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

• Prescriptions/pharmacy/authorizations
• Claims
• Other

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Prescriptions/pharmacy/authorizations

• Mail order form — for filling new prescriptions from Health First Family Pharmacy (for more information, visit Health First Family Pharmacy). You must use MedVantx if you need your drugs shipped outside of Florida.
• Request for Medicare Prescription Drug Coverage Determination — 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.
• Medical Authorization Request Form — for your physician to request authorization for a medical service 
• Hospice pharmacy authorization request form  — if there is a question as to whether a drug should be covered under your prescription drug benefit (Part D) or hospice benefit, you or your doctor can submit this form to our Pharmacy Team for a coverage determination.
• Request for Redetermination of Medicare Prescription Drug Denial  — for members

Claims

• Prescription drug reimbursement form — to request reimbursement for a covered prescription if if you paid out-of-pocket for it
• Medical reimbursement form — if you paid out-of-pocket for a covered medical service, including vision, dental, or hearing services

Other

Please send completed form(s) below to:
Health First Health Plans
6450 US Highway 1
Rockledge, Florida 32955

• Enrollment Request Form 2019 | 2020  — use this form if you will be joining our Medicare Advantage plan.
• Disenrollment form  — for current members to change from one of our plan options to another.
• Plan selection form 2019 | 2020 — for current members to change from one of our plan options to another (for example, change from Value to Classic)
• Appointment of representation form —  if you want to name someone (such as a relative, friend, advocate, doctor, lawyer, or anyone else) to handle appeals and grievances with us on your behalf
• Authorization to disclose your Protected Health Information (PHI) form — if you want to give someone permission to access your personal health information (for example claims, medical, or financial information)

 

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Health First Health Plans is an HMO plan with a Medicare Contract. Enrollment in Health First Health Plans depends on contract renewal.

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Y0089_EL7846_M | Accepted date: 10/1/2019
Last updated: 2/11/2020