BackWe’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.
Coverage Decisions, Appeals, and Complaints for Medicare Plan Members
If Your Benefit Isn’t Covered
Coverage Determinations
A determination is a decision Healthfirst makes about your benefits, coverage, or the amount we will pay for medical service or prescription drugs. A prescription drug determination may be requested when a drug you take is not on the formulary, or you wish to use a drug in a way that is not covered. 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.
- Call: 1-888-394-4327
- TTY 711
- Monday to Friday, 8:30am–5:30pm
- Fax: 1-646-313-4603
- Healthfirst Medicare Plan
- Provider Services Intake 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.
Part D Prescription Drug Determination
Fill out this form
Please include a statement of support from your doctor with your request.
Submit to us via fax or mail:
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?
- Signature (HMO) Plan Call: 1-855-771-1081
- Signature (PPO) Plan Call: 1-833-350-2910
- All other Medicare Plans Call: 1-888-260-1010
- TTY 1-888-542-3821
- Fax: 1-646-313-4618
- Hours: 8am-8pm 7 days a week (October-March) and 8am-8pm Monday-Friday (April-September)
Appeals
If you’re dissatisfied with our decision, you, your appointed representative, or your doctor may submit an appeal for us to reconsider the decision. The appeal must be submitted within 60 days of the date on the determination notice.
Medical Appeal
You, your doctor, or your appointed representative can call or write us to explain the situation.
- Signature (HMO) Plan Call: 1-855-771-1081
- Signature (PPO) Plan Call: 1-833-350-2910
- All other Medicare Plans Call: 1-888-260-1010
- TTY 1-888-542-3821
- Fax: 1-646-313-4618
- Hours: 8am-8pm 7 days a week (October-March) and 8am-8pm Monday-Friday (April-September)
- 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
Signature Plan: 1-855-771-1081
All other Medicare Plans: 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?
- Signature (HMO) Plan Call: 1-855-771-1081
- Signature (PPO) Plan Call: 1-833-350-2910
- All other Medicare Plans Call: 1-888-260-1010
- TTY 1-888-542-3821
- Fax: 1-646-313-4618
- Hours: 8am-8pm 7 days a week (October-March) and 8am-8pm Monday-Friday (April-September)
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).
Submit a Complaint or Grievance
Complaints, also known as grievances, can be about any problem you have with your Healthfirst Medicare Plan or one of our providers. It does not pertain to the payment of or approval of benefits or prescription drugs, which are called determinations (see section on medical and prescription determinations).
Medical Complaints
Call or write us to explain the situation.
Contact us within 60 days of the incident.
- Signature (HMO) Plan Call: 1-855-771-1081
- Signature (PPO) Plan Call: 1-833-350-2910
- All other Medicare Plans Call: 1-888-260-1010
- TTY 1-888-542-3821
- Fax: 1-646-313-4618
- Hours: 8am-8pm 7 days a week (October-March) and 8am-8pm Monday-Friday (April-September)
- 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.
- Signature (HMO) Plan Call: 1-855-771-1081
- Signature (PPO) Plan Call: 1-833-350-2910
- All other Medicare Plans Call: 1-888-260-1010
- TTY 1-888-542-3821
- Fax: 1-646-313-4618
- Hours: 8am-8pm 7 days a week (October-March) and 8am-8pm Monday-Friday (April-September)
- 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.
If you would like information on the aggregate number of Medicare Advantage grievances and appeals filed with Healthfirst, please contact Healthfirst Member Services at 888-260-1010, (TTY – 888-542-3821 ) 8 am to 8 pm, seven days a week (October through March) and Monday to Friday, 8am–8pm (April through September).
You have the option to submit complaints/grievances directly through Medicare.gov
You can also access additional support through them, including help from an Ombudsman.
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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