Pharmacy and Prescription Benefits

Pharmacy services

AmeriHealth Caritas Delaware members can get 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 on this list, call Pharmacy Member Services at: 

  • Diamond State Health Plan members: 1-877-759-6257 (TTY 711). 
  • Diamond State Health Plan-Plus members: 1- 855-294-7048 (TTY 711).

Or, call if you have questions about our pharmacies.

Copays

  • Brand-name prescriptions: cost to you is $3.00.  
  • Generic prescription: cost to you is $1.00. 

The most that members will pay for prescription copays each calendar month is $15.00 total. Once you pay the $15.00 copay maximum for the calendar month, you will have zero copays for medicines filled for the rest of the calendar month. The copay maximum will start over on the first of each month.

There will be no prescription copay for members who:

  • Are younger than 21 years old.
  • Receive family planning benefits.
  • Are pregnant or gave birth within the last 90 days.
  • Use smoking cessation products.
  • Receive care or reside in an institution.
    • Inpatient hospital.
    • Skilled nursing facility.
    • Hospice.

Show your AmeriHealth Caritas Delaware member ID card when you get your prescriptions. If you have questions, call Pharmacy Member Services at:

  • Diamond State Health Plan members: 1-877-759-6257 (TTY 711). 
  • Diamond State Health Plan-Plus members: 1- 855-294-7048 (TTY 711).

Prescription benefits

AmeriHealth Caritas Delaware covers medicines that:

  • Are medically necessary.
  • Approved by the U.S. Food and Drug Administration (FDA).
  • Prescribed by a Delaware Medicaid Assistance Program (DMAP) 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 Delaware 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 Delaware’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 Member Services for more information. To view the preferred drug list online, visit our searchable formulary.

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 form. 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. We will also let you know what 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 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 AmeriHealth Caritas Delaware's Pharmacy Services.

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.

Dual eligible members and pharmacy services

Members who are eligible for Medicare and Medicaid are called dual eligible members. Federal law restricts which kinds of medications we may cover for our members who are dual eligible.

We may only cover a few medications that are not covered under Medicare Part D. This includes over-the-counter (OTC) medications and vitamin and mineral supplements covered by Delaware Medicaid. All other medications should be submitted to your Medicare Part D plan.

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.

Member 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 21 years of age and older to a specific primary care provider (PCP) and/or pharmacy. A restricted member can choose their PCP and/or pharmacy. Or, one may be chosen for the member.

A member can choose voluntarily to be restricted to a PCP and/or pharmacy. Call Member Services for more information.

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

Don't wait until you run out of medicines.

Get refill reminders in the member portal. 

Members