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2021 Prescription Drug ListEffective January 1, 2021Ambetter.SuperiorHealthPlan.com
FormularyIntroductionSUMMARY OF FORMULARY BENEFITSThe information in this document is designed to help you understand the prescription drug benefits offered under this planand to compare these benefits to those offered by other plans. Information contained in this summary is designed to helpyou compare both the value and scope offormulary benefits.HOW TO FIND INFORMATION ON THE COST OF PRESCRIPTION DRUGSTo find the cost of your prescription please visit pharmacyresources.html. In the Drug Cost Tool please select the plan in which you are participating (planning to participate) andenter medications thatyou are taking.The toolwill provide you anapproximate costofyour prescriptions, excludingany deductible or maximumoutofpocketrequirements. ualallowedcostfor branded products. If the total medication cost is less than the co-pay that you would pay forthat Tier you will be responsible only for the lesser of amount.FORMULARY BY HEALTH BENEFIT PLANPlanAmbetter Balanced Care 11(2021)Ambetter Balanced Care 12(2021)Ambetter Balanced Care 201HSA (2021)Ambetter Balanced Care 203(2021)Ambetter Balanced Care 204HSA (2021)Ambetter Balanced Care 205(2021)Ambetter Balanced Care 207(2021)Ambetter Balanced Care 209(2021)Ambetter Balanced Care 25(2021)Ambetter Balanced Care 25HSA (2021)Ambetter Balanced Care 27(2021)Ambetter Balanced Care 28(2021)Ambetter Balanced Care 29(2021)Ambetter Balanced Care 5(2021)Ambetter Essential Care laryStandardFormularySummary of Benefits and 21brochures.html?plan m/2021brochures.html?plan m/2021brochures.html?plan m/2021brochures.html?plan m/2021brochures.html?plan m/2021brochures.html?plan m/2021brochures.html?plan m/2021brochures.html?plan m/2021brochures.html?plan m/2021brochures.html?plan m/2021brochures.html?plan m/2021brochures.html?plan m/2021brochures.html?plan m/2021brochures.html?plan m/2021brochures.html?plan EssentialCare
Ambetter Essential Care 10(2021)Ambetter Essential Care 2HSA (2021)Ambetter Secure Care 15(2021)Ambetter Secure Care 201HSA (2021)Ambetter Secure Care 202(2021)Ambetter Secure Care 5 21brochures.html?plan om/2021brochures.html?plan om/2021brochures.html?plan 2021brochures.html?plan 2021brochures.html?plan 2021brochures.html?plan SecureCareDRUG BY COST-SHARING TIERTier01234Percentofdrugsineachcost-sharing tier:6%84%2%2%6%HOW PRESCRIPTION DRUGS ARE COVERED UNDER THE PLANA) FORMULARY COMPOSITION:a. Ambetter formulary is guided by the principle of offering widest possible access to drugs at the lowestcost. With that in mind, we start with the Affordable Care Act mandated benchmark. We then review theformulary for addition of other clinically necessary and appropriate drugs. Ambetter’s formulary isconsidered a closed formulary. This means that any drug not found in the formulary requires priorauthorization. To make sure thatour members teourformulary ona monthly basis.
B) RIGHT TO APPEALa. If we deny your request for Prior Authorization you have 180 days from being denied coverage for a drugto file an appeal, and your appeal will be resolved within 30 days. In the event that your appeal issuccessful, non-specialty non-formulary drugs will be covered at your Tier 3 cost-share (co-pay or coinsurance) and specialty non-formulary drugs will be covered at your Tier 4 cost-share (co-pay or coinsurance). Please consult your individual Summary of Benefits and Coverage for additional informationon your cost-share. All other provisions of your benefit, such as deductibles and maximum out ofpockets, apply to formulary and non-formulary drugs that have been provided through an appeal.C) CONTINUATION OF COVERAGEa. continuationofcoverage.However,ifaformulary change is made requiring a continuation of coverage, you would have the right to continuetaking veredatthebeginningoftheplanyearuntil your plan is renewed.D) OFF-LABEL DRUG USEa. We provide coverage for off-label drug use. Off-label use indicates medication use that has not beenFDA approved for that condition. Coverage of a product under off-label use policy requires that thefollowing must be true:i. Use must be diagnosis specific as defined by ICD-10 code ANDii. Off-label use must be supported by one major multi-site study or three smaller studies publishedin areputable medical journal, peerreviewedspecialty medicaljournal,or listedin reputablecompendia.E) COST SHARINGa. Cost sharing is your monetary participation in your care. You will need to know few items to determine sible for at any given time: how much of your deductible you have already paid, how muchdeductibleremains, what drug you are prescribed, and your maximum out of pocket allowance. All thoseitems, with the nefitsandCoverage(seelinksabove).To obtain the tier for your drug please consult the Formulary. To determine your cost shareplease follow those steps:i. Determine the tier that the drug/product you are filling is listed under by consulting the Formulary.ii. Once you have determined the tier, utilize the Summary of Benefits and Coverage (SBC)document to determine what cost-share will apply to your selected drug/product.iii. If you have not met your deductible, you will be responsible for the full cost of the drug untilyou meet your deductible.iv. If you have met your deductible, but not the Maximum Out of Pocket, you will be charged acopay for drugs that are assigned a copay under your SBC and co-insurance for drugs that areassigned a co-insurance under your SBC. Generally, you will pay one (1) co-pay for each 30day supply of medication. Two co-pays will be charged for 2 month supply and three co-paysfor 3 month supply of your medication, respectively.v. To determine the cost for co-insurance drugs/products, please utilize our online drug searchtool. Pleasesee section:“HOWTOFIND INFORMATIONONTHECOSTOFPRESCRIPTION DRUGS”above.b.Please be aware that pharmacy claims will only process if you present your prescription to an innetwork pharmacy. Out-of-network claims will not be covered. To find an in-network-pharmacy closeto you please consult our Find a Provider tool available on our website under Pharmacy Resources.c.Your cost share for maintenance medications obtained through either Mail Order or at retailpharmacies participating in our Extended Day Supply retail network will be calculated based on the daysupply that you ayorco-insurance,31to60daysupplyyou will be responsible for two (2) copays or co-insurance and for day supply greater than60 but less than 91 you will be charged three (3) copays or co-insurance.
F) MEDICAL MANAGEMENT REQUIREMENTSa. Prior Authorization (PA) – Drugs that have PA indication on the Formulary require Prior Authorization.You or your provider have to requestan authorization from us to use this drug/product prior to be ableto fill a prescription for the drug/product.b. Step Therapy (ST) – Drugs thathave ST indication on the Formulary require thatyou try and fail otherformulary products before you can obtain the drug/product. When your provider does not feel thattrying another product is appropriate your provider or you can submit a regular Prior Authorizationrequest to obtain the Step Therapy drug/product.c. Quantity Limit (QL) – Drugs that have QL indication on the Formulary are limited to the quantityindicated. Those quantity limits are based on the FDA approved maximum doses. If your provider wouldlike to request exception to those limits he/she may submit a Prior Authorization request. All requestrequested for quantity limit exemptions will be processed under our Off-Label policy.d. Non-Formulary Drugs – Drugs not found on this formulary are considered non-formulary drugs. Toobtain non-formulary drugs your provider would have to submit a regular Prior Authorization request. Allrequest for Non-Formulary Drugs will be reviewed under our Non-Formulary Drug Request Policy.STANDARD FORMULARYThe Ambetter from Superior Health Plan Formulary, or Preferred Drug List, is a guideto available brand andgeneric drugs that are approved by the Food and Drug Administration (FDA) and covered through yourprescription drug benefit. Generic drugs have the same active ingredients as their brand name counterpartsand should be considered the first line of treatment. The FDA requires generics to be safe and work the sameas brand name drugs. If there is no generic available, there may be more than one brand name drug to treat acondition. Preferredbrandnamedrugsarelistedon Tier2tohelpidentifybranddrugsthat areclinicallyappropriate, safe, andcost-effective treatment options,ifageneric medication on the formulary is notsuitable for your condition.Drug List Key:BrandnamedrugsarelistedinCAPS andgeneric drugsarelower case. Drugs are covered under different copay tiersdepending on your benefit:Tier 0 - daremandatedbyAffordable 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 gender limits apply.Tier 1 - Lowest copayment for those drugs that offer the greatest value compared toother drugs used totreat similar conditions. Select over-the-counter (OTC), generic orbrand name drugs may be covered underthis tier.Tier 2 - Medium copayment covers brand name drugs that are generally more affordable, or may bepreferred compared to other drugs to treat the same conditions.Tier 3 - Highest copayment covers higher cost brand name drugs. This tier may also cover non-specialtydrugs that are not on the Preferred Drug List but approval has been granted for coverage.Tier 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. Prescriptiondrugscovered under the specialty tier require fulfillment at a pharmacy that participates inAmbetter’s“specialty” or “hemophilia” networks. For additional information on which pharmacies arewithin our“specialty” or “hemophilia” networks, please consult Ambetter website’s pharmacy informationsection.
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)NFNFDrug Nameamphetaminedextroamphetamine 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, 20211
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)Ambetter Formulary Updated December 1, 20212methylphenidate hcl tbcr 18mg, 27 mgmethylphenidate hcl tbcr 36mg, 54 mgmodafinil tabs 100 mg
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 SUSP4PADrug Namegentamicin in saline soln0.9 %-0.8 mg/ml, 0.9 %-1.2mg/ml, 0.9 %-1.6 mg/ml, 1mg/ml-0.9 %gentamicin 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/0.8MLAmbetter Formulary Updated December 1, 20213
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); SP34ILARIS 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 mg1NF11NF1QL(3 ea daily)ibuprofen susp 100 mg/5ml1PA; QL(0.286ea daily); SPibuprofen tabs 400 mg, 600mg, 800 mgindomethacin caps 25 mg,50 mgAmbetter Formulary Updated December 1, 20214Interleukin-1beta Blockers1Interleukin-1 BlockersARCALYST SOLRDrug Requirements/Tier Limitsflurbiprofen tabsGold CompoundsRIDAURA CAPSDrug Name11ST; QL(4 eadaily)RX/OTC
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 LimitsDrug Name1OTEZLA 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)Analgesic 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 ter Formulary Updated December 1, 20215
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)Ambetter Formulary Updated December 1, 20216Drug 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)
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)1NF11morphine 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 NameNew startslimited to 7 daysupply;QL(100ml daily)New startslimited to 7 daysupply;QL(50ml daily)NUCYNTA 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)1Ambetter Formulary Updated December 1, 20217
Drug Nametramadol hcl tabs 50 mgtramadol hcl tb24 100 mg,200 mg, 300 mgULTRAM TABS (Usetramadol hcl)XTAMPZA ER C12AZOHYDRO ER CP12Drug 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)Opioid Combinationsacetaminophen w/ codeinesoln 12 mg/5ml-120mg/5ml1acetaminophen w/ codeinetabs 15 mg-300 mg, 300mg-15 mg1acetaminophen w/ codeinetabs 30 mg-300 mg, 300mg-30 mgacetaminophen w/ codeinetabs 60 mg-300 mgacetaminophen-caffdihydrocod caps 16 mg-30mg-320.5 mgacetaminophen-caffdihydrocod caps 320.5 mg16 mg-30 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 mg113111New 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)Ambetter Formulary Updated December 1, 20218Drug 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, 5 mg-300 mg,7.5 mg-300 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, 5 mg200 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)
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 film0.5 mg-2 mg, 1 mg-4 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
a. Ambetter formulary is guided by the principle of offering widest possible access to drugs at the lowest cost. With that in mind, we start with the Affordable Care Act mandated benchmark. We then review the formulary for addition of other clinically necessary and appropriate drugs. Ambetter’s formulary
