Prescription Drug Coverage Determination Criteria and Forms
If you would like a friend, relative, your doctor or other provider, or
other person to be your representative to ask for a coverage decision
or make an appeal, please call Member Services.
Florida Health Care Plans members call 1-877-615-4022, TTY number 1-800-955-8770. We are open from 8 a.m.
- 8 p.m. EST, seven days a week. Ask for the “Appointment of Representative”
form. (The form is also available on Medicare’s website via the
link below). The form gives that person permission to act on your behalf.
It must be signed by you and by the person who you would like to act on
your behalf. You must send us a copy of the signed form. Instructions
on where to send the form are included in the form
Page Last Updated: 9/29/16