Pharmacy reference guide Form

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Pharmacy Provider Services Providers and pharmacies with questions regarding AmeriHealth Caritas Delaware’s benefit coverage or claims transmission issues may call Pharmacy Provider Services for assistance: • Diamond State Health Plan (DSHP) and Delaware Healthy Children Program (DHCP): 1-855-251-0966. • DSHP Plus: 1-888-987-6396. Pharmacy network and contracting Phone: 1-800-555-5690 Email: pharmacynetwork@performrx.com Pharmacy prescription claims processing information Abarca Health: AmeriHealth Caritas Delaware Bank identification number (BIN): 019595 Processor control number (PCN): PRX00771 Pharmacy online directory https://ahcde.darwinrx.com/PharmacyLocator

Prior authorization How to submit a request for pharmacy prior authorization Online Go to www.amerihealthcaritasde.com/provider/resources/ pharmacy-prior-auth.aspx. 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: • CoverMyMeds • SureScripts

Providers can use this form to: • Electronically submit all relevant member information. • Attach member-specific documents, such as lab results, chart notes, and consultation documentation. • Save unique provider information to expedite future web submissions. • Print a summary page for easy reference. By fax Fax completed prior authorization request forms to 1-855-829-2872:

Forms available : https://www.amerihealthcaritasde.com/provider/resources/pharmacy-prior-auth
By phone Call Pharmacy Services at 1-855-251-0966. Outside of normal business hours, you can also call Member Services at 1-877-759-6257. Emergency supply: Pharmacies are authorized to dispense up to a 72-hour emergency supply

Member copays • Brand-name medications: $3. • Generic medications: $1. Please see www.amerihealthcaritasde.com/provider/pharmacy/copays.aspx for a list of drugs and services that are excluded and do not have copays. Note: Member pays a maximum of $15 per month.

Pharmacy Reference Guide

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Plan limitations Days supply ≤ 34 (see exceptions in 90-day section below).

Quantity limits Drug or drug class Quantity/day limit Opiate naïve 50 morphine milliequivalents daily/7 days Chronic opiates 50 morphine milliequivalents daily Sedative hypnotics 30 units/30 days Triptans 9 units/45 days Skeletal muscle relaxants 120 units/30 days Carisoprodol 84 tablets/90 days Benzodiazepines 120 units/30 days Tramadol or tramadol combinations 240 units/30 days Narcotic cough medications 480mL/30 days Adjunctive anticonvulsants 240 units/30 days Injectable anticoagulants 10-day supply Drugs taken less frequently than once a day 34-day supply Emergency supply Up to a 72-hour emergency supply Refill frequency ≥ 83 percent of the non-controlled medication must be utilized (25 days of a 30-day supply) and 90 percent for controlled medications.

Formulary Searchable formulary

For the most current formulary information, visit https://www.amerihealthcaritasde.com/apps/formulary . You can also scan the QR code at left with your mobile device. Mandatory generic Requests for “brand necessary” require prior authorization. Prior authorization required (list is not exhaustive) • All non-formulary medications. • All prescriptions that exceed plan limits (see plan limitations above). • Non-formulary prescriptions that exceed $20,000. • Compounded prescriptions that exceed $500. • Early refills. Other notes • Over-the-counter (OTC): Some products may be covered with a prescription. • School supply: Some products may be covered with a prescription. • Out-of-network pharmacy services: AmeriHealth Caritas Delaware does not permit to fill outside of the network (state of Delaware). If the member goes out of network, the member will be responsible for 100% of the cost.”

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Durable medical equipment (DME) covered under pharmacy benefit* Blood glucose meters (one meter per 365 days) Both regular and continuous blood glucose monitors are covered without a prior authorization. Please reference the state’s preferred drug list or AmeriHealth Caritas Delaware’s prior authorization lookup tool for the preferred monitors. Diabetes testing supplies • Lancets. • Testing strips (for the above meters). Aerochambers Must be billed for a quantity of “1” with a day supply of “365.” Quantity limit is two per year without prior authorization. Note: If you have questions or concerns regarding DME coverage, call the PerformRxSM Pharmacy Provider Services Help Desk at 1-855-251-0966, from Monday to Friday, 8 a.m. to 7 p.m.

• Only products listed by First DataBank and loaded into Abarca Health, LLC are potentially billable via the pharmacy benefit.

  Recipient restriction Eligible members may be restricted to any combination of their primary care provider (PCP) and pharmacy. Providers who suspect member fraud, misuse, or abuse of services can refer a member to the Recipient Restriction Program by calling the AmeriHealth Caritas Delaware Abuse Hotline at 1-866-833-9718 or emailing performpro@performrx.com with “Refer a member for the Recipient Restriction (Lock-In) Program” in the subject line.

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