Pharmacy and Prescription Benefits

Pharmacy services

AmeriHealth Caritas New Hampshire members have pharmacy benefits. If you need medicine, your doctor will write you a prescription. Take it to one of our pharmacies.

If you can't find your regular pharmacy in our pharmacy search tool, call Pharmacy Member Services at 1-888-765-6383 (TTY 711), 24 hours a day, seven days a week.

Or, call if you have questions about our pharmacies.

Prescription benefits

AmeriHealth Caritas New Hampshire covers medicines that:

  • Are medically necessary.
  • Approved by the U.S. Food and Drug Administration (FDA).
  • Prescribed by an AmeriHealth Caritas New Hampshire network provider.

Over-the-counter medicines

We cover some generic over-the-counter medicines. You must have a prescription from a health care provider for your over-the-counter medicine. Some examples of over-the-counter medicines we may cover are:

  • Cough and cold medicines.
  • Sinus and allergy medicines.
  • Pain medicine, such as acetaminophen or ibuprofen.
  • Nicotine replacement products for quitting smoking.

Preferred drug list (list of medicines)

Your preferred drug list is the list of medicines AmeriHealth Caritas New Hampshire covers. This list helps your health care provider prescribe medicines for you.

Brand-name and generic medicines are on the preferred drug list. The list of medicines on this list should be the first drugs you try.

If a certain medicine is non-preferred on the preferred drug list or requires a prior authorization, your doctor may ask for it through AmeriHealth Caritas New Hampshire’s prior authorization process.

If you have questions about which medicines are covered, or need a printed copy of the preferred drug list, please call Pharmacy Member Services at: 1-888-765-6383 (TTY 711), 24 hours a day, seven days a week for more information.

Copays

A “copayment” or “copay” is the fixed amount you may pay each time you fill and refill a prescription. Prescription drug copayment amounts are subject to change.

Prescription drug copayments are:

  • $1 copayment for each preferred or approved prescription drug up to a 34-day supply.
  • $1 copayment for a prescription drug that is not identified as either a preferred or non- preferred prescription drug.
  • Copayments are not required for family planning products or for Clozaril® (Clozapine) prescriptions.

If you have any questions around prescription drug types, call Pharmacy Member Services at 1-888-765-6383 (TTY 711), 24 hours a day, seven days a week.

You do not have to pay a copayment if:

  • You fall under the designated income threshold (100% or below the federal poverty level);
  • You are under age 18 years;
  • You are in a nursing facility or in an intermediate care facility for individuals with intellectual disabilities;
  • You participate in one of the Home and Community Based Care (HCBC) waiver programs;
  • You are pregnant and receiving services related to your pregnancy or any other medical condition that might complicate your pregnancy;
  • You are receiving services for conditions related to your pregnancy and your prescription is filled or refilled within 60 days after the month your pregnancy ended;
  • You are in the Breast and Cervical Cancer Program;
  • You are receiving hospice care; or
  • You are a Native American or Alaskan Native.

If you believe you may qualify for any of these exemptions and are charged a copayment, contact NH DHHS Customer Service Center toll-free at 1-844-ASK-DHHS (1-844-275-3447) (TDD Relay Access: 1-800-735-2964), Monday through Friday, 8 a.m. to 4 p.m. ET.

Show your AmeriHealth Caritas New Hampshire member ID card when you get your prescriptions. If you have questions, call Member Services at 1-833-704-1177 (TTY 1-855-534-6730), 24 hours a day, seven days a week.

Prior authorization (pre-approval)

Some medicines on the preferred drug list and all medicines not on the list need prior authorization. If your doctor writes a prescription for a medicine that needs prior authorization, they will need to send us a prior authorization request. We will review it and let you and your doctor know our decision.

We will cover the medicine if it is medically necessary. If it is not, we will send you and your doctor a letter that will tell you why. We will also let you know which other medicines or therapies may be used. The letter will tell you how to appeal if you want to do so.

If you have questions about these criteria, please call Member Services at 1-833-704-1177 (TTY 1-855-534-6730), 24 hours a day, seven days a week, for more information.

Monthly prescription limits

Some medicines may have monthly limits on the number of prescriptions or refills. This is shown in the preferred drug list. To request a prescription limit override, the doctor who prescribed the medicine should contact Pharmacy Provider Services: 1-888-765-6394.

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 preferred drug list shows which drugs this applies to. We may also cover drug B with prior authorization if your doctor believes drug A is not appropriate for you.

Emergency supply

Sometimes your medicine may need prior authorization, but you need to start it right away. Your pharmacy can give you a three-day emergency supply. Your pharmacist may not give you a three-day supply of some medicines if they feel it is not safe for you to take the medicine.

Pharmacy lock-in program

Our lock-in program prevents members from overusing medicine or medical services. As part of this program, we review all medicines that members take and services that members use. When we find overuse, we can restrict members to a specific pharmacy. A restricted member can choose their pharmacy. Or, one may be chosen for the member.

A member can choose voluntarily to be restricted to a pharmacy. Call Member Services at 1-833-704-1177 (TTY 1-855-534-6730), 24 hours a day, seven days a week, for more information.

When you are restricted to a provider, you must still use your AmeriHealth Caritas New Hampshire ID card to get services.

Programs to help members use drugs safely

We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs.

We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as:

  • Possible medication errors;
  • Drugs that may not be necessary because you are taking another drug to treat the same medical condition;
  • Drugs that may not be safe or appropriate because of your age or gender;
  • Certain combinations of drugs that could harm you if taken at the same time;
  • Prescriptions that have ingredients you are allergic to; and
  • Possible errors in the amount (dosage) of a drug you are taking.

If we see a possible problem in your use of medications, we will work with your provider to correct the problem.

If you have any questions regarding our network pharmacies or prescription benefits, call Pharmacy Member Services at 888-765-6383 (TTY 711), 24 hours a day, seven days a week.

Members