Prescription drugs (Part D)

The following information can help you get the most from your prescription drug (Part D) coverage. Just click on the links below to learn more about your benefits or to request the forms you need.

To review your prescription drug benefits, log in to amerihealth.com/login to find drug pricing and information, manage mail-order service, use the pharmacy locator, view claims, and more.

Important message about what you pay for vaccines: Some vaccines are considered medical benefits. Other vaccines are considered Part D drugs. You can find these vaccines listed in the plan's List of Covered Drugs (Formulary). Our plan covers most adult Part D vaccines at no cost to you even if you haven't paid your deductible. Refer to your plan's formulary or contact our Member Help Team for coverage and cost sharing details about specific vaccines.

Additional resources to help: You can contact our Member Help Team seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail. AmeriHealth contracts with an independent pharmacy benefits management (PBM) company to provide Medicare Part D prescription benefit management services.

Prescription drug formularies

A formulary is a list of prescription drugs covered by the plan. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the drug list.

Find a prescription drug

To find covered prescription drugs, select your health plan from the AmeriHealth Drug Formularies on our Find a drug page.

Pharmacy network

The AmeriHealth pharmacy network allows you to get your prescription filled at over 60,000 locations. To learn more about our pharmacy network go to our Find a drug page.

Vaccines

Part B vaccines — available at no cost at an in-network doctor or pharmacy!

• COVID-19
• Flu shot (influenza)
• Pneumonia (pneumococcal)
• Hepatitis B (for intermediate or high-risk individuals)

The following are covered to treat an injury or because of direct exposure to a disease or condition:

• Tetanus
• Rabies
• Botulin antitoxin
• Antivenin sera

Part D vaccines

• Shingles
• Human papillomavirus (HPV)
• Measles, mumps, rubella (MMR)
• Diphtheria
• Pertussis

If you do not meet the Part B coverage rules above, the following are covered under Part D:

• Tetanus
• Rabies
• Botulin antitoxin
• Antivenin sera

How to request reimbursement if you pay out of pocket for a vaccine

Part B vaccines

• We recommend getting a Part B vaccination at an in-network doctor or pharmacy location.
• If you get a Part B vaccination as part of a doctor's office visit where you’ve received a separate additional non-preventive evaluation and/or service, a copayment will apply. The copayment amount depends on the provider type or place of service.
• Part B vaccines are also available at some pharmacies, but you may have to pay out of pocket and submit for reimbursement.

If you receive the flu shot at an out-of-network provider or pharmacy and paid out of pocket, you can submit the Influenza Vaccine Reimbursement Form to apply for reimbursement.

Part D vaccines

In order to be guaranteed you're charged the correct Part D cost-share, we recommend you get your Part D vaccines at a pharmacy, rather than your doctor's office.

To request a reimbursement for a vaccine and/or a vaccine administration fee, please use the Vaccine and Administration Direct Member Reimbursement Form. This form is for Part D vaccines only and should not be used for Part B vaccines.

Prior authorization and coverage determinations for Part D drugs

For certain drugs, you or your provider may need to get approval from the plan before we will agree to cover the drug for you. This is called "prior authorization," "pre-approval," or "precertification". This is put in place to ensure medication safety and help guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan.

Please reference your plan's formulary for a list of drugs that require prior authorization. Prior authorization approval criteria are developed and endorsed by our Pharmacy and Therapeutics Committee and are based on information from the Food and Drug Administration (FDA), manufacturer guidelines, medical literature, actively practicing consultant physicians, and appropriate external organizations.

Step therapy

Step therapy is a type of coverage determination that applies to certain drugs covered under Medicare Part B. Step therapy requires you to first try certain drugs (sometimes referred to as "preferred products") to treat your medical condition before the plan will cover another drug (sometimes called a "nonpreferred product") for that condition. For example, if "Drug A" and "Drug B" both treat your medical condition, AmeriHealth may not cover "Drug B" unless you try "Drug A" first. If "Drug A" does not work for you, AmeriHealth will then cover "Drug B".

You can refer to the Medicare Part B Drugs Subject to Step Therapy Drug List for a list of all specialty drugs that have step therapy requirements.

How to submit a prior authorization/step therapy request

You may submit a request for medications requiring prior authorization/step therapy. The pharmacy benefits manager reviews all requests. If you, your appointed representative, or your prescriber would like to initiate a prior authorization request, please submit a coverage determination. A standard coverage decision takes 72 hours after we receive a request. An expedited coverage decision means we will answer within 24 hours after we receive a request.

Prior authorization and coverage determination process

For more information on the prior authorization process, please reference your plan's Evidence of Coverage (EOC) or contact the Member Help Team.

• 2025 AmeriHealth Medicare PPO EOC
• 2024 AmeriHealth Medicare PPO EOC

Non-formulary exception and quantity limit exception

If your drug is not on the plan's formulary, you can request an exception by asking the plan to cover the drug. Or if the drug has a quantity limit, you can ask the plan to cover a greater quantity of the drug than what the plan allows.

You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for a quantity limit exception, your provider can help you request an exception to the rule.

Drugs approved for a formulary exception cannot be approved for tier exception.

Tier cost-sharing

The plan puts each covered drug into one of several different cost-sharing tiers. How much you pay for your prescription depends on which cost-sharing tier your drug is in.

If your drug is in the non-preferred tier, you or your provider can ask the plan to make an exception to allow the drug to be covered at the preferred tier, so you pay less for it. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the non-preferred tier. See the instructions below for requesting an exception.

If we approve the non-preferred request, the drug will be processed at the appropriate preferred formulary benefit cost-sharing tier. If we deny the request for access at the preferred tier, you and your physician will receive a denial letter that explains the appeal process. You may still receive the drug at the non-preferred cost-sharing level.

Please note that certain drugs in some of our cost-sharing tiers are not eligible for this exception. Such scenarios include:

• Generic drugs that are already on our lowest generic tier (preferred generic)
• Brand drugs that are already on our lowest brand tier (preferred brand)
• Drugs that are on our specialty tier
• Drugs that were already approved through the formulary exception process

How to submit a tier cost-sharing or formulary exception request

You may submit a request for a formulary or tier exception. The pharmacy benefits manager reviews all requests. If you, your appointed representative, or your prescriber would like to initiate an exception request, please submit a coverage determination.

Please note that if you are approved for a formulary exception, you are not permitted to also request a tier exception for that same drug. For more information on coverage determinations, including how to submit, please reference the coverage determination section.

Medicare Part B vs. Part D determinations

Centers for Medicare and Medicaid Services (CMS) limits coverage of some drugs to either the Part B or Part D benefit depending on how the drug is prescribed, dispensed, and/or administered.

Please refer to the appropriate formulary to determine if your drug requires a Medicare Part B vs. Part D determination. Please complete the Medicare Administrative Prior Authorization for Part B/D coverage form if needed. This drug may be covered under Medicare Part B or D depending upon the circumstances. You may need to provide information such as the use and setting of the drug so we can make the determination.

Certain drugs are generally covered only under the Part B benefit. These drugs typically will not be listed on the formulary. However, some Part B drugs require precertification. Please see the link below to determine if precertification is required:

Specialty Drugs Requiring Precertification under Medicare Part B

Your physician may refer to the Direct Ship Injectables Program for more information about certain injectable drugs covered under the Medicare Part B benefit.

Hospice Medicare coverage

CMS requires Medicare beneficiaries under hospice care with Part D coverage to get prior authorization for prescriptions that fall under these four classes of medications.

There are four categories of drugs that should be covered under the Medicare Part A payment for hospice, which are:

• Analgesics (drugs used for pain)
• Antiemetics (drugs used for nausea)
• Laxatives
• Antianxiety drugs

These medications are considered under hospice benefit if they are prescribed for diagnoses related to the member's terminal illness.

These medications will be covered under Medicare Part D only if they are prescribed for diagnoses unrelated to the member's terminal illness.

If you feel that these drugs should be covered under Medicare Part D and would like to initiate a prior authorization, you, your appointed representative, or your prescriber can fill out the necessary information using the Hospice Information for Medicare Part D request form. The pharmacy benefits manager reviews all requests.

Providers:

• You may print and fax your completed Hospice Information for Medicare Part D request form to the pharmacy benefits manager for review at 1-888-671-5285. Make sure to include your office telephone and fax number on the form.
• When filling out a prior authorization form, please supply all the requested information. Incomplete requests will require an outreach to your office to obtain additional information.
• You will be notified by fax if the request is approved or denied. You and your patient will also receive a denial letter.
• If you have not received a response 72 hours after submitting complete information, contact the pharmacy benefits manager at 1-888-678-7015, option 1.

Members:

• You, your authorized representative, or your physician may fax the Hospice Information for Medicare Part D request form to the pharmacy benefits manager (PBM) for review at 1-888-671-5285.
• Complete the prior authorization form. Please supply all requested information. Note: The PBM may need to reach out to your provider for additional information.
• You may take the appropriate request form to your physician to complete and fax to the PBM for review at 1-888-671-5285.
• If you have not received a response from the PBM after 72 hours, you may contact the provider who made the request on your behalf, or call the PBM directly at 1-888-678-7015 (TTY/TDD: 711).
• If you have questions, please contact our Member Help Team.

Transition supply process

What if there are changes to the way my current prescription is covered?

As a member of the plan, you may notice that a medication that you are currently taking is either not on the upcoming year's formulary or that coverage is limited in the upcoming year. In either case, we will provide a temporary supply, or a transition fill, typically a one-time 30-day supply of a drug you were taking. You are eligible to receive this transition supply within the first 120 days after your plan becomes effective. Doing this gives you time to talk with your doctor about the change in coverage. Please note that not all medications qualify for a transition supply.

AmeriHealth can only offer a temporary transition supply of drugs that are eligible for coverage under Medicare Part D. Drugs that are excluded from Part D coverage are not eligible for a transition supply.

For more information on excluded drugs, please reference your plan's EOC. If you have more questions about our transition policy or need help asking for a coverage determination, call the Member Help Team.

Coverage determination for Part D drugs

Coverage determination is the process by which the plan decides whether a Part D drug prescribed for you is covered. It also decides the amount, if any, you are required to pay. An initial coverage decision about your Part D drugs is called a coverage determination. You, your doctor, or someone you've authorized may make an oral or written, standard or expedited request. In most cases, the plan will require clinical information from your prescriber.

If you are an AmeriHealth Rx PPO member, you can file a coverage determination by using one of the methods below.

• Members can submit a secure online request.
• Have your provider fill out and mail or fax the drug-specific coverage determination form. If you do not see a specific form for your request, you or your physician can use our generic coverage determination request form.
• Call 1-866-569-5190 (TTY/TDD: 711). Calls to this number are free. Representatives are available seven days a week, from 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
• Fax: 1-888-671-5285
• Write: PO Box 25183
  Santa Ana, CA 92799

Through the coverage determination process, you can ask us to make an exception. This includes requesting coverage of a drug that is not on the formulary, waiving restrictions on the plan's coverage for a drug, or asking to pay a lower cost-sharing amount. You may use the coverage determination form to request an exception.

Part D appeals

If you, your doctor, or your representative disagree with the outcome of the initial coverage determination, you can appeal the decision by requesting a redetermination.

Ways to file an appeal for AmeriHealth Rx PPO members

• Call 1-866-569-5190 (TTY/TDD: 711) for expedited appeals only. Calls to this number are free. Representatives are available seven days a week, from 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
• Complete the secure online Coverage Redetermination Request Submission Form
• Download and print the Coverage Redetermination Request Form to send by fax or mail.
  • Fax: 1-888-289-3008
  • Mail to:
    Medicare Member Appeals Unit
    PO Box 13652
    Philadelphia, PA 19101-3652

If our answer is yes to part or all of what you requested:

• If we approve a coverage request, we must provide the coverage we have agreed upon as quickly as your health requires, but no later than seven calendar days after we receive your appeal.
• If we approve a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request.
• If we approve an expedited (or fast) coverage request, we must provide the coverage we have agreed upon as quickly as your health requires, but no later than 72 hours after we receive your appeal.

If our answer is no to part or all of what you requested:

• We will send you a written statement that explains why we said no and how to appeal our decision.

Part D appeals process

For more information on Part D appeals, please reference your plan's EOC or contact the Member Help Team.

• 2025 AmeriHealth Medicare PPO EOC
• 2024 AmeriHealth Medicare PPO EOC

Part D grievances

A grievance is a formal complaint or dispute. You can file a grievance if you are dissatisfied with any aspect of the operations, activities or behavior of AmeriHealth or its network pharmacies. If you disagree with a coverage determination decision, please see the Part D Appeals section above.

You will receive a resolution within 30 days of filing a grievance. Once a decision is rendered, we will notify you.

Ways to file a complaint for AmeriHealth Rx PPO

• Call: 1-866-569-5190 (TTY/TDD: 711). Calls to this number are free. Representatives are available seven days a week, from 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.
• Fax: 1-888-289-3008
• Write:
  Medicare Member Appeals Unit
  PO Box 13652
  Philadelphia, PA 19101-3652

Part D grievances process

For more information on Part D grievances, please reference your plan's EOC or contact the Member Help Team.

• 2025 AmeriHealth Medicare PPO EOC
• 2024 AmeriHealth Medicare PPO EOC

To obtain an aggregate number of grievances, appeals, and exceptions filed with AmeriHealth, please contact the Member Help Team.

Appointment of a representative

If you want someone other than your provider to act on your behalf, please complete the Appointment of Representative (AOR) form.

If you are filing an AOR for a coverage determination, please submit the form to:

Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-800-527-0531

If you are filing an AOR for an appeal or a grievance, please submit the form to:

Medicare Member Appeals Unit
PO Box 13652
Philadelphia, PA 19101-3652

Contact information

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, please contact the Member Help Team.

To obtain an aggregate number of grievances, appeals, and exceptions filed with AmeriHealth, please mail a written request to:

Medicare Member Appeals Unit
PO Box 13652
Philadelphia, PA 19101-3652

If you prefer to file a grievance through CMS, please complete the Medicare Complaint Form.

Quality assurance policies and procedures

AmeriHealth has developed a system of checks and balances to help ensure that you get the right medications, in the right amounts, at the right times. Our goal is to avoid potential health risks to you, to keep the plan affordable, and to help members manage their medications.

AmeriHealth complies with the CMS requirement to apply additional safety measures to opioid products.

Members who were newly prescribed an opioid medication will be limited to a 7-day supply for their first fill. All other prescription fills for opioid medications will be limited to a 30-day supply.

Please note that individual pharmacies may have additional limitations on opioid medications.

AmeriHealth limits the total daily dose of opioids through a measurement called the Morphine Milligram Equivalent (MME) dose. MME is a number that is calculated from the number of opioid drugs, their potencies, and the duration of therapy. It is used to determine and compare the potency of opioid medications, and it helps to identify when additional caution is needed.

Pharmacies have safety interventions based upon the MME dose, which may require intervention from your pharmacy or require a prior authorization.

2025 Medication Therapy Management (MTM) program

In collaboration with PerformRx^SM, we offer a Medication Therapy Management (MTM) program to ensure that you receive the most effective medications. MTM also helps to reduce the risk of side effects and interactions and lower your out-of-pocket costs. Your plan pays for the program, at no cost to you. This program is not considered a benefit. MTM does not change your insurance benefits, copayments, prescription coverage, or available doctors or pharmacies. Specially trained pharmacists will work closely with you and your doctors to solve any problems related to your medications and to help you get the best results.

Who is eligible for the 2025 MTM program?

The MTM program is designed to help you get the most from your medications if you meet all the following criteria:

• You have three or more chronic diseases, including:
  • Alzheimer's disease
  • Bone disease-arthritis (including osteoporosis, osteoarthritis, and rheumatoid arthritis)
  • Chronic congestive heart failure (CHF)
  • Diabetes
  • Dyslipidemia
  • End-stage renal disease (ESRD)
  • Human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS)
  • Hypertension
  • Mental health (including depression, schizophrenia, bipolar disorder, and other chronic/disabling mental health conditions)
  • Respiratory disease (including asthma, chronic obstructive pulmonary disease (COPD), and other chronic lung disorders
• You take eight or more maintenance medications for chronic conditions.
• Those who have an active coverage limitation under a Drug Management Program for opioid use.
• You spend $1,623 or more per year on Medicare Part D covered medications.

What happens if you qualify for the program?

1. You will receive an introduction letter that describes the program to you.
2. You will receive a comprehensive medication review:
   • A specially trained clinical pharmacist will contact you for an interactive person-to-person medication consultation to review all your medications and answer any questions that you may have.
   • Following the consultation, you will receive a summary of your comprehensive medication review. The summary will contain a medication action plan for you to take notes or write down any follow-up questions.
3. Your medications will be reviewed on an ongoing basis.
   • A comprehensive medication review will be offered once a year.
   • At least every three months, your medicines will be reviewed, and your MTM pharmacist will work with you and your doctor(s) if any changes are needed.

Medicare requires that MTM programs automatically enroll those who qualify throughout the calendar year, but participation is voluntary, and you may opt out at any time. Once you are enrolled, you will remain enrolled through the calendar year unless you opt out or leave our plan.

To learn more, or to obtain MTM documents (including a Mediation List), please call PerformRx at 1-888-349-0501 (TTY/TDD: 1-888-765-6351) between 8:30 a.m. and 5 p.m. (EST), Monday through Friday.

A blank copy of the Personal Medication List may be found here.

Understanding the donut hole

If you're enrolled in a Medicare Part D prescription plan, you've likely heard about the Coverage Gap — sometimes called the "donut hole." It's one of the four phases of Part D coverage, and it's important to understand how it works and when it could apply to you. View our infographic to learn more about the Medicare Part D coverage phases.

Contact information

For more information, contact the Member Help Team.

AmeriHealth Rx PPO members: call 1-866-569-5190 (TTY/TDD: 711). Representatives are available seven days a week, from 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 through September 30, your call may be sent to voicemail.

 

 

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Website last updated: 10/1/2024