effective August 1, 2017)

2017 Part D Step Therapy Criteria (Effective August 1, 2017)

2016 Part D Transition Policy

AvMed Medicare is an HMO plan with a Medicare contract. Enrollment in AvMed Medicare depends on contract renewal.
Address: 9400 S. Dadeland Blvd. Miami, FL 33156

 

Prospective Members: 888-492-8633 (TTY 711)
Current Members: 800-782-8633 (TTY 711)
October 1–March 31, 8 am-8 pm, 7 days a week.
April 1–September 30, 8 am-8 pm, Monday-Friday; 9 am- 1pm on Saturday.

H1016_AD832-092018. Last updated September 30, 2018.