Prior Authorization for AmeriHealth Advantage PDP

Certain covered drugs that have been approved by the FDA for specific medical conditions require prior authorization. The approval criteria were developed and endorsed by the Pharmacy and Therapeutics Committee. The criteria are based on information from the FDA, manufacturers, medical literature, actively practicing consultant physicians, and appropriate external organizations.

Prior Authorization Criteria

Step Therapy 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:

• Aranesp Request Form
• Botox Request Form
• Chemotherapy Antiemetic Request Form
• Enbrel^® or Humira^® Self Injectable AS, PsA, Psoriasis Biologics Request Form (for treating arthritis)
• Enbrel^® or Humira^® Self Injectable RA Biologics Request Form (for treating arthritis)
• Forteo/Boniva Injection Request Form
• Fuzeon Lab Tracking Form
• Fuzeon Medication History Form
• Fuzeon Prior Authorization Request Form
• Patient Self-Administered Growth Hormone Request Form
• Home Infusion Therapies Request Form
• Lupron/Zoladex Request Form
• Physician Office Administered Injectable Drug Request Form
• Self-Administered Specialty Drugs Request Form
• Self Injectable Non Pegylated Interferons Request Form (for Hepatitis C treatment)
• Self Injectable Peg-Intron Interferons Request Form (for Hepatitis C treatment)
• Procrit Request Form
• Remicade Request Form
• Risperdal-Consta Request Form
• Serostim Prior Authorization Request Form
• White Blood Cell Stimulators (Leukine, Neupogen, Neulasta) Request Form
• Xolair Prior Authorization Request 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 PerformRx for review to the number listed on the form. 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 received a response after two business days after submitting a completed coverage determination form information, contact the Provider Services Department at 1-866-457-3007.

Members:

• Take the Coverage Determination form to your physician to be completed.
• You or your physician may fax the completed form to the PerformRx for review. PerformRx fax numbers:
• 1-866-369-6041 (standard) and 1-866-533-5497 (urgent).
• If you have not received a response after two business days after your provider submitted a complete coverage determination form, contact the provider who requested the prior approval on your behalf.
• If you have questions, please contact Customer Services at the number listed on the back of your identification card.

Tiered cost-sharing exceptions

Physicians, on behalf of members, may request coverage of a non-preferred medication, at the preferred formulary copay. The physician should complete the Non-preferred Exception Request Form providing detail to support use of the non-preferred medication and fax the request to 866-533-5498. The Non-preferred Exception Request Form can also be obtained by calling 866-369-6037.

If the non-preferred request is approved, the drug will be processed at the appropriate formulary benefit copay. If the request is denied, the member and physician will receive a denial letter that explains the appeal process. The member may still receive benefits for the drug at the non-preferred copay or coinsurance.