AmeriHealth Medicare PPO 2026 Formulary (Drug List)
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This document describes the AmeriHealth Medicare PPO 2026 formulary, including coverage rules (prior authorization, step therapy, quantity limits), member exception and transition supply rights, and where to find drug coverage information for plan members and their prescribers/pharmacies.
No material clinical or coverage changes in this revision.
Coverage Criteria & Formulary Rules
inv-01: General Coverage Conditions
Covered when ALL of the following are met:
Based on formulary definition and coverage statement.
inv-02: Formulary Exception Timelines
Decision timing for exception requests:
Prescriber must provide supporting clinical statement with the request.
inv-03: Transition and Emergency Supply
Temporary coverage during member transitions or new membership:
If coverage is not approved after the first 30-day supply, the plan will not pay subsequently; LTC residents may receive a 31-day emergency supply.
inv-04: Formulary listing (coverage with criteria flags)
Formulary coverage with utilization management annotations:
Excerpt shows presence of PA/QL/NF per line but does not include full clinical criteria or step sequences.
inv-05: Tier assignments and formulary flags
Formulary coverage and restrictions by product/strength:
Refer to symbol definitions (see page 6) for full meaning of NF, PA, QL, ST, NDS.
inv-06: Prior authorization and quantity limits
Utilization management requirements where specified:
Providers must follow payer PA process and respect listed QL when adjudicating claims; exceeding QL may trigger PA or denial.
In the formulary table the notation Non-Formulary (NF) indicates that the drug is not covered under the AmeriHealth Medicare PPO plan. Members and prescribers may request a Formulary Exception if a medically necessary reason exists for coverage of an NF drug; the exception process and required supporting statement are described elsewhere in the formulary.
The extracted formulary lines in this segment do not include discrete medical‑necessity criteria or indication‑specific exclusion language. Entries are limited to the drug name and the Tier Requirements/Limits column showing tier placement and annotations such as PA (prior authorization) and QL (quantity limit); clinical PA criteria are not provided in these chunks.
Multiple individual formulary rows in this extract are annotated with NF in the Tier Requirements/Limits column. Each line marked NF denotes that particular product/strength is classified as non‑formulary (not included on the plan’s drug list).
A drug designated Non‑Formulary (NF) is not covered by the plan unless the member obtains an approved formulary exception. Failure to secure an approved exception means the plan may not pay for the NF drug.
Coding and Selected Codes
| PAXLOVID (150/100) ORAL TABLET THERAPY PACK | Tier Requirements/Limits = QL (20 EA per 5 days) |
| PAXLOVID (300/100 & 150/100) ORAL TABLET THERAPY PACK | Tier Requirements/Limits = QL (11 EA per 5 days) |
| PAXLOVID (300/100) ORAL TABLET THERAPY PACK | Tier Requirements/Limits = QL (30 EA per 5 days) |
| EPCLUSA ORAL PACKET 150-37.5 MG | Tier Requirements/Limits = PA; QL (84 EA per 365 days) |
| EPCLUSA ORAL PACKET 200-50 MG | Tier Requirements/Limits = PA; QL (168 EA per 365 days) |
| EPCLUSA ORAL TABLET 200-50 MG | Tier Requirements/Limits = PA; QL (168 EA per 365 days) |
| QL (240 EA per 30 days) | Quantity limit for ENTRESTO oral capsule sprinkle |
| QL (60 EA per 30 days) | Quantity limit shown for sacubitril-valsartan and tadalafil (as listed) |
| QL (30 EA per 30 days) | Quantity limit shown for VERQUVO and some valsartan 320 mg |
| PA; QL (360 EA per 30 days) | PA and QL shown for sildenafil 20 mg |
| PA; QL (450 ML per 30 days) | PA and QL shown for CORLANOR oral solution |
| PA; QL (60 EA per 30 days) | PA and QL shown for tadalafil (PA; QL (60 EA per 30 days)) |
Provider Actions, Authorization & Documentation
Prior Authorization Required
Prior Authorization (PA) is required for many drugs listed in the formulary. When a drug row shows the "PA" symbol in the Requirements/Limits column, the prescriber or member must obtain approval from AmeriHealth before the prescription is filled. Failure to obtain required PA may result in the plan denying coverage for the drug.
- Check the Requirements/Limits column in the formulary for "PA" before prescribing or dispensing.
- Obtain prior authorization before filling PA‑flagged products to avoid claim denial.
Quantity Limits May Trigger Authorization
Quantity limits (QL) shown in formulary rows may restrict the amount covered and can trigger the need for authorization or an exception if a higher quantity is clinically necessary. QLs must be documented on claims and on authorization requests.
- Examples: QL (84 EA per 28 days), QL (168 EA per 365 days), QL (10 ML per 30 days).
- Document the requested quantity and clinical rationale when requesting PA or an exception for amounts above the QL.
PA for Specialty and Select Formulations
Many specialty, oncology, and select formulations are PA‑flagged (showing "PA" and often a QL). Providers should anticipate PA requirements for specialty oral agents, injectables, transdermal patches, and certain solutions.
- Specialty oncology examples: PIQRAY, ROZLYTREK, RUBRACA, RYDAPT, SCEMBLIX (PA; QL noted on some strengths).
- Specialty examples across the formulary include many oral targeted therapies and high-cost agents listed with PA.
Prior Authorization Applies to Specific Products
Some common products and classes have specific PA or QL rules (for example, select erythropoiesis-stimulating agents, sodium oxybate, EMSAM, NUEDEXTA, and VMAT2 inhibitors). Review formulary rows for PA and QL flags before ordering or dispensing.
- Examples: DOPTELET and PROCRIT list PA or QL requirements; sodium oxybate and EMSAM show PA; AUSTEDO/AUSTEDO XR show PA; XDEMVY listed as PA; QL (10 ML per 30 days).
- If a product is PA‑flagged, submit an authorization request with clinical documentation prior to dispensing.
Opioid Supply, PA and Quantity Limits
Selected opioids and long‑acting opioid formulations have Non‑Extended Day Supply (NDS), Quantity Limits and/or PA. Providers must follow opioid supply limits and obtain PA where required.
- Fentanyl transdermal patches: some strengths list PA; NDS; QL (15 EA per 30 days).
- Morphine ER: certain strengths list PA; NDS; QL (90 EA per 30 days).
- All opioid fills are subject to the plan's NDS/30‑day retail limit and may have additional pharmacy or home‑delivery rules.
Documentation Required for PA and Exception Requests
When prior authorization or quantity limit documentation is required, prescribers should submit supporting clinical documentation and a medical statement explaining the need for the drug or an exception to the restriction. The plan generally issues decisions within 72 hours (or 24 hours for expedited requests) upon receipt of the prescriber's supporting statement.
- Include diagnosis, prior therapies tried (for Step Therapy), clinical rationale for exceeding QL or for a non‑formulary drug, and relevant labs or notes.
- Request expedited review if waiting could seriously harm the member; expedited decisions are rendered within 24 hours when approved.
Follow Listed Tier Requirements / Limits
Follow the formulary's Tier Requirements/Limits values when adjudicating coverage. Tier assignments indicate preferred versus non‑preferred products and may affect cost‑sharing and the need for PA, ST, or QL compliance.
- Review Tier, PA, ST, QL, NDS, and NF flags in the Requirements/Limits column for each product.
- Tiering/tier exceptions can be requested via the formulary exception process; prescriber must provide supporting medical reasons.
Step Therapy: Requirements and Flags
Step Therapy (ST) applies to select agents; when a product is marked 'ST' providers must document trials of required preferred agents before the plan will cover the requested drug. The formulary does not detail all step algorithms in this excerpt — consult the plan documents or website for full ST protocols.
- Examples: SAVELLA, FANAPT, FETZIMA, SECUADO, SANCUSO have ST flags on some strengths/forms.
- If ST applies, include documentation of inadequate response or intolerance to required step drugs when submitting an exception or PA request.
Use Formulary Notation When Submitting Requests
Use formulary notation (NF, PA, QL, ST, NDS) when submitting prior authorization, exception, or appeal requests. These notations determine which operational rules apply and which documentation is needed.
- Consult page 6 (symbol definitions) for full meanings of NF, PA, QL, ST, NDS.
- Reference the exact formulary row and notation (e.g., "EPCLUSA — PA; QL (84 EA per 365 days)") on the request to avoid processing delays.
Formulary Symbol Guidance
Formulary symbols and abbreviations are defined in the plan materials (see page 6). Confirm symbol meanings (PA, QL, ST, NDS, NF) before adjudicating claims or preparing authorization requests.
- Page 6 contains the official key for formulary symbols — verify interpretation before submission.
- When in doubt, contact AmeriHealth or refer to the online plan documents for clarification.
Background & Scope
This formulary groups drugs by therapeutic area and lists each product with a Tier Requirements/Limits value that indicates coverage status (numeric tier or NF) and any utilization management flags such as PA or QL. The table is intended to communicate formulary placement, required prior authorization, quantity limits, and whether a drug is non‑formulary; definitions and symbol meanings are referenced elsewhere in the formulary (see page 6).
Key Definitions & Symbols
Step Therapy Rules & Flags
| Step therapy overview |
|---|
| Member must try specified preferred drug(s) first before the plan will cover an alternative drug for the same condition (step therapy). |
| Step therapy absence note |
|---|
| No explicit step therapy algorithm is detailed in these formulary chunks; entries show tiering and PA/QL annotations rather than step sequences. |
| Step therapy not present in extract |
|---|
| Step therapy details are not present in this extract; refer to the formulary legend (page 6) or the full formulary for step therapy rules. |
| No explicit step therapy steps provided |
|---|
| These entries identify Tier, PA, QL and NF status but do not provide explicit step‑therapy sequences or required prior medication trials in this excerpt. |
| PA/QL flagged but no step sequences |
|---|
| PA and QL flags are shown on many formulary lines; however, explicit step therapy steps or sequencing are not included in these chunks. |
| No step‑therapy entries in excerpt |
|---|
| No explicit step‑therapy entries appear in this excerpt; only tier, PA, and QL indicators are provided for listed products. |
| Tier assignments vs step therapy |
|---|
| Tier assignments (numeric tiers and 'NF') indicate preferred versus non‑preferred products, but explicit drug‑to‑drug step therapy failure rules are not present in these chunks. |
| Tier numbers provided but no sequences |
|---|
| Tier numbers are shown for products (e.g., tiers 2–5) but no explicit step therapy sequences or required prior trials are listed in these chunks. |
| SAVELLA — ST indicated |
|---|
| SAVELLA oral tablet entries include 'ST' indicating step therapy is required for some strengths (e.g., 100 mg shows ST; lower strengths show ST with QL). |
| FANAPT and FETZIMA — ST |
|---|
| FANAPT and FETZIMA are labeled 'ST' in the formulary, indicating step therapy edits apply prior to coverage for those products. |
| SECUADO — ST |
|---|
| SECUADO transdermal patch is listed with 'ST', indicating step therapy is required for that transdermal formulation. |
| Tier influence on step/coverage |
|---|
| Tier assignments shown in the extract may influence step therapy or coverage preference, but explicit step‑therapy logic is not contained in these chunks. |
| SANCUSO — ST referenced |
|---|
| SANCUSO transdermal patch listing references 'ST' alongside other controls (PA/QL), indicating step therapy may be required prior to coverage. |
Quantity Limits by Drug / Strength
Policy Revision History
AmeriHealth Medicare PPO formulary updated (document current as of 1/20/2026) with comprehensive Drug List including tiering, PA, QL, and ST annotations.
Standard annual formulary update cycle (most major changes typically occur January 1); members are advised to review changes for the new benefit year.
Formulary changes may be posted monthly online; the plan posts updates to amerihealthmedicare.com/formulary.
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