 |
 |
 |
 |
 |
 |
 |
AmeriHealth® AdvantageExceptions and appealsMany 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 Coverage DeterminationThe coverage determination is a decision by the plan 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 this form to request a formulary exception. You, your doctor, or someone you’ve authorized may make a written or oral request.  Coverage Determination Form for Enrollees Coverage Determination Form for Providers Coverage Determination InstructionsPrior AuthorizationThe plan requires prior authorization (approval in advance) for certain covered drugs that have been approved by the FDA for specific medical conditions. Contact us for more information. AppealsIf you or your doctor do not agree with the outcome of the initial coverage determination, the decision may be appealed by having your doctor request a redetermination. For more information see section 5 of the Evidence of Coverage. GrievancesYou 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 if you have any type of problem with us or one of our network pharmacies. See section 4 of the Evidence of Coverage or contact us for more information. Appointment of a RepresentativeYou can ask us for a coverage determination or appeal, 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 person(s) may already be authorized under state law to act for you. If you want someone to act for you, then you and that individual 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: Medicare Appeals Unit To learn how to name your appointed representative, call Customer Service at the number printed on the back of your ID card, 8 a.m. to 8 p.m., seven days a week.
Evidence of CoverageThe Evidence of Coverage (EOC) is a comprehensive resource guide to your health care coverage and is considered a legal document. See the EOC for information on the grievance, coverage determination, and appeals processes.
Contact InformationYou have the right to get a summary of information about the appeals and grievances that members have filed against our plan in the past. To get this information, call Customer Service. 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. |