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

Download 2012 Coverage Determination Instructions

AmeriHealth 65 NJ HMO Coverage Determination Instructions Y0041_H3156_AH12_01a File & Use 09/13/2011

AmeriHealth Rx PDP Coverage Determination Instructions Y0041_S2321_AHRx12_01 File & Use 09/13/2011

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:

Download 2012 Appeals Information

AmeriHealth 65 NJ HMO Appeals AHNJ65 HMO Y0041_H3156_AH12_01a File & Use 09/13/2011

AmeriHealth Rx PDP Appeals Y0041_S2321_AHRx12_01 File & Use 09/13/2011

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:

Download 2012 Grievances Information

AmeriHealth 65 NJ HMO Grievances Y0041_H3156_AH12_01a File & Use 09/13/2011

AmeriHealth Rx PDP Grievances Y0041_S2321_AHRx12_01 File & Use 09/13/2011

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.

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