In order to be eligible for Medicare Part D, you must be eligible for Medicare Part A and/or Medicare Part B. If you currently get your health care covered by Medicare, including those who have some Medicare costs paid through Medicaid, this prescription drug coverage will be a new benefit. If you currently have both Medicare and Medicaid, as of January 1, 2006, you will begin receiving your prescription drugs through Medicare only.

If you would like further detailed information regarding Medicare Part D coverage and benefits, please visit the Medicare website at:

For information about cost-sharing for low-income beneficiaries, please visit the CMS website.

To inquire about low income subsidy status or level, please call Social Security at (800) 122-1213

Medicare Part-D

Vaccine and Administration (Injection) Claim Form

This claim form is for reimbursement of covered Part D vaccines and their administration (injection).

Please consult your Formulary or Evidence of Coverage for specific coverage information.

Medicare Part-D

Coverage Determination-Redetermination Req.

Part D Grievance and Appeals process.


You may call our Member Services department for any complaint or issue you may have related to services and coverage that does not involve a denial. We will always be ready to provide you with the information you need, listen to your concerns, and resolve those concerns or problems. You may file a Grievance. Grievances may include any complaint regarding the timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. Grievance issues may also include complaints that a covered health service or item during a course of treatment did not meet accepted standards for delivery and health care. Contact our Member Services department by calling us toll free, at 1-866-988-2210, or if you have a hearing or speech impairment at TTY 1-800-955-1270, from 8 a.m. to 8 p.m., seven days a week.


We also have procedures to help all members resolve their concerns related to service or medication denials and claims payment disputes. Those concerns are addressed through the Appeals process. You may file an appeal related to a denial of services, medications, claims payment, or a dispute of any amounts you must pay for services or medications you have received.

Filing an Appeal

You may file an Appeal by completing the Grievance and Appeal Form. You may do so by following the steps below:

  • Complete all sections on the form.
  • Include any information that may support your appeal.
  • Include copies of our initial denial notice and/or bills you may have received.
  • Sign the form
  • Mail or fax the form and supporting documents to:

Florida Healthcare Plus, Inc.
2100 Ponce De Leon Boulevard, Suite PH1
Coral Gables, FL 33134