For assistance with any of these forms, please contact customer service.

• Prescriptions/pharmacy/authorizations
• Claims
• Premiums
• Other

Prescriptions/pharmacy/authorizations

Mail order a 90-day supply of your prescription from Health First Family Pharmacy

Mail order a 90-day supply of your prescription from MedVantx (formerly Ameripharm) — you must use MedVantx if you need your drugs shipped outside of Florida

 Prescription drug reimbursement form — to request reimbursement for a covered prescription if if you paid out-of-pocket for it (H1099 EL624_18706A19206)

 Pharmacy authorization/exception request form — if a drug requires prior authorization or an exception, your doctor should submit this form with applicable medical information to our Pharmacy Team for consideration.

 Medicare prescription drug exception & appeal form — to request an authorization, formulary exception (for a drug that is not on our formulary), or a tiering exception (to pay less for a covered drug because you can’t take a lower-cost drug), or an appeal if we deny coverage for your drug or deny your exception request. For exception requests, your doctor must call or write us to explain why it is medically necessary. (H1099 EL599-08906A09506)

 Authorization request (medical) — for your physician to request authorization for a medical service 

Claims

 Prescription drug reimbursement form — to request reimbursement for a covered prescription if if you paid out-of-pocket for it (H1099 EL624_18706A19206)

 Medical reimbursement form — if you paid out-of-pocket for a covered medical service, including vision, dental, or hearing services (H1099 MP942_31807A03108)

Premiums

 Automatic payment form — if you would like to have your premium automatically charged to your credit card or withdrawn from your bank account each month
(H1099_EL2647 File and Use 03142012)

Other

 Plan selection form (MA-PD) — for current members to change from one of our plan options to another (for example, change from Value to Classic)
(H1099_EL2624 File and Use 09122011)

 Appoint a representative (general) — to authorize us to disclose your personal health information to a person or organization you choose (such as a relative, friend, advocate, doctor, lawyer, or anyone else), so they can handle matters with us on your behalf.
(H#1099 EL901_25407A25907)

 Appoint a representative (appeals) — to authorize a person or organization to file an appeal on your behalf (H1099_EL2608 File & Use 08202011)

 Pro-Health hold form — If you’re already a member of Pro-Health and then join Health First Medicare Plans, it’s your responsibility to contact Pro-Health's billing office to fill out a "hold form" to cancel your membership payments.

H1099_MP2760 CMS Approved 10212011
Last updated: 5/10/2012