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
Adapalene
Adcetris
Adempas
ADHD Narcolepsy
Advair
Afinitor
Afrezza
Aggrenox
Aldara
Alecensa
Alimta
Aloxi
Alpha-1 Proteinase Inhibitors
Alprolix
Amitiza
Ampyra
Androgens
Angiotensin Receptor Blocker (ARB)
Antiepileptics
Antihemophilic and Clotting Factors
Antipsychotic Medications Age and Step Therapy
Aranesp
Arcalyst
Argatroban
Arimidex
Aristada
Arixtra
Aromasin
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 Bupropion
Brand Ophthalmic Allergy
Breo Ellipta
Buprenorphine with Naloxone
Butorphanol Nasal Spray
Cabometyx
Caprelsa
Celebrex
Cerdelga
Cesamet
Chelation Therapy
Cholbam
Cimzia
Cinryze
Cipro
Clindamycin Tretinoin Combo Agents
Colcrys
Colony Stimulating Factors
Cometriq
Contraceptive Products
Copaxone
Cordarone
Corlanor
Cosentyx
Cosmetic Anti-Aging
Cotellic
Cresemba
Cymbalta
Cyramza
Daklinza
Daliresp
Danazol
Daraprim
Darzalex
DDP4
Diabetic Test Strips
Diclegis
Differin
Dificid
Dihydroergotamine
Dose Optimization
Dose Optimization Mental Health
Doxorubicin Hydrochloride Liposome
Doxycycline
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
Epivir
Eraxis
Erbitux
Erivedge
Erwinaze
Esbriet
Evekeo
Exjade
Eylea
Fabrazyme
Farydak
Faslodex
Femara
Fentanyl Citrate Lozenges
Fentora
Firazyr
Forteo
Fuzeon
Gattex
Gaucher Disease
Gazyva
Gilenya
Gilotrif
Gleevec
Gleostine
Glumetza
Glyxambi
Gonadotropin Releasing Hormone Analogs (GnRH)
Grastek
Growth Hormone
Halaven
Harvoni
Hepatitis B Interferon
Hepsera
Herceptin
Hetlioz
Horizant
HP Acthar
Humira
Hyaluronan Injections
Hycamtin
Hysingla ER
Ibrance
Iclusig
Ilaris
Iluvien
Imbruvica
Immune globulins
Increlex
Infliximab/Infliximab-dyyb
Inhaled Agents
Injectable Triptan Agents Step Therapy
Inlyta
Invega Sustenna
Invega Trinza
Irenka
Iressa
Isotretinoin Agents
Istodax
Ivacaftor-Lumacaftor
Ixempra
Jadenu
Jakafi
Juxtapid
Kadcyla
Kalbitor
Kalydeco
Kanuma
Ketorolac
Keveyis (dichlorphenamide)
Keytruda
Kineret
Korlym
Krystexxa
Kuvan
Kynamro
Kyprolis
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
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
Nexavar
Nilandron
Ninlaro
Non Preferred Ophthalmic
Non-Pegylated Interferons
Non-Preferred Agents for Actinic Keratosis
Nonpreferred Agents for Dementia
Non-Preferred Angiotensin Receptor Blocker(ARB) Agents Step Therapy
Non-Preferred Angiotensin Receptor Blocker(ARB)/Thiazide Diutetic Combination Agents Step Therapy
Non-Preferred Buprenorphine/Naloxone Step Therapy – WA MCD Only
Non-Preferred Fluoroquinolone Otic Agents
Nonpreferred High Potency Topical Corticosteroid Step Therapy
Non-Preferred Inflammatory Bowel Disease Step Therapy
Nonpreferred Inhaled Corticosteroid (ICS)
Nonpreferred 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)Coombination Agents Step Therapy
Non-Preferred Long-Acting Opioid Analgesic Step Therapy
Non-Preferred Long-Acting Opioid Analgesic Step Therapy – WA Medicaid Only
Nonpreferred low potency topical corticosteroid step therapy
Nonpreferred medium potency topical corticosteroid step therapy
Non-Preferred Minocycline
Non-Preferred Naloxone Agents
Non-Preferred Nasal Corticosteroids
Non-Preferred Overactive Bladder Agents Step Therapy
Non-Preferred Short-Acting Beta-2 Agonist (SABA) Agents Step Therapy
Non-Preferred Statins
Nonpreferred Topical Agents for Cutaneous Fungal Infections Step Therapy
Non-Preferred Topical Fluorouracil Agents
Non-Preferred Very High Potency Topical Corticosteroid Step Therapy
Noxafil
Nplate
NSA
Nucala
Nuedexta
Nulojix
Nuplazid
Nuvigil
Ocaliva
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
Provenge
Provigil
Pulmozyme
Purixan
Qualaquin
Ragwitek
Ranexa
Receptor Agonist Step Therapy
Regranex Gel
Relenza
Relistor
Remicade
Restasis
Revlimid
Rexulti
Ribavirin
Rilutek
Rituxan
Rosiglitazone Agents Step Therapy
Ruconest
Sancuso
Savella
Selected Weight Loss
SGLT2 Inhibitor Step Therapy
Signifor
Sildenafil
Simponi
Sivextro
Smoking Cessation
Solaraze
Soliris
Soolantra
Sovaldi
Sprycel
Stelara
Stimate
Stivarga
Strattera
Strensiq
Stribild
Subsys
Subutex
Sutent
Sylatron
Sylvant
Symbicort
Symlin
Synagis
Tadalafil
Tafinlar
Tagrisso
Taltz
Tamiflu
Tarceva
Targretin
Tasigna
Taxotere
Tazarotene Agents
Tecfidera
Technivie
Temodar
Testopel
Testosterone Injectable
Thalomid
Thiazolidinedione Step Therapy
Thiazolidinediones
Thiola
Torisel
Tracleer
Transdermal Estrogen
Transdermal Fentanyl
Treanda
Triptan Quantity Limit
Triptans
Triptans Duplicate Therapy
Tykerb
Tysabri
Tyzeka
Valchlor
Vancocin
Varubi
Vectibix
Velcade
Venclexta
Vfend
Viberzi
Victoza
Victrelis
Vidaza
Viekira
Vimizim
Vimovo
Virazole
Vistogard
Vivitrol
Votrient
Vytorin
Vyvanse
Xalkori
Xeljanz
Xeloda
Xgeva
Xiaflex Injection
Xifaxan
Xiidra
Xofigo
Xolair
Xtampza
Xtandi
Xuriden
Xyrem
Yervoy
Zaltrap
Zavesca
Zelboraf
Zepatier
Zetia
Zinbryta
Zithromax
Zohydro ER
Zoledronic Acid
Zolinza
Zontivity
Zovirax (acyclovir) Topical Agents
Zurampic
Zyclara
Zydelig
Zyflo
Zykadia
Zytiga
Zyvox