Prior Authorization

For members who have prescription drug coverage administered by AmeriHealth, prior authorization is required for certain prescribed formulary drugs in order for such drugs to be covered. The approval criteria were developed and endorsed by the Pharmacy and Therapeutics Committee and are based on information from the U.S. Food and Drug Administration, manufacturers, medical literature, actively practicing consultant physicians, and appropriate external organizations.

All requests will be reviewed by our pharmacy benefits manager on behalf of AmeriHealth. To simplify your experience with prior authorization and save time, please submit your prior authorization request through any of the following online portals:

• CoverMyMeds^®
• Surescripts^®

Prior authorization via fax

If you prefer, you can also submit prior authorization requests by fax using the forms listed below:

Commercial prior authorization forms
Select formulary

• General fax form
• Acute migraine agents
• CNS stimulants — high cumulative dose
• Immune modulating therapy
• Opioid management — Buprenorphine/naloxone (Bunavail^®/Suboxone^®/Zubsolv^®) and Buprenorphine (Subutex^®)
• Opioid Management — Morphine Milligram Equivalent (MME) > 90 mg/day, Long-acting opioids, Short-acting opioids for short term Use, and Quantity
• Opioid Management — Short-acting opioids for continuation beyond 30 days
• Cost-share exception policy for preventative medications and women’s preventive services
• Select formulary exception prior authorization request form

Premium formulary

• Dispense as written (DAW) override request form
• General fax form
• Health care reform copay waiver request form

Value formulary

• General fax form
• Acute migraine agents
• CNS stimulants — high cumulative dose
• Immune modulating therapy
• Opioid management — Buprenorphine/naloxone (Bunavail^®/Suboxone^®/Zubsolv^®) and Buprenorphine (Subutex^®)
• Opioid Management — Morphine Milligram Equivalent (MME) > 90 mg/day, Long-acting opioids, Short-acting opioids for short term Use, and Quantity
• Opioid Management — Short-acting opioids for continuation beyond 30 days
• Value formulary exception prior authorization request form

Request form instructions

Providers

• \When completing a prior authorization form, be sure to supply all requested information.
• Fax completed forms to 1-888-671-5285 for review. Make sure you include your office telephone and fax numbers.
• You will be notified by fax if the request is approved. If the request is denied, you and your patient will receive a denial letter.
• If you have not received a response after two business days from when you submitted your completed form, please call our pharmacy benefits manager at 1-888-678-7012.

Members

• Take the appropriate request form to your physician for completion.
• You or your physician should fax the completed form to 1-888-671-5285 for review.
• If you have not received a response after two business days from when your completed form was submitted, please contact the physician who requested your prior authorization.

As with all our preauthorization requirements, the prior authorization form must be completed in full to avoid delay. If you have questions about the preauthorization process, call 1-800-275-2583.

Please refer to Drug formularies for more information about the Standard and Select Drug Program^® formularies.