MDwise Medicare
Plan Documents and Forms

Plan Documents and Forms

Summary of Benefits

• Summary of Benefits
• Summary of Benefits D-SNP

Evidence of Coverage

• MDwise Medicare Inspire
• MDwise Medicare Inspire Plus
• MDwise Medicare Inspire Flex
• MDwise Medicare Inspire Duals

Dental Certificates of Coverage

• Delta Dental - for Inspire, Inspire Plus and Inspire Flex
• Delta Dental - for Inspire Duals
• Delta Dental - for optional supplemental benefit Option 1
• Delta Dental - for optional supplemental benefit Option 2

Prior Authorization Form

• Prior Authorization Form for Members

Member Reimbursement Form

• Member Reimbursement Form
• Electronic Funds Transfer (EFT) Payments