Latest AmeriHealth prior authorization updates25

• Prior AuthReimbursement/Payment PolicyEff. 2026-04-01Select Drug Program FormularyThis 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.AmeriHealthGeneralAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyEff. 2026-01-01AmeriHealth Medicare PPO 2026 Formulary (Drug List)This document is the AmeriHealth Medicare PPO 2026 formulary (Drug List) describing covered prescription drugs, coverage rules, restrictions (e.g., prior authorization, step therapy, quantity limits), and how members can request exceptions. It applies to AmeriHealth Medicare PPO members and their prescribers/pharmacies.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyEff. 2026-01-01AmeriHealth Medicare PPO 2026 Formulary (Drug List)This document describes the AmeriHealth Medicare PPO 2026 formulary, including coverage rules (prior authorization, step therapy, quantity limits), member exception and transition supply rights, and where to find drug coverage information for plan members and their prescribers/pharmacies.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/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.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyEff. 2026-01-01Specialty drugs requiring precertificationList of specialty drugs that require precertification for AmeriHealth Medicare Advantage members, effective January 1, 2026; applies to listed brands, generics, and biosimilars and affects providers submitting precertification requests.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyEff. 2025-10-17AmeriHealth Medicare PPO 2025 Formulary (Drug List)This document is the AmeriHealth Medicare PPO 2025 Formulary describing which prescription drugs are covered, applicable coverage restrictions (prior authorization, quantity limits, step therapy), and how members or prescribers can request exceptions or transition supplies. It applies to AmeriHealth Medicare PPO members and participating network pharmacies.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthAdministrative/Operational PolicyEff. 2025-07-01Precertification Requirements for Elective (Non‑Emergency) ServicesLists services, tests, drugs and devices that require precertification for elective (non-emergency) care and clarifies that precertification does not guarantee coverage; applies to AmeriHealth commercial and Medicare Advantage members as indicated. Some reviews are performed by independent review vendors.AmeriHealthGeneralAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyEff. 2025-01-01AmeriHealth Medicare Part D Drug Coverage and Utilization Management Criteria — Pharmacy & Specialty DrugsThis document lists drugs covered under the AmeriHealth Medicare PPO formulary and details utilization management requirements (prior authorization, step therapy, quantity limits), clinical requirements, prescriber and age restrictions, and coverage durations affecting members and prescribing providers.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyEff. 2025-01-01Most Cost-Effective Setting (MCES) Program Drug ListDefines the AmeriHealth Most Cost-Effective Setting program and lists medications whose treatment setting must be approved through the precertification process; applies to providers requesting medical-benefit administration settings for listed drugs.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthAdministrative/Operational PolicyEff. 2024-01-01Precertification requirements for AmeriHealth Medicare Advantage servicesThis document lists services and items that require precertification for AmeriHealth Medicare Advantage members for elective, non-emergency care and identifies third-party reviewers for select service categories. It affects providers and facilities submitting precertification requests for Medicare Advantage members.AmeriHealthGeneralAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyEff. 2012-01-01Most Cost-Effective Setting (MCES) Program Drug ListDefines the AmeriHealth Most Cost-Effective Setting Program listing medications for which the treatment setting must be approved as part of precertification; affects providers requesting medical-benefit administration of listed drugs for AmeriHealth members.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyEff. 2012-01-01Most Cost-Effective Setting (MCES) Program Drug List — Treatment Setting PrecertificationDefines the AmeriHealth MCES program that requires precertification of the treatment setting for certain medical-benefit medications to ensure safety and cost-effectiveness; affects providers requesting coverage for listed drugs under the AmeriHealth medical benefit in North Carolina.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyAmeriHealth Medicare PPO pharmacy prior authorization and utilization management criteria (partial)Portion of the AmeriHealth Medicare PPO pharmacy policy listing drugs subject to utilization management (prior authorization, step therapy, quantity limits) and providing criteria summaries for selected products.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyAmeriHealth Medicare PPO — Partial Formulary Utilization Management Criteria (Pharmacy & Specialty Drugs)This document describes utilization management requirements (prior authorization, step therapy, quantity limits) and specific PA criteria for multiple pharmacy products covered under the AmeriHealth Medicare PPO plan; it affects prescribers and pharmacies serving plan members.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/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.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyAmeriHealth Select Drug Program Formulary and Prior Authorization ProceduresThis document governs the AmeriHealth Select Drug Program formulary structure, safety edits (prior authorization, age/quantity/MME/stimulant limits), and related pharmacy benefit procedures that affect members and providers participating in AmeriHealth plans.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyAmeriHealth Value Formulary Guide — Coverage & Prior Authorization CriteriaExplains 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.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyCoverage Determination Request FormA pharmacy/coverage determination request form used by providers to request prior authorization, non-formulary coverage, step therapy exceptions, quantity limit exceptions, tier exceptions, and continuation of therapy for medications. Collects provider, patient, medication and clinical justification information and attestation for special cases (opioids, high-risk medications in elderly).AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyDispense As Written (DAW) Override Prior Authorization Request FormForm and instructions for providers to request a prior authorization to override generic substitution (Dispense As Written) for a medication; applies to AmeriHealth members and their prescribing providers submitting DAW override requests to the pharmacy benefit manager.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyFormulary step therapy and prior authorization rules for selected drugsDefines 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.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyFormulary utilization management: prior authorization and step therapy for select drugsDefines prior authorization, step therapy, and quantity limits for specific prescription drugs on the AmeriHealth Medicare PPO formulary and describes requirements that affect prescribers and members for new-start and continuing therapy.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyFormulary utilization management: step therapy requirements for selected drugsDefines step therapy and prior authorization requirements applied to specific outpatient prescription drugs on the AmeriHealth Medicare PPO formulary; affects prescribers and pharmacies serving AmeriHealth Medicare PPO members.AmeriHealthPharmacy & Specialty DrugsAll AmeriHealth updates
• Prior AuthClinical/Medical PolicyOmalizumab (Xolair) prior authorization for allergic asthma and chronic urticariaForm and criteria governing prior authorization and delivery of omalizumab (Xolair) for patients with allergic asthma or chronic spontaneous urticaria; intended for prescribing physicians submitting requests to AmeriHealth.AmeriHealthAllergy/Clinical ImmunologyAll AmeriHealth updates
• Prior AuthAdministrative/Operational PolicyPrecertification Requirements for Elective ServicesGoverns which elective, non-emergency services and items require precertification for AmeriHealth members; affects providers and members subject to the payer's benefit plans.AmeriHealthGeneralAll AmeriHealth updates
• Prior AuthAdministrative/Operational PolicyPrecertification requirements for elective servicesDefines services and items that require precertification for elective, non-emergency care and notes that precertification does not guarantee coverage; applies to AmeriHealth members per plan benefits. A list of specific services, procedures, equipment, and genetic tests requiring precertification is provided.AmeriHealthGeneralAll AmeriHealth updates