CurrentAmeriHealthPolicy N/A

Specialty medical benefit drug list

Defines the list of drugs considered specialty medical benefit drugs for AmeriHealth and categorizes them by therapeutic class; informs providers and members which products are typically covered under the specialty medical benefit rather than the prescription drug benefit.

Policy Summary

PayerAmeriHealth

PolicySpecialty medical benefit drug list

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionConfirm coverage and prior authorization requirements by contacting AmeriHealth (phone number on member ID card) or via payer systems.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~300+listed specialty drugs

Multipletherapeutic categories

All biosimilarsbiosimilars treated as specialty

Member ID cardcontact phone

Coverage Criteria

This list identifies drugs that AmeriHealth currently treats as part of the specialty medical benefit. Drugs not included on this list may not be considered specialty drugs for the medical benefit and instead may be eligible for coverage under the member's prescription drug benefit. Prescription drug benefit products are typically self‑administered (for example, oral agents, topical agents, or self‑injectable drugs). Providers should confirm benefit and coverage applicability for drugs not on this list before initiating therapy.

Provider Actions & Notices

Prior Authorization

Confirm coverage and authorization

Confirm member coverage and obtain any required prior authorization before administering specialty medical benefit drugs. Authorization requirements vary by plan and drug; failure to verify may result in denied claims or member cost responsibility.

Verify eligibility and benefits for the date of service.
Obtain and document prior authorization when required.
Include clinical rationale and supporting documentation with authorization requests.

Policy Summary

PayerAmeriHealth

PolicySpecialty medical benefit drug list

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionConfirm coverage and prior authorization requirements by contacting AmeriHealth (phone number on member ID card) or via payer systems.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Billing Rule

Coverage contingent on list inclusion

Drugs not listed on the AmeriHealth Specialty Medical Benefit Drug List may not be covered under the specialty medical benefit and could be processed under the member's prescription drug benefit instead. Coverage is contingent on a drug's inclusion on the specialty medical benefit list.

If a drug is not on the specialty medical benefit list, check the member's prescription drug benefit.
Biosimilars are treated as specialty drugs once FDA-approved if the reference product appears on the list.

Note

Contact for information

For additional information about specialty medical benefit drugs, member-specific coverage, or benefits questions, call the phone number on the back of the member's ID card.

Use the member ID card number to reach the appropriate customer service line.
Document the representative name and reference number for your records.

Denial Risk

Provider notice — verify benefit and authorization

Before providing specialty medical benefit drugs, confirm coverage, benefit category, and any plan-specific requirements to avoid claim denials and unexpected member financial liability.

Verify whether the drug is listed on the Specialty Medical Benefit Drug List.
Confirm prior authorization, quantity limits, and site-of-care requirements.
When in doubt, contact the number on the member’s ID card for plan-specific guidance.

Background

This document is a categorical listing of specialty medical benefit drugs organized by commonly recognized therapeutic indication or treatment class. It notes that some drugs may be used for indications other than those shown, that the list may change without notice, and that biosimilars to any reference products on this list are considered specialty drugs after U.S. FDA approval. For additional information, contact the phone number on the back of the member ID card.

Definitions

inv-07: Biosimilars

Policy on biosimilarsBiosimilars to any reference products on this list are considered specialty drugs after they have been approved by the U.S. Food and Drug Administration.

ScopeApplies to biosimilars corresponding to reference products listed on the specialty medical benefit drug list.

Effective conditionDesignation as a specialty medical benefit drug for a biosimilar is contingent on FDA approval.

inv-08: Prescription drug benefit vs specialty medical benefit

General ruleDrugs that members can self-administer (for example, oral agents, topical agents, self-injectable drugs) are typically covered under the prescription drug benefit rather than the specialty medical benefit.

Implication for coverageDrugs not included on the specialty medical benefit list may instead be eligible for coverage under the member's prescription drug benefit.

Provider actionConfirm benefit type (prescription drug vs specialty medical) when a product is self-administered or not listed on the specialty medical benefit list.

Biosimilar Policy Note

Billing Rule

Biosimilars considered specialty drugs after FDA approval

Biosimilar products to any reference drugs on this list are treated as specialty drugs for the specialty medical benefit once they have been approved by the U.S. Food and Drug Administration.