Request for Redetermination of Medicare Prescription Drug Denial

Please submit this form to make a request for redetermination of Medicare prescription drug denial.

Because we, AmeriHealth, denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.

Expedited appeal requests can be made by phone at 1-866-569-5190 (TTY/TDD: 711).

Your prescriber may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. Please call us to learn how to name a representative.

Member’s Information (* required fields)

* First Name:

* Last Name:

* Date of birth:

* Address:

Address 2:

* City:

* State:

* ZIP:

* Phone Number:

* Member ID (numeric portion only):

Complete the following section ONLY if the person making this request is not the enrollee or prescriber:

Requestor’s Information

First name:

Last name:

Requestor’s relationship to member:

Address:

Address 2:

City:

State:

ZIP:

Phone number:

Drug Information (* required fields)

* Name of prescription drug you are requesting (if known, include strength and quantity requested per month):

* Have you purchased the drug pending appeal?

Yes

If you answered “Yes” to the above:

Date purchased:

Amount paid:

Pharmacy name:

Pharmacy phone number:

Prescriber’s information (* required fields)

* First name:

* Last name:

Address:

Address 2:

City:

State:

ZIP:

* Phone number:

Fax number:

REQUEST FOR EXPEDITED REVIEW: If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your prescriber’s support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

I need a decision within 72 hours.

Reason for appealing

Provide any additional information you believe may help your case, such as a statement from your prescriber and relevant medical records. You may want to refer to the explanation we provided in the Notice of Denial of Medicare Prescription Drug Coverage.

Explanation:

To ensure your privacy, all information will be sent via a secure connection. AmeriHealth will not disclose any personal information to outside persons or entities unless we have written consent or unless authorized by law.

Please see our Notice of Privacy Practices for more information.

Coverage issued by AmeriHealth Insurance Company of New Jersey.

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Website last updated: 8/8/2023