Documents and Forms
If you need assistance or if you want copies of any of the below forms, give us a call at:
Toll-Free: 1-833-342-7463, TTY 711.
We are open 7 days a week, 8:00 a.m. to 8:00 p.m.
Plans Documents
South Florida
Miami-Dade County
- DrMax (HMO)
- DrSelect (HMO)
- DrPlus (HMO D-SNP)
- DrFlex (HMO D-SNP)
- DrExraCare (HMO C-SNP)
- DrValue (HMO)
Broward County
- DrMax-B (HMO)
- DrPlus-B (HMO D-SNP)
- DrElite-B (HMO)
*DrMax-B(HMO), DrSelect (HMO) – The benefits mentioned are part of a special supplemental program for chronically ill members with one of the following conditions; Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic heart failure, Chronic lung disorders. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefits. Other requirements apply. DrExtraCare (HMO C-SNP) – The benefits mentioned are part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic heart failure and End-Stage Renal Disease (ESRD). Having a qualifying condition alone does not mean you will receive the benefits. Other requirements apply. DrExtraCare (HMO C-SNP) has been approve by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until 12/31/2025 based on a review of the Model of Care.
**DrPlus (HMO D-SNP), DrPlus-B (HMO D-SNP) and DrFlex (HMO D-SNP) – Must be a Qualified Medicare Beneficiary (QMB, QMB+), Specified Low-Income Medicare Beneficiary (SLMB, SLMB+), Full Benefit Dual Eligible (FBDE), Qualified Individual (QI) or Qualified Disabled and Working Individual (QDWI). DrPlus (HMO D-SNP), DrPlus-B(HMO D-SNP) and DrFlex (HMO D-SNP) is sponsored by Doctors HealthCare Plans, Inc. and the State of Florida Agency for Health Care Administration. DrPlus (HMO D-SNP), DrPlus-B (HMO D-SNP) and DrFlex(HMO D-SNP) have been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until December 31, 2027 based on a review of the Model of Care.
South Florida
- DrMax (HMO)
- DrPlus (HMO D-SNP)
- DrExraCare (HMO C-SNP)
- DrSelect (HMO)
- DrFlex (HMO D-SNP)
- DrElite – SFL (HMO)
- Summary of Benefits English / Spanish
- Evidence of Coverage (EOC) English / Spanish
- Download the Formulary / Drug List
Central Florida
- DrSelect – CFL (HMO)
- Summary of Benefits English / Spanish
- Evidence of Coverage (EOC) English / Spanish
- Download the Formulary / Drug List
- DrPlatinum – CFL (HMO D-SNP)
- Summary of Benefits English / Spanish
- Evidence of Coverage (EOC) English / Spanish
- Download the Formulary / Drug List
- DrTotalCare – CFL (HMO C-SNP)
- Summary of Benefits English / Spanish
- Evidence of Coverage (EOC) English / Spanish
- Download the Formulary / Drug List
- 2025 Enrollment Form English / Spanish
- 2026 Enrollment Form English / Spanish
- 2025 Pre-Qualification Assessment for DrExtraCare (HMO C-SNP) English / Spanish
- 2026 Pre-Qualification Assessment for DrExtraCare (HMO C-SNP) English / Spanish
- 2026 Pre-Qualification Assessment for DrTotalCare-CFL (HMO C-SNP) English / Spanish
- Disenrollment Form English / Spanish
- Advance Care Planning:
- You have access to an online advance care planning resource called, MyDirectives® (https://mydirectives.com/). This resource guides you to create an advance directive where you can combine the elements of:
a) A Living Will- What’s important to you! To include medical treatment goals and last wishes.
b) Medical power of attorney-appointment of the person or persons whom you would like to make medical treatment decision on your behalf.
c) Expression of treatment wishes and desires.
d) Decisions on Organ donation form.
- You have access to an online advance care planning resource called, MyDirectives® (https://mydirectives.com/). This resource guides you to create an advance directive where you can combine the elements of:
- Advance Directives English / Spanish
- Appeals Part C Form English / Spanish
- Appointment of Representative (AOR) English / Spanish
- Authorization for Release of Information English / Spanish
- Authorization for Release of Information – Discontinuation Form English / Spanish
- Member Grievance Form English / Spanish
- Health Risk Assessment English / Spanish
- Member Newsletter – Member Connect
- Member Rights and Responsibilities English / Spanish
- Prior Authorization/Organization Determination Form English / Spanish
- Request for Reimbursement Medical Benefits English / Spanish
- Prepaid Card Catalogs
- Star Rating Information for 2025 English / Spanish
- Star Rating Information for 2026 English / Spanish
Prescription Drug Forms
- Prescription Drug Coverage Request Form English / Spanish
- Prescription Drug Appeals Form English / Spanish
- Prescription Drug Mail Order English / Spanish
- Transition Policy English / Spanish
- Prescription Drug Reimbursement Form English / Spanish
- Medicare Prescription Payment Plan Participation Request Form English / Spanish
Privacy
H4140_WSMEMDOCFORM_C
Last updated: 10/23/2025