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This article provides information to ensure better drug coverage determination outcomes for you and your Medicare Advantage HMO patients who are covered under the Medicare Part D program through AmeriHealth. Please note that for these members, prior authorization is required for coverage of certain drugs approved by the U.S. Food and Drug Administration for specific medical conditions.

Prior authorizations and overrides

To eliminate the need for additional outreach when processing coverage determination requests, follow the tips below:

• Prior to submitting a request, review the Centers for Medicare & Medicaid Services (CMS) approved prior authorization criteria to ensure you understand what information needs to be provided.
• Always attach supporting documentation when it's available. Examples of supporting documentation include chart notes and laboratory results.

Please note that if the request is for a high-risk medication (as defined on the Beers Criteria list), a statement must be included in the request demonstrating that the provider is both:

• Aware of the risk of use of that drug in the elderly
• Still opting to prescribe that drug

Prior authorization forms
AmeriHealth, in conjunction with FutureScripts^® Secure, provides drug-specific forms for drugs that require prior authorization. Completing the necessary prior authorization forms will reduce the need for outreach to the physician's office and could avoid denials being issued due to lack of information. A link to FutureScripts Secure's prior authorization forms can be found on their website and on AmeriHealth NaviNet^® Plan Central in the Administrative Tools and Resources section.

If a drug-specific form is not available for the drug requested, please use the General Pharmacy (Quantity Edit/Prior Authorization) form.

Request time frames
Time frame requirements must be considered when submitting a request. Per CMS guidelines, Medicare Part D plans are required to adhere to the following time frames for reviewing requests:

• Standard: 72 hours to process.
• Urgent (life-threatening to the member): 24 hours to process.

Requests submitted on Fridays, especially urgent requests, often require additional information to complete the review. Please ensure that you or someone in the office is available to provide additional information, if needed, during non-business hours and weekends. Also note that the call may come from a FutureScripts Secure representative.

Drug formularies

The formulary-based prescription drug benefits program includes all generic drugs and a defined list of brand drugs that have been chosen for formulary coverage based on their reported medical effectiveness, positive results, and value. There are two types of drug formularies:

• Open formulary. All Medicare Part D drugs are considered "formulary" and are available for coverage. Some drugs on an open formulary may require prior authorization.
• Closed formulary. Only the drugs listed on the formulary are covered. Drugs not listed on the formulary are considered non-formulary and therefore not covered. In order to obtain a non-formulary drug, the physician must request consideration for a formulary exception.

Formulary exceptions
When submitting a Non-Formulary Exception request, keep in mind the following:

• All formulary exception requests must include a supporting clinical statement.
• The member must try and fail at least three formulary alternatives when available or have a documented reason why he or she cannot try and fail the formulary alternatives.

Please note that when a formulary exception is approved, the drug will default to the "non-preferred brand" tier, and the member will be charged the cost-sharing associated with that tier (unless the member is in the coverage gap, catastrophic, or deductible phase of their benefit). Also, approvals for formulary exceptions will remain in effect until the end of the coverage year.

The FutureScripts Non-Formulary Exception Request form can be found on the Provider Forms page of our website.

Tier exceptions
Once a drug is approved through the formulary exception process, the plan is prohibited from also approving a tier exception for that drug.

• Similar to formulary exceptions, a supporting clinical statement is required to demonstrate that the member has tried at least three lower-tiered formulary alternatives when available or documentation to support intolerance or contraindication to the formulary alternatives.
• Tier exceptions can only be approved for a non-preferred brand drug, allowing the member to pay the preferred brand cost-sharing. Tier exceptions cannot be approved to lower the cost of non-preferred generic drugs, to charge generic cost-sharing for any brand drug, or to lower the cost-sharing for any drug on the specialty tier.

Please note that the member's Medicare Part D benefit still applies. All applicable deductible and/or coverage gap cost-sharing applies, and members will be required to pay the applicable cost-sharing in that phase of their benefit.

To submit a tier exception, use the FutureScripts Non-Formulary Exception Request form.

Ramifications and more information

Lack of adherence to the above process can lead to a delay in members receiving coverage for their medication and/or increased outreach attempts by AmeriHealth or FutureScripts to your office. In cases where information in a request is incomplete and outreach attempts are unsuccessful, requests for coverage may be denied and are subject to the appeals process.

If you have any questions regarding this process, please contact Customer Service at 1-888-YOUR-AH1 (1-888-968-7241).

NaviNet is a registered trademark of NaviNet, Inc.

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