Use this form to request a medical reimbursement for something you have paid out-of-pocket but you believed should have been covered by El Paso Health Medicare Advantage.
An appointed representative is a relative, friend, advocate, doctor, or other person authorized to act on your behalf in obtaining a grievance, coverage determination, or appeal. If you would to appoint a representative, you and your appointed representative must complete this form and mail it to El Paso Health Medicare Advantage at:
El Paso Health Medicare Advantage P.O. Box 971100 El Paso, TX 79997-1100
Use this form to request coverage for a drug that is not on the formulary (a formulary exception), an exception to a quality limit, a lower copayment for a drug on the formulary or reimbursement for a covered drug that you purchased out-of-pocket.
Use this form to request a pharmacy reimbursement for something you have paid out-of-pocket but you believed should have been covered by El Paso Health Medicare Advantage.
