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Prior Authorization
AmeriHealth requires prior authorization of certain covered drugs that have been approved by the Food and Drug Administration (FDA) for specific medical conditions. The approval criteria was developed and endorsed by the AmeriHealth Pharmacy and Therapeutics Committee and is based on information from FDA and manufacturers, medical literature, actively practicing consultant physicians and appropriate external organizations.
 Prior Authorization Criteria
A request form must be completed for all medications requiring prior authorization. The forms below are available in PDF format. Current prior authorization medications are:
- Analgesic Medications (Celebrex®, Mobic®, and Ultram ER®)
- Angiotensin II Receptor Blockers
- Anti-Infective Agents
- Arthritis/Psoriasis agents (Enbrel®, Kineret®, Humira®, Amevive® and Raptiva®)
- Botulinum Toxins (Type A and B)
- Diabetic Agents (Exubera®, Byetta®, and Symlin®)
- Direct Ship Injectable Form
- Erectile Dysfuntion Medications (Viagra®, Caverject®/Edex®, MUSE®, Levitra®, and Cialis®)
- Exjade®
- Fentora®/Opana®/Opana Er®
- Forteo® Injection
- Lipitor® (Atorvastatin)/Caduet®(Amlodipine/Atorvastatin)
- Growth Hormone Enrollment Form
- Lyrica® (pregabalin)/Cymbalta® (duloxetine)
- Medicare Administrative Prior authorization for Part B/D
- Miglustat (Zavesca®)
- Migraine Agents
- Non-Formulary Exception Request
- Oral chemotherapy agents (Thalomid®, Gleevec®, Sprycel®, Iressa®, Tarceva®, Sutent®, Nexavar®, and Revlimid®)
- Proton Pump Inhibitors (Aciphex®, Nexium®, Prevacid®, Prevacid NapraPAC®, and Protonix®)
- Provigil® (modafenil)
- Sildenafil (Revatio®)
- Singulair®
- Synagis® (palivizumab)
- Synvisc®, Supartz®, Hyalgan®, Euflexxa®, Orthovisc®
- Xolair® (omalizumab)
- General Pharmacy Prior Authorization Form
Request Form Instructions
Providers:
Download a Coverage Determination Form:
Coverage Determination Form for Enrollees
Coverage Determination Form for Providers
Coverage Determination Instructions
- When filling out a prior authorization form, all requested information must be supplied. Incomplete requests will be faxed back to your office for completion, which will delay the review process.
- Fax completed forms to the Pharmacy Services Department for review. Make sure you include your office telephone and fax number.
- You will be notified by fax if the request is approved. You and your patient will receive a denial letter if the request is denied.
- If you have not gotten a response after two business days from submitting complete information, contact the Provider Services Department. Information regarding expedited requests.
Members:
- Take the appropriate request form to your physician to be completed.
- You or your physician may fax the completed form to the Pharmacy Services Department for review.
- If you have not gotten a response after two business days from your provider submitting complete information, contact the provider who requested the prior approval on your behalf.
- If you have questions, please contact Member Services at the number listed on the back of your identification card.
Pharmacy Services Department fax numbers:
- 215-241-3073 inside local Philadelphia area
- 888-671-5285 toll-free outside the local calling area
As with all our pre-authorization requirements, a provider should complete the process fully to avoid delay. Any questions about prior-certification applications or process, providers should call Provider Services at 1-215-567-3590 or 1-800-227-3119 (outside the Philadelphia area). To receive a printed copy of our Select Drug Program® and standard formularies, please call our Supply Line at 1-800-858-4728.
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