AmeriHealth Medicare PPO 2025 Formulary (Drug List)
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This document is the AmeriHealth Medicare PPO 2025 Formulary describing which prescription drugs are covered, applicable coverage restrictions (prior authorization, quantity limits, step therapy), and how members or prescribers can request exceptions or transition supplies. It applies to AmeriHealth Medicare PPO members and participating network pharmacies.
No material clinical or coverage changes in this revision.
Formulary Coverage & Application
inv-01: Standard Formulary Coverage — Covered when ALL of the following are met
Covered when ALL of the following are met:
ALL of the following
- The drug is listed on the AmeriHealth formulary or a formulary exception has been approved.
- The prescription is filled at an AmeriHealth Medicare PPO network pharmacy (or other network delivery channel allowed by the plan).
- The drug is medically necessary for the member as determined by the prescriber and consistent with accepted standards of care.
- Any applicable utilization management requirements (Prior Authorization, Step Therapy, Quantity Limits, Non-Extended Day Supply) are satisfied at the time of dispensing.
inv-03: General formulary coverage logic — Coverage is agent-specific and subject to tier assignment, quantity limits (QL), and prior authorization (PA) where indicated.
Coverage is agent-specific and subject to tier assignment, quantity limits (QL), and prior authorization (PA) where indicated.
ALL of the following
- Each formulary row reflects the drug, strength, formulation, tier, and any Requirements/Limits annotations (e.g., PA, QL, ST, NDS, NF).
- Coverage availability and member cost-share are determined by the assigned formulary tier and any utilization controls shown in the Requirements/Limits column.
- Non-Formulary (NF) drugs are not covered under the plan unless a formulary exception is approved; members may request exceptions per plan procedures.
- When multiple formulations or strengths exist, utilization controls may vary by formulation; follow the specific row-level Requirements/Limits for coverage determinations.
inv-04: Formulary tier and control application — Coverage and utilization controls as listed in the formulary table (by drug/formulation/strength).
Coverage and utilization controls apply as listed in the formulary table (drug/formulation/strength specific).
ALL of the following
- Providers and pharmacies must follow the Requirements/Limits annotations shown for each drug (e.g., PA, QL, ST, NDS).
- Prior Authorization (PA) must be obtained prior to dispensing when indicated; if PA is not obtained, the claim may be denied.
- Quantity Limits (QL) restrict the maximum quantity covered per time period and are applied per the formulary row.
- Step Therapy (ST) requires trial of specified agents prior to coverage of alternative agents when noted.
inv-05: Coverage logic per formulary row — Formulary coverage with utilization management
Formulary coverage is applied per row and may include utilization management annotations.
ALL of the following
- When a drug row includes multiple annotations (e.g., PA; QL; NDS), all listed controls apply concurrently unless otherwise noted in the plan guidance.
- Non-Extended Day Supply (NDS) indicates limits on days supplied (commonly applied to opioids) and may be enforced at retail and mail order per plan policy.
- For opioid medications, opioid-specific limits (NDS, QL, PA) described in the formulary and plan opioid policy must be followed for dispensing and refills.
inv-06: Formulary utilization management — Coverage and utilization management determined by formulary annotations; drugs listed may be covered subject to listed tier, PA, ST, and QL.
Coverage and utilization management are determined by formulary annotations; drugs listed may be covered subject to listed tier, PA, ST, and QL.
ALL of the following
- Members and providers may request a formulary exception for Non-Formulary (NF) drugs; exceptions are evaluated per AmeriHealth exception procedures and medical necessity criteria.
- Formulary designations (covered tiers, NF) and annotations (PA, QL, ST, NDS) are binding for benefit determination unless an approved exception or other coverage policy applies.
- Pharmacies should verify the member’s specific plan benefit and any active authorizations prior to dispensing to avoid claim denials and member liability.
inv-07: COVERAGE CRITERIA — Non-Formulary (NF) drugs are not covered under the plan unless a formulary exception is approved.
Transition and Emergency Supply — temporary coverage allowances when a member needs immediate access to medication.
ANY of the following
- Transition supply: When a member is newly enrolled or when a drug’s formulary status changes, the plan may permit a one-time transition supply (up to a time-limited quantity) to allow the member to continue therapy while PA/ST or a formulary exception is obtained; the exact allowed quantity and duration follow plan transition rules.
- Emergency supply: Pharmacies may dispense a limited emergency supply when a delay in obtaining prior authorization, a refill authorization, or access to a network pharmacy would result in an interruption of clinically necessary therapy; emergency fills are limited to the lesser of the prescriber-intended quantity or a plan-defined short-term supply (commonly a 72-hour to 30-day supply depending on the drug class and plan rules).
- Opioid-specific emergency/transition rules: For opioid medications, Non-Extended Day Supply (NDS) and opioid quantity limits still apply; emergency supplies must comply with opioid safety and dispensing limits defined by the plan and applicable regulations.
- Documentation and follow-up: Emergency or transition supplies should be accompanied by documentation of the reason for the supply (e.g., new enrollment, pending PA, urgent need). Providers must complete any required PA or submit needed clinical information within the plan-specified timeframe to continue coverage beyond the transition/emergency supply period.
- Member notification and cost-sharing: Members should be informed that transition or emergency supplies are temporary; standard cost-sharing applies unless otherwise specified by the plan, and ongoing therapy requires meeting applicable utilization management requirements.
inv-08: COVERAGE CRITERIA — Drugs labeled 'NF' are designated as not formulary in this listing (examples noted).
Drugs labeled 'NF' are designated as not formulary in this listing (examples noted).
ALL of the following
- An NF designation means the drug is not included in the formulary and is not covered unless an exception is granted following the plan’s exception process.
- Members and prescribers may request a formulary exception when a medically appropriate alternative is not available or has failed; exception requests must include clinical justification and supporting documentation.
inv-16: COVERAGE CRITERIA — No explicit 'Not Medically Necessary' (NMN) determinations present in these chunks.
No explicit 'Not Medically Necessary' (NMN) determinations are present in these formulary chunks. Coverage determinations rely on formulary status and utilization controls.
ALL of the following
- Where a service or drug is not listed as covered (NF) or exceeds utilization controls, providers may submit supporting clinical documentation for review under the plan’s exception or appeal processes.
- Standard medical necessity and benefit-check processes apply for requests outside formulary listings; decisions will be made per AmeriHealth clinical and coverage policies.
Prior Authorization, Step Therapy & Documentation Requirements
Obtain Prior Authorization for PA‑flagged drugs
Certain drugs require prior authorization; providers must obtain approval from AmeriHealth Medicare PPO before the prescription will be covered.
Get PA before dispensing
Prior authorization is required for listed drugs; members or providers must secure prior approval before filling prescriptions or coverage may be denied.
PA required for select hepatitis C agents (EPCLUSA, MAVYRET)
Drugs marked 'PA' and specific hepatitis C agents (e.g., EPCLUSA, MAVYRET) include PA flags and QL entries; prescribers must follow the PA process before these products will be covered.
- EPCLUSA entries show 'PA; QL (168 EA per 365 days)' and 'PA; QL (84 EA per 365 days).
- MAVYRET entries are marked 'PA' with QL (560 EA per 365 days) for packets and QL (336 EA per 365 days) for tablets.
PA required for many oral oncology drugs
Many oral oncology agents in the formulary are designated 'PA'; prescribers must obtain prior authorization for these antineoplastic drugs prior to coverage.
- Examples include ALECENSA, ALUNBRIG, AYVAKIT (PA; some with QL), and multiple other oral antineoplastics shown with 'PA'.
Follow Step Therapy when 'ST' is indicated
Some drugs are subject to step therapy (ST); members must try specified alternative drugs first before coverage of a non‑preferred drug is provided.
- Where products are annotated 'ST' the plan requires trial of preferred agent(s) before covering the listed product.
Document prior therapy for ST exceptions
Step Therapy may require trying specified alternative drug(s) first (Drug A before Drug B) — the prescriber must document prior steps have been tried and failed or were intolerable before the plan will cover the next‑step drug.
- Plan documentation and prior therapy evidence should be provided when requesting coverage of the next‑step agent.
Coverage may be denied without PA
Failure to obtain required prior authorization may result in AmeriHealth Medicare PPO not covering the drug.
PA not obtained → denial risk
If Prior Authorization (PA) is required and not obtained, the plan may deny coverage for the drug — prescribers must submit PA before dispensing to avoid denial.
See page 6 for symbol legend
Consult the formulary legend on page 6 for definitions of symbols and abbreviations used in the Requirements/Limits column (e.g., NF, PA, QL, ST, numeric tiers).
- Refer to page 6 of the formulary for the full symbol/abbreviation legend.
Provide prescriber supporting statement for exceptions
A prescriber's supporting statement is required when requesting a formulary or tiering exception; standard decision timeframe is generally 72 hours and expedited requests may be decided within 24 hours.
- Prescriber must explain medical reasons for the exception; plan generally decides within 72 hours of receiving the supporting statement.
- If expedited, the plan must decide within 24 hours after receiving the prescriber's supporting statement.
Follow the Requirements/Limits field on the formulary
Providers must follow the Requirements/Limits column on the formulary for each drug; entries indicate if PA, QL, ST, NDS, or NF apply and determine what documentation or authorization is needed.
- Use the Requirements/Limits field on the formulary row to identify necessary prior authorization, quantity limits, or step therapy requirements.
Submit PA with required documentation for PA‑flagged strengths
Products flagged 'PA' require prior authorization; formulary rows list strength‑level PA flags that prescribers must follow when submitting authorization requests.
- Examples in the table show PA adjacent to specific strengths and formulations (e.g., armodafinil entries labeled 'PA; QL').
Adhere to Quantity Limits (QL) or request exception
Prescriptions that exceed the listed quantity limit (QL) may be denied or require additional review; providers should adhere to the specified QL or request an exception with supporting documentation.
- Examples of QLs include QL (30 EA per 30 days), QL (60 EA per 30 days), QL (180 EA per 30 days); exceeding these limits may trigger coverage limits or denial.
PA/QL enforcement may cause denial
Claims for drugs noted with 'PA' and for prescriptions exceeding specified QLs are subject to denial if prior authorization is not obtained or quantity limits are exceeded.
Codes, Flags & Quantity Examples
| albuterol sulfate HFA inhalation aerosol 108 mcg/act | NF; QL (13.4 GM per 30 days) |
| albuterol sulfate nebulization solution 2.5 mg/3ml | Tier 2; PA; QL (13.4 GM per 30 days) |
| arformoterol tartrate inhalation nebulization solution | Tier 4; PA; QL (13.4 GM per 30 days) |
| morphine sulfate (concentrate) oral solution 100 mg/5ml | Tier 2; NDS; QL (150 ML per 30 days) |
| morphine sulfate oral solution | NDS; QL (1000 ML per 30 days) |
| morphine sulfate ER oral tablet extended release 15-100 mg | NDS; QL (90 EA per 30 days) or NDS; QL (180 EA per 30 days) depending on strength |
| oxycodone HCl oral concentrate 100 mg/5ml | NDS; QL (180 ML per 30 days) |
| oxycodone HCl oral solution | NDS; QL (900 ML per 30 days) |
| oxycodone HCl oral tablet | NDS; QL (180 EA per 30 days) |
| methadone HCl oral tablet | PA; NDS |
| diazepam intensol oral concentrate | QL (240 ML per 30 days) |
| diazepam oral solution 5 mg/5ml | QL (1200 ML per 30 days) |
| eszopiclone oral tablet 1-3 mg | PA; QL (30 EA per 30 days) for 3 mg; QL (30 EA per 30 days) for 1-2 mg |
| aprepitant oral capsule 40/80/125 mg | PA; QL (4-12 EA per 30 days depending on strength) |
| budesonide inhalation suspension | PA; QL (120 ML per 30 days) |
| BREZTRI AEROSPHERE INHALATION AEROSOL | QL (23.6 GM per 28 days) |
Step Therapy Placement & Notes
| Policy Point | Description |
|---|---|
| Step therapy applies when plan requires trying certain drugs first | |
| Members must try specified alternative (preferred) agent(s) before coverage will be provided for a non-preferred drug; if the preferred agent is ineffective or not tolerated, coverage for the next-step drug will be considered | |
| See the formulary Requirements/Limits column for entries marked 'ST' to identify which products have step therapy |
| Examples (product/presentation) | Formulary annotation |
|---|---|
| TOPAMAX (topiramate) — various oral forms (sprinkle, ER, tablets) | |
| XCOPRI (cenobamate) — therapy packs and tablets | |
| VIGAFYDE oral solution — listed with ST | |
| Savella and Fanapt (as noted elsewhere in formulary) — marked ST in entries |
| Product | Formulary annotation / requirement |
|---|---|
| SANCUSO transdermal patch | |
| Requirements/Limits: ST; QL (4 EA per 28 days) — step therapy required prior to coverage |
| Tier note | Interpretation |
|---|---|
| Numeric tiers (1–5) shown adjacent to many products | |
| Tier placement indicates relative formulary placement (preferred vs non-preferred) but the excerpt does not specify multi-step sequences tied to tier numbers | |
| Some high-cost or specialty agents are placed on higher tiers (3–5) and may be subject to PA or step requirements per the Requirements/Limits column |
Per-Product Quantity Limits (selected examples)
Formulary Site-of-Care Notes
Document site‑of‑care for outpatient/home formulations
Many agents listed include formulations intended for outpatient/home use (oral tablets/capsules, transdermal patches, subcutaneous auto‑injectors); ensure appropriate site‑of‑care documentation when submitting claims or prior authorization requests.
- Examples include oral tablets, transdermal patches, and subcutaneous auto‑injectors intended for home administration.
Key Terms & Abbreviations
Formulary Scope & Structure
This formulary groups medications by medical condition and lists each drug line with a Tier and Requirements/Limits column. Requirements and limits include flags such as PA (prior authorization), QL (quantity limits), ST (step therapy), and NF (non‑formulary). The document therefore defines which drugs are covered and indicates any utilization management (e.g., PA or QL) that must be satisfied for coverage.
Biosimilar Substitution & Policy
Biosimilar substitution and tier changes — document exceptions if needed
The plan may immediately replace an original biological product with a biosimilar (including interchangeable biosimilars) and may move the original biologic to a different tier; providers may request an exception to continue the original product.
- If a biosimilar is added, the plan can substitute or change tiering for the original biologic without advance notice; prescribers can request an exception to maintain the original product.
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