Pharmacy Prior Authorization
Opioid treatment resources
AmeriHealth Caritas Pennsylvania Community HealthChoices continues to carefully review and update our requirements for opioid prescriptions. Our collaborative goal with you is to ensure that our members are receiving the correct treatment for their pain and that opioid utilization is managed and monitored appropriately. We will continue to provide you with the most up-to-date information and resources to attain that goal.
Opioid-related prior authorization request forms:
Prior authorization
Pharmacy prior authorizations are required for pharmaceuticals that are not in the formulary, not normally covered, or which have been indicated as requiring prior authorization.
For more information on the pharmacy prior authorization process, call the Pharmacy Services department at 1-888-674-8720.
Important payment notice
Please note that reimbursement for all rendering network providers subject to the ordering/referring/prescribing (ORP) requirement for an approved authorization is determined by satisfying the mandatory requirement to have a valid Pennsylvania Medical Assistance (MA) Provider ID. Effective January 1, 2018, any claim submitted by rendering network providers that are subject to the ORP requirement will be denied when billed with the NPI of an ORP provider that is not enrolled in MA.
To check the MA enrollment status of the practitioner ordering, referring, or prescribing the service you are providing, visit the DHS provider look-up portal.
How to submit a request for pharmacy prior authorization
Online
Save time by submitting all your pharmacy prior authorization requests online. To submit electronically please submit an electronic prior authorization (ePA) through your electronic health record (EHR) tool software, or you can submit through any of the following online portals:
By phone
Call the Pharmacy Services department at 1-888-674-8720.
By fax
Please see available prior authorization request forms below.
Prior authorization criteria
Many medicines have specific requirements and conditions that must be met to receive prior authorization. Save time by viewing a list of medications and their prior authorization criteria (PDF) before submitting your request.
Drug- and Drug class-specific prior authorization request forms
Please see available prior authorization request forms below.
- Antidepressants prior authorization form (PDF)
- Antihemophilia agents prior authorization form (PDF)
- Antipsychotics prior authorization form (PDF)
- Botulinum Toxins prior authorization form (PDF)
- Casgevy prior authorization form (PDF)
- Cytokine and CAM antagonists prior authorization form (PDF)
- Dupixent prior authorization form (PDF)
- Erythropoiesis stimulating agents prior authorization form (PDF)
- Hepatitis C agents prior authorization form (PDF)
- Hypoglycemic, incretin mimetics-enhancers prior authorization form (PDF)
- Intra-Articular Hyaluronates prior authorization form (PDF)
- HCPCS (Healthcare Common Procedure Coding System) prior authorization form (PDF)
- Long-acting opioid prior authorization form (PDF)
- Lyfgenia prior authorization form (PDF)
- Migraine prevention agents (PDF)
- Monoclonal antibodies prior authorization form (PDF)
- Obesity treatment agents prior authorization form (PDF)
- Oncology agents, oral prior authorization form (PDF)
- Opioid dependence treatments (oral) prior authorization form (PDF)
- Short-acting opioid prior authorization form (PDF)
- Stimulants and related agents prior authorization form (PDF)
- Synagis prior authorization form (PDF)
The form must be completed in its entirety and faxed to 1-855-851-4058. Failure to submit all requested information could result in denial of coverage or a delay of approval as the result of insufficient information.
General prior authorization request form
- If the drug you are requesting is not included in the options above and you wish to submit a faxed request, please use the universal pharmacy oral prior authorization form (PDF).