Formulary utilization management: prior authorization and step therapy for select drugs
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Defines prior authorization, step therapy, and quantity limits for specific prescription drugs on the AmeriHealth Medicare PPO formulary and describes requirements that affect prescribers and members for new-start and continuing therapy.
No material clinical or coverage changes in this revision.
Coverage Criteria for Formulary Drugs
Vigafyde (Vigabatrin) trial requirement
Covered when specified prior trials are met for these products (applies to new starts unless otherwise noted):
applies to VIGAFYDE SOLUTION 100 MG/ML ORAL
Generic trial requirements for antidepressants and antipsychotics
Covered when specified generic formulary alternatives are tried (applies to new starts):
applies to FETZIMA strengths and titration pack listed
applies to listed FANAPT, REXULTI, SECUADO, and VRAYLAR products
Drizalma (milnacipran) step requirement
Covered when a specified generic alternative is tried (applies to new starts):
applies to DRIZALMA SPRINKLE CAPSULE delayed release 40 mg and 60 mg
Various product-specific trial requirements
Covered when specified trials are completed (applies to new starts or always applies as noted):
applies to EPRONTIA SOLUTION 25 MG/ML ORAL
Always applies to BASAGLAR KWIKPEN / TEMPO products
applies to listed REBIF products
applies to RELISTOR SOLUTION and TABLET; Always applies
Antiemetic and anticonvulsant step requirements
Covered when specified anticonvulsant or antiemetic trials are completed (applies to new starts or always applies as noted):
applies to SANCUSO PATCH 3.1 MG/24HR; Always applies
applies to XCOPRI products and therapy packs listed
Zonisade step requirement
Covered when specified generic alternative is tried (applies to new starts):
applies to ZONISADE SUSPENSION 100 MG/5ML ORAL
This document does not list any product-specific clinical exclusions within its coverage criteria section. For information about exclusions that may apply to a particular drug, consult the AmeriHealth Medicare PPO Formulary and the product-specific prior authorization criteria referenced in the plan materials.
The policy does not enumerate explicit conditions labeled “not medically necessary.” Instead, coverage can be denied when utilization management requirements are not met. In particular, failure to satisfy required Prior Authorization (PA), Step Therapy (ST), or Quantity Limits (QL) listed in this document and the formulary may result in the plan not covering the drug.
Initial Therapy (New Starts) Requirements
Initial therapy (new starts)
Initial therapy (new starts) rules as listed for each product:
See product‑specific entries (Vigafyde, Fetzima, antipsychotics, Drizalma, Eprontia, Basaglar, Rebif, Relistor, Sancuso, Xcopri, Zonisade)
Step Therapy Requirements and Tables
| Product / Affected Strengths | Required prior trial(s) | Applies to |
|---|---|---|
| VIGAFYDE SOLUTION 100 MG/ML ORAL | ||
| Trial of Vigpoder or Vigabatrin powder for oral solution | ||
| Applies to new starts | ||
| FETZIMA CAPSULE ER 20, 40, 80, 120 MG; FETZIMA TITRATION PACK 20 & 40 MG | ||
| Trial of two generic formulary serotonin‑norepinephrine reuptake inhibitors (SNRIs) | ||
| Applies to new starts | ||
| FANAPT (various strengths); REXULTI (various strengths); SECUADO PATCH (3.8/5.7/7.6 MG/24HR); VRAYLAR (1.5,3,4.5,6 MG) | ||
| Trial of two generic formulary antipsychotic products | ||
| Applies to new starts | ||
| DRIZALMA SPRINKLE CAPSULE 40 MG, 60 MG | ||
| Trial of generic formulary duloxetine | ||
| Applies to new starts | ||
| EPRONTIA SOLUTION 25 MG/ML ORAL | ||
| Trial of generic formulary immediate‑release pregabalin or topiramate (capsules or solution) | ||
| Applies to new starts | ||
| BASAGLAR KWIKPEN / TEMPO (100 UNIT/ML) | ||
| Trial of two of the following: Lantus, Toujeo, Tresiba | ||
| Always applies | ||
| REBIF products (various auto‑injectors/syringes/titration packs) | ||
| Trial of two of the following formulary MS disease‑modifying therapies: Avonex, Betaseron, Glatopa, Tecfidera, Gilenya, Teriflunomide | ||
| Applies to new starts | ||
| RELISTOR SOLUTION 12 MG/0.6ML SUBCUTANEOUS; RELISTOR TABLET 150 MG ORAL | ||
| Trial of lubiprostone or lactulose | ||
| Always applies | ||
| SANCUSO PATCH 3.1 MG/24HR TRANSDERMAL | ||
| Trial of (a) ondansetron or granisetron AND (b) aprepitant | ||
| Always applies | ||
| SAVELLA (various strengths) | ||
| Trial of generic formulary duloxetine | ||
| Applies to new starts | ||
| XCOPRI (various strengths and therapy packs) | ||
| Trial of two generic formulary anticonvulsants | ||
| Applies to new starts | ||
| ZONISADE SUSPENSION 100 MG/5ML ORAL | ||
| Trial of generic zonisamide capsule | ||
| Applies to new starts |
Provider Actions and Authorization Requirements
Prior Authorization Required
Our plan requires prior authorization (PA) for certain drugs. You or the prescribing provider must obtain approval from AmeriHealth before the prescription is filled. If prior authorization is not obtained when required, the plan may not cover the drug.
- See 2025 Utilization Management Criteria: Prior Authorization for the list of drugs requiring PA.
- Contact the Member Help Team at 1-866-569-5190 (TTY 711) for assistance with PA requirements or documentation.
- Failure to obtain PA when required may result in denial of coverage at the point of claim.
Step Therapy Required
Step therapy (ST) is required for multiple listed products. For many drugs, the plan requires trials of one or two specified generic formulary alternatives (e.g., two generic formulary SNRIs for Fetzima, two generic formulary antipsychotics for certain antipsychotic products, two generic formulary anticonvulsants for Xcopri). These step-therapy requirements apply to new starts.
- Fetzima products: trial of two generic formulary SNRIs. (Applies to new starts.)
- Antipsychotics (e.g., Rexulti, Vraylar, Secuado): trial of two generic formulary antipsychotic products. (Applies to new starts.)
- Drizalma: trial of generic formulary duloxetine. (Applies to new starts.)
- Xcopri: trial of two generic formulary anticonvulsants. (Applies to new starts.)
Documentation and Submission Instructions
For details about required supporting documentation and where to submit prior authorization requests, consult the plan Formulary and the 2025 Utilization Management Criteria: Prior Authorization, or contact the Member Help Team.
- Visit www.amerihealthmedicare.com to view the Formulary (List of Covered Drugs) and Utilization Management Criteria.
- Member Help Team: 1-866-569-5190 (TTY 711), seven days a week from 8 a.m. to 8 p.m.; note possible voicemail routing on weekends/holidays April 1–Sept 30.
Denial Risk if Requirements Not Met
Not obtaining required prior authorization or failing to meet step-therapy requirements may lead to denial of coverage for the drug.
- If PA is required and not approved before dispensing, the claim may be denied and the member may be responsible for the cost.
- Providers may request an exception or submit supporting documentation as described in the Formulary and Evidence of Coverage.
Definitions
Background and Scope
This document provides the AmeriHealth Medicare PPO outpatient prescription drug utilization management requirements including Prior Authorization (PA), Step Therapy (ST), and Quantity Limits (QL) for specific formulary drugs. These requirements are intended to be used alongside the plan Formulary and the 2025 Utilization Management Criteria: Prior Authorization to determine coverage for new-start and continuing therapy.
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