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To verify your benefits, please call Meritain Customer Service directly at 800.925.2272.
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Rx Benefit Review
If you are a new SMH employee and do not yet have your insurance card with your ID, please complete the information below and submit this form. The Pharmacy Case Manager will contact you in 2-3 business days.
* indicates required information
*Reason for Request:
$1500 Benefit
*I would like to schedule an appointment to meet with the Pharmacy Case Manager:
Yes
No
*Contact me by:
Home Phone
Cell Phone
Email
*First Name:
*Last Name:
*Date of Birth:
(mm/dd/yyyy)
/
/
Home phone number
(include area code):
*
Cell phone
(include area code):
*
Email address:
*List ALL your medications below
(Example:
Lipitor 20mg once a day
)
Medication
Dose
Frequency
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
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20.
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Copyright 2021 Gulf Coast Medical Management
• All Rights Reserved • Last Updated: 09/16/2024 •
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