AmeriHealth Administrators provides coverage for plan members in accordance with the medical necessity criteria in our policies and the terms of each plan member’s benefit contract. Through the Dosage and Frequency Program, AmeriHealth Administrators 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 plan members enrolled in AmeriHealth Administrators medical plans.
Dosage and frequency guidelines are included in AmeriHealth Administrators 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
You can access medical policies through our Medical Policy Portal To view a specific policy, select Accept and Go to Medical Policy Online, select Commercial Policies from the top of the page (depending on which version you would like to view), and type the name of the drug 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 Administrators 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. Plan members currently receiving a drug included in the program are subject to review for dosage and frequency at every precertification renewal.
- Accurate plan member information. Having accurate information about the plan member is necessary for AmeriHealth Administrators to approve a requested drug from the program. If a plan member’s dosage, frequency, or regimen changes (due to factors like changes in plan member weight or incomplete therapeutic response), providers must submit those changes to AmeriHealth Administrators for a new approval through the precertification process.
AmeriHealth Administrators 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.