Transcription
2021 Prescription Drug ListEffective January 1, 2021
Formulary IntroductionFORMULARYThe Ambetter from Magnolia Health Formulary, or Preferred Drug List, is a guide to available brand and genericdrugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription drugbenefit. Generic drugs have the same active ingredients as their brand name counterparts and should beconsidered the first line of treatment. The FDA requires generics to be safe and work the same as brand namedrugs. If there is no generic available, there may be more than one brand name drug to treat a condition. Preferredbrand name drugs are listed on Tier 2 to help identify brand drugs that are clinically appropriate, safe, and costeffective treatment options, if a generic medication on the formulary is not suitable for your condition.Please note, the Formulary is not meant to be a complete list of the drugs covered under your prescription benefit.Not all dosage forms or strengths of a drug may be covered. This list is periodically reviewed and updated and maybe subject to change. Drugs may be added or removed, or additional requirements may be added in order to approvecontinued usage of a specific drug.Specific prescription benefit plan designs may not cover certain products or categories, regardless of theirappearance in this document. Please check your benefits for coverage limitations and your share of cost for yourdrugs.Drug List Key:Brand name drugs are listed in CAPS and generic drugs are lower case.Drugs are covered under different copay tiers depending on your benefit:Tier 0 -No copayment for those drugs that are used for prevention and are mandated by the Affordable CareAct. Select oral contraceptives, vitamin D, folic acid for women of child bearing age, over-the-counter(OTC) aspirin, and smoking cessation products may be covered under this tier. Certain age or genderlimits apply.Tier 1 -Lowest copayment for those drugs that offer the greatest value compared to other drugs used to treatsimilar conditions. Select over-the-counter (OTC), generic or brand name drugs may be covered underthis tier.Tier 2 -Medium copayment covers brand name drugs that are generally more affordable, or may be preferredcompared to other drugs to treat the same conditions.Tier 3 -Highest copayment covers higher cost brand name drugs. This tier may also cover non-specialty drugsthat are not on the Preferred Drug List but approval has been granted for coverageTier 4 -Coverage for this tier is for “specialty” drugs. Specialty drugs are used to treat complex, chronicconditions and may require special handling, storage, or clinical management. Prescription drugscovered under the specialty tier require fulfillment at a pharmacy that participates in Ambetter’s“specialty” or “hemophilia” networks. For additional information on which pharmacies are within our“specialty” or “hemophilia” networks, please consult Ambetter website’s pharmacy information section.Prior Authorization for Non-Formulary DrugsTo obtain prior authorization for a non-formulary drug, your provider must fill out the Prior Authorization form. EnvolvePharmacy Solutions will respond via fax or phone within 24 hours of receipt of all necessary information for urgentrequests, and within 72 hours for non-urgent requests, unless state law requires faster response. If the request isdisapproved, the notice of disapproval will contain a clear explanation of the specific reasons for disapproving theprior authorization request, or if the request was incomplete, the explanation will identify the missing materialinformation that is necessary to complete the request.
Formulary Abbreviations:AbbreviationTermWhat it meansALAge LimitSome drugs are only covered for certain ages.QLQuantity LimitSome drugs are only covered for a certain amount.PAPrior AuthorizationYour doctor must ask for approval from Ambetter beforesome drugs will be covered.STStep TherapyNFNon-formularyRX/OTCPrescription and OTCIn some cases, you must first try certain drugs beforeAmbetter covers another drug for your medical condition.For example, if Drug A and Drug B both treat yourmedical condition, Ambetter may not cover Drug Bunless you try Drug A first.This product is not covered unless you or your providerrequest an exception. Alternative medications are listednext to non-covered productThese drugs are made in both prescription form andOver-the-counter (OTC) form.
Drug NameDrug Requirements/Tier LimitsADHD/ANTI-NARCOLEPSY/ANTIOBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating DisordersAmphetaminesADDERALL TABS 1.25MG-1.25 MG-1.25 MG-1.25MG, 1.875 MG-1.875 MG1.875 MG-1.875 MG, 2.5MG-2.5 MG-2.5 MG-2.5MG, 3.125 MG-3.125 MG3.125 MG-3.125 MG, 3.75MG-3.75 MG-3.75 MG-3.75MG, 5 MG-5 MG-5 MG-5MG (Use amphetaminedextroamphetamine)ADDERALL TABS 7.5 MG7.5 MG-7.5 MG-7.5 MG(Use amphetaminedextroamphetamine)ADDERALL XR CP24 1.25MG-1.25 MG-1.25 MG-1.25MG, 2.5 MG-2.5 MG-2.5MG-2.5 MG (Useamphetaminedextroamphetamine)ADDERALL XR CP24 3.75MG-3.75 MG-3.75 MG-3.75MG (Use amphetaminedextroamphetamine)ADDERALL XR CP24 5MG-5 MG-5 MG-5 MG,6.25 MG-6.25 MG-6.25MG-6.25 MG, 7.5 MG-7.5MG-7.5 MG-7.5 MG (Useamphetaminedextroamphetamine)ADZENYS ER SUER (Useamphetamine)amphetaminedextroamphetamine cp241.25 mg-1.25 mg-1.25 mg1.25 mg, 2.5 mg-2.5 mg2.5 mg-2.5 mgamphetaminedextroamphetamine cp243.75 mg-3.75 mg-3.75 mg3.75 mgQL(3 ea daily)NFQL(2 ea daily)NFQL(1 ea daily)NFNFQL(2 ea daily)NFNFamphetaminedextroamphetamine cp24 5mg-5 mg-5 mg-5 mg, 6.25mg-6.25 mg-6.25 mg-6.25mg, 7.5 mg-7.5 mg-7.5 mg7.5 mgamphetaminedextroamphetamine tabs1.25 mg-1.25 mg-1.25 mg1.25 mg, 1.875 mg-1.875mg-1.875 mg-1.875 mg,2.5 mg-2.5 mg-2.5 mg-2.5mg, 3.125 mg-3.125 mg3.125 mg-3.125 mg, 3.75mg-3.75 mg-3.75 mg-3.75mg, 5 mg-5 mg-5 mg-5 mgamphetaminedextroamphetamine tabs7.5 mg-7.5 mg-7.5 mg-7.5mgDESOXYN TABS (Usemethamphetamine hcl)DEXEDRINE CP24 10 MG,15 MG (Usedextroamphetaminesulfate)DEXEDRINE CP24 5 MG(Use dextroamphetaminesulfate)dextroamphetamine sulfatecp24 10 mg, 15 mgdextroamphetamine sulfatecp24 5 mgdextroamphetamine sulfatetabs 10 mg, 5 mgDrug Requirements/Tier LimitsQL(2 ea daily)1QL(3 ea daily)1QL(2 ea daily)1QL(5 ea daily);NF AL(At least 6yrs old)QL(4 ea daily)NFNF1QL(4 ea daily)11QL(4 ea daily)QL(5 ea daily);AL(At least 6yrs old)ST; QL(1 eadaily)methamphetamine hcl tabs31VYVANSE CAPS 10 MG,20 MG, 30 MG, 40 MG, 50MG, 60 MG, 70 MG31Anorexiants Non-AmphetamineADIPEX-P CAPS (UseNF PAphentermine hcl)phendimetrazine tartrate1 PAtabsQL(1 ea daily)Ambetter Formulary Updated December 1, 20211Drug Name
Drug Namephentermine hcl capsDrug Requirements/Tier Limits1 PAAnti-Obesity AgentsBELVIQ TABS3CONTRAVE TB123PA; QL(2 eadaily)PA; QL(4 eadaily)Drug Requirements/Tier LimitsQL(1 ea daily)dexmethylphenidate hclcp24 35 mg, 10 mg, 15 mg,120 mg, 25 mg, 30 mg, 40mg, 5 mgQL(2 ea daily);dexmethylphenidate hcl1 AL(At least 6tabs 2.5 mg, 10 mg, 5 mgyrs old)QL(2ea daily);FOCALIN TABS (UseNF AL(At least 6dexmethylphenidate hcl)yrs old)Drug NameAttention-Deficit/Hyperactivity Disorder (ADHD)QL(2 ea daily);atomoxetine hcl caps 101 AL(At least 6mg, 25 mg, 40 mg, 18 mgyrs old)QL(1 ea daily);atomoxetine hcl caps 1001 AL(At least 6mg, 60 mg, 80 mgyrs old)FOCALIN XR CP24 (Usedexmethylphenidate hcl)NF QL(1 ea daily)METHYLIN SOLN (Usemethylphenidate hcl)clonidine hcl (adhd) tb12methylphenidate hcl cp2420 mg, 40 mgQL(30 mlNF daily); AL(Atleast 6 yrs old)1 AL(At least 6yrs old)QL(3 ea daily);1 AL(At least 6yrs old)QL(1 ea daily);1 AL(At least 6yrs old)QL(30 ml1 daily); AL(Atleast 6 yrs old)QL(5 ea daily);1 AL(At least 6yrs old)QL(6 ea daily);1 AL(At least 6yrs old)QL(3 ea daily);1 AL(At least 6yrs old)QL(1 ea daily);1 AL(At least 6yrs old)QL(2 ea daily);1 AL(At least 6yrs old)PA; QL(1 ea1 daily); AL(Atleast 16 yrsold)guanfacine hcl (adhd) tb24INTUNIV TB24 (Useguanfacine hcl (adhd))1QL(1 ea daily);AL(At least 6yrs old)QL(1 ea daily);NF AL(At least 6yrs old)1KAPVAY TB12 (UseNFclonidine hcl (adhd))STRATTERA CAPS 10QL(2 ea daily);MG, 25 MG, 40 MG, 18 MG NF AL(At least 6(Use atomoxetine hcl)yrs old)QL(1 ea daily);STRATTERA CAPS 100NF AL(At least 6MG, 60 MG, 80 MG (Useatomoxetine hcl)yrs old)Dopamine and Norepinephrine Reuptake3 PASUNOSI TABSmethylphenidate hcl cp2430 mgmethylphenidate hcl cpcr40 mg, 20 mg, 60 mg, 10mg, 30 mg, 50 mgmethylphenidate hcl soln10 mg/5ml, 5 mg/5mlmethylphenidate hcl tabs10 mg, 20 mgmethylphenidate hcl tabs 5mgmethylphenidate hcl tbcr 10mg, 20 mgStimulants - Misc.armodafinil tabsCONCERTA TBCR 18 MG,27 MG (Usemethylphenidate hcl)CONCERTA TBCR 36 MG,54 MG (Usemethylphenidate hcl)DAYTRANA PTCHPA; QL(1 ea1 daily); AL(Atleast 17 yrsold)QL(1 ea daily);NF AL(At least 6yrs old)QL(2 ea daily);NF AL(At least 6yrs old)3 PA; QL(1 eadaily)methylphenidate hcl tbcr 18mg, 27 mgmethylphenidate hcl tbcr 36mg, 54 mgmodafinil tabs 100 mgAmbetter Formulary Updated December 1, 20212
Drug Namemodafinil tabs 200 mgNUVIGIL TABS (Usearmodafinil)PROVIGIL TABS 100 MG(Use modafinil)PROVIGIL TABS 200 MG(Use modafinil)RITALIN LA CP24 20 MG,40 MG (Usemethylphenidate hcl)RITALIN LA CP24 30 MG(Use methylphenidate hcl)RITALIN TABS 10 MG, 20MG (Use methylphenidatehcl)RITALIN TABS 5 MG (Usemethylphenidate hcl)Drug Requirements/Tier LimitsPA; QL(2 ea1 daily); AL(Atleast 16 yrsold)PA; QL(1 eaNF daily); AL(Atleast 17 yrsold)PA; QL(1 eaNF daily); AL(Atleast 16 yrsold)PA; QL(2 eaNF daily); AL(Atleast 16 yrsold)AL(At least 6NF yrs old)QL(3 ea daily);NF AL(At least 6yrs old)QL(5 ea daily);NF AL(At least 6yrs old)QL(6 ea daily);NF AL(At least 6yrs old)ALLERGENIC EXTRACTS/BIOLOGICALS MISCAllergenic ExtractsGRASTEK SUBL3PA3PAAMEBICIDESAmebicidesSOLOSEC PACKAMINOGLYCOSIDES - Drugs to Treat BacterialInfectionsAminoglycosidesamikacin sulfate soln1ARIKAYCE SUSP4PAAmbetter Formulary Updated December 1, 20213Drug Namegentamicin in saline soln0.8 mg/ml-0.9 %, 0.9 %-1mg/ml, 0.9 %-1.2 mg/ml,0.9 %-1.6 mg/mlgentamicin sulfate soln 40mg/mlHUMATIN CAPS (Useparomomycin sulfate)KITABIS PAK NEBU (Usetobramycin)Drug Requirements/Tier Limits11NFNF PAneomycin sulfate tabs1paromomycin sulfate caps1streptomycin sulfate solr3TOBI NEBU (UseNF PAtobramycin)tobramycin nebu 3004 PAmg/5mltobramycin sulfate soln 101mg/ml, 40 mg/ml, 80mg/2mlANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditionsAnti-TNF-alpha - Monoclonal AntibodiesPA; 1 rtl packlmt amt,180 rtlpack lmtHUMIRA PEDIATRIC4 day(s),1 mailCROHNS DISEASEpack lmtSTARTER PACK PSKTamt,180 mailpack lmtday(s),HUMIRA PEN PNKT 404 PA; QL(0.143MG/0.4ML, 40 MG/0.8MLea daily)PA; 1 rtl packlmt amt,180 rtlpack lmtHUMIRA PEN PNKT 804 day(s),1 mailMG/0.8MLpack lmtamt,180 mailpack lmtday(s),HUMIRA PEN-CD/UC/HSPA; QL(0.1434 ea daily)STARTER PNKT 40MG/0.8ML
Drug Requirements/Tier LimitsPA; 1 rtl packlmt amt,180 rtlpack lmtHUMIRA PEN-CD/UC/HS4 day(s),1 mailSTARTER PNKT 80pack lmtMG/0.8MLamt,180 mailpack lmtday(s),PA; 1 rtl packlmt amt,180 rtlpack lmtHUMIRA PEN-PEDIATRIC4 day(s),1 mailUC STARTER PACKpack lmtPNKTamt,180 mailpack lmtday(s),PA; 1 rtl packlmt amt,180 rtlpack lmtHUMIRA PEN-PS/UV4 day(s),1 mailSTARTER PNKTpack lmtamt,180 mailpack lmtday(s),HUMIRA PEN-PS/UV4 PA; QL(0.143STARTER PNKTea daily)4 PA; QL(0.143HUMIRA PSKTea daily)Drug NameAntirheumatic - Enzyme InhibitorsRINVOQ TB244XELJANZ TABS 10 MG4XELJANZ TABS 5 MG4XELJANZ XR TB244PA; QL(1 eadaily)PA; QL(2 eadaily)PA; QL(2 eadaily); SPPA; QL(1 eadaily)Antirheumatic AntimetabolitesMETHOTREXATE TABS4PA; QL(1.714ea daily); SP34Interleukin-1beta BlockersILARIS SOLN4PA; QL(0.072ml daily)Nonsteroidal Anti-inflammatory Agents (NSAIDs)ARTHROTEC 50 TBECNF(Use diclofenac w/misoprostol)ARTHROTEC 75 TBECNF(Use diclofenac w/misoprostol)CELEBREX CAPS (UseNF PAcelecoxib)1 PAcelecoxib capsCHILDRENS ADVIL SUSP(Use ibuprofen)CHILDRENS MOTRINSUSP (Use ibuprofen)DAYPRO TABS (Useoxaprozin)diclofenac potassium tabs50 mgNF RX/OTCNF RX/OTCNF1diclofenac sodium tb241diclofenac sodium tbec1diclofenac w/ misoprostoltbecEC-NAPROSYN TBEC 500MG (Use naproxen)etodolac caps 200 mg, 300mgetodolac tabs 400 mg, 500mgFELDENE CAPS (Usepiroxicam)fenoprofen calcium tabs600 mg1NF11NF11QL(3 ea daily)ibuprofen susp 100 mg/5ml1PA; QL(0.286ea daily); SPibuprofen tabs 400 mg, 600mg, 800 mgindomethacin caps 25 mg,50 mgInterleukin-1 BlockersARCALYST SOLRDrug Requirements/Tier Limitsflurbiprofen tabsGold CompoundsRIDAURA CAPSDrug NameST; QL(4 eadaily)RX/OTC11Ambetter Formulary Updated December 1, 20214
Drug Nameindomethacin cpcr 75 mgketoprofen caps 50 mg, 75mgketorolac tromethaminetabs or 10 mgLODINE TABS (Useetodolac)meclofenamate sodiumcapsmefenamic acid capsmeloxicam tabs 15 mg, 7.5mgMOBIC TABS (Usemeloxicam)nabumetone tabsNALFON TABS 600 MG(Use fenoprofen calcium)NAPROSYN SUSP 125MG/5ML (Use naproxen)NAPROSYN TABS 500MG (Use naproxen)naproxen sodium tabs 550mgDrug Requirements/Tier Limits1OTEZLA TBPK11QL(0.667 eadaily)NFDrug Requirements/Tier LimitsPA; 1 rtl pack4 lmt amt,180 rtlpack lmtday(s),Pyrimidine Synthesis InhibitorsARAVA TABS (UseNF QL(1 ea daily)leflunomide)1 QL(1 ea daily)leflunomide tabs1NF ST; QL(4 eadaily)NF PASoluble Tumor Necrosis Factor Receptor Agents4 PA; QL(0.15 mlENBREL MINI SOCTdaily)ENBREL SOLN 254 PA; QL(0.146MG/0.5MLml daily)4 PA; QL(0.286ENBREL SOLR 25 MGea daily); SPENBREL SOSY 254 PA; QL(0.146MG/0.5MLml daily); SP4 PA; QL(0.28 mlENBREL SOSY 50 MG/MLdaily); SPENBREL SURECLICK4 PA; QL(0.143SOAJml daily); SPNFANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint Conditions11ST; Must tryibuprofen.;QL(5 ea daily)QL(1 ea daily)NF QL(1 ea daily)11naproxen susp 125 mg/5ml1naproxen tabs 250 mg, 375mg, 500 mg1naproxen tbec 500 mg1oxaprozin tabs1piroxicam caps1sulindac tabs1tolmetin sodium caps1tolmetin sodium tabs1PAPhosphodiesterase 4 (PDE4) Inhibitors4 PA; QL(2 eaOTEZLA TABSdaily)Ambetter Formulary Updated December 1, 20215Drug NameAnalgesic Combinationsbutalbital-acetaminophentabs 325 mg-50 mg, 50 mg325 mgbutalbital-acetaminophencaffeine caps 40 mg-50mg-300 mg, 40 mg-50 mg325 mgbutalbital-acetaminophencaffeine tabs 325 mg-40mg-50 mg, 40 mg-50 mg325 INOPHEN CAPS (Usebutalbital-acetaminophen)ESGIC TABS (Usebutalbital-acetaminophencaffeine)1111NFNF
Drug NameFIORICET CAPS (Usebutalbital-acetaminophencaffeine)FIORINAL CAPS (Usebutalbital-aspirin-caffeine)SalicylatesDrug Requirements/Tier LimitsNFNFaspirin chew0aspirin tabs0aspirin tbec0diflunisal tabs1salsalate tabs1AL(At least 45yrs old - Up to79 yrs old)AL(At least 45yrs old - Up to79 yrs old)AL(At least 45yrs old - Up to79 yrs old)ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint ConditionsOpioid AgonistsACTIQ LPOP (Use fentanylcitrate)CODEINE SULFATE TABS15 MG, 60 MGcodeine sulfate tabs 30 mgCONZIP CP24 (Usetramadol hcl)DEMEROL SOLN 100MG/ML, 25 MG/ML, 50MG/ML (Use meperidinehcl)DILAUDID LIQD OR 1MG/ML (Usehydromorphone hcl)DILAUDID SOLN IJ 1MG/ML, 2 MG/ML (Usehydromorphone hcl)DILAUDID TABS OR 2MG, 4 MG, 8 MG (Usehydromorphone hcl)NF PA; QL(4 eadaily)New starts1 limited to 7 daysupplyNew starts1 limited to 7 daysupplyNFNFNew startsNF limited to 7 daysupplyNFNew startsNF limited to 7 daysupply;QL(8 eadaily)Drug NameDURAGESIC PT72 (Usefentanyl)fentanyl citrate lpop bu1200 mcg, 1600 mcg, 200mcg, 400 mcg, 600 mcg,800 mcgfentanyl pt72 td 12 mcg/hr,100 mcg/hr, 25 mcg/hr, 50mcg/hr, 75 mcg/hrFENTORA TABS (Usefentanyl citrate)hydrocodone bitartratecp12 10 mg, 15 mg, 30 mg,40 mg, 50 mgHYDROCODONEBITARTRATE ER CP12Drug Requirements/Tier LimitsNF QL(0.34 eadaily)PA; QL(4 ea1 daily)1NF11hydromorphone hcl liqd or1 mg/ml1hydromorphone hcl soln ij10 mg/ml, 50 mg/5ml, 500mg/50ml1hydromorphone hcl tabs or2 mg, 4 mg, 8 mg1hydromorphone hcl tb24 or12 mg, 16 mg, 8 mghydromorphone hcl tb24 or32 mgHYDROMORPHONEHYDROCHLORIDE SOLNIJ 10 MG/ML (Usehydromorphone hcl)KADIAN CP24 100 MG, 20MG, 30 MG, 50 MG, 60MG, 80 MG (Use morphinesulfate)NFlevorphanol tartrate tabs 2mg1meperidine hcl soln ij 100mg/ml, 25 mg/ml, 50 mg/ml1meperidine hcl soln or 50mg/5mlQL(0.34 eadaily)11PA; QL(2 eadaily)PA; QL(2 eadaily)New startslimited to 7 daysupplyNew startslimited to 7 daysupply;QL(8 eadaily)PA; QL(2 eadaily)PA; QL(1 eadaily)PA; QL(2 eaNF daily)1New startslimited to 7 daysupplyNew startslimited to 7 daysupply;QL(500ml per fill retail)Ambetter Formulary Updated December 1, 20216
Drug Namemeperidine hcl tabs or 50mgmethadone hcl conc or 10mg/mlmethadone hcl soln ij 10mg/mlMETHADONE HCL SOLNIJ 10 MG/ML (Usemethadone hcl)methadone hcl soln or 10mg/5mlmethadone hcl soln or 5mg/5mlmethadone hcl tabs or 10mgmethadone hcl tabs or 5mgmethadone hcl tbso or 40mgMETHADOSE CONC (Usemethadone hcl)METHADOSE SUGARFREE CONC (Usemethadone hcl)MORPHABOND ER T12A100 MG, 30 MG, 60 MGMORPHABOND ER T12A15 MGmorphine sulfate cp24 or100 mg, 20 mg, 30 mg, 50mg, 60 mg, 80 mgmorphine sulfate soln ij 0.5mg/ml, 1 mg/mlMORPHINE SULFATESOLN IV 10 MG/ML (Usemorphine sulfate)morphine sulfate soln or 10mg/5mlmorphine sulfate soln or 20mg/5mlDrug Requirements/Tier LimitsNew starts1 limited to 7 daysupply;QL(6 eadaily)1 QL(10 ml daily)1QL(50 ml daily)1QL(100 mldaily)QL(10 ea daily)1QL(4 ea daily)1QL(2 ea daily)1NF QL(10 ml daily)QL(10 ml daily)NF331PA; QL(1 eadaily)PA; QL(3 eadaily)PA; QL(2 eadaily)1NF11New startslimited to 7 daysupply;QL(100ml daily)New startslimited to 7 daysupply;QL(50ml daily)Ambetter Formulary Updated December 1, 20217morphine sulfate tabs or 15mgmorphine sulfate tabs or 15mg, 30 mgmorphine sulfate tbcr or100 mg, 15 mg, 200 mg, 30mg, 60 mgMS CONTIN TBCR (Usemorphine sulfate)11Drug NameNUCYNTA ER TB12NUCYNTA TABSOPANA TABS (Useoxymorphone hcl)OXAYDO TABS 5 MGoxycodone hcl t12a 15 mg,30 mg, 60 mg, 80 mg, 10mg, 20 mg, 40 mgDrug Requirements/Tier Limits111NF QL(2 ea daily)PA; QL(2 eadaily)2 PA; QL(6 eadaily)NF PA; QL(12 eadaily)New starts2 limited to 7 daysupply;QL(12ea daily)PA; QL(2 ea3 daily)2oxycodone hcl tabs 10 mg,15 mg, 20 mg, 30 mg, 5 mg1OXYCONTIN T12A3oxymorphone hcl tabs 10mg, 5 mgoxymorphone hcl tb12 10mg, 15 mg, 20 mg, 30 mg,5 mg, 7.5 mgoxymorphone hcl tb12 40mgROXICODONE TABS (Useoxycodone hcl)SUBSYS LIQD 100 MCGSUBSYS LIQD 1200 MCG,1600 MCG, 800 MCGSUBSYS LIQD 200 MCG,400 MCG, 600 MCGNew startslimited to 7 daysupply;QL(6 eadaily)QL(2 ea daily)11New startslimited to 7 daysupply;QL(12ea daily)PA; QL(2 eadaily)PA; QL(12 eadaily)PA; QL(2 eadaily)PA; QL(4 eadaily)New startsNF limited to 7 daysupply;QL(12ea daily)3 PA; QL(3 eadaily)3 PA; QL(8 eadaily)3 PA; QL(4 eadaily)1
Drug Nametramadol hcl tabs 50 mgtramadol hcl tb24 100 mg,200 mg, 300 mgULTRAM TABS (Usetramadol hcl)XTAMPZA ER C12AZOHYDRO ER CP12Opioid Combinationsacetaminophen w/ codeinesoln 12 mg/5ml-120mg/5ml, 120 mg/5ml-12mg/5mlacetaminophen w/ codeinetabs 15 mg-300 mgacetaminophen w/ codeinetabs 30 mg-300 mgacetaminophen w/ codeinetabs 300 mg-60 mg, 60mg-300 mgacetaminophen-caffdihydrocod caps 16 mg-30mg-320.5 mgacetaminophen-caffdihydrocod caps 16 mg-30mg-320.5 mgbutalbital-acetaminophencaffeine w/ codeine caps30 mg-40 mg-50 mg-300mgbutalbital-acetaminophencaffeine w/ codeine caps30 mg-40 mg-50 mg-325mg, 325 mg-30 mg-40 mg50 mgDrug Requirements/Tier LimitsNew starts1 limited to 7 daysupply;QL(8 eadaily)1 QL(1 ea daily)New startsNF limited to 7 daysupply;QL(8 eadaily)2 PA; QL(2 eadaily)1 PA; QL(2 eadaily)11113111New startslimited to 7 daysupply;QL(75ml daily)New startslimited to 7 daysupply;QL(13ea daily)New startslimited to 7 daysupply;QL(12ea daily)New startslimited to 7 daysupply;QL(6 eadaily)PA; New startslimited to 7 daysupplyNew startslimited to 7 daysupplyNew startslimited to 7 daysupplyNew startslimited to 7 daysupply;QL(6 eadaily)Drug Requirements/Tier LimitsNew startsbutalbital-aspirin-caffeine1 limited to 7 daysupply;QL(6 eaw/cod capsdaily)FIORICET/CODEINENew startsCAPS (Use butalbitallimited to 7 dayacetaminophen-caffeine w/ NF supplycodeine)New startsFIORINAL/CODEINE #3NF limited to 7 dayCAPS (Use butalbitalsupply;QL(6 eaaspirin-caffeine w/cod)daily)Drug Namehydrocodoneacetaminophen soln 10mg/15ml-325 mg/15mlhydrocodoneacetaminophen soln 2.5mg/5ml-108 mg/5ml, 217mg/10ml-5 mg/10ml, 325mg/15ml-7.5 mg/15ml, 5mg/10ml-217 mg/10ml, 7.5mg/15ml-325 mg/15mlhydrocodoneacetaminophen tabs 10mg-300 mg, 7.5 mg-300mg, 300 mg-5 mg, 5 mg300 mghydrocodoneacetaminophen tabs 5 mg325 mg, 10 mg-325 mg,325 mg-10 mg, 325 mg-7.5mg, 7.5 mg-325 mghydrocodone-ibuprofentabs 10 mg-200 mg, 200mg-5 mg, 5 mg-200 mghydrocodone-ibuprofentabs 200 mg-7.5 mg, 7.5mg-200 mgLORTAB ELIXNORCO TABS (Usehydrocodoneacetaminophen)1111New startslimited to 7 daysupplyNew startslimited to 7 daysupply;QL(180ml daily)New startslimited to 7 daysupply;QL(13ea daily)New startslimited to 7 daysupply;QL(12ea daily)PA1New starts1 limited to 7 daysupply;QL(5 eadaily)New starts2 limited to 7 daysupply;QL(60ml daily)New startsNF limited to 7 daysupply;QL(12ea daily)Ambetter Formulary Updated December 1, 20218
Drug Nameoxycodone w/acetaminophen tabs 7.5mg-325 mg, 10 mg-325mg, 325 mg-10 mg, 325mg-5 mg, 5 mg-325 mgoxycodone-ibuprofen tabsPERCOCET TABS 7.5MG-325 MG, 10 MG-325MG, 5 MG-325 MG (Useoxycodone CODEINE #3TABS (Use acetaminophenw/ codeine)TYLENOL/CODEINE #4TABS (Use acetaminophenw/ codeine)ULTRACET TABS (Usetramadol-acetaminophen)Opioid Partial AgonistsBUNAVAIL FILM 0.3 MG2.1 MG, 2.1 MG-0.3 MGBUNAVAIL FILM 0.7 MG4.2 MGBUNAVAIL FILM 1 MG-6.3MGBUPRENEX SOLN (Usebuprenorphine hcl)buprenorphine hcl soln ij0.3 mg/mlbuprenorphine hcl subl sl 2mg, 8 mgbuprenorphine hclnaloxone hcl dihydrate film1 mg-4 mg, 0.5 mg-2 mg, 2mg-0.5 mgDrug Requirements/Tier LimitsNew startslimited to 7 day1 supply;QL(12ea daily)New starts1 limited to 7 daysupply;QL(1 eadaily)New startslimited to 7 dayNF supply;QL(12ea daily)New starts1 limited to 7 daysupply;QL(8 eadaily)New startsNF limited to 7 daysupply;QL(12ea daily)New startsNF limited to 7 daysupply;QL(6 eadaily)New startsNF limited to 7 daysupply;QL(8 eadaily)333PA; QL(4 eadaily)PA; QL(2 eadaily)PA; QL(1 eadaily)1QL(3 ea daily)QL(3 ea daily)1Ambetter Formulary Updated December 1, 20219buprenorphine hclnaloxone hcl dihydrate film2 mg-8 mg, 3 mg-12 mgbuprenorphine hclnaloxone hcl dihydrate subl0.5 mg-2 mg, 2 mg-0.5 mg,2 mg-8 mg, 8 mg-2 mgbuprenorphine ptwk td 10mcg/hr, 15 mcg/hr, 20mcg/hr, 5 mcg/hr, 7.5mcg/hrbutorphanol tartrate soln ij1 mg/ml, 2 mg/mlbutorphanol tartrate soln na10 mg/mlBUTRANS PTWK 10MCG/HR, 15 MCG/HR, 20MCG/HR, 5 MCG/HR (Usebuprenorphine)BUTRANS PTWK 7.5MCG/HR (Usebuprenorphine)Drug Requirements/Tier LimitsQL(2 ea daily)1QL(3 ea daily)11PA; QL(0.143ea daily)11PAPA; QL(0.143NF ea daily)3PA; QL(0.143ea daily)nalbuphine hcl soln1QL(8 ml daily)pentazocine w/ naloxonehcl tabs1SUBOXONE FILM 1 MG-4MG, 0.5 MG-2 MG (Usebuprenorphine hclnaloxone hcl dihydrate)SUBOXONE FILM 2 MG-8MG, 3 MG-12 MG (Usebuprenorphine hclnaloxone hcl dihydrate)New startslimited to 7 daysupplyQL(3 ea daily)NFQL(2 ea daily)NFANDROGENS-ANABOLIC - Drugs to RegulateHormonesAnabolic SteroidsNF1Drug NameANADROL-50 TABS3oxandrolone tabs1AndrogensANDRODERM PT242PA; QL(1 eadaily)
Drug NameANDROGEL GEL 25MG/2.5GM, 50 MG/5GM(Use testosterone)danazol capsDEPO-TESTOSTERONESOLN (Use testosteronecypionate)METHITEST TABSTESTIM GEL (Usetestosterone)TESTOSTERONECYPIONATE SOLN IJ 200MG/MLtestosterone cypionate solnij 200 mg/mltestosterone cypionate solnim 100 mg/ml, 200 mg/mltestosterone enanthatesolnVOGELXO GEL (Usetestosterone)VOGELXO PUMP GEL(Use testosterone)Drug Requirements/Tier LimitsPROCTOCORT SUPP(Use hydrocortisoneacetate (rectal))NFRectal SteroidsANUSOL-HC CREA (Usehydrocortisone (rectal))hydrocortisone (rectal) creahydrocortisone acetate(rectal) suppPROCTOCORT CREA(Use hydrocortisone(rectal))Drug Requirements/Tier LimitsNFVasodilating Agents1RECTIV OINTNF33AnthelminticsNFalbendazole tabsALBENZA TABS (Usealbendazole)BILTRICIDE TABS (Usepraziquantel)1111NF PAEMVERM CHEW2ivermectin tabs or 3 mg1praziquantel tabs1NFNFNF1PA; QL(3.2 gmdaily)NF11PANF PA14QL(2 gm daily)ANTHELMINTICS - Drugs to Treat WormInfectionsANORECTAL AND RELATED PRODUCTS Rectal Drugs to Treat Pain, Swelling and ItchingIntrarectal SteroidsCORTENEMA ENEM (Usehydrocortisone (intrarectal))hydrocortisone (intrarectal)enemUCERIS FOAM RE 2MG/ACTDrug NameQL(2 ea daily,6ea per fillretail,6 ea perfill mail)1 rtlMAX fill,60 rtlday(s) supply,1mail MAX fill,60mail day(s)supply,PASTROMECTOL TABS (Use NFivermectin)ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial InfectionsAnti-infective Agents - Misc.bacitracin solrFLAGYL TABS 500 MG(Use metronidazole)3NFIMPAVIDO CAPS3metronidazole tabs or 250mg, 500 mg1trimethoprim tabs1XIFAXAN TABS3NFPA; QL(3 eadaily)PA; AL(At least12 yrs old)Anti-infective Misc. - CombinationsAmbetter Formulary Updated December 1, 202110
Drug NameDrug Requirements/Tier LimitsBACTRIM DS TABS (UseNFsulfamethoxazoletrimethoprim)BACTRIM TABS e1trimethoprim solnsulfamethoxazole1trimethoprim suspsulfamethoxazole1trimethoprim tabsAntiprotozoal AgentsALINIA SUSR 1002 PAMG/5MLALINIA TABS 500 MG (Use 2 PAnitazoxanide)atovaquone suspMEPRON SUSP (Useatovaquone)nitazoxanide tabs or1NF1PAertapenem sodium solr1imipenem-cilastatin solr1meropenem solrMERREM SOLR (Usemeropenem)PRIMAXIN IV SOLR nicol sodiumsuccinate solrCyclic LipopeptidesCUBICIN RF SOLR (Usedaptomycin)CUBICIN SOLR (Usedaptomycin)DAPTOMYCIN SOLR 350MG (Use daptomycin)daptomycin solr 500 mgFIRVANQ SOLRVANCOCIN CAPS (Usevancomycin hcl)VANCOCIN HCL CAPS(Use vancomycin hcl)vancomycin hcl caps or125 mg, 250 mgvancomycin hcl solr iv 500mg, 1 gm, 10 gm, 1000 mgVANCOMYCINHYDROCHLORIDE SOLROR 250 MG/5MLLeprostaticsLincosamidesCLEOCIN CAPS OR 75MG, 150 MG, 300 MG (Useclindamycin hcl)CLEOCIN PEDIATRICGRANULES SOLR (Useclindamycin palmitatehydrochloride)CLEOCIN PHOSPHATESOLN IJ 600 MG/4ML, 900MG/6ML, 300 MG/2ML, 9GM/60ML (Use clindamycinphosphate)NF1NFNFNF1QL(300 ml perfill retail)QL(4 eaNF daily,40 ea perfill retail)QL(4 eaNF daily,40 ea perfill retail)QL(4 ea1 daily,40 ea perfill retail)2121NFNFNFclindamycin hcl caps1clindamycin palmitatehydrochloride solr1NFclindamycin phosphate soln1NFLINCOCIN SOLN (Uselincomycin hcl)4PA; SPlincomycin hcl solnAmbetter Formulary Updated December 1, 202111Drug Requirements/Tier LimitsGlycopeptidesdapsone tabsCarbapenemsINVANZ SOLR (Useertapenem sodium)Drug NameNF1QL(300 ml perfill retail)
Drug NameMonobactamsAZACTAM SOLR (Useaztreonam)Drug Requirements/Tier Limits1CAYSTON SOLR4Oxazolidinoneslinezolid susr or 100mg/5mlPA; QL(3 mldaily)1linezolid tabs or 600 mg1SIVEXTRO TABS OR3ZYVOX SUSR OR 100MG/5ML (Use linezolid)ZYVOX TABS OR 600 MG(Use linezolid)RANEXA TB12 1000 MG(Use ranolazine)RANEXA TB12 500 MG(Use ranolazine)NFaztreonam solrPA; QL(2 eadaily)PANFNF PA; QL(2 eadaily)Polymyxinspolymyxin b sulfate solrUrinary Anti-infectivesfosfomycin tromethaminepackHIPREX TABS (Usemethenamine hippurate)MACROBID CAPS (Usenitrofurantoin monohydmacro)MACRODANTIN CAPS 50MG, 100 MG (Usenitrofurantoin macrocrystal)methenamine hippuratetabsMONUROL PACK (Usefosfomycin tromethamine)nitrofurantoin macrocrystalcaps 50 mg, 100 mgnitrofurantoin monohydmacro capsnitrofurantoin suspDrug Name1Drug Requirements/Tier LimitsNF QL(2 ea daily)NF QL(3 ea daily)ranolazine tb12 1000 mg1QL(2 ea daily)ranolazine tb12 500 mg1QL(3 ea daily)NitratesISORDIL TITRADOSETABS 5 MG (Useisosorbide dinitrate)isosorbide dinitrate tabs 30mg, 10 mg, 20 mg, 5 mgisosorbide dinitrate tbcr 40mgNF11isosorbide mononitrate tabs1isosorbide mononitratetb241NITRO-BID OINT33NITRO-DUR PT24 0.1MG/HR, 0.4 MG/HR, 0.2MG/HR, 0.6 MG/HR (Usenitroglycerin)nitroglycerin cpcr or 2.5mg, 6.5 mg, 9 mgnitroglycerin pt24 td 0.1mg/hr, 0.4 mg/hr, 0.2mg/hr, 0.6 mg/hrNITROGLYCERIN SOLNIV 5 MG/MLnitroglycerin subl sl 0.3 mg,0.4 mg, 0.6 mgNITROSTAT SUBL (Usenitroglycerin)1ANTIANXIETY AGENTS - Drugs to Treat Anxiety1Antianxiety Agents - Misc.buspirone hcl tabs 10 mg,30 mg, 7.5 mg, 15 mg1NFNFNF11ANTIANGINAL AGENTS - Drugs to Treat ChestPainAntianginals-OtherNF1QL(4 ea daily)111NF1buspirone hcl tabs 5 mg1hydroxyzine hcl soln im 50mg/ml1QL(6 ea daily)Ambetter Formulary Updated December 1, 202112
Drug Namehydroxyzine hcl syrp or 10mg/5mlhydroxyzine hcl tabs or 10mg, 25 mg, 50 mgDrug Requirements/Tier LimitsANTIARRHYTHMICS - Drugs to treat abnormalheart rhythms1Antiarrhythmics Type I-Adisopyramide phosphatecapsNORPACE CAPS (Usedisopyramide phosphate)procainamide hcl soln 500mg/ml1meprobamate tabs1Benzodiazepinesalprazolam tabs 0.25 mg,0.5 mg, 1 mg, 2 mgalprazolam tb24 0.5 mg, 1mg, 2 mg, 3 mgalprazolam tbdp 0.25 mg,0.5 mg, 1 mg, 2 mgATIVAN TABS OR 0.5 MG,2 MG (Use lorazepam)ATIVAN TABS OR 1 MG(Use lorazepam)Drug Requirements/Tier Limits1hydroxyzine pamoate capsVISTARIL CAPS (Usehydroxyzine pamoate)Drug NameNFquinidine sulfate tabs1QL(4 ea daily)1Antiarrhythmics Type I-Bmexiletine hcl caps 250mg, 150 mg, 200 mg1NF111Antiarrhythmics Type I-C1NF QL(3 ea daily)NF QL(4 ea daily)flecainide acetate tabs1propafenone hcl cp121propafenone hcl tabs1chlordiazepoxide hcl caps1clorazepate dipotassiumtabs1diazepam conc or 5 mg/ml1diazepam soln or 5 mg/5ml1diazepam tabs or 10 mg, 2mg, 5 mg1lorazepam conc or 2 mg/ml1lorazepam tabs or 0.5 mg,2 mg1QL(3 ea daily)TIKOSYN CAPS (Usedofetilide)lorazepam tabs or 1 mg1QL(4 ea daily)ANTIASTHMATIC AND BRONCHODILATORAGENTS - Drugs to Treat Lung Conditionsoxazepam caps 10 mg, 15mg, 30 mgTRANXENE T TABS (Useclorazepate dipotassium)VALIUM TABS (Usediazepam)XANAX TABS (Usealprazolam)XANAX XR TB24 (Usealprazolam)QL(4 ea daily)1NF11dofetilide caps1MULTAQ TABS3NFAnti-Inflammatory AgentsQL(8 ml daily)NFcromolyn sodium nebuNF QL(4 ea daily)Antiasthmatic - Monoclonal Antibodies4 PAFASENRA PEN SOAJNF QL(4 ea daily)NFAmbetter Formulary Updated December 1, 202113RYTHMOL SR CP12 (Usepropafenone hcl)Antiarrhythmics Type IIIamiodarone hcl soln iv 150mg/3ml, 50 mg/mlamiodarone hcl tabs or 100mg, 200 mg, 400 mgFASENRA SOSY14PA
Drug NameNUCALA SOAJDrug Requirements/Tier Limits4 PANUCALA SOLR4PANUCALA SOSY4PAXOLAIR SOLR 150 MG4PA; SPXOLAIR SOSY 150MG/ML, 75 MG/0.5ML4PAATRO
Formulary Introduction FORMULARY . The Ambetter from MagnoliaHealth Formulary, or Preferred Drug List, is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription drug benefit. Generic drugs have the same ac
