Determinations, Grievances & Appeals

Medical Care & Services
Prescription Drug Coverage
Request for Medicare Prescription Drug Coverage Redetermination
- Download the Request for Medicare Prescription Drug Coverage Determination Form to request an exception.
- Download the Request for Redetermination of Medicare Prescription Drug Denial Form to request a redetermination.
Appointment of Representative Form
- For instructions on how to use the form to appoint a representative, visit Appointment of Representative Form Instructions.

Last updated Monday, November 26, 2018

Capital Health Plan Silver Advantage (HMO), Advantage Plus (HMO), Preferred Advantage (HMO), and Retiree Advantage (HMO) are HMO plans with a Medicare contract. Enrollment in Capital Health Plan Silver Advantage, Advantage Plus, Preferred Advantage, and Retiree Advantage depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

If you have questions please call Member Services at (850) 518-6679 or 1 (877) 247-6512 8:00 a.m. – 8:00 p.m., seven days a week, October 1 – March 31; 8:00 a.m. – 8:00 p.m., Monday – Friday, April 1 – September 30. State of Florida members call 1-877-392-1532, 7:00 a.m. – 7:00 p.m.

H5938_WEB088_M2024

Determinations, Grievances & Appeals

Warning!