AmeriHealth Coverage Criteria
Latest AmeriHealth coverage criteria updates4
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Select Drug Program Formulary (pharmacy benefit) — Coverage CriteriaDefines 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.All AmeriHealth updates
- Coverage CriteriaClinical/Medical PolicyAmeriHealth Medicare PPO — Utilization Management: Prior Authorization, Step Therapy, Quantity Limits and Clinical Criteria for Selected Drugs (coverage criteria)Lists utilization management rules (prior authorization, step therapy, quantity limits, clinical criteria, age and prescriber restrictions, coverage durations, and exclusions) for specific covered drugs under the AmeriHealth Medicare PPO plan; applies to providers, prescribers, pharmacists, and members.All AmeriHealth updates
- Coverage CriteriaClinical/Medical PolicyRequest for Medicare Drug Coverage Determination (Form and Coverage Criteria)Form and instructions for requesting a Medicare drug coverage determination (prior authorization, formulary exception, reimbursement, tiering or quantity limit exceptions) from AmeriHealth; intended for plan enrollees, prescribers, or authorized representatives submitting requests.All AmeriHealth updates
- Coverage CriteriaClinical/Medical PolicySelect Drug Program formulary coverage criteriaGoverns how prescription drugs are covered under the AmeriHealth Select Program formulary, including tiering, prior authorization, safety edits (age, quantity, MME, stimulant limits), and ACA preventive medications; affects AmeriHealth members and their prescribing providers.All AmeriHealth updates
Tool Description
Search AmeriHealth coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
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Coverage policies are updated every day. Follow payer coverage policy updates in the live policy feed, or browse all CPT, HCPCS and DRG billing codes.
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