The following forms may be helpful to you. Go to the appropriate link to download printable copies*.
Appointment of Representative Form (CMS-1696) - An appointed
representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage
determination or appeal. If you would like to appoint a representative, you and your appointed representative must complete this form and mail or fax
to Healthy Advantage (HMO) Medicare at:
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FAX: |
1-801-587-6433 |
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MAIL: |
Healthy Advantage (HMO) Medicare |
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127 S 500 E, Suite 360 |
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SLC, Utah 84102 |
Coverage Determination Request Form - Use
this form to request coverage for a drug that is not on the formulary (a formulary exception), an exception to a quantity limit,
a lower copayment for a drug on the formulary (a tiering exception) or reimbursement for a covered drug that you purchased at an
out-of-network pharmacy. Complete this form and mail or fax to:
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FAX: |
1-866-290-1309 |
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MAIL: |
Healthy Advantage (HMO) Medicare |
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7050 S Union Park Center, Suite 200 |
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Midvale, Utah 84047 |
Drug Authorization Request Form - Use this form to get prior authorization of certain
prescription drug benefits. Complete this form and fax or mail to:
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FAX: |
1-866-290-1309 |
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MAIL: |
Healthy Advantage (HMO) Medicare |
| |
|
7050 S Union Park Center, Suite 200 |
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|
Midvale, Utah 84047 |
Drug Determination Request Form -
Use this form to request coverage for a drug that is not on the formulary (a formulary exception), an exception to a quantity limit, a lower
copayment for a drug on the formulary (a tiering exception) or reimbursement for a covered drug that you purchased at an out-of-network
pharmacy. Complete this form and mail or fax to:
| |
FAX: |
1-866-290-1309 |
| |
MAIL: |
Healthy Advantage (HMO) Medicare |
| |
|
7050 S Union Park Center, Suite 200 |
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|
Midvale, Utah 84047 |
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Paper copies of information posted
on our web site are available upon request. |
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