Pharmacy & Prescription Drugs

Have your medicines mailed to you

We make getting your prescriptions filled as convenient as possible. You can log in to your account and have prescriptions filled through home delivery services. With your secure online account, you can:

• Order refills
• Track your shipments
• Get notifications

Log in to your account

Drugs we cover

Your benefits include a wide range of prescription drugs. Amerigroup also covers many over-the-counter (OTC) medicines with a prescription from your doctor.

Apple Health (Medicaid) Preferred Drug List

The Apple Health (Medicaid) Preferred Drug List (PDL) is a list of brand name and generic drugs available on your plan. These drugs are chosen for their quality and effectiveness. Your doctor will use this PDL first when prescribing your medicines. Most of these drugs do not need preapproval (prior authorization) from us first.

 

Amerigroup Preferred Drug List

We also cover medicines and supplies that are not included in the Apple Health (Medicaid) Preferred Drug List (PDL). You can use our Amerigroup PDL to find things like diabetic supplies, spacers and vaccines. We chose these items for their quality and effectiveness.

• Amerigroup Preferred Drug List - English
• Amerigroup Preferred Drug List - Spanish

Amerigroup Searchable Formulary

The formulary is a list of all the brand-name and generic drugs available in your plan. It lists all the drugs found on the PDL, plus others. All drugs on the formulary are covered, but some may require preapproval before the prescription can be filled.

Find your medicine

Do you want to look up your medicine and find out if it’s covered in your plan? It’s easy when you use our search tool. This tool will help you learn about the limitations or restrictions for any particular drug.

You can search for your drug by:

• Typing the name (at least the first three letters) of the drug in the search box
• Using the A-Z list to search by the first letter of your drug
• Clicking on the therapeutic class of the drug

Search

If you have primary insurance through another carrier and you are having trouble getting your copay covered through us, please call CarelonRx Member Services at 1-833-207-3121 (TTY 711). We want to help you so you do not have to pay out of pocket when you have both primary insurance and Amerigroup.

Don’t see it listed?

If you need a drug that isn’t listed on our formulary or preferred drug list, you may be able to receive it through the Exception to the Rule (ETR) process. Your provider can request Amerigroup to cover it under the ETR process. You or someone you choose to act for you can request a formulary exception by:

• Emailing submitmyexceptionreq@amerigroup.com
• Calling Pharmacy Member Services at 1-833-207-3121 (TTY 711)

We may need to ask your doctor why you can’t use the drugs on our formulary or PDL.

Prior authorization (preapprovals)

Some medicines need a preapproval, or an “OK,” from Amerigroup before your provider can prescribe them. The preapproval, or prior authorization, process helps us make sure that you’re taking medications safely and correctly.

Here are some reasons that preapproval may be needed:

• There is a generic or formulary alternative drug available
• The drug could be misused or abused
• There are other drugs that may be tried first
• The drug has the potential for severe side effects
• The drug is prescribed at a higher dosage than recommended
• There is additional information needed about your condition so we can match it to the FDA approval of the drug and/or studies of effectiveness

If your provider wants to prescribe a drug that needs preapproval, they’ll contact Amerigroup. If the request for preapproval is denied, Amerigroup will let you know. Amerigroup reviews all preapproval requests within 24 hours. If you need help with a medication that needs preapproval, we can help you. Contact CarelonRx Member Services at 1-833-207-3121 (TTY 711).

Filling a prescription

Do you have medicines you take regularly to treat a chronic or long-term condition? If so, you can fill up to a 90-day supply at retail pharmacies. If you have refills, you can refill your prescription every:

• 81 days for a 90-day supply.
• 27 days for a 30-day supply.

Payment

You don’t have a copay for covered medicines that your provider prescribes. Most of the time, your provider can’t ask you to pay for services, including drugs.

Prescription Drug Reimbursement Form

If you paid for a prescription that’s normally paid by your pharmacy benefits and would like to be reimbursed, use this form.

• CarelonRx Reimbursement Form – English
• CarelonRx Reimbursement Form – Spanish

Prescription Drug Mail Order Form

If you would like your prescriptions delivered to you, use this form:

• Home Delivery Form - English
• Home Delivery Form - Spanish

Vacation supply

Every six months, you can fill a “vacation supply” of your medication. This means you can refill your prescriptions early to prepare for when you won’t be able to get to your pharmacy every 30 days. We’ll give you up to a 90-day supply for each of your prescriptions during the vacation period. You can ask your pharmacy to call us and request a vacation supply. Or, you can call CarelonRx Member Services at 1-833-207-3121 (TTY 711).

Lost, stolen or destroyed fills

If your prescription is lost, stolen or destroyed, you can ask for an early refill once every six months. Your refill will include up to a 90-day supply if you fill your prescription at a pharmacy or using mail order.

To request an early refill, call CarelonRx Member Services at 1-833-207-3121 (TTY 711).

Vaccines

For members ages 19 and older, we cover all vaccines that are recommended by the Centers for Disease Control and Prevention (CDC). You may be able to get these vaccines at your pharmacy. Ask your pharmacist about vaccines you may need.

Vaccines for members ages 18 and younger are covered through the Vaccines for Children Program. Ask your doctor about vaccines you may need.

Emergency fills

During emergencies, you can ask your pharmacy for a seven-day emergency supply of your medicines. An emergency might be when:

• There's a natural disaster
• Your pharmacist believes you have an urgent health need.

If you need more than a seven-day emergency supply, your pharmacist can call the Pharmacy Help Desk anytime at 1-833-253-4453 to ask for our permission.

Family planning

Amerigroup covers all forms of family planning with a prescription from your doctor. At no cost, you can get birth control pills, rings, patches, and shots; condoms; and intrauterine devices (IUDs) and birth control implants. You can also get emergency contraception if you need it. Learn more about family planning covered by Amerigroup.

Opioid policy

The Health Care Authority (HCA), Apple Health (Medicaid) and Amerigroup are committed to safe pain management. In 2017, the HCA created a policy for opioid use that limits the quantity of pain medications members can fill. Patients undergoing active cancer treatment or who are in hospice, palliative care, or end-of-life care are exempt from this policy. Read more about the Health Care Authority’s opioid policy.

Amerigroup covers naloxone (Narcan) to treat opioid overdose without a prescription. For more information, ask your pharmacist or call CarelonRx at 1-833-207-3121 (TTY 711).

Medical assisted therapy (MAT)

We cover all medicines to treat substance use disorder. Talk to your provider about substance use disorder treatment.

Get your specialty medications

If you have a specialty condition, you’re covered. We partner with CarelonRx Specialty Pharmacy to meet all your specialty medication needs.

These include medicines that are high cost, require special handling and are often given by injection. They are often given by injection or infusion to treat complex, chronic conditions such as cancer, rheumatoid arthritis, multiple sclerosis, or psoriasis.

Learn more about specialty pharmacy

If you need help with any of your medications, contact CarelonRx Member Services at 1-833-207-3121 (TTY 711).