AmeriHealth 65^® Basic

Exceptions & Appeals

Many of the forms or brochures on this page are saved in Portable Document Format, also known as "PDF." Those documents will be marked with a PDF icon . Click on each link to view the PDF. More information.

Appeals & Grievances

Appeals: If you or your doctor do not agree with the outcome of the initial coverage determination – you or your doctor may appeal the decision by having your doctor request a re-determination.

Appeals

Grievance: A grievance is any complaint other than one that involves a coverage determination (a decision by your health plan to provide or pay for a Part D drug). You would file a grievance if you have any type of problem with us or one of our network pharmacies. Contact us for more information.

Grievances

Coverage Determination

Use this form if you need a drug that is not on the plan's list of covered drugs (formulary exception) or have been using a drug that was previously included on the plan's list of covered drugs, but is being removed or was removed from this list during the plan year (formulary exception).

Coverage Determination Form for Enrollees

You, your doctor, or an authorized representative may make a written or oral request (attach documentation that shows authority to represent enrollee, if other than prescribing physician). Contact us for more information.

Coverage Determination Form for Providers

Coverage Determination Instructions

Prior Authorization

AmeriHealth 65 requires prior authorization of certain covered drugs that have been approved by the Food and Drug Administration (FDA) for specific medical conditions. View the Prior authorization process. Contact us for more information.

Appointment of a Representative

You can ask us for a coverage determination or appeal yourself, or your prescribing doctor or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already be authorized under state law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. This statement must be sent to us at the Medicare Appeals Unit, PO Box 41820 Philadelphia, PA 19101-1820. You can call the Member Services Department to learn how to name your appointed representative.

Appointment of Representative form

Evidence of Coverage

The Evidence of Coverage is a comprehensive resource guide to your health care coverage. See sections 9, 10 and 11 for information on the grievance, coverage determination and appeals processes.

• AmeriHealth 65 Basic Evidence of Coverage Your Member Handbook

Contact Information

For enrollees and physicians who have questions about the grievance, coverage determination, or appeals processes.

For enrollees and physicians to inquire about the status of a coverage determination or appeal request.

Important information about links to other sites