You have the right to appoint a person to file a grievance, coverage determination, exception or appeal for you. You will need to fill out an Appointment of Representation form and have that form signed by the individual you would like to represent you as well as yourself. Once you have completed the form, you must submit that form to GEMCare Health Plan before we can talk to your representative.
Appointment of Representative Form - (PDF)
Use this form to appoint a person as your representative who acts on your behalf.
To access this form on the CMS website, click here.
Prescription Drug Grievance and Redetermination Request Form (PDF)
(click here for online form)
Use this form to submit a redetermination after an initial coverage determination was denied, in full or in part, to GEMCare Health Plan for prescription drugs.
Coverage Determination – Provider (PDF)
(click here for online form)
Use this form to submit an initial determination request (coverage determination/exception) to GEMCare Health Plan's contracted pharmacy Manager PTI/NPS.
Coverage Determination – Member (PDF) (click here for online form)
Use this form to submit an initial determination request (coverage determination/exceptions) to GEMCare Health Plan for prescription drugs.
To access this form on the CMS website, click here.
Prescription Claim Form - (PDF)
Use this form to request reimbursement for prescription drugs you paid out of pocket. This form and all supporting receipts should be submitted to GEMCare Health Plan for processing. If you have any questions about how to fill out this form, please contact Member Services.
Prescription Drug Request for Reconsideration IRE (PDF)
Use this form to submit a reconsideration to the Independent Review Entity after GHP has denied, in full or in part, a redetermination. This form will be submitted directly to the IRE.