Clinical Policies | Providers – Amerigroup

Clinical Pharmacy Policies

As a wholly owned subsidiary of Anthem, Inc. (Anthem), Amerigroup and its subsidiary health plans adopted UniCare’s nationally recognized, evidence-based medical policies and clinical utilization management guidelines effective May 1, 2013.* These policies are publicly available at Anthem’s UniCare subsidiary website.

The drug coverage policies below are based on medical necessity considerations subject to applicable benefits. The documents below assist with medical necessity coverage decisions, may include state-specific guidance regarding coverage and do not constitute medical advice. Benefit determination is based on the applicable contract language and/or state requirements.

These policies are not a guarantee of coverage. Contract language or state requirements will prevail when there are conflicts with any medication coverage policy. In all cases, Medicaid contracts or Centers for Medicare & Medicaid Services requirements supersede UniCare policy criteria.

If Amerigroup does not manage the pharmacy benefit for your state, please reference the applicable pharmacy benefit manager’s website and/or manual.

Clinical Pharmacy Policies

5 Alpha Reductase Inhibitors
Abaloparotide
Abilify Maintena
Abraxane
Abrilada
Actemra
Actimmune
Aczone
Adakveo
Adapalene
Adcetris
Adempas
Adenu
ADHD Narcolepsy
Aemcolo
Afinitor
Afrezza
Aggrenox
Aimovig
Ajovy
Aklief
Akynzeo
Albenza
Aldara
Aldurazyme
Alecensa
Alimta
Aliqopa
Aloquin, Quinja
Aloxi
Alpha-1 Proteinase Inhibitors
Alunbrig
Amiodarone (Formerly Cordarone)
Amitiza
Amjevita
Ampyra
Amzeeq
Ancobon
Androgens with QTY
Angiotensin Receptor (ARB)/Thiazide Diuretic Combination Agents Step Therapy
Antiepileptics
Antihemophilic and Clotting Factors
Antihypertensive Oral Solution
Antipsychotic Medications Age and Step Therapy
Anzemet Quantity Limit
Aptivus
Aranesp
Arcalyst
Argatroban
Arikayce
Arimidex
Aristada
Aristada Initio
Arixtra
Arthrotec
Arzerra
Asparlas
Aubagio
Austedo
Axid Oral Solution
Ayvakit
Azedra
Azelaic Acid Agents
Bafiertam
Balversa
Baraclude
Bavencio
Beleodaq
Belrapzo
Bendamustine
Benlysta
Beovu
Berinert
Besponsa
Bevacizumab
Bijuva
Blincyto
Blood Glucose Lancets
Blood Glucose Test Strips and Monitors Step Therapy
Bonjesta Diclegis
Bosulif
Botulinum Toxin
Braftovi
Brand Azelastine Nasal Spray Agents
Brand Bupropion
Brand EpiPen/EpiPen Jr.
Brand Ophthalmic Allergy
Breo Ellipta
Breztri
Brineura
Brukinsa
Buphenyl
Buprenorphine SL Tablets for Medication Assisted Treatment
Buprenorphine with Naloxone
Buprenorphine with naloxone (FLHK Only)
Buprenorphine-Naloxone GA Policy
Buprenorphine-Naloxone LA Policy
Buprenorphine-Naloxone NJ Policy
Butorphanol Nasal Spray
Cablivi
Cabometyx
Calcitriol Agents
Calquence
Cambia
Caprelsa
Carbaglu
Cerdelga
Cesamet
Cetylev
Chelation Therapy
Chenodal
Chloroquine
Cholbam
Cimzia
Cinquair, Fasenra, Nucala
Cinryze
Cinvanti
Cipro
Clindamycin-Tretinoin Combination Products
Codeine Agents Age Edit
Colcrys
Colony Stimulating Factors
Cometriq
Conjupri
Consensi
Continuous Glucose Monitors
Contraceptive Products
Copiktra
Corlanor
Cosentyx
Cosmetic Anti-Aging
Cotellic
Cresemba
Crofelemer
Crysvita
Cumulative Morphine Equivalent Dose (MED) for Opioid Analgesic Therapy
Cycloserine
Cycloset
Cyclosporine Ophthalmic (Cequa, Restasis)
Cyltezo
Cyramza
Cystaran
Daklinza
Daliresp
Danazol
Daraprim
Darzalex
Daurismo
Dementia and Alzheimer's Disease
Demser
Depo-Estradiol
Descovy
Desoxyn
Diabetic Test Strips
Dibenzyline
Dificid
Dihydroergotamine
Docetaxel
Dojolvi
Doptelet
Dose Optimization
Dose Optimization Mental Health
Dovato
Doxepin Cream
Doxorubicin Hydrochloride Liposome
Doxorubicin Liposome
Doxycycline 40mg Rosacea Agents
Doxycyclines - Acne
Doxylamine Pyridoxine Agents
DPP-4 Dipeptidyl Peptidase-4
Dronabinol agents
Duavee
Duexis
Duloxetine (Previously Cymbalta, Irenka)
Duobrii
Duopa
Dupixent
Durlaza
Durysta
Duzallo
Edurant
Egrifta
Elaprase
Elidel
Elitek
Ellence
Eloctate
Elzonris
Emcyt
Emend Injectable
Emend Oral
Emflaza
Emgality
Empliciti
Emsam
Enbrel
Endari
Enhertu
Entresto
Entyvio
Enzyme Replacement Therapy For Gaucher Disease
Epclusa
Epidiolex
Epiduo, Epiduo Forte
Epinephrine - Self Injected Agents Quantity Limit
Epivir
Epogen, Procrit, Retacrit
Equetro
Eraxis
Erbitux
Erelzi
Erivedge
Erleada
Erwinaze
Esbriet
Ethyol
Eticovo
Eucrisa
Evekeo
Evenity
Evrysdi
Evzio
Exjade
Eylea
Fabrazyme
Farydak
Faslodex
Ferriprox
Firazyr
Firdapse
Fluoroquinolone Ophthalmics
Fragmin Quantity Supply
Fusilev
Fuzeon
Galafold
GamaSTAN
Gamifant
Gattex
Gazyva
Gilenya
Gilotrif
Givlaari
Glatiramer (Copaxone Glatopa)
Gleevec
Gleostine
Gloperba
GLP-1 Long-Acting Insulin Combo
GLP-1 Receptor Agonist Step Therapy
Glycate
Gocovri ER
Gonadotropin Releasing Hormone Analogs (GnRH)
Gralise
Granisetron Agents Quantity Limit
Grastek
Growth Hormones
Hadlima
Haegarda
Halaven
Harvoni
Hectorol
Hemady
Hepsera
Herceptin Hylecta
Hetlioz
Hexalen
Horizant
HP Acthar
Humira
Humulin R U-500
Hyaluronan Injections
Hyaluronan Injections (GA Only)
Hycamtin
Hydrocodone Containing Cough and Cold Agents Age Edit
Hydroxyprogesterone caproate injection
Hyrimoz
Ibrance
Ibsrela
Iclusig
Idhifa
Ilaris
Ilumya
Iluvien
Imbruvica
Imfinzi
Immunoglobulins
Impavido
Increlex
Inflectra, Renflexis, Remicade
Infliximab/Infliximab-dyyb
Influenza Virus Vaccine Quantity Limit
Ingrezza
Inhaled Corticosteroids (ICS)
Injectable Triptan Agents Step Therapy
Inlyta
Inrebic
Intelence
Interferons for MS
Intravaginal Progesterone
Invega Sustenna
Invega Trinza
Iressa
Isotretinoin Agents
Istodax
Ivacaftor-Lumacaftor
Ixempra
Jadenu
Jakafi
Jelmyto
Jetrea
Jevtana
Juluca
Juxtapid
Jynarque
Kadcyla
Kalbitor
Kalydeco
Kanuma
Katerzia
Ketorolac
Keveyis (dichlorphenamide)
Kevzara
Keytruda
Khapzory
Kineret
Kisqali
Korlym
Koselugo
Krystexxa
Kuvan
Kynamro
Kyprolis
Lacrisert
Lartruvo
Lemtrada
Lenvima
Letairis
Levaquin
Libtayo
Lidocaine gel, cream, ointment
Lidoderm (lidocaine) Patch
Linezolid (ZYVOX)
Linzess
Long-Acting Opioid Analgesics PA-QL
Lonsurf
Lorbrena
Lotronex
Low Molecular Weight Heparins
Lucentis
Lumizyme
Lumoxiti
Lutathera
Lynparza
Lyrica CR
Macugen
Makena
Marinol
Mavenclad
Mavyret
Mayzent
Megestrol acetate
Meglitinide Step Therapy
Mekinist
Mektovi
Mepsevii
Mesnex
Metformin extended-release
Methotrexaate Auto-Injector Agents
Migranal Nasal Spray
Mircera
Mitigare
Motegrity
Movantik
Mozobil
Mulpleta
Multisource Brand MSB Agents
Myalept
Mylotarg
Naglazyme
Namzaric
Narc Analgesic Combo
Narcan Nasal Spray
Narcotic Dup
Nasal Triptan ST
Natpara
Nayzilam
Nerlynx
Neumega
Neupro
Nexavar
Nexletol
Nexlizet
Niacin Agents
Nilandron
Ninlaro
Nitisinone
Nocdurna (Nocura SL tablets)
Noctiva Intranasal Spray
Non-Formulary Prescription Request
Non-Opioid Cough and Cold Agents Age Edit
Non-Pegylated Interferons
Non-Preferred 5-Aminosalicylic Acid Oral Agents Step Therapy
Non-Preferred Agents for Actinic Keratosis
Non-Preferred Angiotensin Receptor Blocker (ARB) Agents Step Therapy
Non-Preferred Anti-Parkinson Agents
Non-Preferred Beta Blocker Step Therapy
Non-Preferred Ciprofloxacin
Non-Preferred Epinephrine Injection
Non-Preferred Fibrate Agents
Non-Preferred Fluoroquinolone Otic Agents
Non-Preferred Inhaled Corticosteroid (ICS)/Long-Acting Beta-2 Agonist (LABA) Combination Agents
Non-Preferred Insulin Pen Needles
Non-Preferred Insulin Syringe or Diabetic Syringe
Non-Preferred Long-Acting Insulin Step Therapy    
Non-Preferred Long-Acting Muscarinic Agonist (LAMA) Agents Step Therapy
Non-Preferred Minocycline
Non-Preferred Nasal Corticosteroids
Non-Preferred Ophthalmic Allergy and Mast Cell Stabilizer Agents
Non-Preferred Ophthalmic NSAIDs
Non-Preferred Oral Triptans Step Therapy
Non-Preferred Oral/Transdermal 5-HT3 Receptor Antagonist
Non-Preferred Overactive Bladder Agents Step Therapy
Non-Preferred Pediculicides for Head Lice
Non-Preferred Rapid Acting Insulin
Non-Preferred Selective Serotonin Reuptake Inhibitors (SSRIs) Step Therapy
Non-Preferred Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Non-Preferred Short-Acting Beta-2 Agonist (SABA) Agents Step Therapy - DNA to WA
Non-Preferred Skeletal Muscle Relaxants Step Therapy
Non-Preferred Statins
Non-Preferred Topical Agents for External Anogenital Warts Step Therapy
Non-Preferred Topical Anti-Infective - Benzoyl Peroxide Combo Agents
Non-Preferred Topical Corticosteroid - High Potency
Non-Preferred Topical Corticosteroid - Low Potency
Non-Preferred Topical Corticosteroid - Medium Potency
Non-Preferred Topical Corticosteroid - Very High Potency
Non-Preferred Topical Fluorouracil Agents
Non-Preferred Vaginal Atrophy Agents
Non-Sedating Antihistamines
Noritate
Northera
Noxafil
NP LAMA-LABA
Nplate
NSA
Nubeqa
Nuedexta
Nulojix
Nuplazid
Nurtec
Nuvigil
Nuzyra
Ocaliva
Ocrevus
Octreotide
Odactra
Odomzo
Ofev
Ofloxacin Quantity Limit
Olumiant
Omega-3 Fatty Acid Step Therapy
Oncaspar
Ondansetron
Onpattro
Onychomycosis
Opdivo
Opioid Analgesic Combo
Opsumit
Oral Antifungals
Oral HIV Antiretrovirals Quantity Limit
Oral Triptans
Oralair
Orencia
Orenitram
Orfadin
Oriahnn
Orilissa
Orkambi
Orlistat
Ortikos
Osmolex ER
Osphena
Otezla
Oxandrin
Oxbryta
Oxervate
Oxsoralen-Ultra
Oxycontin
Oxymorphone
Ozurdex
Padcev
Palforzia
Palynziq
Pancreatic Enzymes
Parsabiv
Pemazyre
Penicillamine
Pennsaid
Pepcid Oral Susp
Perjeta
Perseris
Phosphate Binders
Picato
Piqray
Pizensy
Plaquenil
Pliaglis
Polivy
Pomalyst
Praluent
Pretomanid
Prevymis
Prialt
Probuphine
Procysbi
Proleukin
Prolia
Promacta
Prostacyclins for PAH
Proton Pump Inhibitors
Provenge
Provigil
Pulmozyme
Purixan
Qbrexza Cloth
Qinlock
Qualaquin
Radicava
Ragwitek
Ranexa
Ravicti
Rayaldee
Rayos
Reblozyl
Reclast
Rectal Steroid Foam
Regranex Gel
Relenza
Relistor
Repatha
Retevmo
Retisert
Revcovi
Revlimid
Rexulti
Rexulti -NV ONLY
Reyvow
Ribavirin
Rilutek
Rinvoq
Riomet
Risperdal Consta
Rituxan
Rozyltrek
Rubraca
Ruconest
Ruzurgi
Rydapt
Samsca
Sandostatin
Santyl
Sarclisa
Savella
Scenesse
Sedative Hypnotic Agents for Insomnia
Sensipar
Seysara
SGLT2- DPP4 Inhibitor Combination
SGLT2 Inhibitor Step Therapy
Short-Acting Opioid Analgesics for Acute Pain Duration of Use
Signifor
Signifor LAR
Siklos
Sildenafil
Siliq
Simponi
Simvastatin
Single Agent NSAID Step Therapy
Sirturo
Sivextro
Skyrizi
Smoking Cessation
Smoking Cessation (DC, GA)
Solaraze
Soliris
Solosec
Somatuline Depot
Somavert
Soolantra
Sovaldi
Spinraza - MD only
Spravato
Sprycel
Stelara
Stimate
Stivarga
Strattera
Strensiq
Stribild
Subcutaneous Hormonal Implants (Formerly Testopel)
Subutex
Sucraid
Sulfonylareas
Sunosi
Sutent
Sylatron
Sylvant
Symdeko
Symlin
Symproic
Synagis
Synera
Synribo
Tabrecta
Tadalafil
Tafamidis Agents
Tafinlar
Tagrisso
Takhzyro
Taltz
Talzenna
Tamiflu
Tarceva
Targretin
Tasigna
Tasmar
Tavalisse
Taxotere
Tazarotene Agents
Tazverik
Tecentriq
Tecfidera
Technivie
Tegsedi
Temodar
teriparatide (Bonsity, Forteo)
Testosterone Injectable
Thalomid
Thiazolidinedione Step Therapy
Tibsovo
Tildrakizumab
Tiopronin Agents
Topical Agents for Cutaneous Fungal Infections Step Therapy
Topical and Buccal Agents for Recurrent Herpes Labialis
Topical Anti-Infective-Benzoyl Peroxide Combo
Topical NSAIDs
Topical Onychomycosis
Torisel
Tracleer
Tramadol Agents Age Limit
Transdermal Estrogen
Transmucosal Immediate Release Fentanyl (TIRF) Agents
Trelegy Ellipta
Tremfya
Trientine
Trikafta
Triptan Quantity Limit
Trodelvy
Trogarzo
Trulance
Tukysa
Turalio
Tykerb
Tymlos
Tysabri
Tyzeka
Ubrelvy
Uceris Oral Tablets
Uloric
Ultomiris
Uptravi
Valchlor
Valtoco Nasal
Vancomycin
Varubi
Vectibix
Velcade
Vemlidy
Venclexta
Verzenio
Vfend
Viberzi
Victrelis
Vidaza
Viekira
Vimizim
Vimovo
Virazole
Viread
Vistogard
Vitrakvi
Vizimpro
Vosevi
Votrient
Vumerity
Vyepti
Vytorin
Vyvanse
Wakix
Xalkori
Xatmep
Xeljanz
Xeloda
Xenleta
Xermelo
Xgeva
Xiaflex Injection
Xifaxan
Xiidra
Xofigo
Xolair
Xospata
Xpovio
Xtampza
Xtandi
Xuriden
Xyrem
Yervoy
Yonsa
Yosprala
Yutiq
Zaltrap
Zavesca
Zejula
Zelboraf
Zelnorm
Zemplar
Zepatier
Zeposia
Zetia
Zevalin
Zinbryta
Zinplava
Zithromax
Zoledronic Acid
Zolinza
Zometa
Zontivity
Zovirax (acyclovir) Topical Agents
Ztlido
Zulresso
Zurampic
Zyclara
Zydelig
Zyflo
Zykadia
Zyprexa Relprevv
Zytiga