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Plan documents

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

Privacy practices

Notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can get access to this information.

HIPAA Privacy Practices and Forms contains privacy information and documentation related to the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Claim reimbursement forms

Influenza claim

With your AmeriHealth PPO 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 PPO Influenza Vaccine Reimbursement Form

Out-of-network claim

To request a reimbursement for an out-of-network claim as an AmeriHealth PPO 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).

Summary of Benefits

2025 Summary of Benefits — updated 10/1/2024

AmeriHealth Medicare PPO

2024 Summary of Benefits — updated 10/1/2023

AmeriHealth Medicare PPO

Evidence of Coverage and Outline of Coverage

The Evidence of Coverage (EOC) is a complete description of your Medicare Advantage plan coverage and your rights as a member. It explains your benefits, premiums, and cost-sharing; conditions and limitations of coverage; and plan rules.

After you've joined the plan, you will receive the Evidence of Coverage in the mail. This is a legal document that should be kept in a safe place.

2025 Evidences of Coverage — updated 10/1/2024

AmeriHealth Medicare PPO EOC

2024 Evidences of Coverage — updated 10/1/2023

AmeriHealth Medicare PPO EOC

AmeriHealth Medigap Outlines of Coverage — updated 10/1/2023

AmeriHealth Medigap Outlines of Coverage

Annual Notice of Changes

2025 Annual Notice of Changes (ANOC) — updated 10/1/2024

Change Forms

Use a Change Form to move from one plan to another plan. For example, you can use a Change Form to move from AmeriHealth Medicare Core PPO to AmeriHealth Medicare Enhanced PPO. This change can only occur during a valid Election Period.

AmeriHealth Medicare PPO

Disenrollment instructions

If you'd like to switch or leave your current health plan, below are the disenrollment forms available to you. Not all plan changes require a form, and there are only certain times of year that you can switch plans throughout the year. Please read these important instructions regarding requesting disenrollment from the plan.

Medicare Advantage disenrollments

When can I make changes to my Medicare coverage?

Annual Enrollment Period (AEP) from October 15 through December 7 each year: Anyone can make any type of change for the following year, including adding or dropping Medicare prescription drug coverage or changing to a new Medicare Advantage plan. The effective date for the newly selected plan is January 1 of the following year.
Open Enrollment Period (OEP) from January 1 through March 31 each year: Anyone enrolled in a Medicare Advantage plan (except for a Medicare Medical Savings Account/MSA) has an opportunity to enroll in a different Medicare Advantage plan or disenroll from their Medicare Advantage plan and return to Original Medicare. The effective date of the disenrollment from the MA plan is the first day of the month following the date the disenrollment request is received. Disenrollment requests received by MA organization in January are effective February 1; those received in February are effective March 1; and those received in March are effective April 1. The OEP does not provide an opportunity for those enrolled in Original Medicare to enroll in a Medicare Advantage plan, nor does it allow for Part D changes for individuals enrolled in Original Medicare, including those enrolled in stand-alone Part D plans.
Special Exceptions: You are unable to make changes at other times of the year, unless you meet certain special exceptions, such as moving out of the plan's service area, joining a plan in your area with a 5-star rating, or qualifying for extra help with your prescription drug costs. If you qualify for extra help with your prescription drug costs you may enroll in, or disenroll from, a plan at any time. If you lose this extra help during the year, your opportunity to make a change continues for two months after you are notified that you no longer qualify for extra help.

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.

When should I fill out the disenrollment request form?

You should fill out the appropriate disenrollment form during a valid election period, if you want to change to Original Medicare only and do not want Medicare prescription drug coverage.

You shouldn't fill out the appropriate disenrollment form if you are planning to enroll, or have enrolled, in another Medicare Advantage plan or other Medicare health plan. Enrolling in another Medicare plan will automatically disenroll you from our plan.

You shouldn't fill out the appropriate disenrollment form if you are enrolling in a Medicare prescription drug plan. Enrolling in a Medicare prescription drug plan will automatically disenroll you from the plan to Original Medicare.

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 Original Medicare, as described above, you may fill out the appropriate disenrollment form during a valid election period, sign it, and send it back to us at:

AmeriHealth Medicare Department
1901 Market Street
Philadelphia, PA 19103

You can also fax the form with a readable signature and date to us at 1-215-761-0300.

For information and help choosing a Medicare plan available in your area, you can call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Medicare Advantage disenrollment forms

What are my Medigap rights?

If you will be changing to Original Medicare, you might have a special temporary right to buy a Medigap policy, also known as Medicare supplemental insurance, even if you have health problems. For example, if you are age 65 or older and you enrolled in Medicare Part B within the past 6 months or if you move out of the service area, you may have this special right.

Federal law requires the protections described above. Your state may have laws that provide more Medigap protections. If you have questions about Medigap or Medigap rights in your state, you should 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

Electronic Funds Transfer (EFT)form

EFT form

Cancellation Request Forms

AmeriHealth Medigap Cancellation Request Forms (without Estate)

AmeriHealth Medigap Cancellation Request Forms (with Estate)

How to appoint a representative

You may designate someone, such as a relative, friend, lawyer, or anyone else, to file an appeal or grievance on your behalf. This is known as assigning an appointed representative. To do this you must:

Download the Appointment of Representative Form. It can also be found on CMS's website
Fill out the form. Both you and the person you are assigning to represent you must sign and date it.
Send the form back to us at the address below:

Medicare Appeals Unit
P.O. Box 13652
Philadelphia, PA 19101-3652

You can call the Member Help Team to learn how to name your appointed representative or for assistance with filling out the form.

Benefits during disasters

In the event of a presidential emergency declaration, a presidential (major) disaster declaration, a declaration of emergency or disaster by a governor, or an announcement of a public health emergency by the Secretary of Health and Human Services, but absent, or prior to the issuance of, a section 1135 waiver by the Secretary, AmeriHealth will:

Allow beneficiaries to seek care at specified non-contracted facilities (note that Part A and Part B benefits must be furnished at Medicare certified facilities);
Waive in full, requirements for referrals where applicable;
Pay out of network claims, or claims where prior authorization/referrals were not obtained at the in-network benefit level;
Allow members to seek care from non-network providers at the in-network benefit level;
Waive the 30-day notification requirement to enrollees as long as all the changes (such as reduction of cost-sharing and waiving authorization) benefit the enrollee and;
Lift refill-too-soon edits for Part D prescription drugs;

Typically, the source that declared the disaster will clarify when the disaster or emergency is over. If, however, the disaster or emergency timeframe has not been closed 30 days from the initial declaration, and if CMS has not indicated an end date to the disaster or emergency, AmeriHealth will resume normal operations 30 days from the initial declaration.

Non-discrimination Notice and Multi-Language Insert — updated 10/1/2023

View our Non-discrimination Notice and Multi-Language Insert.

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Website last updated: 7/31/2024