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Gulf Coast Medical Management
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:
*I would like to schedule an appointment to meet with the Pharmacy Case Manager:
*Contact me by:
*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
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