Formulary step therapy and prior authorization rules for selected drugs
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Defines utilization management restrictions (step therapy, prior authorization, quantity limits) for specific prescription drugs on the AmeriHealth Medicare PPO formulary; applies to prescribers and network pharmacies serving AmeriHealth Medicare PPO members.
No material clinical or coverage changes in this revision.
Drug-specific Coverage Criteria
Fetzima (example)
Covered when ALL of the following are met (examples from product listings):
Applies to new starts
Fanapt
Covered when ALL of the following are met:
Applies to new starts
Drizalma
Covered when ALL of the following are met:
Applies to new starts
Exxua and related antidepressants
Covered when ALL of the following are met:
Applies to new starts
Basaglar (insulin) requirements
Covered when ALL of the following are met:
Always applies
Rebif (multiple sclerosis)
Covered when ALL of the following are met:
Applies to new starts
Relistor
Covered when ALL of the following are met:
Always applies
Sancuso
Covered when ALL of the following are met:
Always applies
Savella (milnacipran)
Covered when ALL of the following are met:
Applies to new starts
Xcopri
Covered when ALL of the following are met:
Applies to new starts
Zonisade
Covered when ALL of the following are met:
Applies to new starts
Some covered drugs may have additional requirements or limits on coverage known as utilization management. These may include Prior Authorization (PA) — plan approval required before dispensing for certain products; Step Therapy (ST) — a requirement that specified alternative drugs be tried first for new starts; and Quantity Limits (QL) — limits on the amount of drug the plan will cover. Specific drugs subject to PA are listed in the 2026 Utilization Management Criteria: Prior Authorization, and drugs with QLs are listed in the AmeriHealth Medicare PPO Formulary (List of Covered Drugs). Providers and members should consult the Formulary or www.amerihealthmedicare.com for details and for the exception request process.
Initial Therapy (New Starts)
Initial therapy (new starts)
Initial therapy (new starts) requires trials of specified formulary alternatives as listed per product.
Applies to new starts
Step Therapy Requirements
| Product | Required trial(s) of formulary alternative(s) |
|---|---|
| {"text":"Fetzima (levomilnacipran ER)","status":""}|{"text":"Trial of two of the following generic formulary SNRIs: desvenlafaxine tablet; duloxetine capsules; venlafaxine HCl immediate‑release tablets; venlafaxine HCl capsules. Applies to new starts.","status":""} | |
| {"text":"Fanapt (iloperidone)","status":""}|{"text":"Trial of two generic formulary antipsychotic products. Applies to new starts.","status":""} | |
| {"text":"Drizalma (drizalma sprinkle)","status":""}|{"text":"Trial of generic formulary duloxetine. Applies to new starts.","status":""} | |
| {"text":"Exxua (extended‑release antidepressant)","status":""}|{"text":"Trial of two of the following: bupropion; citalopram tablets; desvenlafaxine ER; duloxetine; escitalopram; fluoxetine; mirtazapine; paroxetine IR/ER; sertraline; venlafaxine IR/ER. Applies to new starts.","status":""} | |
| {"text":"Basaglar (insulin glargine) KwikPen","status":""}|{"text":"Trial of two of the following: Lantus; Toujeo; Tresiba. Always applies.","status":""} | |
| {"text":"Rebif (interferon beta‑1a)","status":""}|{"text":"Trial of two of the following formulary products: Avonex; Betaseron; Glatopa; Tecfidera (dimethyl fumarate); Gilenya (fingolimod); Teriflunomide. Applies to new starts.","status":""} | |
| {"text":"Relistor (methylnaltrexone)","status":""}|{"text":"Trial of lubiprostone or lactulose. Always applies.","status":""} | |
| {"text":"Sancuso (granisetron/ondansetron patch)","status":""}|{"text":"Trial of (a) ondansetron or granisetron and (b) aprepitant. Always applies.","status":""} | |
| {"text":"Savella (milnacipran)","status":""}|{"text":"Trial of generic formulary duloxetine. Applies to new starts.","status":""} | |
| {"text":"Xcopri (cenobamate)","status":""}|{"text":"Trial of two generic formulary anticonvulsants. Applies to new starts.","status":""} | |
| {"text":"Zonisade (zonisamide suspension)","status":""}|{"text":"Trial of generic zonisamide capsule. Applies to new starts.","status":""} |
Provider Actions and Requirements
Prior Authorization Required
Our plan requires prior authorization (PA) for certain drugs listed in the 2026 Utilization Management Criteria: Prior Authorization. Failure to obtain required PA may result in denial of coverage and the claim being the member's financial responsibility.
- Drugs requiring PA are identified in the plan Utilization Management Criteria and the Formulary 'Requirements' column.
- If PA is not obtained before dispensing, the plan may deny coverage for the drug.
- Providers may request an exception or submit an appeal if initial PA is denied.
Step Therapy Requirements
Step therapy (ST) applies to certain covered drugs. For new starts, members must generally try specified formulary alternatives (step agents) and meet the listed trial criteria before the plan will cover the requested non-preferred product.
- Step therapy requirements and the specific alternative drugs (e.g., trials of two generic formulary SNRIs for Fetzima, two generic formulary antipsychotics for Fanapt) are listed under each affected product in this document.
- Step therapy 'Applies to new starts' means existing stable therapy may be excluded from ST requirements; review product details for exceptions.
- Providers may request an exception if the required step agents are not appropriate for the member.
Documentation and Contact
Providers must follow the plan's PA and step therapy procedures and include supporting clinical documentation when submitting requests. For assistance or to check specific drug requirements, contact the Member Help Team.
- Include relevant clinical notes, prior medication history, and rationale for exceptions when requesting PA or step therapy exceptions.
- Use the Formulary and the 2026 Utilization Management Criteria to identify required documentation and trial details.
- For questions or to initiate PA/exception requests, call 1-866-569-5190 (TTY 711) or visit www.amerihealthmedicare.com.
Prior Authorization Denial Risk
If required prior authorization or step therapy requirements are not met, the plan may deny coverage and the member may be responsible for the cost. Providers should confirm authorization status prior to dispensing.
- Denial risk applies when PA is not obtained or step therapy trials are not documented as required.
- Timely submission of complete documentation can reduce denials; follow up on PA decisions promptly.
- Members and providers may request exceptions or appeals per plan procedures if coverage is denied.
Key Definitions
Background and Scope
This document summarizes the utilization management requirements that apply to selected drugs on the AmeriHealth Medicare PPO plan, including step therapy, prior authorization, and quantity limits. It is intended to be used together with the 2026 Utilization Management Criteria and the plan Formulary; those sources contain full details on which drugs require PA, the specific alternative therapies required by ST, quantity limits, and the process for exceptions or questions. The guidance here identifies products affected and the trials or requirements that typically apply for new starts.
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