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View and download important forms and documents about your Florida Blue Medicare plan - including Medicare Advantage, Prescription Drug and Medicare Supplement plans.

Late Enrollment Penalty (LEP) Appeals

Medicare beneficiaries may incur a late enrollment penalty (LEP) if there is a continuous period of 63 days or more at any time after the end of the individual's Part D initial enrollment period during which the individual was eligible to enroll but was not enrolled in a Medicare Part D plan and was not covered under any creditable prescription drug coverage.

Information about LEP

Information about LEP appeals

LEP Appeal Form

Medicare Advantage (Part C): Appeals & Grievances

You have the right to file a grievance or submit an appeal and ask us to review your coverage determination.

How to file an Appeal or Grievance

Appeals & Grievances Form

Rights and Responsibilities upon Disenrollment: You have the right to ask us to reconsider this decision. You can ask us to reconsider by filing a grievance with us. You can look in your “Evidence of Coverage” for information about how to file a grievance, contact us at 1-800-926-6565 (TTY users: 1-800-955-8770) or click here for more information. Upon request, Medicare Advantage plans are required to disclose grievance and appeals data to Medicare Advantage enrollees in accordance with the regulatory requirements. You can contact us at 1-800-926-6565 (TTY users: 1-800-955-8770) to request this information.

Prescription Drug (Part D): Appeals & Grievances

You have the right to file a grievance or submit an appeal and ask us to review your coverage determination.

How to file an Appeal or Grievance

Coverage Determination Form

Coverage Redetermination Form

Rights and Responsibilities upon Disenrollment: You have the right to ask us to reconsider this decision. You can ask us to reconsider by filing a grievance with us. You can look in your “Evidence of Coverage” for information about how to file a grievance, contact us at 1-800-926-6565 (TTY users: 1-800-955-8770) or click here for more information. Upon request, Prescription Drug plans are required to disclose grievance and appeals data to Prescription Drug enrollees in accordance with the regulatory requirements. You can contact us at 1-800-926-6565 (TTY users: 1-800-955-8770) to request this information.

Appoint a Representative

You can appoint someone to act on your behalf. Go to Medicare.gov to download a form to Appointment of Representative. Go to Medicare.gov

Send a complaint to Medicare

You can file a complaint about your Medicare health or drug plan. Go to Medicare.gov to file a Medicare Complaint Form. Go to Medicare.gov

Find forms and documents to help you manage your plan.

Your Member Rights

Prior Authorization Request

Automatic Payment

Claims

Medication Therapy Management Program (MTM)

Find forms and documents to help you manage your plan.

Prime Therapeutics

Automatic Payment

Claims

Medication Therapy Management Program (MTM)

If your prescription drug coverage is not from Florida Blue Medicare (through our pharmacy benefits manager, Prime Therapeutics), please contact your pharmacy benefits administrator for the forms you need.

Find forms and documents to help you manage your plan.

Automated Payment Form - Medicare Supplement (PDF)

Take advantage of convenience security and savings with our Automatic Payment Option.

Medicare Supplement Plan Contract
Log in to your member account to see your plan specific contract.

To view FHCP Medicare forms & documents click here.

FBM FORM 001 F 082021
Last Updated: 12.30.2022
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