​AmeriHealth HMO, Inc., AmeriHealth Insurance Company of New Jersey, and AmeriHealth Administrators (collectively, AmeriHealth) are committed to providing our members with high-quality, comprehensive, cost-effective prescription drug coverage.

The prescription drug coverage includes a formulary feature. The formulary is a list of drugs approved by the U.S. Food and Drug Administration (FDA) and selected by the AmeriHealth Pharmacy and Therapeutics (P&T) Committee, a group of physicians and pharmacists from the area. The formulary drugs are selected based on their reported medical effectiveness, safety, and value.

The pharmacy benefit manager (PBM) manages the administration and claims processing of the AmeriHealth prescription drug programs. The PBM 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 the PBM.

Select Drug Program^®

The Select Drug Program formulary is organized by cost-share tiers. 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.

• Low-Cost Generic: Availability varies by benefit. Offers copays lower than the cost-share for the generic tier, when possible. Applies to certain drugs that are typically used to treat chronic conditions.
• Generic: Includes most generic medications. Drugs are covered at the lowest formulary level of cost-sharing.
• Preferred Brand: Includes preferred brand-name medications. Drugs are covered at a higher formulary level of cost-sharing.
• Non-Preferred Drug: Includes non-preferred medications. Drugs are covered at the highest non-formulary level of cost-sharing.

Some brand-name drugs without generic equivalents and some 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 Administrators, 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 those 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 P&T Committee. 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 that includes appeal rights and instructions.

Coverage for drugs is based on the member's prescription drug benefits. You can download the latest Value Formulary from the AmeriHealth Administrators, 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.

Mail-order services

The pharmacy benefit manager (PBM) 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 the PBM 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 New Jersey, go to Drug Formulari es, then select the Search the formulary link for Value or Select.
• 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.

For information on how to request prior authorization for a drug, please review the “Prescribing safety" section in this article.

For AmeriHealth Administrators plans, visit the Prescription Drug Information section of the website to determine if the drug you prescribed requires prior authorization.

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.

The PBM 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 member 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 the PBM. 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 contraindications 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 member will pay the highest level of cost-sharing for these drugs.
• Brand-name drugs are not eligible for coverage on the generic tier.

The provider should complete the formulary exception form, providing details to support the request and fax it to the pharmacy benefit manager 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 P&T Committee. The PBM 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 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,), may be limited based on the member's prescription drug benefit design.

Claim dollar limits are placed to require review for clinical appropriateness on prescription claims exceeding a defined dollar limit threshold. The member's provider will need to submit a prior authorization request to any claim exceeding $10,000.

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^® and SureScripts™ that support electronic prior authorization (ePA) to submit a prior authorization request. Alternatively, the provider can complete a prior authorization for m and fax all supporting medical information to the pharmacy benefit manager at 1-888-671-5285.

Safety edits

Safety edits are applied to prescription medications to ensure 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, others will require prior authorization review. Safety edits include age limits, quantity limits, morphine milligram equivalent (MME) limits, high cumulative stimulant dose limit, 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. 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. Similar to other prior authorization requests, quantity limit override requests for certain drugs may have a limited approval timeframe.

Morphine milligram equivalent limits

AmeriHealth applies additional safety measures to opioid products by limiting the total daily dose. This limit accounts for various 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. 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.

Cumulative stimulant limit

Central nervous system (CNS) stimulants such as amphetamine and methylphenidate, when used in high doses, are associated with increased risk for cardiac-related adverse events such as hypertension and new or worsening psychosis including manic behavior. Cumulative stimulant limit is a safety measure designed to ensure the provider has assessed the member for alternative medication and advised the member about the risks associated with stimulant use. The cumulative stimulant limit works by calculating the total daily stimulant dose by the drug's active ingredient. Stimulant claims that exceed the limit outlined would require prior authorization.

Concurrent drug utilization review

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. ​

Your Health Plan uses an independent company to provide pharmacy benefits management services.