We are committed to the health of our Members

Our goal is to provide you with the access to the health care providers, benefits, information and services that will allow you to stay in the best health possible.

Use our handy Quick Links connections on the left hand side of this page to access the most up to date, frequently needed information about your health plan including directories of doctors, hospitals, and pharmacies along with a list of prescription drugs covered by our Formulary. Find a complete list and links to our Plan Forms below on this page.

Plan Benefit Information, click on the specific plan link below to get comprehensive information on benefits, copay and coinsurance, including the Summary of Benefits and Evidence of Coverage.

Plan Forms

Following is a list of forms for use by Community HealthFirst members. If you don’t see the form that you need or have questions about any of these forms, please contact Customer Service, 8 a.m. to 8 p.m., 7 days a week, at 1-800-942-0247 or for TTY / TDD hearing impaired, call 1-866-816-2479.

Enrollment Applications

Click here for the Enrollment Application

Payment Option Form

Click here for the form and instructions for choosing the payment option that best fits your needs

Privacy

The following form is for use with all Community HealthFirst Medicare Advantage Plans.

Authorization to Disclose Personal Health Information standard form to use for releasing your personal health information to authorized medical or health plan personnel.

Medical Benefits
The following forms are for use with all Community HealthFirst Medicare Advantage Plans

Medical Claim Form - standard form to use if you are seeking reimbursement for out-of –pocket costs associated with medical benefits which you feel should be covered by your health plan benefits.

Prior Authorization/Medical Exception Request - standard form to use when seeking prior authorization or seeking an exception to the established utilization criteria for medical benefits covered by your health plan

Prescription Drug Benefits
The following forms and instructions are for use only with the Community HealthFirst Medicare Advantage Plans with Pharmacy and Community HealthFirst Special Needs Plan.

2008 Coverage for Vaccinations

Prescription Mail Order Form - standard form to be used when ordering prescription drugs by mail. Please contact Customer Service at 1-800-942-0247, 8 a.m. to 8 p.m., 7 days a week to request a prescription claim form.

Prescription Drug Claim Form – standard form to use if you are seeking reimbursement for out-of–pocket costs associated with prescription drugs which you feel should be covered by plan prescription drug benefits.

Medicare Part D Coverage Determination Request (from Provider) – standard form to use when you wish your doctor to request a decision on coverage for your prescription drugs.

Request for Medicare Prescription Drug Coverage Determination (from Member) – standard form to use when you are requesting a decision on coverage for your prescription drugs.

Member Request for Medicare Prescription Drug Coverage Reconsideration Form - standard form to use when you are requesting reconsideration of a decision made regarding coverage for your prescription drugs.

Appeals & Grievances

Appeal Form - standard form to use when seeking to file an appeal to reconsider a decision we have made about what benefits are covered under your plan or what we will pay.

Grievance Form – standard form to use when seeking to file a complaint about a problem with your health care provider or the service we provide to you.

Appointment of Representative – standard form to use if you wish to have someone act on your behalf regarding an Appeal or Grievance. You must fill out the Appointment of Representative Form and return it with the Appeal or Grievance Form that you are seeking representation on.

Low Income Subsidy Program
To obtain the proper forms to apply for the Low Income Subsidy Program please contact the following:

Social Security: Monday - Friday, 7 a.m. to 7 p.m. at 1-800-772-1213 (TTY 1-800-325-0778) or www.socialsecurity.gov/prescriptionhelp/
Medicare: 24 hours a day, 7 days a week at1-800-633-4227 (TTY 1-877-486-2048) or www.medicare.gov

Important Note: You will leave the Community HealthFirst website by clicking on either of the above links.