AmeriHealth is contracted with FutureScripts^®, a pharmacy benefit manager, to manage the administration and claims processing of our prescription drug programs. FutureScripts provides mail-order services and works with community pharmacies to provide medications to our members. Medication claims are generally processed directly with the pharmacy provider when the member obtains the prescription.

In order to oversee our pharmacy policies and procedures and to promote the selection of clinically safe, clinically effective, and cost-effective medications for our members, AmeriHealth maintains a Pharmacy and Therapeutics Committee. This Committee is a group of local physicians and pharmacists who meet quarterly to review, evaluate, and update the medications included in our formularies to ensure their continued effectiveness, safety, and value.

Select Drug Program^®

The Select Drug Program is a formulary managed by AmeriHealth and includes all generic drugs and a defined list of brand-name drugs that have been reviewed for medical effectiveness, safety, and value and approved by the U.S. Food and Drug Administration (FDA). This program is generally set up with a three-tiered cost-sharing structure:

• Tier 1 ? Generic: Includes most generic medications. Drugs are covered at the lowest formulary level of cost-sharing.
• Tier 2 ? Preferred Brand: Includes preferred brand medications. Drugs are covered at a higher formulary level of cost-sharing.
• Tier 3 ? Non-Preferred Drug: Includes non-preferred medications. Drugs are covered at the highest non-formulary level of cost-sharing.

Coverage for drugs is based on the member's prescription drug benefits. You can download the latest Select Drug Program Formulary for AmeriHealth New Jersey or for AmeriHealth Pennsylvania. To request a printed copy, call 1-888-YOUR-AH1 for AmeriHealth New Jersey or 1-800-275-2583 for AmeriHealth Pennsylvania.

Value Formulary (for AmeriHealth Pennsylvania only)

The Value Formulary is a restricted formulary managed by AmeriHealth. The selection of drugs for inclusion in the Value Formulary is similar to the Select Drug Program Formulary. Drugs are included based on medical effectiveness, positive results, and value. Drugs not included on the formulary (non-formulary drugs) have covered equivalents and/or alternatives used to treat the same condition.

New drugs are not included on the Value Formulary until reviewed by AmeriHealth. Once reviewed, if it has been determined that a drug should remain non-formulary, it will be added to the Non-Formulary Drug List and formulary alternatives will be provided if applicable. An exception process is available if you feel it is necessary to prescribe your AmeriHealth patient a non-formulary drug.

Coverage for drugs is based on the member?s prescription drug benefits. You can download the latest Value Formulary for AmeriHealth Pennsylvania. To request a printed copy, call 1-800-275-2583 for AmeriHealth Pennsylvania.

Non-formulary exceptions for Value Formulary members

Physicians may request consideration of formulary coverage of a non-formulary drug when there has been a trial of at least three formulary alternatives or there are contraindications to using the formulary alternatives. The physician should complete a non-formulary exception request form to provide details to support use of the non-formulary drug and should fax the request to 1-888-671-5285. If the non-formulary exception request is approved, the drug will be paid at the highest applicable level of cost-sharing. Please note that safety edits, such as quantity limits, will still apply. If the request is denied, the member and physician will receive a denial letter with the appropriate appeals language.

Mail-order services

FutureScripts provides mail-order services as an option for AmeriHealth members to receive their medications. Most of the time, medication requests are processed upon receipt of a prescription from a physician; however, there may be times when the physician will need to contact FutureScripts for medication coverage, such as when formulary management limitations exist. See the "Prescribing safety" section below for more details.

Generic drugs

According to the FDA, generic drugs are equivalent to their brand-name originator in active ingredients, dosage, safety, strength, and performance and are held to the same strict standards as their brand-name counterparts. The only noticeable difference between a generic drug and its brand-name counterpart may be the shape and/or color of the drug. Generic drugs are generally as effective as the corresponding brand-name drugs; however, they may cost up to 70 percent less, helping to reduce health care costs for members. The generic drug option is generally the lowest cost for the member.

Please note that FutureScripts does not determine when a generic drug will be provided at the pharmacy. In accordance with state laws, generic drugs may be provided by the pharmacist at the point of sale, if available, unless the physician indicates "dispense as written" or "brand medically necessary" on the prescription. However, if brand-name drugs are prescribed in place of a generic drug, prior authorization may be needed before the drug is dispensed.

Exceptions

When necessary, consideration for a tier exception can be requested for a non-preferred medication to be covered at a preferred level of cost-sharing. Physicians may request a less costly level of cost-sharing on behalf of a member when the following conditions are met:

• All formulary alternatives have been exhausted or there are contraindications to using them.
• A completed Formulary Exception Fax Form has been faxed to FutureScripts at 1-888-671-5285 and contains at least the following information:
  • – diagnosis for the drug requested
  • – medication history
  • – supporting medical information for the requested medication

The request form can be found on the FutureScripts website.

If the tier exception request is approved, the physician will receive written notification and the drug will be processed at the appropriate formulary level of cost-sharing. If the request is denied, the physician and member will receive a denial letter.

Prescribing safety

As part of formulary management, AmeriHealth implements safe prescribing procedures that are designed to optimize the member?s prescription drug benefits by promoting appropriate utilization. These procedures are based on FDA guidelines, and the approval criteria were developed and endorsed by our Pharmacy and Therapeutics Committee. FutureScripts continuously monitors the effectiveness and safety of drugs and drug prescribing patterns. Several procedures support safe prescribing patterns for our prescription drug programs, such as prior authorization and age and quantity limits.

Prior authorization

Prior authorization is required for certain covered drugs to review whether the drug is medically necessary, appropriate, and prescribed according to FDA guidelines. The approval criteria for these medications may include that the physician prescribe a trial of a different drug, such as a generic or a therapeutic alternative. Clinical pharmacists evaluate the information submitted by the member?s prescribing physician, including available prescription drug therapy history. The clinical pharmacists determine whether there are any drug interactions or contraindications, if the dosing and length of therapy are appropriate, and whether other drug therapies, if necessary, were utilized where appropriate.

The prior authorization process may take up to two business days once completed information from the prescribing physician has been received. The prescriber will be notified if an approval has a defined time frame, such as 12 months. Once the approval time period elapses, the physician will need to request consideration for a new prior authorization. Physicians should fax the appropriate prior authorization form and all supporting medical information to FutureScripts at 1-888-671-5285. Prior authorization forms are available on the FutureScripts website.

Age limits

Upon approval of a drug, the FDA indicates specific safety limitations that govern prescribing practices. Age limits are designed to prevent potential harm to members and to promote appropriate use. Pharmacists have access to up-to-date information regarding FDA guidelines. If a member?s prescription falls outside of the FDA guidelines, it may not be covered until prior authorization is obtained. The prescribing physician may request consideration for prior authorization of these medications when medically necessary by completing the General Fax Form. The member should contact the prescribing physician to request that he or she initiate the prior authorization process.

Quantity limits

Certain drugs have a limit on how many doses a member can receive per day or a total limit for the month. Quantity limits are based upon FDA-approved maximum daily doses and/or length of therapy of a particular drug. If medically necessary, a physician can request consideration for a quantity limit exception by completing the General Fax Form.

Visit the Pharmacy section of our website for AmeriHealth New Jersey or AmeriHealth Pennsylvania for additional information on pharmacy policies and programs.