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Member Resources

Behavioral Health

Behavioral healthcare services (mental health and substance use disorders) services are a covered benefit. Services may include treatment for anxiety, depression or other behavioral health problems

Low Income Subsidy Premium Information

Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs.

Best Available Evidence
Information about Extra Help
More Information on Late Enrollment Penalty

Out-of-Network Coverage

With limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services.

Nurse Advice Line

It's free and easy! Just call 1-800-609-4166 (TTY 711), 24 hours a day, 7 days a week.

Appointment of Representative

Individuals who represent enrollees may either be appointed or authorized. An enrollee may appoint any individual (such as a relative, friend, advocate, an attorney, or any physician) to act as his or her representative and file an appeal on his or her behalf.

Notice of Privacy Practice

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Rights & Responsibilities (Disenrollment)

For more information on ending your membership, please refer to EOC Chapter 10 Section 2 of your Evidence of Coverage Document.

Disaster /Emergency Information

Learn how to prepare for and recover from disasters and emergencies. Find information you need to be ready to handle a disaster or emergency.

Durable Medical Equipment

What is Durable Medical Equipment? What equipment is covered in my health plan? Members New to Care1st Health Plan, Plan Coverage Decision.

Organization Determinations

Organization determination means that Care1st would be making a decision about whether items or services are covered or how much you have to pay for covered items or services. Also included are requests for reimbursement of medical service or prescription drug costs.

Part D Coverage Determinations

Coverage determination means that Care1st would be making a decision about whether prescription drugs are covered under your plan. Your benefits as a member of our plan include coverage for many prescription drugs.

Prior Authorizations and Exceptions (for Medication and Treatment)

To request assistance with a prior authorization, please call Care1st Member Services at 1-800-544-0088 from 8 a.m. - 8 p.m., 7 days a week. TTY users should call: 711.

Appeals Process

What is an Appeal? An appeal is a way for you to challenge our action if you think we made a mistake. It is a formal way of asking us to review and change a coverage decision we have made.

Grievance Process

As a Care1st Health Plan Member, you have a right to file a complaint (grievance) if you have a problem with your medical care or our services. However, the complaint process is used for only certain types of problems. They include quality of care, waiting times and the customer service you receive.

Prescription Drug Information - Medication Transition Process

Medication Transition Policy. What can you do if your drug is not on the Drug List or if the drug is restricted in some way?

Quality Assurance Policies

We have established measures and systems to conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care.

Utilization Management

This program incorporates utilization management tools to encourage appropriate and cost-effective use of Part D medications.

Medication Therapy Management Program

We offer a full range of Pharmacy benefits to our members who are at high risk for medication-related problems. This program is offered to qualified members at no cost and can help them better manage their medications.