Find a drug
A formulary is a list of covered medications. This list of drugs is carefully selected by the plan with the help of a team of doctors and pharmacists, and is reviewed and approved by Medicare. We may periodically add or remove covered drugs, change coverage limitations on certain drugs, or change how much you pay for a drug.
Find a prescription drug
To find covered prescription drugs, select your health plan below. You can search AmeriHealth Drug Formularies alphabetically by drug name and check for drugs recently added to or removed from the formulary.
2024 formularies for individual members
| Documents | |
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You can contact us for the most recent list of drugs.
See Coverage Determination for Part D Drugs, Part D Appeals, and Part D Grievances to learn how to obtain an exception to the plan's formulary. This is not a complete list of all formulary alternatives covered by the Part D sponsor for the drug you have selected.
For Utilization Management information please visit our Quality Assurance page. For Tiered Cost-Sharing information please visit our Prior Authorization page.
The AmeriHealth pharmacy network
AmeriHealth contracts with an independent pharmacy benefits management (PBM) company to provide Medicare Part D prescription benefit management services.
The network includes:
- national chain and independent retail pharmacies
- long-term care and home-infusion pharmacies
- Indian Health Service/Tribal/Urban Indian Health (I/T/U) Program pharmacies
- a network mail order pharmacy service
In order to receive benefits through the plan, prescriptions generally must be filled at a network pharmacy.
Standard and Preferred pharmacies
Some pharmacies contract with our plan to offer lower cost-sharing to plan members. This is known as preferred pharmacy cost-sharing. You may fill your prescriptions at either a preferred or standard pharmacy. You can save money on certain prescriptions by using a preferred pharmacy:
- Tier 1 and 2 prescriptions (which include most generic drugs) will have lower copayments when you have them filled at preferred pharmacies.
- Tier 3, 4 and 5 prescriptions (which include brand-name, specialty and high-cost generic drugs) will have the same copayments at both preferred and standard pharmacy locations.
| Preferred pharmacies | Standard pharmacies |
|---|---|
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CVS |
Acme |
Find a network pharmacy
To locate or confirm that a pharmacy is currently in our network:
If you need to use an out-of-network pharmacy in special circumstances, including illness while traveling, you may submit a Direct Member Reimbursement for review.
To request a reimbursement, please use the Direct Member Reimbursement Form. Please note that we cannot pay for any prescriptions that are filled by pharmacies outside of the United States, even for a medical emergency.
Out-of-network coverage
Covered Part D drugs are available at out-of-network pharmacies in special circumstances, including illness while traveling outside of the plan's service area where there is no network pharmacy. We may cover your prescription at an out-of-network pharmacy for up to a 30-day supply if at least one of the following applies:
- If the prescriptions are related to care for a medical emergency or urgent care
- If you are unable to obtain a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service
- If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail-order pharmacy (including high-cost and unique drugs)
You may have to pay more than your normal cost-sharing amount, and will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement. We will consider your request and make a coverage decision. If we decide that the drug is covered and you followed all the rules for getting the drug, we will pay for our share of the cost.
We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency.
Step therapy
Certain Medicare Part B prescription drugs may be subject to Step Therapy. Step therapy is a type of coverage determination that applies to certain drugs. Step therapy requires you to first try certain drugs to treat your medical condition before the plan will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, AmeriHealth may not cover Drug B unless you try Drug A first. If Drug A does not work for you, AmeriHealth will then cover Drug B.
How to submit a paper claim
When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy for one of the reasons listed above, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. When you return home, simply submit a claim form and your receipt. Please note that we can only reimburse up to our allowed amount. Please call the Member Help Team for more information on paper claims.
To request a reimbursement, please use the Direct Member Reimbursement Form.
To request a reimbursement specifically for a vaccine and/or a vaccine administration fee, please use the Vaccine and Administration Direct Member Reimbursement Form. This form is for Part D vaccines only and should not be used for Part B vaccines such as the flu shot.
For the Influenza Vaccine Reimbursement Form, please see the Claim Reimbursement Forms section.
Mail-order pharmacy service
Your benefit includes the option to receive prescription drugs shipped to your home through our network mail-order delivery program.
Pharmacies are required to obtain consent prior to shipping or delivering any prescriptions that the beneficiary did not personally initiate. Your PBM does not offer automated mail-order delivery. Our plan's mail-order service allows you to order up to a 90-day supply for certain prescriptions. Please note that due to package sizes, some prescriptions may not be available for our 90-day supply mail-order service.
To begin using our network mail-order delivery program, please use the Prescription Mail-order Form.
For questions about filling your prescriptions by mail please call 1-888-678-7015 (TTY/TDD: 711), 7 days a week, 24 hours a day. Your copay is the same for anything between a 31 — 90 day supply at mail order. If you use a mail-order pharmacy that is not in the plan's network, your prescription will not be covered. Usually a mail-order pharmacy order will get to you in no more than 14 days. If you should not receive your prescription drugs, please call 1-888-678-7015 (TTY/TDD: 711), 7 days a week, 24 hours a day.
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Website last updated: 1/24/2024
