Prior Authorization for AmeriHealth 65 NJ HMO

Certain covered drugs that have been approved by the FDA for specific medical conditions require prior authorization. The approval criteria were developed and endorsed by the Pharmacy and Therapeutics Committee. The criteria are based on information from the FDA, manufacturers, medical literature, actively practicing consultant physicians, and appropriate external organizations.

A request form must be completed for all medications requiring prior authorization. The forms below are available in PDF format. Current prior authorization medications are:

Request Form Instructions

Providers:

Download a Coverage Determination Form:

PDF icon Coverage Determination Form for Enrollees

PDF icon Coverage Determination Form for Providers

PDF icon AmeriHealth 65 NJ HMO Coverage Redetermination Form

PDF icon Coverage Determination Instructions Y0041_S2321_AHRx12_01 File & Use 09/13/2011

When filling out a prior authorization form, all requested information must be supplied. Incomplete requests will be faxed back to your office for completion, which will delay the review process.
Fax completed forms to the FutureScripts^® Secure for review. Make sure you include your office telephone and fax number.
You will be notified by fax if the request is approved. You and your patient will receive a denial letter if the request is denied.
If you have not received a response after two business days from submitting complete information, contact the Provider Services Department.

Members:

PDF icon HMO Prior Authorization Criteria

Take the appropriate request form to your physician to be completed.
You or your physician may fax the completed form to the FutureScripts^® Secure for review. FutureScripts^®Secure fax numbers:

215-241-3073 inside local Philadelphia area
888-671-5285 toll-free outside the local calling area

If you have not received a response after two business days from your provider submitting complete information, contact the provider who requested the prior approval on your behalf.
If you have questions, please contact Customer Services at the number listed on the back of your identification card.

Tiered cost-sharing exceptions

Physicians, on behalf of members, may request coverage of a non-preferred medication, at the preferred formulary copay. The physician should complete the Non-preferred Exception Request Form providing detail to support use of the non-preferred medication and fax the request to 215-241-3073 or 1-888-671-5285. The Non-preferred Exception Request Form can also be obtained by calling 1-888-678-7015 (Option #3).

If the non-preferred request is approved, the drug will be processed at the appropriate formulary benefit copay. If the request is denied, the member and physician will receive a denial letter that explains the appeal process. The member may still receive benefits for the drug at the non-preferred copay or coinsurance.

You must continue to pay your Medicare Part B premium.

The Medicare Contract is renewed annually, and the availability of coverage beyond the end of the current year is not guaranteed.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1, 2013. Members may enroll in the plan during specific times of the year. Contact the plan for more information. Please reference the Evidence of Coverage for information on premiums, cost-sharing, out-of-network coverage, rights and responsibilities upon disenrollment and any applicable conditions associated with using the plan benefits, as well as limitations, copayments, and restrictions.

Members must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days 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.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your 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.

You must use plan providers except in emergency or urgent care situations or for out-of-are renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor AmeriHealth 65 NJ HMO will be responsible for the costs.

Please contact AmeriHealth 65 HMO for more information.

In lots of cases, your prescriptions are covered under AmeriHealth 65 NJ HMO, AmeriHealth Rx PDP if they are filled at a network pharmacy or through our mail-order pharmacy service. There are thousands of network pharmacies, including:

national chain and independent retail pharmacies
long-term care and home-infusion pharmacies
Indian Health Service/Tribal/Urban Indian Health (I/T/U) Program pharmacies

Website last updated: 12/30/11
Y0041_HNS_12_301a Pending CMS Approval