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Have any questions?

Healthfirst
100 Church Street
New York, NY 10007

Want to become a Healthfirst member? Have a question about our benefits?

Contact us at:

Medicaid, Child Health Plus, and Family Health Plus
1-866-463-6743

Medicare
1-877-237-1303
TDD/TTY English
1-888-542-3821
TDD/TTY Español
1-888-867-4132
Monday-Friday, 8:30 am to 6 pm

Already a Healthfirst member? For answers to your questions, contact us at:

Medicaid, Child Health Plus, and Family Health Plus
1-866-463-6743
Monday - Friday, 8 am to 6 pm

Medicare
1-888-260-1010
TDD/TTY English
1-888-542-3821
TDD/TTY Español
1-888-867-4132
Monday - Sunday, 8 am to 8 pm

Leaf Plans
1-888-250-2220
TDD/TTY English
1-888-542-3821
TDD/TTY Español
1-888-867-4132
Monday - Friday, 8 am to 8 pm

Healthfirst Small Group and Healthy NY Small Group
1-888-260-1010
TDD/TTY English
1-888-542-3821
TDD/TTY Español
1-888-867-4132
Monday - Friday, 8 am to 8 pm


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2014 Healthfirst Medicare Plan Materials

We want to make being a Healthfirst member as easy as possible. Below, you will find all the forms and documents you need to make sure you get good health coverage.

Need help? Just call us or visit a Healthfirst community office near you. We can help you fill out any of these forms.

To open the forms, you will need Adobe Acrobat software installed on your computer. Download the software by clicking here. * Please note that clicking on this link will take you away from the Healthfirst website.


Plan Documents

 

Summary of Benefits Evidence of Coverage Member Handbook  

65 Plus Plan
(HMO)

English  Español  中文

English  Español  中文

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AssuredCare
(HMO SNP)

English  Español  中文

English  Español  中文

N/A PDF icon image

CompleteCare
(HMO SNP)

English  Español  中文

English  Español  中文

English  Español  中文

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Coordinated Benefits Plan (HMO)

English  Español  中文

English  Español  中文

N/A PDF icon image

Increased Benefits Plan (HMO)

English  Español  中文

English  Español  中文

N/A PDF icon image

Life Improvement Plan (HMO SNP)

English  Español  中文

English  Español  中文

N/A PDF icon image

Maximum Plan
(HMO SNP)

English  Español  中文

English  Español  中文

English  Español  中文

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General Forms and Documents

  Download the PDF

Enrollment Form

  • Complete an Enrollment Request Form to enroll in Healthfirst Medicare Plan.

English  Español  中文

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Short Enrollment Form

  • Fill out a Short Enrollment Request Form to change plans within Healthfirst Medicare Plan.

English  Español  中文

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Multi-language Interpreter Services Multi-language Insert PDF icon image

Prescription Drugs Covered By Healthfirst Medicare Plan (Formulary)

  • Healthfirst may add or remove drugs from our formulary during the year.  Any additions, deletions and utilization management changes can be obtained on our Medicare Part D Pharmacy Benefits Page.
English/Español/中文 PDF icon image

Prescription Claim Form

  • Fill out a claim form if you need money back for buying a prescription medicine that is usually covered by your Healthfirst Medicare Plan.

English

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Appointment of Representative Form

English  Español 中文

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Star Ratings English  Español 中文 PDF icon image

Health Care Proxy Form & Information

How to make a living will and/or choose who will make health care
decisions for you*   

English

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Part D Coverage Determination Form

Fill out this form if you need:

  • Prior Authorization: Prescription medicines that need to be approved by Healthfirst
  • Non-Formulary Medications: Prescription medicines that are not listed on the Healthfirst formulary
  • Utilization Management: Medications with special rules about you can use them

English

 

CMS Website - English

* Please note that clicking on this link will take you away from the Healthfirst website.

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Member Reimbursement Form

  • Fill out this form to receive reimbursement for services received while a member of Healthfirst Medicare Plan.

English  Español  中文

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Part D Redetermination Request Form English  Español PDF icon image
OTC Reimbursement Form English  Español  中文 PDF icon image
CVS Mail Service Order Form English PDF icon image

Federal Privacy Notice       

English  Español  中文 PDF icon image

New York State Privacy Notice  

English PDF icon image

* = By clicking this link, you will be sent to another website.


Healthfirst Medicare Plan is an HMO plan with a Medicare contract and a contract with the New York Medicaid program. Enrollment in Healthfirst Medicare Plan depends on contract renewal.

H3359_MKT14_18 CMS Approved 10252013

Last update 2014-07-11 14:24