In 2024, AmeriHealth HMO, Inc. and AmeriHealth Insurance Company of New Jersey (collectively, AmeriHealth) will supply providers across our network with information about Medicare Part D formulary changes that go into effect January 1, 2025. This includes resources to help providers determine specifically which prescribed drugs are changing and how this could impact our Medicare Advantage members next year.
In addition, the AmeriHealth Member Help Team (MHT) is reaching out to our Medicare Advantage members to provide information, education, and updates. Our goal is to help prepare our members and providers as much as possible for these formulary changes.
Drug Cost-Sharing by benefit year for Preferred Pharmacies
| 1 |
$0 Copay |
$0 Copay |
Neutral |
|
2 |
$7 / $8 Copay |
$0 Copay |
Positive |
|
3 |
$47 Copay |
25% Coinsurance |
Typically Negative |
|
4 |
$100 Copay |
50% Coinsurance |
Typically Negative
|
|
5 |
33% Coinsurance* |
33% Coinsurance† |
Neutral |
In this example:
Tier 2 generic drugs (using a Preferred Pharmacy) will have a $0 copay. If a member fills the prescription at a standard pharmacy, a copay will apply.
Tier 3 preferred brand and Tier 4 non-preferred brand drug costs will be changing from copays to coinsurance. That means our Medicare Advantage members will pay a percentage of the full cost of the drug (which can vary from month to month).
Some AmeriHealth plans have a pharmacy deductible on Tier 3, Tier 4, and Tier 5 drugs. This means members with plans that have a deductible will have to pay out of pocket until their deductible is met before they will benefit from having drug coinsurance.
Members (those on plans without pharmacy deductibles) will benefit from having a drug copay or coinsurance at the start of the year, rather than having to pay out of pocket until their deductible is met.
Five changes that can impact the formulary
The formulary is a list of drugs covered by AmeriHealth that are chosen based on effectiveness, safety, and value. A local group of network physicians and pharmacists, known as the Pharmacy and Therapeutics Committee, regularly reviews this drug list. AmeriHealth can only make changes to its formulary with approval from this committee and the Centers for Medicare & Medicaid Services (CMS).
There are five changes that can impact our formulary each year:
-
A drug can be removed from the formulary
Non-formulary (NF) indicates that a
drug
has been
removed
from
the
formulary. -
A drug can have new prior authorization requirements
Prior authorization (PA) means a prescriber will need to request and get approval from AmeriHealth before the drug will be covered. -
A drug can have new step therapy requirements
Step therapy (ST) means a member may need to try one or more other drugs first to see if they work for them before the plan can keep covering the drug they are currently taking. -
A drug can have restrictive quantity limits
Quantity limits (QL) are rules on how much of a drug a member can get at a time. -
A drug's tier can change
Tier changes (TC) mean a drug will move from one cost-sharing tier on the formulary to another, possibly increasing the cost.
These changes are not effective until January 1, 2025.
For more information
To stay up to date, please check the AmeriHealth Pharmacy & IRA resource page, found on the right of the Provider News Center, for information and updates.
*In 2024, coinsurance for various AmeriHealth Medicare Advantage plans ranges from 25-33% for Tier 5.
†In 2025, coinsurance for various AmeriHealth Medicare Advantage plans will range from 30-33% for Tier 5.
24-0223