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
Abilify Maintena
Abraxane
Abstral
Actemra
Actimmune
Aczone
Adapalene
Adcetris
Adempas
ADHD Narcolepsy
Advair
Afinitor
Afrezza
Aggrenox
Aldara
Aldurazyme
Alecensa
Alimta
Aloxi
Alpha-1 Proteinase Inhibitors
Amitiza
Amjevita
Ampyra
Androgens
Angiotensin Receptor Blocker (ARB)
Antiepileptics
Antihemophilic and Clotting Factors
Antipsychotic Medications Age and Step Therapy
Anzemet Quantity Limit
Aranesp
Arcalyst
Argatroban
Arimidex
Aristada
Arixtra
Aromasin
Arthrotec
Arzerra
Aubagio
Auvi-Q
Avastin
Azelaic Acid Agents
Baraclude
Belbuca
Beleodaq
Benlysta
Berinert
Blincyto
Blood Glucose Lancets
Blood Glucose Test Strips and Monitors Step Therapy
Bosulif
Botulinum Toxin
Brand Azelastine Nasal Spray Agents
Brand Bupropion
Brand EpiPen/EpiPen Jr.
Brand Ophthalmic Allergy
Breo Ellipta
Buprenorphine SL Tablets for Medication Assisted Treatment
Buprenorphine with Naloxone
Butorphanol Nasal Spray
Cabometyx
Calcitriol Agents
Caprelsa
Carbaglu
Celebrex
Cerdelga
Cesamet
Cetylev
Chelation Therapy
Cholbam
Cimzia
Cinryze
Cipro
Clindamycin-Tretinoin Combination Products
Colcrys
Colony Stimulating Factors
Cometriq
Contraceptive Products
Copaxone
Cordarone
Corlanor
Cosentyx
Cosmetic Anti-Aging
Cotellic
Cresemba
Crofelemer
Cycloset
Cymbalta
Cyramza
Daklinza
Daliresp
Danazol
Daraprim
Darzalex
Diabetic Test Strips
Diclegis
Differin
Dificid
Dihydroergotamine
Docetaxel
Dose Optimization
Doxorubicin Hydrochloride Liposome
Doxycycline
DPP-4 Dipeptidyl Peptidase-4
Dronabinol agents
Duexis
Dulera
Duopa
Durlaza
Egrifta
Elaprase
Elidel
Elitek
Eloctate
Embeda
Emend Injectable
Emend Oral
Emergency Contraceptives
Empliciti
Enbrel
Entresto
Entyvio
Enzyme Replacement Therapy For Gaucher Disease
Epclusa
Epiduo, Epiduo Forte
Epivir
Eraxis
Erbitux
Erelzi
Erivedge
Erwinaze
Esbriet
Eucrisa
Evekeo
Exjade
Eylea
Fabrazyme
Farydak
Faslodex
Femara
Fentanyl Citrate Lozenges
Fentora
Firazyr
Forteo
Fusilev
Fuzeon
Gattex
Gaucher Disease
Gazyva
Gilenya
Gilotrif
Glatiramer acetate
Gleevec
Gleostine
GLP-1 Insulin Combo
Glyxambi
Gonadotropin Releasing Hormone Analogs (GnRH)
Granisetron Agents Quantity Limit
Grastek
Growth Hormone
Halaven
Harvoni
Hectorol
Hepatitis B Interferon
Hepatitis B Oral Agents Duplicate Therapy
Hepsera
Hetlioz
Horizant
HP Acthar
Humira
Hyaluronan Injections
Hycamtin
Ibrance
Iclusig
Ilaris
Iluvien
Imbruvica
Immune globulins
Increlex
Inflectra, Remicade
Infliximab/Infliximab-dyyb
Inhaled Agents
Inhaled Agents Duplicate Therapy
Injectable Triptan Agents Step Therapy
Inlyta
Invega Sustenna
Invega Trinza
Irenka
Iressa
Isotretinoin Agents
Istodax
Ivacaftor-Lumacaftor
Ixempra
Jadenu
Jakafi
Jevtana
Juxtapid
Kadcyla
Kalbitor
Kalydeco
Kanuma
Ketorolac
Keveyis (dichlorphenamide)
Keytruda
Kineret
Korlym
Krystexxa
Kuvan
Kynamro
Kyprolis
Lartruvo
Lazanda
Lemtrada
Lenvima
Letairis
Leukotriene Modifiers
Levaquin
Linzess
Long-Acting Opioid Analgesics
Lonsurf
Lotronex
Low Molecular Weight Heparins
Lucentis
Lumizyme
Lyrica
Macugen
Makena
Marinol
Meglitinide Step Therapy
Mekinist
Mesnex
Metformin extended-release
Methotrexaate Auto-Injector Agents
Methoxsalen
Migranal Nasal Spray
Mircera
Mitigare
Montelukast
Morphine Sulfate
Movantik
MS Agents
Multisource Brand MSB Agents
Naglazyme
Namzaric
Narc Analgesic Combo
Narcan Nasal Spray
Narcotic Dup
Narcotics Long Acting Duplicate Therapy
Narcotics Short Acting Duplicate Therapy
Nasal Triptan ST
Natpara
Neumega
Neupro
Nexavar
Nilandron
Ninlaro
Non-Formulary Prescription Request
Non-Pegylated Interferons
Non-Preferred Agents for Actinic Keratosis
Non-Preferred Agents for Dementia
Non-Preferred Angiotensin Receptor Blocker(ARB) Agents Step Therapy
Non-Preferred Angiotensin Receptor Blocker(ARB)/Thiazide Diuretic Combination Agents Step Therapy
Non-Preferred Anti-Parkinson Agents
Non-Preferred Beta Blocker Step Therapy
Non-Preferred Buprenorphine/Naloxone Step Therapy – WA MCD Only
Non-Preferred Doxycycline
Non-Preferred Fenofibrate Agents
Non-Preferred Fluoroquinolone Otic Agents
Non-Preferred High Potency Topical Corticosteroid Step Therapy
Non-Preferred Inflammatory Bowel Disease Step Therapy
Non-Preferred Inhaled Corticosteroid (ICS)
Non-Preferred Long-Acting Insulin
Non-Preferred Long-Acting Insulin Step Therapy    
Non-Preferred Long-Acting Muscarinic Agonist(LAMA) Agents Step Therapy
Non-Preferred Long-Acting Muscarinic Agonist(LAMA)/Long-Acting 2 Agonist(LABA)Combination Agents Step Therapy
Non-Preferred Long-Acting Opioid Analgesic Step Therapy
Non-Preferred Long-Acting Opioid Analgesic Step Therapy – WA Medicaid Only
Non-Preferred Low Potency Topical Corticosteroid Step Therapy
Non-Preferred Medium Potency Topical Corticosteroid Step Therapy
Non-Preferred Minocycline
Non-Preferred Naloxone Agents
Non-Preferred Nasal Corticosteroids
Non-Preferred Ophthalmic
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 Sedative Hypnotic Agents for Insomnia
Non-Preferred Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Non-Preferred Short-Acting Beta-2 Agonist (SABA) Agents Step Therapy
Non-Preferred Single Agent NSAID Step Therapy
Non-Preferred Skeletal Muscle Relaxants Step Therapy
Non-Preferred Statins
Non-Preferred Topical Agents for Cutaneous Fungal Infections Step Therapy
Non-Preferred Topical Agents for External Anogenital Warts Step Therapy
Non-Preferred Topical Anti-Infective - Benzoyl Peroxide Combo Agents
Non-Preferred Topical Fluorouracil Agents
Non-Preferred Very High Potency Topical Corticosteroids
Noritate
Noxafil
Nplate
NSA
Nucala
Nuedexta
Nulojix
Nuplazid
Nuvigil
Ocaliva
Ocrevus
Odomzo
Ofev
Ofloxacin
Oforta
Olysio
Omega-3 Fatty Acid
Oncaspar
Ondansetron
Onsolis
Onychomycosis
Opdivo
Opsumit
Oral Antifungals
Oralair
Orencia
Orenitram
Orfadin
Orkambi
Orlistat
Osphena
Otezla
Oxandrin
Oxycontin
Oxymorphone
Ozurdex
Pegylated Interferons
Perjeta
Phosphate Binders
Picato
Pomalyst
Praluent
Preferred PPIs
Prialt
Probuphine
Procrit and Epogen
Procysbi
Prolia
Promacta
Prostacyclins for PAH
Proton Pump Inhibitors
Provenge
Provigil
Pulmozyme
Purixan
Qualaquin
Ragwitek
Ranexa
Rayaldee
Rayos
Regranex Gel
Relenza
Relistor
Remicade
Repatha
Restasis
Revlimid
Rexulti
Ribavirin
Rilutek
Riomet
Risperdal Consta
Rituxan
Rosiglitazone Agents Step Therapy
Rubraca
Ruconest
Samsca
Sancuso
Sandostatin
Santyl
Savella
Selected Weight Loss
Sensipar
SGLT2 Inhibitor Step Therapy
Short-Acting Opioid Analgesics for Acute Pain Duration of Use
Signifor
Signifor LAR
Sildenafil
Simponi
Simvastatin
Sivextro
Smoking Cessation
Solaraze
Soliris
Somatuline Depot
Somavert
Soolantra
Sovaldi
Spinraza
Sprycel
Stelara
Stimate
Stivarga
Strattera
Strensiq
Stribild
Subsys
Subutex
Sutent
Sylatron
Sylvant
Symbicort
Symlin
Synagis
Tadalafil
Tafinlar
Tagrisso
Taltz
Tamiflu
Tarceva
Targretin
Tasigna
Tasmar
Taxotere
Tazarotene Agents
Tecentriq
Tecfidera
Technivie
Temodar
Testopel
Testosterone Injectable
Thalomid
Thiazolidinedione Step Therapy
Thiazolidinediones
Thiola
Topical and Buccal Agents for Recurrent Herpes Labialis
Torisel
Tracleer
Transdermal Estrogen
Transdermal Fentanyl
Transmucosal Immediate Release Fentanyl (TIRF) Agents
Treanda
Triptan Quantity Limit
Triptans Duplicate Therapy
Tykerb
Tysabri
Tyzeka
Uloric
Valchlor
Vancocin
Varubi
Vectibix
Velcade
Vemlidy
Venclexta
Vfend
Viberzi
Victoza
Victrelis
Vidaza
Viekira
Vimizim
Vimovo
Virazole
Vistogard
Vivitrol
Votrient
Vytorin
Vyvanse
Xalkori
Xeljanz
Xeloda
Xermelo
Xgeva
Xiaflex Injection
Xifaxan
Xiidra
Xofigo
Xolair
Xtampza
Xtandi
Xuriden
Xyrem
Yervoy
Zaltrap
Zavesca
Zelboraf
Zemplar
Zepatier
Zetia
Zinbryta
Zinplava
Zithromax
Zoledronic Acid
Zolinza
Zontivity
Zovirax (acyclovir) Topical Agents
Zurampic
Zyclara
Zydelig
Zyflo
Zykadia
Zyprexa Relprevv
Zytiga
Zyvox