We're proud to offer two new plans that include Prescription Drug (Part D) benefits only — Essential (PDP) and  Prime (PDP). The Summary of Benefits, Evidence of Coverage, and other information below explain the details about each plan:

• Benefits and formulary
  • Summary of Benefits
  • Evidence of Coverage
  • Formularies
• How and where to fill your prescriptions
  • Pharmacy Directory
  • Forms
  • Requirements
  • Extra help for prescription drug costs
• Your privacy, rights, and procedures for grievances, appeals, and exceptions

Benefits and formulary

Summary of Benefits — This booklet explains general information about our Essential and Prime options and compares them to original Medicare. It also includes information about premiums, cost sharing, out-of-network coverage, any limitations, and more:

Evidence of Coverage — These documents provide the most detailed information about each plan:

Essential EOC	Prime EOC
English  (S0223_MP0006 File & Use 09252011)	English   (S0223_MP0005 File & Use 09252011)
Español (S0223_SP0006 File & Use 09252011)	Español  (S0223_SP0005 File & Use 09252011)

Formulary (drug list)  — These documents lists the drugs covered by each plan:

How and where to fill your prescriptions 

Health First Health Plans has contracts with pharmacies that equal or exceed the Centers for Medicare and Medicaid Services (CMS) requirements for pharmacy access in your area. We have more than 6,000 network pharmacy locations throughout Florida, and more than 65,000 nation-wide.This printable directory includes information about pharmacy locations throughout Florida: 

Forms

Mail order prescriptions from Health First Family Pharmacy

Mail order prescriptions from MedVantx

Prescription reimbursement form (H1099 EL624_18706A19206)

Requirements

 Prior authorization criteria (S0223_MP020 CMS Approved 10212011)

Transition policy (S0223_EL0104 File and Use 11092011)

Transition policy—Español (S0223_SP0104 File and Use 11092011)

Medication therapy management, and drug and/or utilization management (S0223_MP00017 CMS Approved 11082011)

Step therapy criteria (S0223_MP0025 CMS Approved 12122011)

Extra help for prescription drug costs

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to one hundred (100) percent of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Extra Help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7days a week;
• The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778; or
• Your local Social Security office.
• Your State Medicaid Office.

Assistance with Best Available Evidence for Low Income Subsidy 

Monthly plan premiums for people who get extra help from
Medicare to help pay for their prescription drug costs 
(S0223_MP0100 CMS Approved 11022011)

Your privacy, rights, and procedures
for grievances, appeals, and exceptions

Process for Part D prescription drug prior authorizations, exceptions, appeals and grievances — English

Process for Part D prescription drug prior authorizations, exceptions, appeals and grievances — Spanish (coming soon)

 Notice of privacy practices

Please refer to the Evidence of Coverage (EOC) for more details about these topics, as well as your rights and responsibilities upon disenrollment:

For more information about our quality assurance policies and procedures or to obtain an aggregate number of the our grievances, appeals, and exceptions, contact customer service.

S0223_MP0018 CMS Approved 10202011
Last updated: 4/10/2012