Select Drug Program Formulary (pharmacy benefit) — Coverage Criteria
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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.
No material clinical or coverage changes in this revision.
Coverage & Utilization Management Criteria
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.
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 limits are intended to ensure safe and appropriate utilization; override requests may be time-limited.
MME limit and requirement for PA are specified in policy.
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 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
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.
Coding Thresholds and Limits
Provider Requirements, Prior Authorization & Submission
Prior Authorization Requirement
Prior Authorization Required — scope and overview. AmeriHealth requires prior authorization (PA) for many prescription drugs to confirm medical necessity and clinical appropriateness. PA applies to specific drugs and to certain claim and product thresholds; claims submitted without an approved PA may be denied at point-of-sale or at adjudication. Clinical pharmacists and medical directors review PA requests using criteria approved by the Pharmacy & Therapeutics Committee.
- PA applies to many listed drugs across the formulary — drugs marked with the requirement code "PA" require authorization before coverage.
- PA applies to all formulations of listed drugs (tablet, capsule, oral suspensions, injectables, topical, etc.) where noted.
- High-dollar claim threshold: prescription claims exceeding $10,000 per claim require prior authorization.
- Compound products with total cost >= $75 per prescription require prior authorization.
- Some drugs also include plan-specific indicators (R = Requires Rider) or specialty flags — check requirement codes.
- Quantity/day-supply/MME enforcement: when quantity limits, day-supply (5DS), or Morphine Milligram Equivalent (MME) limits apply, claims exceeding limits require supporting documentation and may be denied or reduced.
- PA approvals may be time-limited (e.g., 6–12 months); renewal requires a new PA submission when the authorization expires.
Prior Authorization Documentation & Supporting Evidence
Documentation required for PA requests. Provide complete clinical information to support medical necessity, including diagnosis, previous therapies and outcomes, rationale for the requested agent/dose, and any relevant lab or monitoring data. Incomplete submissions may delay the decision or result in denial. When requesting overrides for quantity limits or MME/5DS flags, include documentation justifying the need (e.g., dosing records, specialty clinic notes).
- When limits apply (QL, 5DS, MME), include supporting documentation for overrides.
- For opioid PA requests exceeding 90 MME/day, include opioid therapy history and justification.
- For stimulant cumulative limit overrides, provide active-ingredient dosing history and clinical rationale.
- Some PA approvals require periodic reauthorization; include documentation for continuation requests.
How to Submit Prior Authorization & Formulary Exception Requests
How to submit PA and formulary exception requests. Use the electronic prior authorization (ePA) platform (e.g., SureScripts™) for faster, sometimes real-time, decisions. Alternatively, submit a completed prior authorization fax form or a letter of medical necessity to the pharmacy benefit manager. Formulary tier exception requests follow a separate process and require demonstration of trials or contraindications to formulary alternatives.
- ePA (SureScripts™) is supported and may provide real-time approvals.
- Fax prior authorization forms or letters of medical necessity to: 1-888-671-5285. Forms available: https://www.amerihealth.com/providers/pharmacy_information/index.html
- Tier exception requests: typically require trial of, or contraindication to, at least three formulary alternatives when applicable; some tiers/plan types are not eligible for tier exceptions — check the member benefit booklet.
- If PA is approved, provider will be notified via fax/phone and the claim system will be coded with the approval; if denied, appeals instructions are provided in the denial letter.
Requirement Codes, Legend & Utilization Management
Utilization management procedures and requirement codes. The formulary includes management codes (PA, QL, 5DS, MME, LDD, AL, R, SP, +) that indicate required actions or limits. Providers must review these codes when prescribing; PA and other limits are enforced at adjudication.
- Legend highlights: PA = Prior Authorization; QL = Quantity Limits; 5DS = Day Supply Limit; MME = Morphine Milligram Equivalent; LDD = Limited Distribution Drug; AL = Age Limit; R = Requires Rider; + = Claim Dollar Limit.
- Drugs flagged with PA require an approved authorization before coverage; drugs flagged with QL/5DS/MME may be denied or reduced if limits are exceeded.
- Some entries also include plan-specific 'R' (Requires Rider) indicators — verify member benefit/rider eligibility before prescribing.
Authorization Scope — applicable products and examples
Authorization scope and specific examples. Prior authorization applies to numerous specific listed agents across the formulary — including many brand and generic products, specialty agents, topical agents, prenatal vitamins, diabetic test strips (except specified brands), high-cost biologics, and other listed drugs. PA frequently applies to all formulations of the listed agents.
- All brand prenatal vitamins require prior authorization.
- All diabetic test strips require prior authorization except for Contour®.
- Compound prescriptions with total cost >= $75 require PA.
- Many specialty products (e.g., Epidiolex Soln, Emgality Prefilled Pen/Auto-Injector) are marked PA and may also have QL/5DS/MME flags.
- Numerous topical and dermatology agents are subject to PA and QL (see formulary listing).
High-dollar Claims, MME, Quantity & Stimulant Limits — Provider Actions
Provider actions for high-cost and limit-exceeding claims. Before submitting prescriptions or dispensing, check formulary requirement codes and submit PA for high-dollar claims or when limits are exceeded. Failure to obtain PA will likely result in claim denial and member financial liability.
- Claims exceeding $10,000 per claim require prior authorization.
- Claims for opioids exceeding 90 MME/day require prior authorization.
- Stimulant claims exceeding cumulative active-ingredient dose limits (per formulary) require prior authorization and may be denied at point-of-sale.
- When quantity/day-supply limits are exceeded, submit PA with supporting clinical rationale to request an override.
Step Therapy & Management Codes
| Utilization management tool | How it's used / examples |
|---|---|
| Prior Authorization (PA) | |
| Required for many listed agents and specialty drugs; claims exceeding the dollar threshold (>= $10,000) and certain high-cost compounds (>= $75 per prescription) require PA before coverage |
| Formulary code | Meaning / use |
|---|---|
| PA | |
| Prior Authorization — provider must obtain approval for coverage of drugs marked PA | |
| QL | |
| Quantity Limits Apply — quantity limits established (examples shown in document) | |
| LDD | |
| Limited Distribution Drug — product may have restricted distribution channels | |
| AL | |
| Age Limit / Day supply Limit — age or day-supply restrictions may apply | |
| 5DS | |
| Day Supply Limit — limits on days supplied per fill (5DS) | |
| R | |
| Requires Rider — plan-specific rider or additional requirements may apply | |
| Q/T | |
| Quantity Over Time — tracking of quantity across timeframes | |
| MME | |
| Morphine Milligram Equivalent — opioid dose safety edit (e.g., PA required > 90 MME/day) |
| Product or class | PA | Quantity / day-supply limits |
|---|---|---|
| {"text":"Amphetamine products (examples: amphetamine tablet, ER suspension)","status":""},{"text":"Yes — many amphetamine entries show PA","status":"covered"},{"text":"Some entries show QL and 5DS; cumulative stimulant dose limits apply by active ingredient (high-dose thresholds listed separately)","status":""} | ||
| {"text":"Butalbital-containing products","status":""},{"text":"PA (butalbital/apap combinations indicated PA in listing)","status":"covered"},{"text":"QL, 5DS, and MME flags appear for some formulations","status":""} | ||
| {"text":"Opioid products (examples: endocet, various ER opioids)","status":""},{"text":"PA indicated for some opioid formulations","status":"covered"},{"text":"MME and 5DS limits apply (opioid MME safety edit = 90 MME/day)","status":""} |
| Coverage condition | Examples (documented entries) |
|---|---|
| Prior authorization required before coverage | |
| Many specialty and non-preferred products in the extract are listed with REQUIREMENTS/LIMITS = PA (examples: Emgality Prefilled Pen/Auto-Injector, Epidiolex Solution, Opsynvi, Orenitram, Ormalvi Tab) |
| Enforcement type | Example(s) showing code |
|---|---|
| Prior Authorization (PA) | |
| Multiple drug list entries indicate REQUIREMENTS/LIMITS = PA (e.g., amphetamine entries, phentermine hcl, many topical agents) — claims may be denied without PA | |
| R (Requires Rider) / Day supply limits | |
| Some stimulant and weight-management products show R or R + PA (e.g., amphetamine entries, phentermine/topiramate) and 5DS day-supply flags | |
| AL (Age/Day-supply limit) | |
| Topical agents such as adapalene entries list AL and PA in some formulations (Adapalene pad 0.1% = PA, AL) |
| Specialty agent | PA required? |
|---|---|
| {"text":"Ormalvi Tab","status":""},{"text":"Yes — listed with PA","status":"covered"} | |
| {"text":"Orenitram","status":""},{"text":"Yes — listed with PA","status":"covered"} | |
| {"text":"Opsynvi","status":""},{"text":"Listed in segment (PA indicated for many specialty agents in this section)","status":"covered"} |
| Agent / class | Required codes before coverage |
|---|---|
| {"text":"Amphetamine-class stimulants","status":""},{"text":"PA; many entries also show QL and 5DS; cumulative stimulant dose limits apply by active ingredient","status":""} | |
| {"text":"Butalbital and related products","status":""},{"text":"PA, QL, 5DS, MME flags present on several formulations — PA required for listed formulations","status":""} | |
| {"text":"Epidiolex Solution (specialty)","status":""},{"text":"PA required (entry shows PA); QL (weekly only) noted for some formulations","status":""} |
Quantity and Day-Supply Limits
Specialty Pharmacy and Site-of-Care
Follow PBM Specialty Pharmacy Program requirements for specialty drugs
Specialty drugs covered under the pharmacy benefit may be managed by the PBM's Specialty Pharmacy Program; providers should follow specialty pharmacy procedures as indicated by the PBM for dispensing and PA.
- Specialty tier drugs often have higher cost-sharing and may be ineligible for tier exceptions.
Policy Background
The formulary is developed and reviewed to support safe, effective, and value-based medication use. The list includes FDA‑approved therapies and applies utilization management tools (such as prior authorization, quantity limits, and specialty pharmacy management) where appropriate. Formulary decisions, including specialty designations and tier placement, are reviewed by the Pharmacy and Therapeutics Committee to consider clinical effectiveness, safety, and value.
Definitions & Legend
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.