Plan forms

For your convenience, below are important forms and documents to help you easily manage your health coverage.

Claim reimbursement forms

Influenza claim

With your AmeriHealth Medicare Advantage health plan, you are covered for an influenza vaccine each year. If you received your vaccine at a non-participating provider and paid out of pocket, you can use the following forms to apply for reimbursement.

AmeriHealth Influenza Vaccine Reimbursement Form

Out-of-network claim

To request a reimbursement for an out-of-network claim as an AmeriHealth MA member, please complete the non-network claim form and submit to the AmeriHealth Claims Department at the address listed on the form.

Cataract glasses claim

Reimbursement claims for post-surgery cataract glasses and lenses for AmeriHealth Medicare Advantage members must be submitted by the provider. If you have any questions, please contact Provider Services at 1-800-275-2583 (TTY/TDD:711).

Disenrollment instructions

If you want to leave your current Medicare Advantage plan or switch plans, review the information below.

Important: You can only make changes during certain times of the year unless you qualify for a special enrollment period.

Do I need a disenrollment form?

Fill out a disenrollment form if:

• You want to return to Original Medicare only and do not want Medicare drug coverage (Part D).

Do NOT fill out a disenrollment form if:

• You are joining another Medicare Advantage plan. Your new plan enrollment will automatically remove you from your current plan.
• You are enrolling in a Medicare prescription drug plan (Part D). Enrolling in a Part D plan will automatically remove you from your Medicare Advantage plan and return you to Original Medicare.

  When can I make changes to my Medicare coverage?

  Annual Enrollment Period (AEP) - October 15 through December 7

  During this time, you can:

  • Join a Medicare Advantage plan
  • Switch to a different Medicare Advantage plan
  • Add or remove prescription drug coverage
  • Return to Original Medicare

  Your new coverage starts January 1.

  Open Enrollment Period (OEP) - January 1 through March 31

  If you are already enrolled in a Medicare Advantage plan (except a Medicare Medical Savings Account plan), you can:

  • Switch to another Medicare Advantage plan, or
  • Leave your Medicare Advantage plan and return to Original Medicare

  Your change becomes effective on the first day of the month after your request is received.

  For example:

  Request received	Coverage change effective
  January February March	February 1 March 1 April 1

  Note: During OEP, people with Original Medicare cannot join a Medicare Advantage plan. Most people with Original Medicare also cannot change their standalone Part D plan during this period.

  Special Exceptions:

  You may be able to make changes at other times of the year if you qualify for a Special Enrollment Period.

  Examples include:

  • Moving outside your plan's service area
  • Joining a 5-star Medicare plan
  • Qualifying for Extra Help with prescription drug costs

  If you qualify for Extra Help, you may be able to join or leave a plan at any time. If you lose Extra Help, you may still have up to two months to make a plan change.

  Extra help in paying for your insurance plan

  People with limited income may qualify for Extra Help, a Medicare program that can lower prescription drug costs.

  Extra Help may reduce or eliminate:

  • Monthly plan premiums
  • Deductibles
  • Copays and coinsurance
  • Late enrollment penalties

  Many people who qualify don't realize they are eligible.

  Learn more

  • Call Social Security at 1-800-772-1213
  • TTY: 1-800-325-0778
  • Apply online through the Social Security Administration

  You can also learn more about other Medicare savings programs.

  People with limited incomes may qualify for extra help to pay for their prescription drug costs. If you qualify, Medicare could pay for your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify won't have a coverage gap or a late enrollment penalty. Many people qualify for these savings and don't even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at https://www.ssa.gov/medicare/part-d-extra-help.

  Before you leave the plan

  Keep using your current plan's doctors and network providers until your disenrollment is effective.

  To avoid unexpected costs, contact us to confirm your disenrollment date before receiving care outside the plan's network.

  Until your disenrollment date, you must keep using the plan's doctors. To avoid any unexpected expenses, you may want to contact us to make sure you've been disenrolled before you seek medical services outside of the plan's network.

  How do I submit the disenrollment request?

  If you want to return to Original Medicare and are eligible to make a change, complete the appropriate disenrollment form and send it to:

  AmeriHealth Medicare Department
  1901 Market Street
  Philadelphia, PA 19103

  You can also fax your signed and dated form to: 1-215-761-0300.

  Need help?

  For help understanding your Medicare options, call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week.

  2027 Medicare Advantage disenrollment forms

  • 2027 AmeriHealth Medicare Core PPO
  • Large print: 2027 AmeriHealth Medicare Core PPO

  2026 Medicare Advantage disenrollment forms

  • 2026 AmeriHealth Medicare Core PPO
  • Large print: 2026 AmeriHealth Medicare Core PPO
  • 2026 AmeriHealth Medicare Enhanced PPO
  • Large print: 2026 AmeriHealth Medicare Enhanced PPO
  • 2026 AmeriHealth Medicare Ultimate PPO
  • Large print: 2026 AmeriHealth Medicare Ultimate PPO

  What are my Medigap (Medicare supplement) rights?

  If you are returning to Original Medicare, you may have a special right to buy a Medigap (Medicare Supplement) plan, even if you have certain health conditions.

  You may qualify if you:

  • Are age 65 or older and enrolled in Medicare Part B within the last 6 months
  • Are moving out of your current plan's service area
  • Meet other qualifying situations under Medicare rules

  These special protections are required by federal law. Your state may offer additional Medigap protections.

  Need help understanding your Medigap rights?

  For questions about Medigap plans or your rights in your state, contact your State Health Insurance Assistance Program (SHIP) at 1-877-839-2675.

  You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week for more information about trial periods. TTY users should call 1-877-486-2048.

  If you need any help, please contact the Member Help Team.

  Medicare Supplement (Medigap) disenrollments

  Please complete the following form to cancel AmeriHealth Medigap plan coverage. Once you have completed and signed the form, please mail or fax to:

  AmeriHealth Medicare Department
  P.O. Box 7576
  Philadelphia, PA 19101-7576
  Fax: 215-238-2289

  AmeriHealth Medicare Electronic Funds Transfer (EFT) form

  • EFT form
  • Large print: EFT form

  Cancellation Request Forms

  AmeriHealth Medigap Cancellation Request Forms (without Estate)

  AmeriHealth Medigap Cancellation Request Forms (with Estate)

   

   

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  Website last updated 8/4/2026