AmeriHealth is committed to providing our members with high-quality, comprehensive, cost-effective prescription drug coverage. The prescription drug coverage includes a formulary feature, which is a list of drugs approved by the U.S. Food and Drug Administration (FDA) and selected by the AmeriHealth Pharmacy and Therapeutics Committee, a group of physicians and pharmacists from the area. The formulary drugs are selected for their reported medical effectiveness, safety, and value.

FutureScripts^® manages the administration and claims processing of the AmeriHealth prescription drug programs. FutureScripts works with the community, mail-order, and specialty pharmacies to provide medications and customer service to our members and providers. The effectiveness and safety of drugs and drug-prescribing patterns are monitored by FutureScripts.

Select Drug Program^®

The Select Drug Formulary is organized by cost-share tiers in the following manner. The non-preferred tier on the formulary is generally associated with a higher cost-sharing than the preferred brand or the generic tiers. Usually, when a brand-name drug has a generic equivalent, the brand-name drug is covered at the non-preferred level of cost-sharing while the generic equivalent is covered at the lowest level of cost-sharing.

• Tier 1 – Generic: Includes most generic medications. Drugs are covered at the lowest formulary level of cost-sharing.
• Tier 2 – Preferred Brand: Includes preferred brand-name medications. Drugs are covered at a higher formulary level of cost-sharing.
• Tier 3 – Non-Preferred Drug: Includes non-preferred medications. Drugs are covered at the highest formulary level of cost-sharing.

Some brand-name drugs without generic equivalents, authorized generic drugs, and generic drugs are also covered at the non-preferred level of cost-sharing because there are cost-effective alternatives on the preferred or generic tiers to treat the same condition.

You can download the latest Select Drug Program Formulary from the AmeriHealth New Jersey and AmeriHealth Pennsylvania websites. To request a printed copy, call 1-888-YOUR-AH1 (1-888-968-7241) for AmeriHealth New Jersey or 1-800-275-2583 for AmeriHealth Pennsylvania.

Value Formulary

The Value Formulary is organized by cost-share tiers similar to that of the Select Drug Program.  However, drugs not included on the Value Formulary are considered non-formulary. Non-formulary drugs have covered equivalents and/or alternatives used to treat the same condition. New drugs are not included on the Value Formulary until reviewed by the Pharmacy and Therapeutics Committee (P&T). Formulary placement is determined upon review by the P&T Committee.

Non-formulary exceptions for Value Formulary members

Providers may request consideration of formulary coverage of a non-formulary drug when there has been a trial of, or contraindication to, at least three formulary alternatives when available. The provider should complete a non-formulary exception request form to provide details to support use of the non-formulary drug and fax the request to 1-888-671-5285. If the non-formulary exception request is approved, the drug will be covered at the highest applicable level of cost-sharing. Please note that safety edits, such as quantity limits, will still apply. If the request is denied, the member and provider will receive a denial letter which includes appeal rights and instructions.

Coverage for drugs is based on the member’s prescription drug benefits. You can download the latest Value Formulary for AmeriHealth Pennsylvania. To request a printed copy, call 1-800-275-2583.

Note: The Value Formulary for AmeriHealth New Jersey, which becomes effective January 1, 2020, will be available for download at the end of the month on the Drug formularies section of the AmeriHealth New Jersey website.

Mail-order services

FutureScripts provides mail-order services as an option for AmeriHealth members to receive their medications. Most of the time, medication requests are processed upon receipt of a prescription from a provider. However, there may be times when the provider will be contacted by FutureScripts for medication coverage, such as when the requested drug requires prior authorization and/or safety edits apply.

To determine if the drug you prescribed requires prior authorization, please refer to the Formulary Lookup tool on amerihealth.com. To access the tool for AmeriHealth Pennsylvania, go to Drug Formularies, select the member’s formulary and then select Find a Formulary Drug. For Value Formulary members, the provider will also need to select a tier level before accessing the Lookup tool. To access the tool for AmeriHealth New Jersey go to Drug Programs, then select Search the formulary. For information on how to request prior authorization for a drug please review the “Prescribing safety” section in this article.

Generic equivalent drugs

According to the FDA, generic drugs are equivalent to their brand-name originator in active ingredients, dosage, safety, strength, and performance and are held to the same strict standards as their brand-name counterparts. The only noticeable difference between a generic drug form and its brand-name counterpart may be the shape and/or color of the drug. Generic drugs are generally as effective as their brand-name counterparts. However, they may cost up to 70 percent less, which helps to reduce health care costs for members. The generic drug option is generally the lowest cost for the member.

FutureScripts does not determine when a generic drug will be provided at the pharmacy. In accordance with state laws, generic drugs may be provided by the pharmacist at the point of sale, if available, unless the prescriber indicates “dispense as written” or “brand medically necessary” on the prescription. If a brand-name drug is prescribed in place of a generic drug, prior authorization may be needed before the drug is dispensed and the members will be responsible for the higher cost-sharing associated with a brand-name drug.

Therapeutic alternative drugs

Drugs that differ chemically but have the same effect are called “therapeutic alternatives.” These drugs will generally be in the same therapeutic class. For example, ibuprofen and naproxen are both non-steroidal anti-inflammatory drugs that can be therapeutically interchanged in most cases.

Examples of therapeutic alternatives are:

Although they are not the exact chemical equivalents of the brand name drugs, therapeutic alternatives treat medical conditions in a similar way.

Specialty drugs

Specialty drugs meet certain criteria, including, but not limited to drugs used to treat rare, complex, or chronic disease, drugs that have complex storage and/or shipping requirements, and drugs that require comprehensive patient monitoring and/or education. Specialty drugs covered under the pharmacy benefit may be managed by FutureScripts. Benefits may vary, and many plans cover specialty drugs on a specialty tier with higher cost-sharing.

Formulary tier exceptions

Providers may request an exception for a non-preferred drug to be covered at a preferred level of cost-sharing when there has been a trial of, or contraindication to, at least three formulary alternatives. This option is available based on benefit design for both Select Drug Program and Value Formulary members. The following restrictions apply:

• Drugs on the generic, preferred brand, and the specialty tiers are not eligible for a change to cost-share.
• Non-formulary drugs on the Value Formulary are not eligible for change to a lower cost-share. If approved for non-formulary exception, the members will pay the highest level of cost-sharing for these drugs.
• For cost-sharing purposes, authorized generic drugs are treated as brand-name drugs and are not eligible for coverage on the generic tier(s). For example, the authorized generic oxycodone ER is technically a brand-name drug, not a generic of Oxycontin. Brand-name drugs are not eligible for coverage on the generic tier. The lowest tier an authorized generic can fall on is the preferred brand tier.

The provider should complete the formulary exception form, providing details to support the request and fax it to FutureScripts at 1-888-671-5285. If the tier exception request is approved, the provider will receive a fax notification and the drug will be processed at the appropriate formulary level of cost-sharing. If the request is denied, the provider and member will receive a denial letter.

Prescribing safety

As part of formulary management, AmeriHealth implements safe prescribing procedures that are designed to optimize the member’s prescription drug benefits by promoting appropriate utilization. These procedures are based on FDA guidelines, and the approval criteria were developed by the AmeriHealth Pharmacy and Therapeutics Committee. FutureScripts continuously monitors the effectiveness and safety of drugs and drug prescribing patterns. Several procedures, such as prior authorization and safety edits, have been established to support safe prescribing patterns and to promote optimal pharmacotherapy outcome for the members.

Prior authorization

Prior authorization is required for certain covered drugs to ensure medical appropriateness and necessity. The approval criteria for these medications may also include a trial of a different drug, such as a generic equivalent drug or a therapeutic alternative. Using these approved criteria, clinical pharmacists evaluate requests for these drugs based on clinical data, information submitted by the member’s provider, and the member’s available prescription drug therapy history. The evaluation may include a review of potential drug-drug interactions or contraindications, appropriate dosing and length of therapy, and utilization of other drug therapies.

Coverage of certain drugs on the formulary, with or without prior authorization (e.g., weight loss drugs, fertility drugs), may be limited based on the member’s prescription drug benefit design.

The prior authorization process may take up to two business days once complete information from the prescriber has been received. The prescriber will be notified if an approval has a defined time frame, such as 12 months. Once the approval time period expires, the provider will need to request consideration for a new prior authorization.

Providers can access platforms such as CoverMyMeds^{&re g;} and SureScripts^TM that support electronic prior authorization (ePA) to submit a prior authorization request. Alternatively, the provider can complete a prior authorization form and fax all supporting medical information to FutureScripts at 1-888-671-5285.

Prior authorization requirements for selected drugs

Prior authorization requirements for selected drugs is in place for certain medications. This expedites the review process at the pharmacy by using information available in the member’s pharmacy benefit claim history to determine coverage for the requested medication. For example, Flovent^® HFA is a medication that requires previous trial of either of the preferred medications Asmanex^® or Qvar^®. With the prior authorization requirements for selected drugs, a member will be able to receive coverage immediately for Flovent^® HFA if the claim history shows a previous paid claim for either Asmanex^® or Qvar^®. A manual prior authorization request will not be needed. If the claim history does not contain a previous paid claim of either drug, then a prior authorization request will be needed in accordance with the standard prior authorization process.

Safety edits

Safety edits are applied to prescription medications to promote safe and appropriate use of drugs. They are designed to align with clinical practice guidelines and FDA approved use(s) outlined in the manufacturer package insert. There are different types of safety edits; some of which will prompt member counseling at the point-of-sale, while some will require prior authorization review. Examples of safety edits are age limits, quantity limits, morphine milligram equivalent (MME) limits, and concurrent drug utilization review (cDUR).

Age limits

Age limits are designed to prevent potential harm to members and to promote appropriate use of the drug. Age groups are identified through the FDA drug approval process. Age limits are generally noted when safety and efficacy has not been established. If the member’s prescription falls outside of the FDA guidelines, it may not be covered until prior authorization is obtained. In addition, an age limit may be applied when certain drugs are more likely to be used in certain age groups. For example, drugs used to treat Alzheimer’s disease may require prior authorization for use in young adults. The provider may request coverage for drugs outside of the age limit when medically necessary. If a member’s prescription falls outside the FDA guidelines, it may not be covered until prior authorization is obtained.

Quantity limits

Quantity limits are designed to allow a sufficient supply of medication based upon FDA-approved maximum daily doses, standard dosing, and/or length of therapy of a drug. There are several different types of quantity limits to promote safe and appropriate utilization. If a member requires more than the limit, the provider will need to submit a prior authorization request.

Morphine milligram equivalent (MME) limits

AmeriHealth applies additional safety measures to opioid products by limiting the total daily dose. This limit accounts for all the different opioid products through a measurement called the morphine milligram equivalent (MME) dose. The MME is a number that is used to determine and compare the potency of opioid medications and it helps to identify when additional caution is needed. The daily limit is calculated based on the number of opioid drugs, their potencies and the duration of therapy. Prior authorization is required for opioid doses that exceed 90 MME per day.

Concurrent drug utilization review (cDUR)

Concurrent drug utilization reviews(cDURs) are built into the pharmacy claim adjudication system to review a member’s prescription history for possible drug-related problems including drug-drug interactions and drug therapy duplications. Drugs may reject at the point-of-sale and/or generate a message to the dispensing pharmacist when there is a safety concern. The dispensing pharmacist can review the issue with the provider and override the rejection if appropriate for most edits.

Learn more

Visit the Pharmacy section of the AmeriHealth New Jersey or AmeriHealth Pennsylvania websites for additional information on pharmacy policies and programs.