Bravo Health enrollment forms and instructions.
Members of Medicare Advantage plans with prescription drug coverage
Members of Medicare Advantage plans without prescription drug coverage
Members of Private Fee-For Service plans
Members of Special Needs plans
Instructions on how to request a Medicare prescription drug coverage determination
Coverage determination request form
Redetermination request form
Physician Coverage Determination Request Form
The Centers for Medicare and Medicaid Services audit appeals and grievance data is a comprehensive report on Member Medicare appeals and quality of care grievances data for Bravo Health, Inc. The focus of this report is to provide information to our Members, as well as to assist in answering any questions in a proactive manner that the Member may have regarding it.
Centers for Medicare and Medicaid Services audit appeals and grievance data.
To request an oral determination (exceptions)/redetermination (expedited appeal) call:
Coverage Decisions for Part D Prescription Drugs CALL 1-877-504-7252 Calls to this number are free. TTY 1-800-964-2561 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free.
Appeals for Part D Prescription Drugs CALL 1-877-504-7252 Calls to this number are free. After hours, call 1-866-376-0741 TTY 1-800-964-2561 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free.
Complaints about Part D Prescription Drugs CALL 1-877-504-7252 Calls to this number are free. After hours, call 1-866-376-0741. TTY 1-800-964-2561 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free.
To access more information on the grievance and appeals process and procedures specific to your Bravo Health plan, click here.
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for seventy five (75) percent of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.
To see if you qualify for getting Extra Help, call:
1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7days a week;
The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
Your State Medicaid Office
The Federal Government has established periods when a person can join and change their Medicare prescription drug coverage. Unless you qualify for a special election period, you can change Medicare prescription drug plans once a year between November 15th and December 31st.
Medicare beneficiaries may be enrolled in only one Part D plan at a time. If you are enrolled in a Medicare Advantage (MA) coordinated care (HMO or PPO) plan or a Medicare Advantage Private-Fee-for-Service plan (PFFS) that includes Medicare Prescription Drugs, you may not enroll in a stand a lone Prescription Drug Plan unless you disenroll from the HMO, PPO, or MA PFFS plan. If you are enrolled in a Private Fee-for-Service plan that does not provide Medicare Prescription Drug coverage, or an MA Medical Savings Account (MSA) plan you may enroll in a PDP.
Eligible beneficiaries must use network or contracted pharmacies to access your prescription drug benefit, except under non-routine circumstances when you cannot reasonably use network pharmacies. Bravo Health’s mail-order service requires you to order at least a 31-day supply of the drug and no more than a 90-day supply. To get order forms and information about filling your prescriptions by mail, contact Member Services. If you use a mail order pharmacy not in the plan’s network, your prescription will not be covered.
You must use plan providers except in emergent or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor Bravo Health will be responsible for the costs. For full information on Bravo Health benefits, call our Member Services Department at 1-866-442-7498.
Click here to see what your monthly plan premium would be based on your plan.
Best Available Evidence (BAE)
Instructions on how to appoint a personal representative
Appointment of a representative form
Information about ending your membership
Direct Claim Form
Home Safety Improvement Request Form
Pennsylvania Home Safety Benefit Services Agreement
Texas Home Safety Benefit Services Agreement
Information on filling prescriptions at an out-of-network pharmacy
Information about drugs that require Prior Authorization (PA) or Step Therapy (ST) before being approved for coverage.
Prior Authorization (PA)
Step Therapy (ST)
Information on how to receive a temporary supply of prescription drugs due to a change in coverage:
When Bravo Health must end your membership in the plan
Information on the systems in place to ensure quality health care for Bravo Health members
Bravo Health's 2007 quality results and plans for 2008
2009 Regulatory Bulletin
Medication Therapy Management Program
Medicare beneficiaries may be enrolled in only one Part D plan at a time. If you are enrolled in a Medicare Advantage (MA) coordinated care (HMO or PPO) plan or a Medicare Advantage Private Fee-for-Service plan (PFFS) that includes Medicare Prescription Drugs, you may not enroll in a stand alone Prescription Drug Plan unless you disenroll from the HMO, PPO, or MA PFFS plan. If you are enrolled in a Private Fee-for-Service plan that does not provide Medicare Prescription Drug Coverage, or an MA Medical Savings Account (MSA) plan you may enroll in a PDP.
Member rights and responsibilities
Member disenrollment rights and responsibilities
Information on how to receive a temporary supply of prescription drugs due to a change in coverage
To access more information on the grievance and appeals process and procedures click here.
Bravo Health HIPAA Notice of Privacy Practices
Bravo Health HIPAA Privacy Permission Form
Please use the appropriate link below to download the form. Print the form, complete it, and follow the mailing instructions provided on the second page.
Pharmacy mail order form