Select Drug Program Formulary
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This document describes AmeriHealth's Select Drug Program formulary structure, coverage processes (including prior authorization and safety edits), and ACA preventive medication coverage guidance for members and providers affected by AmeriHealth pharmacy benefits.
No material clinical or coverage changes in this revision.
Formulary Coverage Rules & Drug Listings
Coverage criteria and utilization management
Covered when specified by member benefits and medical necessity; ACA preventive medications available at $0 cost-share when criteria met.
See formulary preventive medication list for product-level details.
Coverage Criteria and Processes
Prior authorization and exception criteria summarized from the document excerpt:
MME-based limit applies across opioid products and is calculated from total daily opioid use.
Prior authorization: listed products (partial)
Partial enumerated drug list subject to prior authorization; entries map product names to numbered alternative tokens in the list.
Partial PA product listing
- Abilify (and mapped alternatives 1,2,3) — listed in PA product index.
- Absorica LD (and mapped alternatives) — listed in PA product index.
- Multiple additional brand and generic drugs listed alphabetically (extensive list in source).
Sample drug-tier-requirement entries (Antibiotics & other drugs)
Examples of drug-specific tier and requirement entries (partial list; continues across chunks).
Partial coverage entries
This fragment enumerates drugs with tier and any associated requirements/limits.
Selected drug coverage examples
Formulary stance and coverage controls for listed drugs in this segment.
Seysara coverage
Sample drug requirement nodes
Per-drug coverage controls shown as abbreviations following drug entries; examples from this section include:
Sample drug entries and controls
Per-drug entries include tier and any requirements/limits. Examples from this segment:
Per-drug criteria examples
Per-drug coverage controls (examples from excerpt):
Sample drug criteria from listing
Drug-specific tier and utilization controls (sample entries from this portion of the formulary):
Formulary coverage controls (excerpt)
Drugs listed include an associated tier and one or more requirement/limit flags determining coverage controls.
Sample coverage controls by drug
Per-drug entries include tier and any requirements/limits. Examples from this segment:
Extracted coverage indicators from listed drugs
Formulary entries indicate coverage stance via tier and requirements; many non-preferred or specialty agents require prior authorization.
sample drug-specific annotations
Per-drug coverage annotations in this section (examples):
Coverage entries
The excerpt is a drug list mapping specific dermatology/topical drugs to tiers and any associated requirements or limits.
Tier Codes, Requirement Codes, and Thresholds
| Formulary index listing (partial: drugs beginning with Z shown in this chunk) |
| MME>90 | Opioid daily morphine milligram equivalent exceeds 90 MME — prior authorization required |
| STIM_HIGH_DOSE | Stimulant cumulative daily dose exceeds listed threshold for specific active ingredient — prior authorization required |
| MME>90 | Prior authorization is required for an opioid dose that exceeds 90 MME per day (chunk 18) |
| AMPHETAMINE>60MG | Amphetamine high cumulative daily dose = 60mg/day (chunk 20) |
| AMPH-DEXTRO>60MG | Amphetamine-Dextroamphetamine high cumulative daily dose = 60mg/day (chunk 20) |
| DEXTROAMPHETAMINE>60MG | Dextroamphetamine high cumulative daily dose = 60mg/day (chunk 20) |
| LISDEXAMFETAMINE>70MG | Lisdexamfetamine high cumulative daily dose = 70mg/day (chunk 20) |
| METHAMPHETAMINE>60MG | Methamphetamine high cumulative daily dose = 60mg/day (chunk 20) |
| DEXMETHYLPHENIDATE>40MG | Dexmethylphenidate high cumulative daily dose = 40mg/day (chunk 20) |
| METHYLPHENIDATE>72MG | Methylphenidate high cumulative daily dose = 72mg/day (chunk 20) |
| SERDEXMETHYLPHENIDATE>52.3MG | Serdexmethylphenidate high cumulative daily dose = 52.3mg/day (chunk 20) |
| G | Generic |
| NPD | Non-preferred drug |
| SP | Specialty drug |
| LCG | Low-cost generic |
| PB | Preferred brand |
| ACA | $0 Preventive drug |
| Drug tier designations (e.g., NPD, G, PB, LCG) appear but no standard billing codes provided in this fragment |
| NPD | Non Preferred Drug |
| G | Generic |
| PB | Preferred Brand |
| SP | Specialty Drug |
| LCG | Low Cost Generic |
| NPD | Non Preferred Drug (tier indicator) |
| G | Generic (tier indicator) |
| PB | Preferred Brand (tier indicator) |
| Tagrisso | Tagrisso — TIER = NPD, SP; REQUIREMENTS/LIMITS = PA, QL (chunk 120) |
| Fareston | Fareston — TIER = NPD; example entries in chunk 108 |
| PA | Prior Authorization |
| QL | Quantity Limits Apply |
| SP | Specialty Drug |
| NPD | Non Preferred Drug |
| G | Generic |
| PB | Preferred Brand |
| 5DS | Day Supply Limit |
| MME | Morphine Milligram Equivalent |
| LCG | Low Cost Generic |
| PA | Prior Authorization |
| QL | Quantity Limits Apply |
| 5DS | Day Supply Limit |
| MME | Morphine Milligram Equivalent |
| LDD | Limited Distribution Drug |
| SP | Specialty Drug |
| NPD | Non Preferred Drug |
| G | Generic |
| PB | Preferred Brand |
| LCG | Low Cost Generic |
| PA | Prior Authorization |
| QL | Quantity Limits Apply |
| 5DS | Day Supply Limit |
| MME | Morphine Milligram Equivalent |
| PA | Prior Authorization |
| QL | Quantity Limits Apply |
| SP | Specialty Drug |
| AL | Age Limit |
| MME | Morphine Milligram Equivalent |
| 5DS | Day Supply Limit |
| PA | Prior Authorization |
| QL | Quantity Limits Apply |
| SP | Specialty Drug |
| NPD | Non Preferred Drug |
| PB | Preferred Brand |
| G | Generic |
| N/A | No CPT/HCPCS/ICD-10/NDC codes are present in these chunks; entries are drug-name and tier metadata. |
| PA | Prior Authorization |
| QL | Quantity Limits Apply |
| AL | Day Supply Limit |
| LDD | Limited Distribution Drug |
| SP | Specialty Drug |
| PB | Preferred Brand |
| NPD | Non-Preferred Drug |
| G | Generic |
| LCG | Low Cost Generic |
| PA | Prior Authorization |
| QL | Quantity Limits Apply |
| AL | Age Limit |
| SP | Specialty Drug |
| LCG | Low Cost Generic |
| NPD | Non Preferred Drug |
Actions Providers Must Take to Request Coverage or Exceptions
Prior authorization required for certain drugs and claims > $10,000
Prior authorization is required for certain covered drugs to confirm medical necessity and appropriateness; claim dollar limits trigger review for prescriptions exceeding $10,000 and require prior authorization. Approvals may be time-limited and will require reauthorization when they expire.
- Without prior authorization, the prescription will not be covered at retail or mail-order pharmacy.
- Prior authorization reviews may take up to two business days after complete information is received; incomplete information may delay the decision.
- Some prior authorizations have limited timeframes (e.g., 6–12 months) and require resubmission after expiration.
PA required for opioid >90 MME/day and high-dose stimulants
Prior authorization is required for opioid prescriptions that exceed 90 MME per day; stimulant prescriptions that exceed the listed cumulative daily dose thresholds by active ingredient also require prior authorization.
- Opioid MME threshold: prior authorization required >90 MME/day.
- Stimulant cumulative daily dose 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.
Request PA for safety-edit exceptions with clinical justification
Providers may request coverage for prescriptions that fall outside age or quantity safety edits by submitting a prior authorization with clinical justification; incomplete clinical information may delay review.
- Age limits: provider may request coverage when prescription falls outside FDA age guidance by submitting PA with supporting clinical rationale.
- Quantity limits: if member requires more than the specified quantity limit, the provider must submit a PA; quantity-limit overrides may be time-limited.
- Safety edits include age limits, quantity limits, MME limits and cDUR that may prompt counseling or require PA.
How to submit PA — ePA (SureScripts™) or fax to 1-888-671-5285
Submit prior authorization requests via an electronic prior authorization (ePA) platform such as SureScripts™ or by faxing a completed prior authorization form or a letter of medical necessity to the PBM at 1-888-671-5285; ePA can approve in real time and decisions are communicated by fax/telephone/letter.
- If a clinical pharmacist cannot approve the request, it will be escalated to a medical director for review.
- If approved, the provider is notified via fax/telephone and the adjudication system is coded; if denied, provider and member are notified and appeal instructions are provided.
PA triggers — opioids >90 MME/day and stimulant cumulative limits
Prior authorization is triggered for opioids exceeding 90 MME/day and for stimulant claims that exceed the cumulative dose limits specified by active ingredient; claims above these thresholds require prior authorization before coverage.
- Opioid products containing listed opioid active ingredients are subject to the 90 MME/day PA threshold.
- Stimulant claims exceeding per-ingredient cumulative limits (see documented thresholds) will require PA.
cDUR may reject/flag claims at point-of-sale; pharmacist review required
Concurrent Drug Utilization Review (cDUR) may reject or flag claims at point-of-sale; the dispensing pharmacist may review and, when appropriate, override rejections after consulting the prescriber.
- cDUR may generate POS rejects or messages for drug–drug interactions or therapy duplication.
- Pharmacist may review with provider and can override most edits if clinically appropriate.
Formulary exception requests — trial of ≥3 alternatives; fax to 1-888-671-5285
Tier exception (formulary exception) requests may be submitted when there has been trial of, or contraindication to, at least three formulary alternatives; providers must fax the completed formulary exception request form to 1-888-671-5285 and note that some tiers/plans or certain tiers (generic, preferred brand, specialty) may be ineligible for exceptions.
- If exception approved, the non-preferred drug will be covered at the preferred brand or generic cost-share level as applicable.
- Tier exceptions are not available under some plans—refer to the member benefit booklet for eligibility.
PA applies to all formulations of listed drugs
Prior authorization applies to all formulations (tablet, capsule, oral suspension, etc.) of the drugs listed in the formulary drug rows; providers must obtain PA for any formulation indicated with 'PA'.
- The PA designation on a drug row applies to all formulations of that drug.
- Check the drug list entries for PA flags next to specific products and formulations.
Examples: Doxycycline hyclate DR 80mg and Daraprim Tab require PA
Prior authorization applies to listed drugs shown with 'PA' in the requirements/limits column (examples in the list include Doxycycline hyclate DR 80mg and Daraprim Tab).
- Doxycycline hyclate DR 80mg is listed with REQUIREMENTS/LIMITS = PA.
- Daraprim Tab is listed with REQUIREMENTS/LIMITS = PA.
Mavyret requires PA plus quantity limits (QL, Q/T)
Some products are subject to both prior authorization and quantity controls; for example, Mavyret is listed with REQUIREMENTS/LIMITS = PA, QL, Q/T and requires prior authorization and quantity/quantity-over-time enforcement.
- Mavyret entries show PA, QL, and Q/T — providers must request PA and adhere to quantity/quantity-over-time limits if applicable.
Rezurock (NPD, SP) requires PA and QL
Rezurock is listed as Non-Preferred and Specialty and requires prior authorization and quantity limits (PA, QL) for coverage.
- Rezurock entries indicate TIER = NPD, SP and REQUIREMENTS/LIMITS = PA, QL.
Seysara requires PA and Quantity Over Time (Q/T)
Seysara is listed as Non-Preferred and requires prior authorization and Quantity Over Time (Q/T) controls (REQUIREMENTS/LIMITS = Q/T, PA).
- Seysara entries show REQUIREMENTS/LIMITS = Q/T, PA — providers must submit PA and adhere to Q/T limits.
Sofosbuvir–velpatasvir 400/100 mg requires PA and QL
Sofosbuvir–velpatasvir 400/100 mg is listed as Non-Preferred Specialty and requires prior authorization and quantity limits (PA, QL).
- Sofosbuvir-velpatasvir 400-100mg entries indicate REQUIREMENTS/LIMITS = PA, QL and tier = NPD, SP.
vancomycin formulations may require PA and QL; specialty/LDD noted
Some vancomycin formulations are subject to prior authorization and quantity limits; select vancomycin entries indicate PA/QL and may be designated specialty or limited distribution requiring special handling.
- Review the drug list for vancomycin rows showing REQUIREMENTS/LIMITS = PA, QL and SP/LDD designations where present.
Viread specialty formulation requires PA and QL
Viread entries include a specialty formulation that requires prior authorization and quantity limits (PA, QL) when designated as specialty.
- Viread shown with TIER = NPD, SP and REQUIREMENTS/LIMITS = PA, QL for specialty formulations.
Legend: PA = Prior Authorization; QL, SP, LDD and other abbreviations
The formulary legend defines PA = Prior Authorization and common requirement abbreviations such as QL = Quantity Limits Apply, LDD = Limited Distribution Drug, SP = Specialty Drug; providers should use these flags on drug rows to determine actions required.
- PA = Prior Authorization; QL = Quantity Limits Apply; SP = Specialty Drug; LDD = Limited Distribution Drug; 5DS = Day Supply Limit; MME = Morphine Milligram Equivalent.
- The legend and drug rows indicate which utilization controls (PA, QL, 5DS, AL, Q/T, MME, LDD, SP) apply to each product.
Formulary Terms & Legend
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