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Prescription Drug Frequently Asked Questions (FAQs)

What if my drug is not on the formulary?

First, contact Member Services and ask if your drug is covered. If Member Services says your drug is not covered, you have two options:

  1. You can ask Member Services for a list of similar drugs that are covered by AmeriHealth Caritas VIP Care (HMO-SNP). When you receive the list, show it to your primary care provider (PCP) and ask him or her to prescribe a similar drug that is covered by AmeriHealth Caritas VIP Care.
  2. You can ask AmeriHealth Caritas VIP Care to make an exception and cover your drug. For more information please see the section below titled How do I request an exception to the AmeriHealth Caritas VIP Care Formulary?

What is a coverage determination?

A coverage determination is any decision (an approval or denial) that AmeriHealth Caritas VIP Care makes when you ask for coverage or payment of a drug that you believe AmeriHealth Caritas VIP Care should provide.

  • You or your PCP and other prescribers can ask for a coverage determination.
  • You can also appoint someone (such as a relative) to request a coverage determination for you.
  • You can ask for a standard coverage determination. AmeriHealth Caritas VIP Care will give you a decision in 72 hours.
  • You can also ask for a fast coverage determination (also called an "expedited" determination) if you or your PCP or other prescriber believes that your health could be seriously harmed by waiting up to 72 hours for a decision. AmeriHealth Caritas VIP Care will give you an answer in 24 hours.

How to contact us when you are asking for a coverage decision about your Part D prescription drugs:

Request for Medicare prescription drug coverage determination

Submit online or fill out the paper form (PDF).

Fax urgent: 1-855-446-7893
Fax standard: 1-855-446-7892
Call: Contact Member Services.
Write:
AmeriHealth Caritas VIP Care
Attn: Prior Authorization
200 Stevens Drive, 4th Floor
Philadelphia, PA 19113

What can I do if my coverage determination is denied?

If AmeriHealth Caritas VIP Care denies your coverage determination you have the right to request a redetermination appeal. Please see our section on appeals and grievances for information about your appeal rights.

Can the formulary change?

Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year. However, there are two exceptions. We may remove a drug from our formulary when a new, less expensive generic drug becomes available or when new information is released that a drug is unsafe or doesn’t work. Please check the webpage for the most up to date version of the drug list.

If we remove drugs from our formulary or add prior authorization requirements, quantity limits, or step therapy restrictions on a drug, we must tell affected members there is a change at least 30 days before the change happens. Or we will tell the member about the change when they request a refill of the drug, and the member will receive a 30-day supply of the drug.

If the Food and Drug Administration (FDA) says a drug on our formulary is unsafe or the drug's manufacturer removes the drug from the market, we will remove the drug from our formulary and provide notice to members who take the drug.

What is prior authorization?

Prior authorization means that you will need to get approval from AmeriHealth Caritas VIP Care before you fill your prescriptions for some drugs. If you do not get approval, AmeriHealth Caritas VIP Care may not cover the drug. You can find out which drugs require prior authorization by reviewing the AmeriHealth Caritas VIP Care formulary (PDF). Usually, your PCP or other prescribers will have to give us information about your medical condition or previous prescriptions to receive prior authorization.

Mail or fax the completed form to:

AmeriHealth Caritas VIP Care
Attn: Prior Authorization
200 Stevens Drive, 4th Floor
Philadelphia, PA 19113

Fax urgent: 1-855-446-7893
Fax standard: 1-855-446-7892

How do I request an exception to the AmeriHealth Caritas VIP Care formulary?

Prior authorization exception

You or your PCP or other prescriber can request an exception to the AmeriHealth Caritas VIP Care formulary (PDF). Generally, your PCP or other prescriber must provide a statement of medical necessity. This explains why the formulary drug would not work as well for your condition and/or would cause you to have adverse medical effects.

Mail or fax the completed form to:

AmeriHealth Caritas VIP Care
Attn: Prior Authorization
200 Stevens Drive, 4th Floor
Philadelphia, PA 19113

Fax urgent: 1-855-446-7893
Fax standard: 1-855-446-7892

How do I get reimbursed for my prescription expenses?

In-network pharmacy claims: Direct member reimbursement

Please read the instructions on the form carefully, complete the form, and mail it to:

AmeriHealth Caritas VIP Care
Attn: Direct Member Reimbursement
200 Stevens Drive, 4th Floor
Philadelphia, PA 19113

Out-of-network pharmacy claims: Direct member reimbursement

Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. Before you fill your prescription at an out-of-network pharmacy, call Member Services to see if there is a network pharmacy in your area where you can fill your prescription. You may also access the AmeriHealth Caritas VIP Care pharmacy directory.

If you do go to an out-of-network pharmacy you may have to pay the full cost for the drug (rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a direct reimbursement claim form. However, even after we reimburse you for our share of the cost, you may pay more for a drug purchased at an out-of-network pharmacy because the out-of-network pharmacy's price may be higher than what a network pharmacy would have charged.

You should always submit a claim to us if you fill a prescription at an out-of-network pharmacy, since any amount you pay, consistent with the circumstances listed above, will help you qualify for catastrophic coverage.

Please read the instructions on the reimbursement form (PDF) carefully, complete the form, and mail it to:

AmeriHealth Caritas VIP Care
Attn: Direct Member Reimbursement
200 Stevens Drive, 4th Floor
Philadelphia, PA 19113

What is the AmeriHealth Caritas VIP Care transition policy?

View the 2019 transition policy.

Does the plan have mail-order delivery services?

Yes. For certain kinds of drugs, you can use the plan's network mail-order services. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs available through our plan's mail-order service are marked as "mail-order" drugs in our drug list. Our plan's mail-order service requires you to order a 90-day supply. If you use a mail-order pharmacy not in the plan's network, your prescription will not be covered. Usually you will receive a mail-order pharmacy order in no more than 10 days.

However, sometimes your mail order may be delayed. If you need to start your medications right away, but the mail-order is delayed, ask your provider for a 30-day supply (prescription) to be filled at your local pharmacy.

Find out how to place a mail order (PDF).

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