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Forms

For Medica Prime Solution (Cost) Members

Plan Management Forms

• 2021 Automatic payment form (PDF)
• Appoint a representative form (PDF)
• Online Medicare enrollment change form for Prime Solution members
• Medicare Part D prescription claim form (PDF)
• Reimbursement instructions for prescription Part D costs (PDF)
• Medica Prime Solution Plan Request for Disenrollment (PDF)

Claim Reimbursement Forms

• Dental Reimbursement Form (PDF) – applies to Medica Prime Solution (Cost), Medica Group Prime Solution (Cost)
• Eyewear Reimbursement Form (PDF) – applies to Medica Prime Solution (Cost), Medica Group Prime Solution (Cost)
• Hearing Aid Reimbursement Form (PDF) – applies to Medica Prime Solution (Cost), Medica Group Prime Solution (Cost)
• Travel Reimbursement Form (PDF) – applies to Medica Prime Solution (Cost), Medica Group Prime Solution (Cost)

Looking for 2020 Claim Forms?

Enrollment and Change Forms

Iowa

• 2021 Medica Prime Solution Enrollment Application (PDF)
• 2021 Medica Prime Solution Plan Change Form (PDF)

Kansas

• 2021 Medica Prime Solution Enrollment Application (PDF)
• 2021 Medica Prime Solution Plan Change Form (PDF)

Minnesota

• 2021 Medica Prime Solution Enrollment Application (PDF)
• 2021 Medica Prime Solution Plan Change Form (PDF)
• 2021 Medica Prime Solution with Part D Change Form (PDF)

Nebraska

• 2021 Medica Prime Solution Enrollment Application (PDF)
• 2021 Medica Prime Solution Plan Change Form (PDF)

North Dakota and South Dakota

• 2021 Medica Prime Solution Plan Enrollment Application (PDF)
• 2021 Medica Prime Solution Plan Change Form (PDF)
• 2021 Medica Prime Solution Plan with Part D Change Form (PDF)

Wisconsin

• 2021 Medica Prime Solution Plan Enrollment Application (PDF)
• 2021 Medica Prime Solution Plan Application Supplement (PDF)
• 2021 Medica Prime Solution Plan with Part D Change Form (PDF)
• 2021 Medica Prime Solution Plan Change Form (PDF)
• 2021 Medica Prime Solution Total WI Rider Application (PDF)