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Grievance, Exceptions, Coverage Determinations, and Appeals
Coverage Determination
Coverage determination is the process by which the plan makes a decision about whether a drug prescribed for you is covered and the amount, if any, you are required to pay. If you need a drug that is not on the plan’s formulary or you have been using a drug that has been removed during the plan year, use the Coverage Determination Form to request a formulary exception. You, your doctor, or someone you’ve authorized may make a written request.
Coverage Determination Form for Enrollees
Coverage Determination Form for Providers
Coverage Determination Instructions
AmeriHealth 65 NJ HMO Coverage Determination Instructions
AmeriHealth Rx PDP Coverage Determination Instructions
AmeriHealth Advantage PDP Coverage Determination Instructions
Prior Authorization
The plan requires prior authorization (approval in advance) of certain covered drugs that have been approved by the FDA for specific medical conditions. Learn more about prior authorizations.
Appeals
If you, or your doctor, do not agree with the outcome of the initial coverage determination, you or your doctor (on your behalf) may appeal the decision by having your doctor request a redetermination. Learn more about the appeals process:
AmeriHealth Advantage PDP Appeals
Grievances
You may file a grievance if you have a complaint other than one that involves a coverage determination (see Appeals above). You would file a grievance for any type of problem you might have with us or one of our network pharmacies. Contact us for more information. Learn more about the grievances process:
AmeriHealth 65 NJ HMO Grievances
AmeriHealth Advantage PDP Grievances
Appointment of a Representative
You can ask us for a coverage determination or appeal, or your prescribing doctor or someone you name may do it for you. The person taking action on your behalf is called an appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to be your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives that person legal permission to act as your appointed representative.
This statement must be sent to us at:
Medicare Appeals Unit
P.O. Box 13652
Philadelphia, PA 19101-3652
You can call Customer Service to learn how to name your appointed representative. Learn more about the appointed representative process:
Appointment of Representative form
Evidence of Coverage
The Evidence of Coverage (EOC) is a comprehensive resource guide to your health care coverage and is considered a legal document. Use the EOC for information on the grievance, coverage determination, and appeals processes.
Contact Information
Members and providers who have questions about the exceptions and appeals processes or would like to inquire about the status of a coverage determination or appeal request can contact Customer Service.
