2018 Member Forms

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


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.
  • Prescription drug reimbursement form — to request reimbursement for a covered prescription if you paid out-of-pocket for it
  • 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.
  • Authorization request (medical) — 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.

Claims

Other

Y0089_MP6562FH APPROVED 10/5/2017
Last updated: 3/19/2018