Prior authorization requirements

Prior Authorization Required — AmeriHealth requires prior authorization (PA) for certain prescription drugs to confirm medical necessity, appropriate dosing, and use per FDA‑labeled or medically accepted indications. Clinical pharmacists review PA requests using clinical data, provider‑submitted information, and the member’s prescription history; medical director review may occur if criteria are not met. Without prior authorization, the member’s prescription will not be covered at retail or mail‑order pharmacies. PA approvals may be time‑limited (for example, 6–12 months) and must be renewed when expired. Claim dollar limits trigger PA review for claims exceeding $10,000.

• PA approvals are based on Pharmacy & Therapeutics Committee‑approved criteria and may include review of drug‑drug interactions, contraindications, dosing, therapy duration, and prior therapies.
• PA review may take up to two business days after receipt of complete provider information; incomplete submissions can delay decisions.
• Some drugs require a benefit rider (e.g., certain weight‑loss drugs); contact the health plan for member eligibility and rider details.

Prior authorization required for listed PA drugs

Prior authorization is required for many specific drugs listed on the formulary when the drug’s REQUIREMENTS/LIMITS field includes the notation "PA". This PA requirement applies to all formulations of a listed drug (tablet, capsule, oral suspension, transdermal, injectable, etc.) unless otherwise specified. Claims submitted without the required PA may be denied.

• The drug list shows requirement flags (e.g., PA, QL, Q/T, MME, AL, SP) next to product entries to indicate utilization management controls.
• Providers should check the formulary row for the drug and formulation being prescribed to confirm whether PA applies prior to dispensing.

Authorization/Denial triggers

Denial Risk & Authorization Triggers — Claims for drugs flagged with requirement codes (PA, QL, Q/T, MME) may be denied if required prior authorization or documentation is not obtained. Providers should follow the PA process and supply supporting documentation to avoid payment denials.

• Examples of denial triggers: absence of PA when "PA" is indicated; exceeding Quantity Limits (QL) or Day Supply limits (5DS); exceeding Morphine Milligram Equivalent (MME) thresholds.
• Claim dollar over‑limit (+) will require PA review (claims > $10,000).
• Many specialty products and oncology/transplant agents are frequently marked PA and may also have QL or LDD requirements.

Prior authorization for opioid MME and cumulative stimulant limits

Safety limits that trigger prior authorization — AmeriHealth applies specific safety thresholds that require PA when exceeded, including opioid MME limits and cumulative stimulant dose limits.

• Opioid MME limit: prior authorization is required for opioid dosing that exceeds 90 MME per day. The MME calculation aggregates all opioid products and potencies.
• Cumulative stimulant limits: PA is required when total daily stimulant dose by active ingredient exceeds specified thresholds (examples: amphetamine 60 mg/day; methylphenidate 72 mg/day; lisdexamfetamine 70 mg/day; dexmethylphenidate 40 mg/day; serdexmethylphenidate 52.3 mg/day).
• High‑dose stimulant and opioid claims may be denied without an approved PA.

How to submit PA and formulary exceptions

How to submit prior authorization and formulary exception requests — Providers may submit PA requests electronically (ePA platforms such as SureScripts™) or by fax using the AmeriHealth/PBM prior authorization form. Formulary tier‑exception requests require documentation of trials or contraindications to alternatives as specified.

• ePA (e.g., SureScripts™) can yield real‑time approvals in the office.
• Fax prior authorization and formulary exception requests to the PBM at 1‑888‑671‑5285; forms and instructions are available at https://www.amerihealth.com/resources/for-providers/policies-and-guidelines/index.html.
• Tier exceptions: when applicable, requests for preferred coverage of a non‑preferred drug generally require trial of, or contraindication to, at least three formulary alternatives. Tier exceptions are not available for some tiers/plans—refer to the member benefit booklet.

Requirement abbreviations and required documentation (legend)

Requirement abbreviations and documentation legend — The formulary uses standardized abbreviations to indicate utilization management and documentation needs. Providers must supply documentation consistent with the legend when submitting PA or appeals.

• Key abbreviations: PA = Prior Authorization; QL = Quantity Limits Apply; Q/T = Quantity Over Time; AL = Age Limit; 5DS = Day Supply Limit; LDD = Limited Distribution Drug; SP = Specialty Drug; MME = Morphine Milligram Equivalent; + = Claim Dollar Limit; R = Requires Rider.
• When a drug entry includes PA, providers must submit the PA request with clinical rationale and supporting records (e.g., prior therapy history, contraindications).
• The formulary rows may also include QL, MME, AL flags that indicate additional documentation or limits that must be met.

Provider‑impact procedures and coverage risk

Provider impact summary — Many drugs throughout the formulary are designated PA (Prior Authorization) and/or QL (Quantity Limits) — providers should review the drug‑specific formulary row for requirements before prescribing to avoid claim denials and to ensure timely access.

• PA, QL, Q/T and MME flags appear across specialty, oncology, cardiovascular, CNS, and other therapeutic classes.
• PA applies to all formulations of a listed product unless otherwise noted; specialty or limited distribution drugs may have additional handling and documentation requirements (SP, LDD).
• If prior authorization is denied, the prescribing provider and member will be notified with instructions for appeals; appeals processes are described in denial communications.