Prescription Drug Plan
We look at our members holistically and offer coordinated medical and pharmacy benefits to help close gaps in care and improve overall heath. We may help improve your patient’s health outcomes when we combine our medical, pharmacy and lab data – but we go beyond the data to help ensure coordination of our people, programs and knowledge. We work with IngenioRx to provide the pharmacy benefit. IngenioRx is our Pharmacy Benefits Manager (PBM).
With our drug lists and our gaps-in-care messaging, we improve member health. When we develop our drug lists, we see how drugs work in real life for our members. We use our medical and pharmacy data and analyze claims to make sure the medications really work.
- Improving the health of our members
We encourage medications that improve patient health, and we see how drugs work in real life for our members, helping them make good health care choices.
- Reducing total health care costs
Cost-of-care and clinical programs focus on total costs, and we encourage medications that help to reduce those total costs. Both medical and pharmacy costs are our responsibility.
- Ensuring coordination of care
Medical and pharmacy strategies complement each other; they’re based on the same goals. Policies are aligned. We engage members and you, their doctors.
- Simplifying the member experience
Our medical and pharmacy experts work collaboratively. Members have one vendor, one contact, and one ID card. Clients have one vendor, one contact, one contract, one eligibility feed, and one invoice.
But that’s just the beginning. We are continuously improving how we plan and deliver services, and how we work with our pharmacies and our members.
Apple Health Single Preferred Drug List
The Apple Health Single Preferred Drug List (PDL) is a list of all brand-name and generic drugs available on the plan. The Health Care Authority (HCA) implemented the Apple Health Single PDL on January 1, 2018. All managed care plans and the fee-for-service program serving Apple Health clients use this PDL. To see what drugs are preferred and whether they need a prior authorization (PA), please go to the Apple Health Single PDL website.
Amerigroup Washington, Inc. Preferred Drug List
Amerigroup manages medications and supplies that are not part of the Apple Health Single PDL, listed in the above section. For medications that are not included in the Apple Health Single PDL, such as diabetic supplies, spacers and vaccines, please search the Amerigroup PDL.
We post a formulary change notice on our website quarterly to notify of all formulary changes. View the full Washington Preferred Drug List (formulary) in printable format.
Some drugs, drug combinations and drug doses require prior authorization (PA). To submit electronic prior authorization (ePA) requests, use CoverMyMeds. Creating an account is free.
While ePA helps streamline the PA process, you may initiate a new PA request by fax or phone; please note the following contact numbers and PA form below:
View the Medical Injectable Prior Authorization Form (for injections administered by a Provider).
Members can fill a 90-day supply of maintenance medications at retail pharmacies. Members can refill their prescriptions every 81 days for a 90-day supply of maintenance medications or every 27 days for a 30-day supply.
Pharmacy Emergency Fills
A seven-day emergency supply of medications is covered to prevent interruptions in therapy during an emergency, such as a natural disaster.
Emergency fill also means that the dispensing pharmacist used their professional judgment to meet a member’s urgent medical needs. If the dispensing pharmacist determines the member has an urgent medical need, they can:
- Dispense the medication to the member and use PAMC 22223333444 (prior authorization medical certification code) at the point of sale to process the emergency supply (up to a seven-day supply).
- Call the IngenioRx* Pharmacy Help Desk at 1-833-253-4453 if assistance is needed with an emergency supply fill or more than a seven-day supply is required.
Exception to the Rule
If a prescribed drug is not listed on the PDL, contact Amerigroup. You may be able to receive it through the Exception to the Rule (ETR) process. You can request Amerigroup to cover it under the ETR process.
Pharmacy Paper Claims
To submit a pharmacy paper claim, please complete the Prescription Reimbursement Claim Form and mail it to the address listed on the form or fax it in to the fax number listed on the form for processing.
Prescription Reimbursement Claim Form
Find a Pharmacy
Find a pharmacy in the network using the pharmacy search tool:
Mail Order Pharmacy
We offer home delivery through IngenioRx Mail Order Pharmacy as an option for members to fill up to a 90-day supply of their maintenance medications. Members can download and print the physician fax form from the website of our pharmacy benefits manager, with the new prescription for a 90-day supply. When you write the new prescription, you can fax or e-fax the form and prescription to the number on the form. We'll take it from there.
Mail Order Pharmacy Enrollment Spanish
* CoverMyMeds is an independent company providing pharmacy benefit management services on behalf of Amerigroup Washington, Inc. IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Amerigroup Washington, Inc.
Specialty medications are available through IngenioRx Specialty Pharmacy. These include medicines that are high cost, require special handling, and are often given by injection. Examples include Makena, Synagis, Enbrel, and Humira. IngenioRx Specialty Pharmacy can deliver the medication to your office or to the member’s home. Most specialty medications require prior authorization.
Synagis Enrollment Form
For Synagis prescriptions being filled by a pharmacy, please send all prescriptions to IngenioRx Specialty Pharmacy.
Synagis (palivizumab) requires prior authorization (PA) when billed through the medical or pharmacy benefit. Synagis PA criteria is available on the Clinical Criteria page.
Please submit the Synagis Enrollment Form with your PA request to Amerigroup. If the pharmacy is filling the Synagis prescription, please submit your PA request with the Synagis Enrollment Form electronically to CoverMyMeds. If your office will purchase Synagis, please submit a Medical Injectable Prior Authorization with the Synagis Enrollment Form and fax it to Amerigroup at 1-844-490-4876. View the PA form for medical injectables.
Access the Syngagis Enrollment form.
Patient Review and Coordination Program (PRC)
This program identifies members who may be over-utilizing providers, medications, and pharmacies. Members may be assigned to one pharmacy, designated as the home pharmacy, as part of this program. A partnership with our providers, will enhance this program’s ability to reduce the risk of medication misuse and enable earlier identification of members facing substance use related conditions.
Children’s Behavioral Health Medications
A medication consultation by an Health Care Authority-approved Second Opinion Network (SON) provider is required before Amerigroup may authorize coverage of behavioral health medication(s) or medication regimens for children under eighteen (18) years of age that exceed the medication review thresholds established by the HCA.Providers can submit procedure code 99441 on the claim to receive payment for the time spent engaging in medication review process with the SON.
Partnership Access Line (PAL)
To assist prescribers in meeting the needs of children with a mental health diagnosis, and to minimize the need for required SON review, provider can contact the Partnership Access Line (PAL). PAL is a telephone based child mental health consultation system funded by the state legislature, being implemented in Washington State. PAL employs child psychiatrists, child psychologists, and social workers affiliated with Seattle Children’s Hospital to deliver its consultation services.
The PAL team is available to any primary care provider throughout Washington State. PCPs may call 1‐866‐599‐7257 between the hours of 8:00am and 5:00pm for any type of child mental health issue that arises with any child not just Coordinated Care members. Additional information regarding the PAL may be found on the
Seattle Children's Hospital website.
Apple Health opioid policy
Beginning November 1, 2019, Apple Health will limit the total daily dose of opioid prescriptions. Opioid prescriptions or combinations of opioid prescriptions that add up to a daily dose greater than 120 morphine milligram equivalent (120 MME) will require a new completed and signed chronic opioid attestation form with a prior authorization (PA) request. If the chronic opioid attestation form is not completed, signed and received by Amerigroup, the opioid prescription(s) will be denied. If approved, the opioid medication(s) will be approved for one
year. Amerigroup requires PA for annual renewal with a signed chronic opioid attestation form.
Expedited authorization code 85000000540 can be used by the pharmacy when the member is
undergoing active cancer treatment, in hospice care, in palliative care or receiving end of life
care. It does not override the 120 MME limit.
Expedited authorization code 85000000541 can be used by the pharmacy when the prescriber
indicates EXEMPT for medically necessary condition on the opioid prescription. It does not
override the chronic use limit (42 days in a 90 day period) or the 120 MME limit.
Please read more about the opioid policy on the Health Care Authority (HCA) website. A link to the Provider Attestation Form is below. This is the only chronic opioid attestation form that
Amerigroup will accept starting November 1, 2019.
We cover and encourage the prescribing of (Narcan®) naloxone for the treatment of opioid
Medication Assisted Therapy (MAT)
We cover all medications associated with alcohol or substance use disorder treatment.
Pharmacy Reimbursement Issues
Before June 1, 2019: If you are having an issue with reimbursement, please submit an inquiry to us at email@example.com or call 1-877-892-2692.
After June 1, 2019: Chain and Pharmacy Services Administration Organization (PSAO) pharmacies can submit paid claim appeals through their respective chain or PSAO headquarters, which will then submit appropriate data to Caremark. Independent pharmacies (those which are not affiliated with a PSAO for contracting purposes) can submit paid claim appeals using the Caremark Pharmacy Portal.