CurrentAmeriHealthPolicy N/A

Formulary Exception Prior Authorization Request Form

A required provider form to request formulary exceptions or prior authorizations for medications (including non-preferred, CHIP tier exceptions, and compounded products) for AmeriHealth members. It applies to providers submitting requests on behalf of members in the payer's jurisdiction.

Policy Summary

PayerAmeriHealth

PolicyFormulary Exception Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProvide complete provider, medication, and clinical information including diagnosis with ICD-10 code and documentation of trials of at least three alternatives when requesting non-preferred tier exceptions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3tier exception types

3required info sections

3min alternatives

Coverage Criteria

Form submission and tier-exception criteria

Formulary exception requests are considered when the provider supplies complete clinical information and documents required alternative trials or prior authorization status as applicable.

Submission completeness: Form must include provider information, medication information (name, strength, dosage form, directions), clinical diagnosis with ICD-10 code(s), and any required attachments or comments.complete submission

Incomplete submissions may be denied.

Non-preferred tier exception criteria: For brand-to-preferred or non-preferred generic-to-generic tier exceptions, the patient must have an inadequate response or inability to tolerate at least three preferred or generic tier alternatives in the same pharmacologic class, unless the medication is used to treat stage four/advanced metastatic cancer or a severe adverse health condition resulting from it.>=3 failed alternatives or metastatic cancer indication

Provider must specify all alternatives tried.

Policy Summary

PayerAmeriHealth

PolicyFormulary Exception Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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No specific clinical exclusions are listed on the form. However, requests for Non‑Preferred tier exceptions and other tier exception types require documentation of prior trials of alternatives or a qualifying clinical indication. For Non‑Preferred drug tier exceptions the form asks whether the patient has had an inadequate response or intolerance to at least three preferred or generic alternatives in the same pharmacologic class, unless the medication is used to treat stage four, advanced metastatic cancer or a severe adverse health condition resulting from it. For Non‑Preferred compounded product tier exceptions the form asks whether a prior authorization was previously approved for the compound and whether the patient has had inadequate response or inability to tolerate all other formulary alternatives; providers must specify those alternatives.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization may be required for certain medications. Submit complete clinical and administrative information to avoid processing delays.

If prior authorization is required, include all requested clinical documentation and completed forms.

Denial Risk

Incomplete Submission May Be Denied

Incomplete or missing information may result in denial of the request. Ensure all required fields and attachments are included before submission.

Required patient and provider details (see form): Member name, DOB, Insurance ID, Provider name, NPI, specialty, office phone, fax, and full address.
Include medication details: name, strength, dosage form, directions, and indication if continuation of therapy.
Attach relevant clinical documentation: diagnoses with ICD‑10 codes, prior medication history, and reason for failure or intolerance of alternatives.

Step Therapy

Step Therapy / Alternatives Documentation

Step therapy and alternative-trial documentation must be provided for tier-exception requests. For non-preferred and CHIP tier exceptions, document trials of formulary alternatives.

Non‑Preferred drug tier exception: Document inadequate response or intolerance to at least three preferred or generic-tier alternatives in the same pharmacologic class; list all alternatives and dates/trial durations.
CHIP tier exception: Document inadequate response or intolerance to at least three generic alternatives in the same pharmacologic class; list all alternatives and dates/trial durations.
Non‑preferred compounded products: Indicate whether prior authorization for the compound was previously approved and document trials of all other formulary alternatives.
Provide clinical rationale if fewer than the listed trials are possible (e.g., allergies, contraindications) and attach supporting records.

Documentation Required

Required Form Fields and Attachments

Required form fields and attachments: provide complete member and provider information and supporting documents to substantiate medical necessity.

Provider information: Member name, provider name, insurance ID#, NPI#, specialty, DOB, office phone, office fax, street address, city, state, ZIP.
Medication information: medication name, strength, dosage form, indication, directions for use, and whether generic substitution is acceptable.
Clinical information: diagnoses and ICD‑10 code(s); documentation of trials, dates, and outcomes for prior therapies; reason for request and any relevant notes.
Attach any additional supporting records (office notes, lab results, prior authorization approvals).

Note

Incomplete Requests and PHI Notice

Use this completed form and include all attachments. Missing the required fields or documentation may cause the request to be returned or denied.

The request may be denied unless all required information is received.
If you received this form in error, do not distribute PHI and notify the sender immediately.

Requirement	Provider action
Specify all alternatives tried/failed
List each preferred or generic alternative tried (name and outcome). For non-preferred tier exceptions: document inadequate response or intolerance to at least three preferred or generic alternatives in the same pharmacologic class. For CHIP tier exceptions: document inadequate response or intolerance to at least three generic alternatives in the same pharmacologic class.

OpenPayer

Formulary Exception Prior Authorization Request Form

Coverage Criteria

Coding

Provider Actions & Requirements

Continuation Therapy Criteria

Step Therapy / Alternatives