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Dosage and Frequency Program

AmeriHealth provides coverage for our members in accordance with the medical necessity criteria in our policies and the terms of each member’s benefit contract. Through the Dosage and Frequency Program, AmeriHealth reviews the requested dosage and frequency of certain specialty drugs that are eligible for coverage under the medical benefit to ensure that these regimens adhere to safe prescribing limits.

Coverage of the drugs in the Dosage and Frequency Program is contingent upon review for medical necessity and appropriate dosage and frequency. This review is conducted as part of the precertification process for all members enrolled in AmeriHealth medical plans.

View the complete list of drugs in the Dosage and Frequency Program. This list is subject to change.

Medical Policies

Dosage and frequency guidelines are included in AmeriHealth medical policies. The guidelines are based on a consensus of information obtained from various resources, including, but not limited to:

• U.S. Food and Drug Administration (FDA)
• Company-recognized authoritative pharmacology compendia
• Published peer-reviewed clinical research

To access medical policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online and type the drug name in the Search field.

Requesting a Drug in the Program

Please note the following about requesting a drug in the Dosage and Frequency Program:

• Documentation requirements. AmeriHealth requires providers to submit documentation (i.e., published peer-reviewed literature) when requesting specialty drug coverage beyond the dosage and frequency requirements listed in a medical policy.
• Review at precertification renewal. Members currently receiving a drug included in the program are subject to review for dosage and frequency at every precertification renewal.
• Accurate member information. Having accurate information about the member is necessary for AmeriHealth to approve a requested drug from the program. If a member’s dosage, frequency, or regimen changes (due to factors like changes in member weight or incomplete therapeutic response), providers must submit those changes to AmeriHealth for a new approval through the precertification process.

AmeriHealth reserves the right to conduct a post-payment review and audit of claims submitted for any drug that is part of this program and may recover payments that exceed the treatment amount approved through the precertification process.