AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey (collectively, AmeriHealth) and AmeriHealth Administrators support safe, effective, and affordable medication use through FDA-approved formularies reviewed by the Pharmacy and Therapeutics (P&T) Committee and administered by a pharmacy benefit manager (PBM). The PBM manages claims, works with network pharmacies, and monitors drug safety and prescribing patterns.
Providers should consult the formulary when selecting medications.
Formularies and coverage
Select Drug Program®
Drugs are organized into cost-sharing tiers:
- Low-Cost Generic: Lower copays for certain chronic condition medications.
- Generic: Lowest cost-sharing for most generic drugs.
- Preferred Brand: Higher cost-sharing for preferred brand-name drugs.
- Non-Preferred Drug: Highest cost-sharing for non-preferred drugs.
Brand-name drugs with available generics are typically covered at the non‑preferred level.
For Formulary access, download the latest AmeriHealth in New Jersey or Pennsylvania and AmeriHealth Administrators online or request a printed copy at 1-888-YOUR-AH1 (1-888-968-7241) in New Jersey, 1-800-275-2583 in Pennsylvania, or 1-844-352-1706 for AmeriHealth Administrators.
Value Formulary
Structured similarly to the Select Drug Program, drugs not listed are considered non-formulary, with covered alternatives available. New drugs are added following P&T Committee review.
Non-Formulary Exceptions may be requested after trials of, or contraindications to, at least three alternatives. Approved requests are covered at the highest cost-sharing tier.
Fax exception requests to 1-888-671-5285. Download the latest Value Formulary online or request a printed copy at 1-888-YOUR-AH1 (1-888-968-7241) in New Jersey, 1-800-275-2583 in Pennsylvania or 1-844-352-1706 for AmeriHealth Administrators.
Cost-saving strategies
- Generic equivalents are FDA-approved and therapeutically equivalent to brand-name drugs at a lower cost. Brand prescribing may require prior authorization and could result in higher member cost sharing.
- Therapeutic alternatives are clinically comparable options within the same class (e.g., Dulera® alternatives include Advair® HFA, Symbicort®, Breo-Ellipta®). Although they are not the exact chemical equivalents of the brand-name drugs, therapeutic alternatives treat medical conditions in a similar way.
- Mail‑order pharmacy is available for certain medications; requirements can be verified using the AmeriHealth Formulary Lookup Tool. To access for AmeriHealth in New Jersey or Pennsylvania, go to Drug Formularies, then select the formulary link for Value or Select and enter a term in Search. For AmeriHealth Administrators plans, visit Prescription Drug Information to determine if the drug you prescribed requires prior authorization.
Specialty drugs
Specialty medications for chronic or complex conditions may require special handling, monitoring, or prior authorization. Benefits may vary, and many plans cover specialty drugs on a specialty tier with higher cost-sharing.
Exceptions and prior authorizations
Formulary tier exceptions are available for non‑preferred drugs when clinical criteria are met. 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.
- 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 a formulary exception form for AmeriHealth in New Jersey and Pennsylvania or a formulary exception form for AmeriHealth Administrators, 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.
Prior authorization is required for select medications to confirm medical necessity. The process involves clinical evaluation of alternatives, dosing, and potential interactions. Requests may be submitted electronically through SureScripts™ or by completing a prior authorization form for AmeriHealth in New Jersey and Pennsylvania or a prior authorization form For AmeriHealth Administrators and faxing to 1‑888‑671‑5285 with supporting documentation.
Safe prescribing safeguards
AmeriHealth and AmeriHealth Administrators apply utilization and safety edits to support appropriate drug use, including:
- Age and quantity limits
- Morphine Milligram Equivalent (MME) Limits for daily opioid dosages to 90 MME; higher doses require prior authorization
- Cumulative Stimulant Limits
- Concurrent Drug Utilization Review (cDUR) at point of sale
Additional Information
Visit the Pharmacy Information section of the AmeriHealth in New Jersey or Pennsylvania website and the Prescription drug information section of the AmeriHealth Administrators for detailed formularies, policies, and prescribing resources.
Your health plan uses an independent company to provide pharmacy benefits management services.
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