Pharmacy Benefits

Drug formularies

AmeriHealth Caritas DC has a preferred drug list (drug formulary).

All medicines not on the drug formulary list need prior authorization (prior approval) or they may not be covered. You will receive a copy of the drug formulary every year. You will also be notified when any updates affect you.

Prior authorization criteria (PDF)

Get to know your pharmacist - every day matters.

Pharmacists are medicine experts. They play an important role in the health of you and your family. When you know your pharmacist, it affects your health more than you think. Find out more about why you need to know your pharmacist.

Understand your medicines

There are a lot of medicines doctors can prescribe for their patients. Each medicine works differently. It can be hard to understand what you are taking, how many times you have to take it, and why. Learn more about why you need to understand your medicines.

Life is full of precious moments. You don't want to miss a moment of it.

If you need to fill a prescription before you get your new ID card

  • Use your current enrollee ID card at the pharmacy. The pharmacy will contact us for other information needed to fill your prescription.
  • If you don't have your current enrollee ID card when you go to fill your prescription, tell the pharmacy to call Pharmacy Enrollee Services at 1-888-452-3647 (TTY 1-888-989-0073). We will look up your enrollee ID number and share it with your pharmacy.

Call our Pharmacy Enrollee Services team at 1-888-452-3647 (TTY 1-888-989-0073) if you need help or have questions.

Pharmacy services and prescription drugs

Pharmacies are where you pick up your medicine (drugs). If your doctor gives you a prescription, you must go to a pharmacy in AmeriHealth Caritas District of Columbia's (DC) network. View our pharmacy directory.

To get a prescription filled:

  • Pick a pharmacy that is part of the AmeriHealth Caritas DC network and is close to your work or home.
  • When you have a prescription, go to the pharmacy and give the pharmacist your prescription and your AmeriHealth Caritas DC enrollee ID card.

If you are out of town and you have an emergency or need urgent care and need a prescription filled, call Pharmacy Enrollee Services at 1-888-452-3647.

You do not have to pay anything for any covered, approved prescription drugs.

Mail order pharmacy

Get your medicine sent to you. Your pharmacy benefit includes mail service from Walgreens for maintenance medications. Maintenance medications are used to treat chronic (long-term) conditions.

Learn more about this benefit (PDF).

You can get up to a 3-month supply. Use this pharmacy mail order form (PDF) to get started.

Over-the-counter medicines

AmeriHealth Caritas DC covers all enrollees for some over-the-counter (OTC) drugs with a prescription. Monthly limits may apply and you will get generic brands of OTC drugs, when available. Examples of OTC medicines include:

  • Cough syrup
  • Heartburn medicine, such as antacids, cimetidine and ranitidine
  • Pain medicine, such as acetaminophen, naproxen and ibuprofen
  • Sinus and allergy medicines
  • Vitamins

If you have any questions about your pharmacy benefits, call Enrollee Services at 1-800-408-7511.

Prior authorization

Some prescriptions must be approved before you can get them filled. If a medicine needs prior authorization, your doctor must complete the online prior authorization request form that describes your medical need for the drug. While you are waiting for a drug to be approved, you may be able to get a temporary supply of the medicine. For prior authorization and other pharmacy services questions, call Enrollee Services at 1-800-408-7511. The drug formulary indicates which drugs need prior authorization.

Formulary exceptions

You can make a one-time request to have a medicine that is not on the drug formulary list to be covered for you. You can call Enrollee Services or log on to your enrollee portal.

To suggest adding or deleting medicines in the AmeriHealth Caritas DC drug formulary list, call Enrollee Services at 1-800-408-7511.

Generic substitution

Generic drugs work the same way as brand-name drugs. Generic drugs usually cost less than brand-name drugs. Generic drugs are rated by the U.S. Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs. AmeriHealth Caritas DC does not cover brand-name products for certain drugs if there are equal, less costly generics available. The drug formulary indicates which drugs will be substituted with generics.

Monthly prescription limits

Some medicines may have monthly limits on the number of prescriptions or refills. This is shown in the drug formulary. To request a prescription limit override, the doctor who prescribed the medicine should contact AmeriHealth Caritas DC's Pharmacy Services at 1-888-602-3741, or fax it to 1-855-811-9332.

Step therapy

In some cases, we require you to try certain drugs first to treat your medical condition before another drug for that condition will be covered. For example, if drug A and drug B both treat your medical condition, we may not cover drug B unless you try drug A first. If drug A does not work for you, we will then cover drug B. The drug formulary shows which drugs this applies to.

Specialty pharmacy

AmeriHealth Caritas District of Columbia works with PerformSpecialty to provide enrollees with specialty medications and personalized care. A specialty pharmacy is different than a regular walk-in pharmacy. Specialty pharmacies provide injectable, oral and infused medications. For more information on specialty medications, visit www.performspecialty.com.

Do more online. Don’t wait until you run out. Get automatic refill reminders in the enrollee portal.

Medicaid Enrollees