Coverage Decisions, Appeals, and Complaints for Medicare Plan Members | Healthfirst

Coverage Decisions, Appeals, and Complaints for Medicare Plan Members

We’re here to help you navigate your Healthfirst Medicare Advantage plan benefits. See below for more information on how you, your doctor, or your appointed representative can call or write us to discuss your coverage concerns.

If Your Benefit Isn’t Covered

Coverage Determinations

You, your appointed representative, or your doctor may submit this request. This may result in a coverage exception, or your doctor may decide on an alternate course of treatment.

Medical Determination

You, your doctor, or your appointed representative can call or write us to explain the situation.

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  • Call: 1-888-394-4327
  • TTY 711
  • Monday to Friday, 8:30am–5:30pm
  • Fax: 1-646-313-4603
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  • Healthfirst Medicare Plan
  • Medical Management Department
  • P.O. Box 5166
  • New York, NY 10274-5166

Next Step

We’ll get back to you within 14 days.*
*We’ll reach out if more time is required. If waiting puts your health at risk, you can get a fast decision within 72 hours. If your request is denied, you may submit an appeal. Please see the following section for instructions.

Prescription Drug Determination

Fill out this form

Please include a statement of support from your doctor with your request.

Submit to us via email, fax, or mail:

MedicareCoverageDeterminations @Caremark.com

Fax: 1-855-633-7673

  • CVS Caremark Part D Services
  • MC 109
  • P.O. Box 52000
  • Phoenix, AZ 85072-2000

Next Step

You’ll hear back from us with 72 hours.* If your request is denied, you may submit an appeal. Please see the following section for instructions.
*We’ll reach out if more time is required. If waiting puts your health at risk, you can receive a fast decision within 24 hours.

Need your prescription now?

You may be able to receive a 30-day limited supply of medications to avoid disruption in your care.

Questions?

Medical Appeal

You, your doctor, or your appointed representative can call or write us to explain the situation.

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  • Call: 1-888-260-1010
  • TTY 1-888-542-3821
  • Monday to Friday, 8:30am–8pm
  • Fax: 1-646-313-4618
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  • Healthfirst Medicare Plan
  • Appeals and Grievances
  • P.O. Box 5166
  • New York, NY 10274-5166

Next Step

We’ll get back to you within 30 days.*
*We’ll reach out if more time is required. If waiting puts your health at risk, you can get a fast decision within 72 hours. For fast (expedited) appeals, please call: 1-877-779-2959 (TTY 711), Monday to Sunday, 8am–8pm, or send a fax to 1-646-313-4618.

Part D Prescription Drug Appeal

Fill out this form

Please include a statement of support from your doctor with your request.

Call:

CVS Caremark Part D Services
1-888-260-1010
24 hours a day, 7 days a week
TTY 711

Submit to us via fax or mail:

Fax: 1-855-633-7673

CVS Caremark Part D Services
Attention: Appeals Dept.
MC 109
P.O. Box 52000
Phoenix, AZ 85072-2000

Next Step

We’ll get back to you within 7 days.*
*We’ll reach out if more time is required. If waiting puts your health at risk, you can get a fast decision within 72 hours.

Questions?

Appoint a Representative

Fill out a form to appoint a representative to speak and submit complaints and appeals on your behalf.
Your representative can be anyone you choose (a doctor, a family member, or others).

Appoint a Representative Form

This form is also available on the CMS website

Submit a Complaint

Medical Complaints

Call or write us to explain the situation.

Contact us within 60 days of the incident.

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  • Call: 1-888-260-1010
  • TTY 1-888-542-3821
  • Monday to Friday, 8:30am–8pm
  • Fax: 1-646-313-4618
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  • Healthfirst Medicare Plan
  • Appeals and Grievances
  • P.O. Box 5166
  • New York, NY 10274-5166

Next Step

Most complaints can be handled by phone. Written complaints will be responded to within 30 days of receipt.*
*If the complaint is due to a denial for a fast (expedited) coverage determination or appeal, the complaint will be responded to within 24 hours.

Part D Prescription Drug Complaints

Call or write us to explain the situation.

Contact us within 60 days of the incident.

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  • Call: 1-888-260-1010
  • TTY 711
  • Monday to Friday, 8:30am–5:30pm
  • Fax: 1-866-217-3353
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  • CVS Caremark Part D
  • Grievance Department
  • P.O. Box 30016
  • Pittsburgh, PA 15222-0330

Next Step

Complaints will be acknowledged immediately in writing once the Appeals and Grievances Department has completed their investigation.

If you’re concerned about the quality of care you’ve received, you may also file a complaint with Island Peer Review Organization (IPRO), the State’s Quality Improvement Organizations, or QIO, which is a group of doctors and health professionals who monitor the quality of care given to Medicare beneficiaries.

The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.

Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”). Plans contain exclusions and limitations.

Healthfirst Health Plan, Inc. offers HMO plans that contract with the Federal Government. Enrollment in Healthfirst Medicare Plan depends on contract renewal. Healthfirst Medicare Plan, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-305-0408 (TTY 1-888-867-4132).

注意:如果您使用繁體中文,您可以免費獲得語言援助服 務。請致電 1-866-305-0408 (TTY 1-888-542-3821).

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