Washington Pharmacy | Providers – Amerigroup

Washington Pharmacy

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.

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.

    Amerigroup Preferred Drug List (PDL)

    Starting in 2018, Amerigroup has been working closely with the Health Care Authority (HCA) to create the Apple Health Single Preferred Drug List (PDL). A single Apple Health PDL will simplify preferred drug selection and prior authorization requirements for prescribing providers and pharmacies. More information about the Apple Health Single PDL and which drug classes are included can be found on the HCA website. Currently, the Amerigroup PDL contains the Apple Health Single PDL.

    To search for a medication on the Preferred Drug List, click the link below. We post a formulary change notice on our website quarterly to notify of all formulary changes. To see the full Washington Preferred Drug List (formulary) in printable format, click here

    Prior Authorization

    Some drugs, drug combinations, and drug doses require Prior Authorization. To submit Electronic Prior Authorization (ePA) requests, use CoverMyMeds at www.covermymeds.com.Creating an account is free.

    While ePA helps streamline the prior authorization process, you may initiate a new PA request by fax or phone; please note the following contact numbers and PA form below:

    Phone: 1-800-454-3730

    Fax: 1-844-493-9207

    Medical Injectable Prior Authorization Form (for injections administered by a Provider) PA form for medical injectables is located here

    Pharmacy Emergency Fills

    A 7-day emergency supply of medications may be covered to prevent interruptions in therapy during an emergency.

    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 process. You can request Amerigroup to cover it under the Exception to the Rule (ETR) process.

    Find a Pharmacy

    Find a pharmacy in the network using the pharmacy search tool:

    Mail Order Pharmacy

    We offer home delivery as an option for members to fill up to a 60-day supply of their maintenance medications. Members can download and print the physician fax form from the website of our pharmacy benefits manage, with the new prescription for a 60-day supply. When you write the new prescription, you can fax or efax the form and prescription to the number on the form. We'll take it from there.

    Specialty Pharmacy

    Specialty medications are available through our 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. Our specialty pharmacy can deliver the medication to your office or to the member’s home. Most specialty medications require prior authorization.

    Synagis Enrollment Form

    To access the Syngagis Enrollment form, click here

    Medical Injectable Prior Authorization Form (for injections administered by a Provider) PA form for medical injectables is located here

    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 at: https://www.seattlechildrens.org/healthcare-professionals/access-services/partnership-access-line/.

    Opioid Policy

    On November 1, 2017, a new Health Care Authority (HCA) clinical policy pertaining to opioid prescriptions took effect for Apple Health (Medicaid). The policy includes limits on the quantity of pain medications that can be filled and requires providers to sign and submit an attestation once a year. Please read more about the Opioid Policy on the Health Care Authority (HCA) website. Patients who are undergoing active cancer treatment or who are in hospice, palliative care, or end-of-life care are exempt from this policy. A link to the Opioid PA form with the provider attestation is below.

    We cover naloxone (Narcan) for the treatment of opioid overdose.

    Medication Assisted Therapy (MAT)

    We cover all medications associated with alcohol or substance use disorder treatment.

    Pharmacy Reimbursement Issues

    If you are having an issue with reimbursement, please submit an inquiry to us at remittance@express-scripts.com or call 1-877-892-2692.

    After 6/1/19: 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 at https://rxservices.cvscaremark.com