CurrentAmeriHealthPolicy N/A

Select Drug Program Formulary (pharmacy benefit) — Coverage Criteria

Defines the AmeriHealth Select Drug Program formulary structure, safety edits, prior authorization and quantity limits, and ACA preventive medication coverage affecting members and providers under the pharmacy benefit.

Policy Summary

PayerAmeriHealth

PolicySelect Drug Program Formulary (pharmacy benefit) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization before submitting claims for drugs flagged 'PA' or for claims exceeding dollar or dose thresholds.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>$10kclaim dollar PA threshold

90 MME/dayopioid MME limit

60–72 mg/daystimulant dose thresholds

75%refill policy

SP notedspecialty drugs

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Coverage with utilization management criteria

Coverage and utilization management are governed by prior authorization and safety edits; drugs are covered when criteria below are met.

General prior authorization and safety edits: Provider must obtain prior authorization for drugs that require it; claims with total cost at or above the dollar limit threshold require prior authorization; prior authorization requests must include complete supporting clinical information and may be time-limited.See claim dollar threshold (>= $10,000) and PA documentation requirements

Based on policy requirements for PA, claim dollar limits, and documentation; prior authorization review may take up to two business days after complete information is received.

Quantity and day supply limits: Quantity limits (quantity over time, maximum daily dose, refill-too-soon at 75% utilization) and day-supply limits apply; providers must submit prior authorization for overrides or quantities beyond limits.Examples provided in quantity limits (e.g., Nuvaring = 1 per 28 days; zolpidem = 1/day)

Quantity limits are intended to ensure safe and appropriate utilization; override requests may be time-limited.

Opioid safety edit: Prior authorization is required if the member's total daily opioid dose exceeds the Morphine Milligram Equivalent (MME) limit.>90 MME/day

MME limit and requirement for PA are specified in policy.

Cumulative stimulant safety edit: Stimulant claims that exceed high cumulative daily dose limits calculated by active ingredient require prior authorization; per-ingredient thresholds are provided for amphetamine and methylphenidate classes.See per-ingredient high cumulative daily dose thresholds (e.g., amphetamine = 60 mg/day; lisdexamfetamine = 70 mg/day; methylphenidate = 72 mg/day)

Cumulative stimulant limit calculates total daily stimulant dose by active ingredient to mitigate cardiac and neuropsychiatric risks.

Stimulant cumulative dose coverage

Covered when ALL of the following are met

Cumulative dose within limits or PA obtained: Claims for central nervous system stimulants must have a cumulative daily dose by active ingredient at or below the policy's specified high cumulative daily dose thresholds; if the calculated cumulative dose exceeds the listed per-ingredient threshold, prior authorization must be obtained for coverage.Per-ingredient thresholds (examples): amphetamine = 60 mg/day; amphetamine-dextroamphetamine = 60 mg/day; dextroamphetamine = 60 mg/day; lisdexamfetamine = 70 mg/day; dexmethylphenidate = 40 mg/day; methylphenidate = 72 mg/day; serdexmethylphenidate = 52.3 mg/day

Cumulative stimulant limit is calculated by active ingredient and is a safety measure due to risks of cardiac adverse events and psychosis with high-dose stimulants.

Drugs Requiring Prior Authorization

Covered when prior authorization is obtained for listed drugs and formulary requirement codes met

PA for listed drugs: Prior authorization must be obtained for the specific drugs and all formulations listed in this section before coverage will be approved.See formulary entries and requirement codes (PA, QL, 5DS, MME, etc.)

List in the source is extensive; policy notes that PA applies to all formulations and that some brand prenatal vitamins and certain diabetic test strips also require PA; compound products >= $75 and claims >= $10,000 also trigger PA.

Inclusion of a medication on the formulary does not by itself guarantee coverage for every member. Benefits vary by group, and not all cost-share tiers or incentives (for example, the Low-Cost Generic incentive) are available on every plan. Drugs not listed in the formulary guide may still be covered but will be assigned the appropriate cost-share tier per the member’s benefit booklet; likewise, covered brand drugs not listed in the guide are generally treated at the Non-preferred level of cost-sharing.

Tier exception requests are subject to limits. Providers must generally document trial of, or contraindication to, at least three formulary alternatives when applicable. Drugs on the Generic, Preferred Brand, and Specialty tiers are not eligible for tier exceptions, and some plans do not permit tier exceptions — refer to the member benefit booklet for plan-specific availability.

To request a tier exception, complete the formulary exception request form with supporting clinical detail and fax it to 1-888-671-5285. If approved, the drug will pay at the appropriate preferred brand or generic level of cost-sharing; if denied, the member and provider will receive a denial letter with appeals information.