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AmeriHealth Value Formulary Guide — Coverage & Prior Authorization Criteria
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Explains the AmeriHealth Value formulary design, tier structure, safety procedures (prior authorization, quantity and age limits, MME and stimulant limits), and member/provider responsibilities for prescription drug coverage. Affects AmeriHealth members and their prescribing providers.
Policy Summary
PayerAmeriHealth
PolicyAmeriHealth Value Formulary Guide — Coverage & Prior Authorization Criteria
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionSubmit prior authorization with complete clinical information for drugs flagged PA or when utilization thresholds (e.g., >90 MME/day, stimulant cumulative limits, high-cost claims) are exceeded.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
90opioid MME PA threshold
60amphetamine-class high dose
72methylphenidate high dose
10kclaim dollar review threshold
75compound cost PA threshold
75%refill-too-soon rule
Coverage Criteria and Triggers
Opioid MME Authorization Criteria
Prior authorization required when ANY of the following dosing thresholds are exceeded
Opioid MME threshold: Total daily opioid dose exceeds 90 MME (across opioid products)>90 MME/day
Includes all monitored opioid active ingredients listed in policy
Cumulative Stimulant Authorization Criteria
Prior authorization required when stimulant cumulative doses exceed ingredient-specific thresholds
Amphetamine-class high dose: Amphetamine, amphetamine-dextroamphetamine, dextroamphetamine, methamphetamine exceed 60 mg/day>60 mg/day
Specific impacted medications listed in policy (brands and generics)
Dexmethylphenidate high dose: Dexmethylphenidate exceeds 40 mg/day>40 mg/day
Impacted medications listed (e.g., Focalin IR/XR)
Methylphenidate high dose: Methylphenidate exceeds 72 mg/day>72 mg/day
Impacted medications listed (e.g., Ritalin, Concerta, Daytrana, Quillivant, Jornay PM, others)
Serdexmethylphenidate high dose: Serdexmethylphenidate (Azstarys) exceeds 52.3 mg/day>52.3 mg/day
Impacted medication listed: Azstarys
Cost-based Authorization Criteria
Prior authorization or additional review required for high-cost or high-cost-per-prescription products
Compound cost threshold: Compound products with total cost >= $75 per prescription require prior authorization or review>= $75 per prescription
High dollar claim threshold: Prescription claims exceeding $10,000 per claim require review or authorization> $10,000 per claim
Inclusion of a medication on the AmeriHealth Value formulary does not automatically guarantee coverage for all member benefit plans. Non‑formulary (NF) drugs are only covered when a formulary exception or prior authorization is obtained, and when approved the member may be responsible for the highest non‑specialty level of cost‑sharing. See the Procedures that Support Safe Prescribing for details on exception processing and plan‑specific benefit availability.
Tier‑exception requests are subject to specific limits. Providers may request exceptions when criteria are met (for example, documented trials or contraindications to formulary alternatives), but tier exceptions are not available for drugs placed on the generic, preferred brand, or specialty tiers. Individual plan benefit designs may further restrict availability of tier exceptions; refer to the member benefit booklet for plan‑level rules.
The excerpts in this section do not specify discrete clinical exclusions framed as medical necessity rules; instead the guidance and product listings use tier and administrative annotations (for example, PA, QL, AL, SP, NF) to communicate utilization controls and coverage requirements.
Several entries in the formulary excerpt are marked NF (Non‑Formulary). Examples shown in the list include topical and cardiovascular products such as Rectiv and other items flagged as NF in the drug table. NF designation indicates those products are not on the preferred coverage tiers in the sample excerpt.
The provided excerpt does not contain formal, standalone medical‑necessity exclusion statements. Coverage direction is communicated through formulary tiering and utilization flags (e.g., PA, QL, AL, NF) applied at the drug line level rather than separate exclusion text.
Drugs labeled NF (Non‑Formulary) are designated non‑formulary in the formulary listing. An NF designation means coverage is limited or may be denied unless a formulary exception or prior authorization is obtained in accordance with the exception and PA processes described in the formulary documentation.
Formulary Codes, Flags, and Key Thresholds
Formulary flags and tier codesmixed
| PA | Prior Authorization (legend) |
| QL | Quantity Limits Apply (legend) |
| QIT | Quantity Over Time (legend) |
| SP | Specialty Drug (legend) |
| AL | Age Limit (legend) |
| LCG | Low Cost Generic (legend) |
| G | Generic tier |
| NF | Non-Formulary tier |
| PB | Preferred Brand tier |
| NPD | Non-Preferred Drug |
Formulary entries (no CPT/HCPCS/NDC codes present in this excerpt)mixed
| No codes listed |
Opioid MME limit
Opioid MME threshold> 90 MME per day requires prior authorization
ScopeApplies to total daily opioid dose across monitored opioid active ingredients (MME calculated across products)
ActionPrior authorization required when total daily opioid dose exceeds 90 MME
Opioid MME limit (duplicate)
Opioid MME threshold (duplicate)> 90 MME/day requires prior authorization
Denial riskOpioid prescriptions exceeding 90 MME/day may be denied without prior authorization
CalculationMME is calculated based on opioid potencies and total daily usage across products
Amphetamine high cumulative dose
Amphetamine-class high cumulative dose60 mg/day prior authorization threshold
Affected agentsIncludes amphetamine, amphetamine-dextroamphetamine, dextroamphetamine, methamphetamine (brands/generics listed in policy)
Provider actionClaims exceeding the cumulative 60 mg/day threshold require prior authorization
Dexmethylphenidate high cumulative dose
Dexmethylphenidate threshold40 mg/day prior authorization threshold
Example productFocalin (IR/XR) and generics referenced in policy
RequirementClaims exceeding 40 mg/day require prior authorization
Methylphenidate high cumulative dose
Methylphenidate threshold72 mg/day prior authorization threshold
Affected productsIncludes Ritalin (IR/LA), Concerta, Daytrana, Aptensio XR, Quillivant XR, Jornay PM, and others listed
ActionPrior authorization required when cumulative methylphenidate exceeds 72 mg/day
Serdexmethylphenidate high cumulative dose
Serdexmethylphenidate threshold52.3 mg/day prior authorization threshold
Example productAzstarys (serdexmethylphenidate) referenced in policy
RequirementClaims exceeding 52.3 mg/day require prior authorization
Age Limit and Quantity Over Time indicators
Age Limit (AL) presentSome products on the formulary are annotated with AL to indicate coverage may be restricted by member age
Quantity Over Time (QIT) presentSelected products include QIT annotations (quantity limits based on rolling time windows)
Where shownAL and QIT flags appear in the REQUIREMENTS/LIMITS column for specified products (see drug rows)
Morphine Milligram Equivalent (MME)
MME definition/roleMorphine Milligram Equivalent (MME) is used to compare opioid potency and determine total daily opioid exposure for safety and prior authorization thresholds
Use in utilization controlsMME calculations are applied as a utilization control where indicated (e.g., MME limit triggers PA)
Calculation noteDaily MME is calculated across opioid products considering potency and total daily usage
Provider Responsibilities, Prior Authorization and Documentation
Prior Authorization
Prior Authorization Required
Prior authorization is required for certain covered drugs. Providers must obtain approval from AmeriHealth (via the PBM) to confirm medical necessity and appropriateness before the prescription will be covered at retail or mail-order pharmacies. The authorization review may take up to two business days once complete information is received; incomplete submissions may delay decisions. Some approvals are time‑limited (e.g., 6–12 months) and require reauthorization after expiration.
- Claims exceeding the claim dollar threshold ($10,000) require prior review and the provider must submit a PA request.
- Compound products with total cost ≥ $75 per prescription require review/authorization.
- Certain drugs additionally require a benefit rider (e.g., some weight‑loss drugs) — verify member eligibility with the health plan.
Prior Authorization
Drug‑specific Prior Authorization List
A long list of specific drugs and product families require prior authorization. This applies to all formulations (tablet, capsule, suspension, injectables, specialty presentations) when the formulary row shows REQUIREMENTS/LIMITS = PA.
- Examples (not exhaustive): abiraterone, adalimumab products, apomorphine inj, Alyftrek, brivaracetam, Cabometyx, Calquence, Dupixent, Emgality, Ibrance, Imbruvica, Liraglutide, Mounjaro, Ozempic, Skyrizi, Spevigo, many oncology, dermatology, and specialty agents.
- All brand prenatal vitamins require authorization.
- Providers must submit PA requests with complete clinical information for listed products to the PBM (ePA portal, fax to 1‑888‑671‑5285, or PBM portal).
Prior Authorization
Prior Authorization for Select Agents
Select agents and specialty products listed in the formulary carry a PA flag and may also have additional limits (QL, QIT, SP, LDD, SDS). Prior authorization is required at claim processing for these products; failure to obtain PA may result in denial.
- Specialty (SP) drugs often require PA and may be subject to limited distribution (LDD) or supply limits (SDS).
- Formulary entries show combined flags (e.g., PA, QL, QIT) — review the REQUIREMENTS/LIMITS column for each drug.
Prior Authorization
Prior Authorization Applies to Listed Drugs
Prior authorization applies to many drugs listed in the formulary where REQUIREMENTS/LIMITS is annotated with PA. Claims for these drugs will require PA at point of dispensing and may be rejected if authorization is not on file.
- Coverage status and PA requirements are shown per‑drug in the formulary rows; check DRUG TIER and REQUIREMENTS/LIMITS before dispensing.
- Examples include oncology and immunology agents (numerous entries show PA and SP).
Denial Risk
Denial Risk Without Prior Authorization
Failure to obtain required prior authorization, or exceeding limits (MME, QL, QIT, claim dollar limits), may result in claim denial. Providers and members will be notified if a request is denied and appeals information will be included in the denial communication.
- Denial triggers include: missing PA, exceeding quantity limits (QL/QIT), supply limits (SDS), limited distribution constraints (LDD), non‑formulary (NF) exclusions, and claim dollar thresholds.
- If denied, the prescribing provider and member receive notification and appeals instructions.
Denial Risk
MME Limit — Prior Authorization for >90 MME/day
AmeriHealth enforces a Morphine Milligram Equivalent (MME) daily limit for opioid safety. Prior authorization is required for opioid regimens that exceed 90 MME/day. Claims above the MME threshold may be denied without an approved PA.
- MME applies across opioid products and is calculated using each product's potency and total daily usage.
- Affected active ingredients include morphine, hydromorphone, fentanyl, hydrocodone, oxycodone, oxymorphone, tapentadol, tramadol, methadone, and others listed in the formulary.
- Some opioid products in the formulary are flagged with MME and PA in the REQUIREMENTS/LIMITS column.
Denial Risk
Cumulative Stimulant Limit — PA Required for High Doses
A cumulative stimulant dose limit is enforced by active ingredient. Stimulant claims that exceed the defined ingredient‑specific daily thresholds require prior authorization and may be denied without approval.
- Example high cumulative daily thresholds: amphetamine family = 60 mg/day; dextroamphetamine = 60 mg/day; dexmethylphenidate = 40 mg/day; methylphenidate = 72 mg/day; lisdexamfetamine and others as defined in the formulary.
- Providers should review total daily stimulant dose across all products with the same active ingredient before prescribing/dispensing.
Prior Authorization
Prior Authorization Triggers on the Formulary
Prior authorization is triggered at claim processing when the formulary 'REQUIREMENTS/LIMITS' field contains flags such as PA, QL (quantity limits), QIT (quantity over time), SP (specialty), AL (age limit), LDD (limited distribution), SDS (supply limit), NF (non‑formulary), or MME. Claims with these flags will be subject to the corresponding review and may require submission of clinical documentation.
- Check the formulary row for each drug to determine which flags apply before submitting or dispensing.
- PA triggers include product‑specific entries and class‑level safety edits (e.g., MME, stimulant cumulative limits).
Documentation Required
Required Documentation When Controls Apply
When controls such as PA, QL, MME, SDS, or LDD apply, providers must submit required clinical documentation with the PA request. Lack of documentation can delay review or result in denial.
- Required documentation may include medical history, prior therapy trials, dosing rationale, lab results, and letters of medical necessity.
- Supply limits (SDS) and limited distribution (LDD) requirements may affect where and how the drug is obtained — include distribution details when relevant.
Note
Formulary Legend and Required Codes
The formulary legend defines the meaning of codes/flags used in the REQUIREMENTS/LIMITS column. Providers must understand these abbreviations when evaluating coverage and submission requirements.
- PA = Prior Authorization; QL = Quantity Limits Apply; QIT = Quantity Over Time; SP = Specialty Drug; AL = Age Limit.
- LDD = Limited Distribution Drug; SDS = Supply Limit; R = Requires Rider; NF = Non‑Formulary; PB = Preferred Brand; NPD = Non‑Preferred.
- MME = Morphine Milligram Equivalent; Claim Dollar Limit refers to per‑claim dollar review thresholds.
Step Therapy
Formulary Exceptions and Step‑Therapy Notes
Formulary exceptions and step‑therapy requests are handled via specific exception forms. Providers may request coverage of non‑formulary or tier exceptions, typically requiring documentation of trials of and/or contraindications to formulary alternatives. Some plans do not permit tier exceptions; review the member's benefit booklet.
- Formulary exception for non‑formulary drugs generally requires trial of (or contraindication to) at least three formulary alternatives when applicable.
- Tier exceptions for generic, preferred brand, or specialty tiers are subject to plan rules and may be unavailable for some tiers.
- Submit formulary exception requests using the exception form and fax to 1‑888‑671‑5285; approved exceptions will adjust the member's cost‑sharing level accordingly.
Step Therapy
Step Therapy — Details Managed by PBM
The formulary excerpts do not provide detailed step‑therapy sequences. While some entries imply prior steps or alternatives via tiering and PA requirements, specific step‑therapy algorithms are managed by the PBM and must be confirmed with the PBM's criteria.
- Where step therapy is required, the PBM maintains the clinical criteria and step sequence — providers should consult the PBM ePA portal or criteria documents.
- Do not assume step order from tiering or PA flags alone; submit clinical rationale and prior therapy history when requesting PA or exceptions.
Formulary Background and Scope
Background: The AmeriHealth Value formulary is selected to promote safety, effectiveness, and value. Formulary decisions and utilization management procedures are guided by the local Pharmacy & Therapeutics Committee and implemented by the pharmacy benefits manager. Safety edits described in the formulary (for example, prior authorization, quantity limits, age limits, MME and stimulant dose limits) are applied to support appropriate prescribing and member safety; providers must follow the documented PA and exception procedures when requesting coverage outside standard formulary placement.
Key Terms and Abbreviations
Formulary
Formulary definitionA list of prescribed medications or other pharmacy care products, services or supplies chosen for safety, cost, and effectiveness; medications are listed by category and placed into tiers
GovernanceList is guided by a Pharmacy & Therapeutics Committee which reviews coverage, effectiveness, and value
IncludesBoth brand and generic prescription medications are included and placed into tiers
Tiers
Formulary tiersLow-Cost Generic; Generic; Preferred Brand; Non-preferred Drug; Non-Formulary; Specialty
MeaningTiers reflect cost-sharing levels; non-preferred and non-formulary tiers generally have higher cost-sharing and may require exceptions for coverage
AvailabilityNot all tiers or incentives (e.g., LCG) are available on all plans
Morphine Milligram Equivalent (MME) definition
MME definitionMorphine Milligram Equivalent is a calculated value used to compare opioid potency and determine total daily opioid exposure
PurposeUsed to identify when additional caution or utilization controls (e.g., prior authorization) are needed
ApplicationMME-based limits are applied to opioid prescribing and claims adjudication
Concurrent Drug Utilization Review (cDUR)
cDUR definitionConcurrent Drug Utilization Review (cDUR) are automated pharmacy claim reviews at point-of-sale for safety concerns such as drug-drug interactions and therapy duplications
FunctionMay generate rejects or pharmacist alerts at POS; pharmacist can review and override when appropriate
ExamplesDrug-drug interaction alerts (e.g., sildenafil + nitroglycerin) and therapy duplication alerts (e.g., multiple statins)
PA definition
PA definitionPA = Prior Authorization — requires approval from the health plan before coverage/dispensing
Usage in formularyPA is shown in the REQUIREMENTS/LIMITS field for drugs that require prior approval
Provider actionProviders must submit PA requests per payer process to obtain coverage for PA‑designated drugs
QL definition
QL definitionQL = Quantity Limits Apply — the product has limits on the amount covered over time
TypesIncludes maximum daily dose, quantity over time (QIT), and supply limits (SDS) as applicable
DocumentationSupporting documentation may be required to justify quantities above limits
QIT definition
QIT definitionQIT = Quantity Over Time — a quantity limit based on dosing over a rolling time period (e.g., 30-day lookback)
PurposePrevents dispensing excessive quantities by counting prior fills over the defined time window
ExamplesNuvaring = 1 per 28 ring days; other drugs annotated with QIT in the formulary list
SP definition
SP definitionSP = Specialty Drug — drugs meeting criteria such as treatment of rare/complex conditions, complex storage/shipping, or requiring intensive monitoring
ManagementSpecialty drugs may be managed by a Specialty Pharmacy Program and placed on a specialty tier with higher cost-sharing
ImplicationSP designation may require specialty distribution, PA, or LDD handling
AL definition
AL definitionAL = Age Limit — coverage may be restricted based on member age for annotated products
UsageAge limits are shown in the REQUIREMENTS/LIMITS column for specific dermatologic and other products
ExamplesRetin-A and certain topical products include AL annotations in the formulary list
LCG definition
LCG definitionLCG = Low-Cost Generic — a tier offering lower copays than the standard generic tier for selected chronic-use generics (availability varies by plan)
Plan variabilityNot all plans provide LCG; when not available, drugs are covered at the generic cost-share level
PurposeIntended to provide lower member cost-share for commonly used chronic medications
PA (legend)
PA (legend repetition)PA = Prior Authorization
ContextShown in formulary legend and used in REQUIREMENTS/LIMITS column
Action impliedPA designation requires submission of prior authorization to obtain coverage
QL (legend)
QL (legend repetition)QL = Quantity Limits Apply
ContextAppears in the formulary legend and drug rows to indicate quantity restrictions
DocumentationProviders may need to provide supporting documentation to exceed QL
QIT (legend)
QIT (legend repetition)QIT = Quantity Over Time
ContextUsed in legend and product rows to indicate rolling lookback quantity limits
Relation to QLQIT is a form of quantity limit applied over a defined time window
SP (legend)
SP (legend repetition)SP = Specialty Drug
ContextIndicates specialty tier designation in the formulary legend
ImplicationSP flag may indicate specialty distribution, PA, or higher cost-sharing
Utilization flags and tier abbreviations
Consolidated legendPA = Prior Authorization; QL = Quantity Limits Apply; QIT = Quantity Over Time; SP = Specialty Drug; AL = Age Limit; LDD = Limited Distribution Drug; SDS = Supply Limit; NF = Non Formulary; PB = Preferred Brand; NPD = Non Preferred; G = Generic; LCG = Low Cost Generic
Where usedLegend appears at top of drug list and guides interpretation of REQUIREMENTS/LIMITS entries
EffectThese abbreviations trigger specific provider actions (e.g., PA requires submission of prior authorization)
MME (legend reference)
MME (legend reference)MME = Morphine Milligram Equivalent — referenced as a utilization control for opioid medications
FunctionUsed to impose opioid daily dose limits that trigger PA and other safety edits
PlacementMME appears in the legend and in multiple drug rows where opioid controls apply
PA (duplicate)
PA (definition duplicate)Prior Authorization — requires approval before coverage
NoteRepeated across legend sections to emphasize PA requirement
Provider implicationClaims for PA-designated drugs may be denied without authorization
QL (duplicate)
QL (definition duplicate)Quantity Limits Apply — product has limits on amount covered over time
ExamplesMaximum daily dose, QIT, and SDS are types of QL shown in drug rows
Provider implicationExceeding QL may require PA or supporting documentation
SDS (Supply Limit) definition
SDS definitionSDS = Supply Limit — limits based on supply (e.g., days' supply) apply to some drug classes such as opioids
ExampleShort-acting opioids have supply limits expressed as two 5‑day supplies per 60 days for adults (see QL examples)
ImplicationSDS may be shown with QL and MME in REQUIREMENTS/LIMITS for certain products
NF / NPD / PB / G / LCG
Tier abbreviationsNF = Non-Formulary; NPD = Non-Preferred Drug; PB = Preferred Brand; G = Generic; LCG = Low Cost Generic
MeaningThese abbreviations indicate the formulary tier and corresponding cost-share level for listed products
UsageShown in drug rows to indicate tier placement
PA (additional legend)
PA (additional legend)PA = Prior Authorization (requires approval prior to coverage)
ContextRepeated in multiple legend blocks for clarity
Provider actionSubmission of PA per payer process is required for coverage of PA‑flagged drugs
QL (additional legend)
QL (additional legend)QL = Quantity Limits Apply — product has limits on amount covered over time
Provider implicationQL annotations may require documentation to justify quantities above limits
ExamplesMaximum daily dose and supply limits shown in the formulary list
SP (additional legend)
SP (additional legend)SP = Specialty Drug — drugs requiring specialized handling, monitoring, or distribution
ImplicationSP designation may be associated with PA, QL, LDD, or specialty pharmacy management
Where shownAppears in the legend and in individual drug rows for specialty products
LDD definition
LDD definitionLDD = Limited Distribution Drug — drugs distributed through limited channels and may require specific handling
ImplicationClaims for LDD products may require coordination with specialty distribution and PA
UsageShown in formulary rows for selected specialty products
NF definition
NF definitionNF = Non-Formulary — product is non‑formulary and may require a formulary exception for coverage
Coverage implicationNon‑formulary drugs are covered only when a formulary exception/PA is obtained and may carry higher cost-sharing
Where shownNF appears in the REQUIREMENTS/LIMITS and tier columns throughout the drug list
NPD definition
NPD definitionNPD = Non-Preferred Drug — a tier that usually has higher cost-sharing than preferred brand or generic tiers
EffectMay be associated with PA or QL depending on the product
PlacementUsed in the tier column for many listed products
G definition
G definitionG = Generic — generic tier placement for medications
Cost-shareGeneric tier typically has lower cost-sharing than brand tiers
UsageShown in tier column for generic products in the formulary list
PB definition
PB definitionPB = Preferred Brand — brand-name drugs with preferred status on the formulary
Cost-sharePreferred Brand tier generally has lower cost-sharing than Non-Preferred Drug or Non-Formulary tiers
UsageAppears in tier column for selected brand products
AL definition (duplicate)
AL (duplicate)AL = Age Limit — coverage may be restricted by member age
ExamplesMultiple topical agents and other products include AL annotations in drug rows
Provider actionCheck AL annotation on drug row when prescribing to verify age-based coverage limits
Formulary annotation definitions
Formulary annotation definitionsLegend abbreviations define utilization controls and tier codes used across the formulary (PA, QL, QIT, SP, AL, LDD, SDS, NF, PB, NPD, G, LCG)
PurposeHelps providers interpret REQUIREMENTS/LIMITS annotations on each drug row
ReferenceLegend appears in multiple chunks and should be consulted when submitting claims or PA requests
PA definition (alternate)
PA (alternate chunk)PA = Prior Authorization — requires approval prior to dispensing/coverage
NotationRepeated across legend blocks for clarity
ImplicationClaims for PA-designated drugs are at risk for denial without authorization
QL definition (alternate)
QL (alternate chunk)QL = Quantity Limits Apply — indicates quantity restrictions on coverage
ExamplesMaximum daily dose and supply limits shown in QL examples
Provider implicationSupporting documentation may be required to exceed QL
AL definition (alternate)
AL (alternate chunk)AL = Age Limit — indicates coverage may be restricted by age for specific products
ExamplesTopical dermatologic agents frequently include AL annotations
Provider actionVerify patient age against AL annotation before dispensing or submitting PA
SP definition (alternate)
SP (alternate chunk)SP = Specialty Drug — drugs meeting criteria for specialty handling and monitoring
ManagementMay be managed by a Specialty Pharmacy Program and have higher cost-sharing
AnnotationsSP appears in legend and in drug rows to indicate specialty status
NF definition (alternate)
NF (alternate chunk)NF = Non-Formulary — product is non‑formulary and may require a formulary exception for coverage
Coverage implicationNon‑formulary status often results in restricted coverage unless exception/PA is approved
Where usedAppears throughout the formulary tier column and drug rows
PB definition (alternate)
PB (alternate chunk)PB = Preferred Brand — brand-name drugs with preferred formulary placement
Cost-sharingPreferred Brand tier has cost-sharing characteristics distinct from NPD and NF tiers
UsageAppears in tier column for selected brand products
NPD definition (alternate)
NPD (alternate chunk)NPD = Non-Preferred Drug — tier indicating non-preferred status with higher cost-sharing
AnnotationUsed in drug rows to indicate tier placement and possible PA/QL requirements
ImplicationMay influence step/PA requirements per plan rules
PA (short)
PA (short legend)PA = Prior Authorization
ContextShort legend repeats PA meaning for quick reference
EffectPA flag requires prior approval for coverage
QL (short)
QL (short legend)QL = Quantity Limits Apply
ContextShort legend repeats QL meaning for quick reference
EffectIndicates quantity restrictions on coverage
SP (short)
SP (short legend)SP = Specialty Drug
ContextShort legend repeats SP meaning for quick reference
ImplicationSP flag may indicate specialty pharmacy handling and higher cost-share
NF (short)
NF (short legend)NF = Non‑Formulary
ContextShort legend repeats NF meaning for quick reference
Coverage implicationNF items may require exception/PA for coverage
PB (short)
PB (short legend)PB = Preferred Brand
ContextShort legend repeats PB meaning for quick reference
UsageIndicates preferred brand placement in formulary tiers
NPD (short)
NPD (short legend)NPD = Non‑Preferred
ContextShort legend repeats NPD meaning for quick reference
ImplicationNon‑preferred status may affect cost-sharing and utilization management
LDD (short)
LDD (short)LDD = Limited Distribution Drug
ContextIndicates limited distribution handling for select products
ImplicationMay require coordination with specialty distributors and PA
Formulary abbreviations
Formulary abbreviations (legend)Common abbreviations used across the formulary: PA, QL, QIT, SP, AL, LDD, SDS, NF, PB, NPD, G, LCG
PurposeHelps interpret requirement/limit annotations in drug list
ReferenceLegend appears in multiple locations in the document
PA (repeat)
PA (definition repeat)Prior Authorization — approval required prior to coverage/dispensing
ImplicationClaims without PA where PA is required are at risk of denial
Provider actionSubmit PA per payer instructions to avoid denial
QL (repeat)
QL (definition repeat)Quantity Limits Apply — product has amount limits over a time period
Provider implicationExceeding QL may require PA or documentation
ExamplesMaximum daily dose and rolling QIT examples provided in document
SP (repeat)
SP (definition repeat)Specialty Drug — drug requiring specialized handling/monitoring
ImplicationMay be managed through Specialty Pharmacy Program with PA/QL/LDD requirements
Where shownSP flags appear in drug rows and legend
NF (repeat)
NF (definition repeat)Non-Formulary — product not on formulary; coverage typically requires exception/PA
Coverage implicationNF designation may result in denial without approved exception
ReferenceUsed widely in tier column across drug list
Step Therapy and Trial Requirements
| Requirement | Notes |
|---|---|
| Providers must document trials of, or contraindications to, formulary alternatives when requesting coverage of a non‑formulary medication | When requesting a formulary exception, providers should complete the exception request form and fax to 1-888-671-5285 with supporting clinical detail; tier exceptions are not available for drugs on the generic, preferred brand, or specialty tiers |
| Formulary exception requests for non‑formulary drugs require documentation that at least three formulary alternatives were tried or shown to be contraindicated when applicable | If an exception is approved the drug will be covered at the appropriate preferred brand or generic level; denials will be communicated with appeals language |
| Observation | Source implication |
|---|---|
| No explicit step‑therapy sequences are listed in the provided formulary excerpt | The formulary rows show utilization flags (e.g., PA, QL, QIT, SP) but do not define required step‑by‑step therapy sequences |
| Coverage controls appear as per‑drug attributes (PA, QL, QIT, AL, SP) rather than as explicit multi‑step algorithms in this excerpt | Step therapy specifics are managed by the PBM and are not detailed in these chunks |
| Observation | Implication for providers |
|---|---|
| Several non‑preferred or specialty drugs are annotated with 'PA' in the requirements/limits field (examples shown across the list) | These annotations indicate prior authorization is required; explicit step rules or exact prior‑trial requirements are not provided in this fragment |
| Providers should expect to submit PA requests for non‑preferred or specialty agents marked 'PA' and provide supporting clinical documentation per PA process | If step edits are implemented by the PBM they will be applied per plan/PBM rules; not specified here |
| Observation | Implication |
|---|---|
| Multiple specialty or non‑preferred agents are marked with tier codes (NPD, PB, SP) and have 'PA' in their REQUIREMENTS/LIMITS field | Examples in the list include agents where PA is required alongside specialty designation |
| Such agents will require prior authorization before coverage and may be subject to PBM step edits per plan rules, though specific step sequences are not listed here | Providers should consult plan/PBM procedures when submitting PA for specialty or non‑preferred medications |
| Observation | Practice note |
|---|---|
| Some topical agents are designated as Non‑Preferred (NPD) or Non‑Formulary (NF) in the list; several topical entries also show 'AL' or 'PA' flags | Examples include adapalene formulations with AL and PA annotations in the excerpt |
| NPD/NF designation and PA or AL flags imply that prior authorization, age limits, or formulary exception processes may apply per plan rules | Specific step therapy edits for topical agents are not defined in this excerpt; providers should follow PA and exception procedures as indicated |
| Observation | Summary |
|---|---|
| The excerpt does not provide explicit step‑therapy sequences; individual drug rows primarily show PA and QL flags | Dexcom sensors and many insulin/diabetes supplies are annotated with PA and QL but no step order is shown |
| Providers should prepare to submit PA or document need for quantity overrides when PA/QL flags are present; step‑by‑step algorithms are not specified here | Refer to PBM/plan procedures for any step therapy requirements that may exist outside this excerpt |
| Observation | Implication |
|---|---|
| Some devices and diabetic meters/supplies (e.g., Omnipod systems, Dexcom sensors, test strips, glucometers) are annotated with PA and/or QL in the list | Examples include Omnipod entries and Dexcom Continuous Glucose Monitor sensors showing PA and QL |
| Coverage for these devices/supplies may require prior authorization and are subject to quantity limits; the excerpt does not define any step‑therapy ordering for device coverage | Providers should follow PA submission and quantity‑limit documentation procedures for diabetes devices per plan/PBM guidance |
| Observation | Note |
|---|---|
| The fragment does not specify any step‑therapy sequences; it shows formulary abbreviations and per‑product flags (PA, QL, SP, AL, NF, NPD) only | Testosterone products and other listed items are shown with tier and requirement flags but no step edit instructions |
| Where PA/QL flags appear, prior authorization or quantity limits may be enforced; step therapy applicability (if any) should be confirmed with the PBM/plan | Providers should ensure required documentation accompanies PA requests to avoid denial |
Quantity, Supply, and Refill Limits
Refill rule
Refill ruleMember may refill after 75% of previous supply has been used (refill-too-soon limit)
ExamplesA 30‑day supply filled on 1/1/2025 is refillable on or after 1/24/2025; a 90‑day supply filled 7/1/2025 is refillable on or after 9/7/2025
PurposeTo encourage appropriate utilization and minimize stockpiling
Short-acting opioids example limit
Short-acting opioid supply limit (adults)Two 5-day supplies per 60 days without authorization
Short-acting opioid supply limit (children <18)Two 3-day supplies per 60 days without authorization
Maximum quantity without authorization30 tablets (example: oxycodone/acetaminophen 5/325 mg) — max quantity without authorization
Ibandronate (Boniva 150 mg)
Ibandronate (Boniva 150 mg)1 tablet per 30 days (quantity limit)
ReferenceExample listed under Quantity Over Time in document
ImplicationQL annotation enforces monthly limit for this product
Sumatriptan (Imitrex)
Sumatriptan (Imitrex)18 tablets per 30 days (quantity limit)
ContextListed as an example of Quantity Over Time limits
Provider implicationDispensing beyond this limit may require PA or documentation
Sildenafil, Tadalafil
Sildenafil / Tadalafil8 tablets per 30 days (quantity limit)
ContextExample provided in Quantity Over Time section
ImplicationQL annotation limits monthly quantity for erectile dysfunction agents
Zolpidem (Ambien)
Zolpidem (Ambien)1 tablet per day maximum (maximum daily dose)
ContextProvided as an example of maximum daily dose QL
Provider implicationDispensing beyond daily limit may require PA or documentation
Butalbital-containing headache agents
Butalbital-containing agentsQuantity limit = 6 tablets per day; supply limit = 5-day supply per 30 days; maximum without authorization = 30 tablets
Example agentsButalbital/aspirin and similar headache combinations
ImplicationExceeding these QL/SDS values may require prior authorization
Opioid-containing cough/cold products
Opioid-containing cough/cold productsQuantity limit = 30 mL per day; supply limit = two 5-day supplies per 60 days for adults (two 3-day supplies for children <18); maximum without authorization = 150 mL
Example agentsHydrocodone/homatropine and similar cough/cold opioid formulations
ImplicationSDS and QL annotations enforce these limits; PA may be required for larger quantities
Cresemba — QL and QIT noted
CresembaAnnotated with PA, QL, QIT in formulary list
ImplicationClaims for Cresemba require prior authorization and are subject to quantity limits and quantity-over-time rules
ReferenceSee REQUIREMENTS/LIMITS column in drug row
Itraconazole; ivermectin; griseofulvin
Itraconazole, Ivermectin, GriseofulvinFormulary rows include QIT or QL flags for specific formulations (exact numeric quantities not listed)
ImplicationQuantity-over-time or quantity limits apply to specified formulations as indicated in the drug rows
ReferenceSee drug rows with REQUIREMENTS/LIMITS annotations for details
Molnupiravir 200mg
Molnupiravir 200 mgAnnotated with QL and AL in formulary list
ImplicationQuantity limits and age limits apply to this product as noted in drug row
ReferenceSee REQUIREMENTS/LIMITS column for Molnupiravir 200 mg
Sofosbuvir-velpatasvir 400-100mg
Sofosbuvir-velpatasvir 400/100 mgAnnotated with QL (and PA in some rows) in formulary list
ImplicationQuantity limits apply; prior authorization may also be indicated depending on row
ReferenceSee REQUIREMENTS/LIMITS column for specifics
Solodyn
SolodynAnnotated with QL and QT in formulary list
ImplicationQuantity limits and quantity-over-time rules apply to Solodyn formulations
ReferenceSee drug row REQUIREMENTS/LIMITS for details
Imbruvica
ImbruvicaAnnotated with QL in formulary list
ImplicationQuantity limits apply to Imbruvica as shown in drug row
ReferenceSee REQUIREMENTS/LIMITS in the formulary listing
Multiple opioids and controlled substances
Multiple opioids & controlled substancesMany entries include QL, MME, and SDS annotations as indicated per line
ExamplesActiq, hydrocodone combinations, Adderall and other controlled drugs show QL/MME annotations
ImplicationThese utilization controls may trigger PA or denial if limits are exceeded
Multiple opioids and other listed drugs
Multiple opioids and other drugsSeveral listed drugs include QL and SDS where specified in their formulary rows
ImplicationSupply limits and quantity limits are enforced at claim adjudication
ReferenceSee each drug's REQUIREMENTS/LIMITS column for applicable controls
sildenafil citrate (25/50/100 mg)
Sildenafil citrate (25/50/100 mg)Annotated with QL in formulary list
ImplicationMonthly quantity limits apply to these dosage strengths as indicated
ReferenceSee drug row REQUIREMENTS/LIMITS for specifics
warfarin
WarfarinAnnotated with AL (Age Limit) in formulary list
ImplicationAge-based restrictions may apply to coverage of warfarin formulations
Provider actionVerify patient age against AL annotation before dispensing
Filsuvez Gel 10%
Filsuvez Gel 10%Quantity Limits apply (PA and/or QL noted in drug row)
ImplicationQL annotations restrict amounts covered and may require PA for larger supplies
ReferenceSee REQUIREMENTS/LIMITS column for this product
Litfulo
Litfulo (Opzelura Cream)Annotated with PA and QL in formulary list
ImplicationPrior authorization and quantity limits apply to Litfulo as noted
ReferenceSee REQUIREMENTS/LIMITS column for details
Prudoxin cream 5%
Prudoxin cream 5%Quantity Limits (QL) and AL annotations present in formulary list
ImplicationCoverage may be limited by quantity and age restrictions
ReferenceSee REQUIREMENTS/LIMITS column for Prudoxin cream
Dexcom sensors
Dexcom sensorsDexcom Continuous Glucose Monitor sensors are annotated with PA and QL (quantity limits apply)
ImplicationClaims for Dexcom sensors require prior authorization and are subject to quantity limits
ReferenceSee drug rows for Dexcom G7/G6/G5/G4 sensors in formulary list
Insulin and diabetes supplies (Apidra; Basaglar; Bydureon; Fiasp)
Insulin and diabetes supplies (examples)Certain insulin products (Apidra, Basaglar, Bydureon, Fiasp) and diabetes supplies are annotated with QL
ImplicationQuantity limits apply to many insulin formulations and diabetes supplies; PA may also be required for some
ReferenceSee REQUIREMENTS/LIMITS columns in formulary listing for specifics
Eversense E3 Sensor
Eversense E3 SensorAnnotated with PA and QL in formulary list
ImplicationPrior authorization and quantity limits apply to Eversense sensors
ReferenceSee REQUIREMENTS/LIMITS column for Eversense E3 Sensor
Insulin products (various)
Insulin products (various)Multiple insulin products are annotated with QL in the formulary list
ImplicationQuantity limits apply monthly for many insulin formulations
ReferenceSee individual insulin product rows for exact QL and PA annotations
Teriparatide Pen‑Injector
Teriparatide Pen‑InjectorAnnotated with QIT and QL (quantity over time and quantity limits)
ImplicationClaims subject to QIT/QL and may require prior authorization as indicated
ReferenceSee formulary row for Teriparatide Pen‑Injector 620mcg/2.48ml and related strengths
Multiple listed drugs — QL/QIT annotations
Multiple listed drugsVarious drugs in the formulary are annotated with QL or QIT where noted per drug row
ImplicationProviders should reference individual drug rows for applicable quantity/time limits
ActionExceeding QL/QIT may require PA or supporting documentation
Adalimu-Adaz Inj 40/0.4ml (Sandoz)
Adalimu-Adaz Inj 40/0.4ml (Sandoz)Annotated with QL in formulary list
ImplicationQuantity limits apply to this adalimumab biosimilar product as shown in drug row
ReferenceSee REQUIREMENTS/LIMITS column for details
Adalimumab-adbm Prefilled Syringe Kit
Adalimumab-adbm Prefilled Syringe KitAnnotated with QL (and PA in some entries) in formulary list
ImplicationQuantity limits and prior authorization may apply to this adalimumab product
ReferenceSee drug row REQUIREMENTS/LIMITS for specifics
Policy Summary
PayerAmeriHealth
PolicyAmeriHealth Value Formulary Guide — Coverage & Prior Authorization Criteria
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionSubmit prior authorization with complete clinical information for drugs flagged PA or when utilization thresholds (e.g., >90 MME/day, stimulant cumulative limits, high-cost claims) are exceeded.
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