Prior Authorization Required

AmeriHealth Medicare PPO requires prior authorization (PA) for many drugs listed in the formulary. Prescribers or members must obtain approval from AmeriHealth Medicare PPO before dispensing PA‑designated drugs; claims may be denied or not covered if PA is not obtained.

• Applies to drugs marked 'PA' in the formulary Requirements/Limits column.
• Failure to obtain PA may result in claim denial or non‑coverage.

Prior Authorization for Select Antifungals

Certain antifungal agents and formulations in the formulary are designated PA. Prescribers should check the Requirements/Limits column for PA flags (examples in the antifungals section include amphotericin B liposome, CRESEMBA, posaconazole delayed‑release tablets). Obtain PA prior to dispensing these antifungals.

• Examples: amphotericin B (PA), CRESEMBA (PA), posaconazole oral tablet delayed release (PA).
• Check formulary entries for the 'PA' symbol and follow PA process before fill.

Prior Authorization Required for PA‑Marked Drugs

Any drug in the formulary marked 'PA' requires prior authorization before the plan will cover it. This includes many specialty, oncology, antiviral, CNS, and other agents. Verify PA status at claim adjudication and submit required documentation.

• 'PA' appears across multiple drug classes — verify per‑product requirements before dispensing.
• PA applies to both brand and generic products when indicated in the Requirements/Limits column.

Prior Authorization for Specialty/Oncology Drugs

Many specialty and oncology agents are subject to PA and often also to quantity limits. Prescribers must obtain PA for these agents and include clinical rationale supporting the requested therapy.

• Examples: numerous oral oncology therapy packs and specialty oral agents marked 'PA' (see formulary oncology sections).
• Quantity limits (QL) frequently accompany PA for oncology agents — document dosing and duration in PA submission.

Prior Authorization Required for Some Listed Products

Some listed products across the formulary (vaccines, specialty injectables, lipid agents, CNS agents, etc.) are designated 'PA' — obtain PA before claim submission to avoid denials.

• Examples: certain vaccines (e.g., ENGERIX‑B) show PA; select lipid agents and specialty injectables show PA with QL.
• Follow plan PA process for listed products prior to dispensing.

Prior Authorization Required for Select Agents

Select agents such as specialty lipid therapies and other high‑cost drugs are subject to prior authorization and quantity limits. Providers should confirm PA and QL when prescribing these agents.

• Examples: REPATHA, PRALUENT and similar agents are marked PA with specified QL.
• Include clinical justification and prior therapy history when requesting PA.

Prior Authorization Indicated for Some Agents

Certain stimulant, wakefulness, and other agents are indicated as requiring PA in the formulary. Confirm PA requirements and submit supporting medical documentation as part of the authorization request.

• Examples include modafinil/armodafinil entries with PA and QL.
• Prescribers should document prior therapies and diagnosis to support PA.

Prior Authorization Required for Some Drugs

Some drugs (e.g., UBRELVY, sodium oxybate, others) are listed with PA and accompanying quantity limits; an approved PA is required to avoid claim denial.

• UBRELVY: PA; QL example provided in formulary.
• Sodium oxybate: PA with QL (540 mL per 30 days).

Prior Authorization Required for Select Drugs

Select branded products are specifically marked 'PA' in the formulary and require authorization prior to coverage. Verify PA status for these products at point of prescribing or claims submission.

• Examples: LYBALVI, NUPLAZID show PA with QL in entries.
• Confirm PA and obtain authorization number when approved.

PA and QL May Trigger Denials

The formulary uses PA, QL, ST and NF flags. PA and QL flags may trigger claim denials if requirements are not met; providers must follow the flags and submit authorization requests with necessary documentation.

• PA and QL without an approved authorization can result in denial or non‑coverage.
• ST (step therapy) flags may require trials of preferred agents before coverage of non‑preferred agents.

Prior Authorization Indicated on Many Specialty Drugs

Prior authorization is indicated for many specialty drugs listed throughout the formulary; these frequently include oncology, hematology, rare disease and similar high‑cost therapies. Obtain PA prior to dispensing to prevent denials.

• Numerous specialty agents are labeled 'PA' across the oncology and specialty sections.
• PA requests should include diagnosis, prior treatments, and rationale for the requested agent.

Prior Authorization Triggers for Selected Vaccines

Some vaccines and vaccine formulations are designated PA in the formulary. Verify PA for specific vaccine presentations (e.g., certain formulations of ENGERIX‑B) before administration or billing.

• Check vaccine entries in the formulary Requirements/Limits column for PA flags.
• Obtain authorization when vaccine product row indicates PA to avoid non‑coverage.

PA and QL May Trigger Denial

PA flags combined with QL restrictions may lead to denial if the requested quantity exceeds the plan limit or if no PA is on file. Providers should review and adhere to QL values shown in the formulary.

• Examples: REPATHA QL 3 mL/28 days with PA; sodium oxybate QL 540 mL/30 days with PA.
• If a requested fill exceeds QL, include supporting clinical justification when requesting an exception.

Quantity Limit Enforcement

The formulary specifies quantity limits (QL) for many products. Prescribers and pharmacists must observe these limits; dispensing beyond the QL requires PA or an approved exception.

• Examples shown across multiple sections (e.g., QL 60 EA per 30 days for many products).
• Quantity limits appear in the Requirements/Limits column per product.

Documentation Required for PA/QL Requests

When requesting prior authorization or seeking an override of a quantity limit, providers must submit supporting documentation and clinical rationale. Document dosing, duration, prior therapies, and medical necessity in the PA request.

• Supporting statement from prescriber is required for exception requests; decisions generally within 72 hours (24 hours for expedited).
• Include prior therapy history and medical rationale when requesting PA/QL exceptions.

Document PA Approvals and Quantity Justification

Document and retain authorization details (authorization number, approval scope, approved quantity and duration) and include clinical justification for any QL exceptions. This reduces risk of claims denial at adjudication.

• Include authorization number on claims when required.
• Supply clinical notes showing need for quantities beyond listed QL when seeking exception.

Use of Formulary Flags

The formulary uses flags (PA, QL, ST, NF, NDS) to indicate utilization controls. Providers must interpret and follow these symbols per the formulary legend (see page 6) when prescribing and billing.

• PA = Prior Authorization, QL = Quantity Limit, ST = Step Therapy, NF = Non‑Formulary, NDS = Non‑Extended Day Supply.
• Refer to the formulary legend (page 6) for complete definitions.

Use Formulary Legend for Interpretation

Refer to the formulary legend (page 6) for symbol definitions and interpretation guidance. Follow the flags shown in each product row to determine whether PA, QL, ST or other limits apply.

• Legend clarifies meanings of PA, QL, ST, NF, NDS.
• Use the legend to resolve any ambiguity in product entries.

Documentation for PA/QL/ST Items

For items flagged with PA, QL, or ST, providers should submit the required documentation and clearly indicate the utilized flag in the request. Keep records of approvals to present at claims adjudication if needed.

• PA/ST/QL items require documentation including diagnosis, prior therapies, and intended dosing.
• Retain approval documentation and authorization numbers for claim submission.

Follow Formulary Flags and Page‑6 Legend

Follow the plan's formulary flags and the page‑6 legend when determining prior authorization, quantity limits and step therapy applicability. The formulary entries drive coverage decisions at the time of claim adjudication.

• Coverage determination is contingent on meeting PA/QL/ST requirements shown in each product row.
• When in doubt, contact AmeriHealth Medicare PPO or consult the online PA/ST guidance referenced in the formulary.

Quantity Limits Documentation

The formulary contains many explicit quantity limits; providers should document clinical rationale when requesting quantities exceeding those limits. QL values are shown per product in the Requirements/Limits column.

• Examples include therapy pack and per‑period QL values (e.g., QL 84 EA per 365 days, QL 120 EA per 30 days).
• Include justification for exceptions when requesting QL increases.

Step Therapy Is Required for Some Drugs

Step therapy (ST) is required for some drugs and therapy packs indicated in the formulary. Where ST is shown, members may need to try specified preferred drugs first before coverage of the designated agent.

• Examples: XCOPRI therapy packs and certain psychiatric medication titration packs are marked 'ST'.
• When ST applies, document trials of preferred agents or submit an exception request with clinical rationale.

Step Therapy Not Explicitly Detailed

The formulary does not always provide explicit step‑therapy algorithms in this excerpt. Tier placement and flags imply sequencing but detailed step requirements are available in the plan's PA/ST guidance documents.

• Some entries show tiers and QL but not explicit step sequencing.
• Consult the plan's online documents or contact AmeriHealth for specific ST criteria.

Possible Step Edits (No Explicit Rules)

At claims adjudication, step edits may be applied based on tiers, PA and ST flags even if explicit step rules are not printed in the product row. Providers should anticipate possible step edits and submit supporting documentation.

• Tier placement can imply preference and trigger step edits.
• If a claim is denied for ST, submit documentation of prior trials or request an exception.

Tier Placement May Imply Step Requirements

Formulary tier placement can imply preferred agents and may affect step therapy application; higher tier products are more likely to have PA/ST or QL requirements. Review tier and flaging together when prescribing.

• Tiers indicate cost‑sharing and may reflect preferred sequencing.
• Use tier + flag information to determine if step therapy likely applies.

Formulary Tiers Imply Preferred Agents

Formulary tiers identify preferred agents by tier but do not replace explicit step therapy criteria; use the formulary and PA/ST guidance together to determine coverage sequencing.

• Tiers show preferred agents; ST flags indicate where step therapy applies.
• When requesting an exception, prescribers must provide supporting medical rationale.

Step Therapy Flagged Items

Some products are specifically flagged 'ST' in the formulary indicating step therapy applies (examples include SAVELLA, XCOPRI therapy packs, SANCUSO patch, EXXUA, FANAPT, FETZIMA titration packs). Providers must ensure step requirements are met or request an exception.

• Examples: SAVELLA = ST; XCOPRI therapy packs = ST; SANCUSO TRANSDERMAL PATCH = ST.
• If ST conditions are not met, submit a step‑therapy exception with prescriber's supporting statement.

Step Therapy Indicated for Some Agents

Step therapy is indicated for some agents and therapy packs; when ST applies, document prior use of required first‑line agents or request an exception with medical justification.

• Examples: EXXUA titration pack, FANAPT titration packs, FETZIMA titration pack marked ST.
• Provide documentation of trials and outcomes to support exceptions.

Step Therapy Applies to Select Products

Step therapy applies to select branded and therapy‑pack products; follow ST flags when prescribing and advise patients that prior trials of preferred drugs may be required for coverage.

• ST applies to some titration packs and branded products (listed on their product rows).
• Contact AmeriHealth or consult the PA/ST guidance for the required prior agents.

Step Therapy Examples

Examples of products with ST include SANCUSO TRANSDERMAL PATCH, XCOPRI therapy packs, SAVELLA and various titration packs for psychiatric/neurology agents. Confirm ST applicability before dispensing.

• SANCUSO TRANSDERMAL PATCH = ST; XCOPRI = ST; SAVELLA = ST.
• When ST applies, ensure required step(s) have been met or submit exception documentation.

Exception Request Supporting Statement Required from Prescriber

When requesting an exception to PA, ST, or QL, the prescriber must provide a supporting statement explaining the medical necessity. AmeriHealth generally decides within 72 hours of receiving the prescriber's supporting statement (24 hours for expedited requests).

• Prescriber's supporting statement should explain why alternative/formulary drugs are not appropriate.
• Expedited exceptions may be requested if waiting could seriously harm the patient.