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A-,.aM m gnoliahealth.I2022 Prescription Drug ListEffective January 1, 2022Ambetter.MagnoliaHealthPlan.com
Formulary IntroductionFORMULARYThe Ambetter from Magnolia Health Formulary, or Prescription Drug List, is a guide to available brand and generic drugs thatare approved by the Food and Drug Administration (FDA) and covered through your prescriptiondrug benefit. 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 name drugs. If thereis no generic available, there may be more than one brand name drug to treat a condition. Preferred brand name drugs arelisted on Tier 2 to help identify brand drugs that are clinically appropriate, safe, and cost-effective treatment options, if ageneric 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 their appearancein this document. Please check your benefits for coverage limitations and your share of cost for your drugs.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 Care Act. Select oralcontraceptives, vitamin D, folic acid for women of child bearing age, over-the-counter (OTC) aspirin, and smokingcessation products may be covered under this tier. Certain age limits may apply.Tier 1A- Lowest copayment for select drugs that offer the greatest value compared to other drugs used to treat similarconditions. Select over-the-counter (OTC) drugs may be covered under this tier.Tier 1B- Low copayment for those drugs that offer great value compared to other drugs used to treat similar conditions. Selectover-the-counter (OTC) drugs may be covered under this tier.Tier 2 - Medium copayment covers brand name drugs that are generally more affordable, or may be preferred compared toother drugs to treat the same conditions.Tier 3 - High copayment covers higher cost brand name and non-preferred generic drugs. This tier may also cover nonspecialty drugs that are not on the Prescription Drug List but approval has been granted for coverage.Tier 4 - Highest copayment is for “specialty” drugs used to treat complex, chronic conditions that may require specialhandling, storage or clinical management. Prescription drugs covered under the specialty tier require fulfillment at apharmacy that participates in Ambetter's "specialty" or "hemophilia" networks. For additional information on whichpharmacies are within our "specialty" or "hemophilia" networks, please consult Ambetter website's pharmacyinformation section.
Prior Authorization for Non-Formulary DrugsTo obtain prior authorization for a non-formulary drug, your provider must fill out the Prior Authorization form.Envolve Pharmacy Solutions will respond via fax or phone within 24 hours of receipt of all necessary information forurgent requests, and within 72 hours for non-urgent requests, unless state law requires faster response. If therequest is disapproved, the notice of disapproval will contain a clear explanation of the specific reasons fordisapproving the prior authorization request, or if the request was incomplete, the explanation will identify themissing material information 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 before somedrugs will be covered.STStep TherapyIn some cases, you must first try certain drugs before Ambettercovers another drug for your medical condition. For example, ifDrug A and Drug B both treat your medical condition, Ambettermay not cover Drug B unless you try Drug A first.NFNon-formularyThis product is not covered unless you or your provider requestan exception. Alternative medications are listed next to noncovered productRX/OTCPrescription and OTCThese drugs are made in both prescription form and Overthe-counter (OTC) form.SFSplit FillInitially, certain medications may only be available in 15day-supply increments until you are stabilized on themedication. After you have been taking the medication for90 days, this restriction may no longer apply.
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)amphetamine sulfate tabsamphetaminedextroamphetamine 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)NFNF1Bamphetaminedextroamphetamine 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 mgEVEKEO TABS (Useamphetamine sulfate)Drug Requirements/Tier LimitsQL(2 ea daily)1BQL(3 ea daily)1BQL(2 ea daily)1BQL(5 ea daily);NF AL(At least 6yrs old)QL(4 ea daily)NFNF1B1B3methamphetamine hcl tabs1BVYVANSE CAPS 10 MG,20 MG, 30 MG, 40 MG, 50MG, 60 MG, 70 MG3QL(1 ea daily)1B1BQL(4 ea daily)1BPAAmbetter Formulary Updated June 1, 20221Drug NameQL(4 ea daily)PAQL(5 ea daily);AL(At least 6yrs old)ST; QL(1 eadaily)Anorexiants Non-AmphetamineADIPEX-P CAPS (UseNF PAphentermine hcl)
Drug Namephendimetrazine tartratetabsphentermine hcl capsDrug Requirements/Tier Limits1B PA1BPAAnti-Obesity AgentsCONTRAVE TB123PA; QL(4 eadaily)Attention-Deficit/Hyperactivity Disorder (ADHD)QL(1 ea daily);atomoxetine hcl caps 1001B AL(At least 6mg, 60 mg, 80 mgyrs old)QL(2 ea daily);atomoxetine hcl caps 251B AL(At least 6mg, 10 mg, 18 mg, 40 mgyrs old)clonidine hcl (adhd) tb12guanfacine hcl (adhd) tb24INTUNIV TB24 (Useguanfacine hcl (adhd))1BQL(1 ea daily);AL(At least 6yrs old)QL(1 ea daily);NF AL(At least 6yrs old)1BKAPVAY TB12 (UseNFclonidine hcl (adhd))STRATTERA CAPS 100QL(1 ea daily);NF AL(At least 6MG, 60 MG, 80 MG (Useatomoxetine hcl)yrs old)QL(2 ea daily);STRATTERA CAPS 25MG, 10 MG, 18 MG, 40 MG NF AL(At least 6yrs old)(Use atomoxetine hcl)Dopamine and Norepinephrine Reuptake3 PA; QL(1 eaSUNOSI TABS 150 MGdaily)3 PA; QL(2 eaSUNOSI TABS 75 MGdaily)Drug Requirements/Tier Limits3 PA; QL(1 eaDAYTRANA PTCHdaily)QL(1 ea daily)dexmethylphenidate hclcp24 35 mg, 10 mg, 15 mg, 1B20 mg, 25 mg, 30 mg, 40mg, 5 mgQL(2 ea daily);dexmethylphenidate hcl1B AL(At least 6tabs 2.5 mg, 10 mg, 5 mgyrs old)QL(2 ea daily);FOCALIN TABS (UseNF AL(At least 6dexmethylphenidate hcl)yrs old)Drug NameFOCALIN XR CP24 (Usedexmethylphenidate hcl)NF QL(1 ea daily)METHYLIN SOLN (Usemethylphenidate hcl)QL(30 mlNF daily); AL(Atleast 6 yrs old)1B AL(At least 6yrs old)QL(3 ea daily);1B AL(At least 6yrs old)QL(1 ea daily);1B AL(At least 6yrs old)QL(30 ml1B daily); AL(Atleast 6 yrs old)QL(5 ea daily);1B AL(At least 6yrs old)QL(6 ea daily);1B AL(At least 6yrs old)QL(3 ea daily);1B AL(At least 6yrs old)QL(1 ea daily);1B AL(At least 6yrs old)QL(2 ea daily);1B AL(At least 6yrs old)1B PA; QL(1 eadaily)1B PA; QL(2 eadaily)methylphenidate hcl cp2420 mg, 40 mgmethylphenidate hcl cp2430 mgmethylphenidate hcl cpcr40 mg, 10 mg, 20 mg, 30mg, 50 mg, 60 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)PA; QL(1 ea1B 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)methylphenidate hcl tbcr 18mg, 27 mgmethylphenidate hcl tbcr 36mg, 54 mgmodafinil tabs 100 mgmodafinil tabs 200 mgAmbetter Formulary Updated June 1, 20222
Drug NameNUVIGIL 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(1 eaNF daily); AL(Atleast 17 yrsold)NF PA; QL(1 eadaily)NF PA; QL(2 eadaily)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 solnARIKAYCE SUSPgentamicin 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)1B4PA1B1BNFAmbetter Formulary Updated June 1, 20223Drug NameKITABIS PAK NEBU (Usetobramycin)Drug Requirements/Tier LimitsNF PAneomycin sulfate tabs1Bparomomycin sulfate caps1Bstreptomycin sulfate solr3TOBI NEBU (UseNF PAtobramycin)tobramycin nebu 3004 PAmg/5mltobramycin sulfate soln 101Bmg/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/0.8MLPA; 1 rtl packlmt amt,180 rtlpack lmtHUMIRA PEN-CD/UC/HS4 day(s),1 mailSTARTER PNKT 80pack lmtMG/0.8MLamt,180 mailpack lmtday(s),
Drug Requirements/Tier LimitsPA; 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 TB24 15 MG4XELJANZ 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); SPGold CompoundsRIDAURA CAPS3QL(3 ea daily)Interleukin-1 BlockersARCALYST SOLR4PA; QL(0.286ea daily); SPNonsteroidal Anti-inflammatory Agents (NSAIDs)ANAPROX DS TABS (Use NFnaproxen sodium)ARTHROTEC 50 TBECNF(Use diclofenac w/misoprostol)Drug NameARTHROTEC 75 TBEC(Use diclofenac w/misoprostol)CELEBREX CAPS (Usecelecoxib)Drug Requirements/Tier LimitsNFNF PAPAcelecoxib caps1BCHILDRENS ADVIL SUSP(Use ibuprofen)CHILDRENS MOTRINSUSP (Use ibuprofen)DAYPRO TABS (Useoxaprozin)diclofenac potassium tabs50 mgNF RX/OTCNF RX/OTCNF1Bdiclofenac sodium tb241Bdiclofenac sodium tbec1Bdiclofenac w/ misoprostoltbecDUEXIS TABS (Useibuprofen-famotidine)EC-NAPROSYN TBEC 500MG (Use naproxen)etodolac caps 200 mg, 300mgetodolac tabs 400 mg, 500mgFELDENE CAPS (Usepiroxicam)fenoprofen calcium tabs600 mg1B3PANF1B1BNF1Bflurbiprofen tabs1Bibuprofen susp 100 mg/5ml1Bibuprofen tabs 400 mg, 600mg1Aibuprofen tabs 800 mg1Bibuprofen-famotidine tabs1Bindomethacin caps 25 mg,50 mg1Bindomethacin cpcr 75 mg1BST; QL(4 eadaily)RX/OTCPAAmbetter Formulary Updated June 1, 20224
Drug Nameketoprofen caps 50 mg, 75mgketorolac tromethaminetabs or 10 mgLODINE TABS (Useetodolac)meclofenamate sodiumcapsmefenamic acid capsmeloxicam tabs 15 mg, 7.5mgMOBIC TABS (Usemeloxicam)Drug Requirements/Tier Limits1B1BQL(0.667 eadaily)NF1B1BST; Must tryibuprofen.;QL(5 ea daily)QL(1 ea daily)OTEZLA TBPKDrug Requirements/Tier LimitsPA; 1 rtl pack4 lmt amt,180 rtlpack lmtday(s),Pyrimidine Synthesis InhibitorsARAVA TABS (UseNF QL(1 ea daily)leflunomide)1B QL(1 ea daily)leflunomide tabsNFSoluble 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); SP1BANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint Conditions1ANF QL(1 ea daily)nabumetone tabs1BNALFON TABS 600 MG(Use fenoprofen calcium)NAPROSYN SUSP 125MG/5ML (Use naproxen)NAPROSYN TABS 500MG (Use naproxen)naproxen sodium tabs 550mgNF ST; QL(4 eadaily)NF PAnaproxen susp 125 mg/5ml1Bnaproxen tabs 250 mg, 375mg, 500 mg1Bnaproxen tbec 500 mg1Boxaprozin tabs1Bpiroxicam caps1Bsulindac tabs1Btolmetin sodium caps1Btolmetin sodium tabs1BPAPhosphodiesterase 4 (PDE4) Inhibitors4 PA; QL(2 eaOTEZLA TABSdaily)Ambetter Formulary Updated June 1, 20225Drug NameAnalgesic Combinationsbutalbital-acetaminophentabs 50 mg-325 mgbutalbital-acetaminophencaffeine caps 40 mg-50mg-300 mg, 40 mg-50 mg325 mgbutalbital-acetaminophencaffeine tabs 40 mg-50 mg325 INOPHEN CAPS (Usebutalbital-acetaminophen)ESGIC TABS (Usebutalbital-acetaminophencaffeine)FIORICET CAPS F
Drug NameFIORINAL CAPS (Usebutalbital-aspirin-caffeine)SalicylatesDrug Requirements/Tier LimitsNFNFhydromorphone hcl liqd or1 mg/ml1Bhydromorphone hcl soln ij10 mg/ml, 50 mg/5ml, 500mg/50ml1Baspirin tabs 325 mg0aspirin tbec 325 mg1AECOTRIN REGULARSTRENGTH TBEC (Useaspirin)ECOTRIN TBEC (Useaspirin)salsalate tabsAL(At least 45yrs old - Up to79 yrs old)AL(At least 45yrs old - Up to79 yrs old)0AL(At least 45yrs old - Up to79 yrs old)1B1BANALGESICS - 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)Drug Requirements/Tier LimitsNew startsNF limited to 7 daysupply;QL(8 eadaily)NF QL(0.34 eadaily)PA; QL(4 ea1B daily)DURAGESIC 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 20 mg, 10 mg, 15 mg,30 mg, 40 mg, 50 mg0diflunisal tabsDILAUDID TABS OR 2MG, 4 MG, 8 MG (Usehydromorphone hcl)NFaspirin chew 81 mgaspirin tbec 81 mgDrug NameNF PA; QL(4 eadaily)New starts1B limited to 7 daysupplyNew starts1B limited to 7 daysupplyNFNFNew startsNF limited to 7 daysupplyhydromorphone hcl tabs or2 mg, 4 mg, 8 mg1BQL(0.34 eadaily)NF1B1Bhydromorphone 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 2mg1Bmeperidine hcl soln ij 100mg/ml, 25 mg/ml, 50 mg/ml1B1B1BPA; 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)New startslimited to 7 daysupplyNFAmbetter Formulary Updated June 1, 20226
Drug Namemeperidine hcl soln or 50mg/5mlmeperidine 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)morphine sulfate cp24 or100 mg, 20 mg, 30 mg, 50mg, 60 mg, 80 mgmorphine sulfate soln ij 0.5mg/ml, 1 mg/mlDrug Requirements/Tier LimitsNew starts1B limited to 7 daysupply;QL(500ml per fill retail)New starts1B limited to 7 daysupply;QL(6 eadaily)1B QL(10 ml daily)1B1B1BQL(50 ml daily)1BQL(100 mldaily)QL(10 ea daily)1BQL(4 ea daily)1BQL(2 ea daily)1BNF QL(10 ml daily)QL(10 ml daily)NF1BPA; QL(2 eadaily)1Bmorphine sulfate soln or 10mg/5ml1Bmorphine sulfate soln or 20mg/5ml1Bmorphine sulfate tabs or 15mg, 30 mg1BNew startslimited to 7 daysupply;QL(100ml daily)New startslimited to 7 daysupply;QL(50ml daily)New startslimited to 7 daysupply;QL(6 eadaily)Ambetter Formulary Updated June 1, 20227Drug Requirements/Tier LimitsQL(2 ea daily)morphine sulfate tbcr or100 mg, 15 mg, 200 mg, 30 1Bmg, 60 mgMS CONTIN TBCR (UseNF QL(2 ea daily)morphine sulfate)2 PA; QL(2 eaNUCYNTA ER TB12daily)2 PA; QL(6 eaNUCYNTA TABSdaily)PA; QL(2 eaoxycodone hcl t12a 15 mg,3 daily)30 mg, 60 mg, 10 mg, 20mg, 40 mg, 80 mgNew startsoxycodone hcl tabs 10 mg, 1B limited to 7 daysupply;QL(1215 mg, 20 mg, 30 mg, 5 mgea daily)oxymorphone hcl tabs 101B PA; QL(12 eadaily)mg, 5 mgPA; QL(2 eaoxymorphone hcl tb12 101B daily)mg, 15 mg, 20 mg, 30 mg,5 mg, 7.5 mgoxymorphone hcl tb12 401B PA; QL(4 eadaily)mgNew startsROXICODONE TABS (Use NF limited to 7 dayoxycodone hcl)supply;QL(12ea daily)3 PA; QL(3 eaSUBSYS LIQD 100 MCGdaily)SUBSYS LIQD 1200 MCG,3 PA; QL(8 ea1600 MCG, 800 MCGdaily)SUBSYS LIQD 200 MCG,3 PA; QL(4 ea400 MCG, 600 MCGdaily)New starts1A limited to 7 daytramadol hcl tabs 50 mgsupply;QL(8 eadaily)tramadol hcl tb24 100 mg,1B QL(1 ea daily)200 mg, 300 mgNew startsULTRAM TABS (UseNF limited to 7 daytramadol hcl)supply;QL(8 eadaily)2 PA; QL(2 eaXTAMPZA ER C12Adaily)ZOHYDRO ER CP12 (Use1B PA; QL(2 eahydrocodone bitartrate)daily)Drug Name
Drug NameDrug Requirements/Tier LimitsOpioid Combinationsacetaminophen w/ codeinesoln 12 mg/5ml-120mg/5ml1Aacetaminophen w/ codeinetabs 15 mg-300 mg1Bacetaminophen w/ codeinetabs 30 mg-300 mg1Aacetaminophen w/ codeinetabs 60 mg-300 mg1Bacetaminophen-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-325mgbutalbital-aspirin-caffeinew/cod capsFIORICET/CODEINECAPS (Use butalbitalacetaminophen-caffeine w/codeine)FIORINAL/CODEINE #3CAPS (Use butalbitalaspirin-caffeine w/cod)hydrocodoneacetaminophen soln 10mg/15ml-325 mg/15ml1B31BNew 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)New startslimited to 7 daysupplyPA; New startslimited to 7 daysupplyNew startslimited to 7 daysupplyNew starts1B limited to 7 daysupply;QL(6 eadaily)New starts1B limited to 7 daysupply;QL(6 eadaily)New startsNF limited to 7 daysupplyNew startsNF limited to 7 daysupply;QL(6 eadaily)New starts1B limited to 7 daysupplyDrug Namehydrocodoneacetaminophen soln 2.5mg/5ml-108 mg/5ml, 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 10mg-325 mg, 5 mg-325 mg,7.5 mg-325 mghydrocodone-ibuprofentabs 10 mg-200 mg, 5 mg200 mghydrocodone-ibuprofentabs 7.5 mg-200 mgLORTAB ELIXNORCO TABS (Usehydrocodoneacetaminophen)oxycodone w/acetaminophen tabs 10mg-325 mg, 5 mg-325 mg,7.5 mg-325 mgoxycodone-ibuprofen tabsPERCOCET TABS 10 MG325 MG, 5 MG-325 MG,7.5 MG-325 MG (Useoxycodone CODEINE #3TABS (Use acetaminophenw/ codeine)Drug Requirements/Tier LimitsNew startslimited to 7 day1B supply;QL(180ml daily)1B1BNew startslimited to 7 daysupply;QL(13ea daily)New startslimited to 7 daysupply;QL(12ea daily)PA1BNew starts1B 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)New starts1B limited to 7 daysupply;QL(12ea daily)New starts1B limited to 7 daysupply;QL(1 eadaily)New startslimited to 7 dayNF supply;QL(12ea daily)New starts1B limited to 7 daysupply;QL(8 eadaily)New startsNF limited to 7 daysupply;QL(12ea daily)Ambetter Formulary Updated June 1, 20228
Drug NameULTRACET TABS (Usetramadol-acetaminophen)Opioid Partial AgonistsBUPRENEX 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 mgbuprenorphine hclnaloxone hcl dihydrate film2 mg-8 mg, 3 mg-12 mgbuprenorphine hclnaloxone hcl dihydrate subl0.5 mg-2 mg, 2 mg-8 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 (Usebuprenorphine)nalbuphine hcl solnpentazocine w/ naloxonehcl tabsSUBOXONE FILM 0.5 MG2 MG, 1 MG-4 MG (Usebuprenorphine hclnaloxone hcl dihydrate)SUBOXONE FILM 2 MG-8MG, 3 MG-12 MG (Usebuprenorphine hclnaloxone hcl dihydrate)Drug Requirements/Tier LimitsNew startsNF limited to 7 daysupply;QL(8 eadaily)Drug NameANADROL-50 TABSoxandrolone tabsDrug Requirements/Tier Limits31BAndrogensNFANDRODERM PT241BANDROGEL GEL 25MG/2.5GM, 50 MG/5GM(Use testosterone)NFdanazol caps1BDEPO-TESTOSTERONESOLN (Use testosteronecypionate)NF1BQL(3 ea daily)QL(3 ea daily)1BQL(2 ea daily)1BMETHITEST TABSQL(3 ea daily)1B1BPA; QL(0.143ea daily)1B1BPANF PA; QL(0.143ea daily)1B QL(8 ml daily)1BNew startslimited to 7 daysupplyQL(3 ea daily)NFQL(2 ea daily)NF23TESTIM GEL (UseNFtestosterone)TESTOSTERONE1BCYPIONATE SOLN IJ 200MG/MLtestosterone cypionate soln 1Bim 100 mg/ml, 200 mg/mltestosterone enanthate1BsolnVOGELXO GEL (UseNFtestosterone)VOGELXO PUMP GELNF(Use testosterone)ANORECTAL AND RELATED PRODUCTS Rectal Drugs to Treat Pain, Swelling and ItchingIntrarectal SteroidsCORTENEMA ENEM (Usehydrocortisone (intrarectal)) NFhydrocortisone (intrarectal) 1BenemUCERIS FOAM RE 24 PA; QL(3.2 gmMG/ACTdaily)Rectal SteroidsANUSOL-HC CREA (UseNFhydrocortisone (rectal))ANDROGENS-ANABOLIC - Drugs to RegulateHormoneshydrocortisone (rectal) crea1BAnabolic Steroidshydrocortisone acetate(rectal) supp1BAmbetter Formulary Updated June 1, 20229PA; QL(1 eadaily)
Drug NamePROCTOCORT CREA(Use hydrocortisone(rectal))PROCTOCORT SUPP(Use hydrocortisoneacetate (rectal))Drug Requirements/Tier LimitsDrug NameDrug Requirements/Tier LimitsAnti-infective Agents - Misc.NFbacitracin solrFLAGYL TABS 500 MG(Use metronidazole)NFIMPAVIDO CAPSVasodilating AgentsQL(2 gm daily)3NF3metronidazole tabs or 250mg, 500 mg1BANTHELMINTICS - Drugs to Treat WormInfectionstrimethoprim tabs1BAnthelminticsXIFAXAN TABS3RECTIV OINT3PAalbendazole tabs1BALBENZA TABS (Usealbendazole)BILTRICIDE TABS (Usepraziquantel)NF PAEMVERM CHEWivermectin tabs or 3 mgNF PA21BQL(2 ea daily,6ea per fillretail,6 ea perfill mail)1 rtlMAX fill,60 rtlday(s) supply,1mail MAX fill,60mail day(s)supply,QL(9 ea per fillretail,9 ea perfill mail)1 rtlMAX fill,75 rtlday(s) supply,1mail MAX fill,75mail day(s)supply,PApraziquantel tabs1BSTROMECTOL TABS (Useivermectin)QL(9 ea per fillretail,9 ea perfill mail)1 rtlNF MAX fill,75 rtlday(s) supply,1mail MAX fill,75mail day(s)supply,ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial InfectionsPA; QL(3 eadaily)PA; AL(At least12 yrs old)Anti-infective Misc. - CombinationsBACTRIM DS TABS (UseNFsulfamethoxazoletrimethoprim)BACTRIM TABS e1Btrimethoprim soln iv 80mg/5ml-400 mg/5mlsulfamethoxazole1Btrimethoprim susp or 40mg/5ml-200 mg/5mlsulfamethoxazole1Atrimethoprim tabs or 160mg-800 mg, 80 mg-400 mgAntiprotozoal AgentsALINIA SUSR 100 MG/5ML2PAALINIA TABS 500 MG (Usenitazoxanide)NF PAatovaquone susp1BMEPRON SUSP (Useatovaquone)NFnitazoxanide tabs or1BPACarbapenemsertapenem sodium solr1Bimipenem-cilastatin solr1BAmbetter Formulary Updated June 1, 202210
Drug NameDrug Requirements/Tier LimitsINVANZ SOLR (Useertapenem sodium)NFmeropenem solr1BMERREM SOLR (Usemeropenem)PRIMAXIN IV SOLR nicol sodiumsuccinate solrCyclic LipopeptidesCUBICIN RF SOLR (Usedaptomycin)CUBICIN SOLR (Usedaptomycin)DAPTOMYCIN SOLR 350MG (Use daptomycin)daptomycin solr 500 mgVANCOCIN CAPS (Usevancomycin hcl)vancomycin hcl caps or125 mg, 250 mgvancomycin hcl solr iv 500mg, 1 gm, 10 gm, 1000 mgVANCOMYCINHYDROCHLORIDE SOLROR 250 MG/5MLLeprostaticsdapsone tabsLincosamidesCLEOCIN CAPS OR 75MG, 150 MG, 300 MG (Useclindamycin hcl)CLEOCIN PEDIATRICGRANULES SOLR (Useclindamycin palmitatehydrochloride)NFclindamycin hcl caps1Bclindamycin palmitatehydrochloride solr1Bclindamycin phosphate soln1BLINCOCIN SOLN (Uselincomycin hcl)NFNFlincomycin hcl soln1BNFMonobactamsAZACTAM SOLR (Useaztreonam)NFNF4PA; SPNFaztreonam solrNF1B1BCAYSTON SOLRQL(300 ml perfill retail)QL(4 eaNF daily,40 ea perfill retail)QL(4 ea1B daily,40 ea perfill retail)21B2QL(300 ml perfill retail)Oxazolidinoneslinezolid susr or 100mg/5mllinezolid tabs or 600 mgSIVEXTRO TABS ORZYVOX SUSR OR 100MG/5ML (Use linezolid)ZYVOX TABS OR 600 MG(Use linezolid)1BNFNF4Urinary Anti-infectivesfosfomycin tromethaminepackHIPREX TABS (Usemethenamine hippurate)MACROBID CAPS (Usenitrofurantoin monohydmacro)PA; QL(3 mldaily)1B1B3PA; QL(2 eadaily)PANFNF PA; QL(2 eadaily)Polymyxinspolymyxin b sulfate solrAmbetter Formulary Updated June 1, 202211Drug Requirements/Tier LimitsCLEOCIN PHOSPHATESOLN IJ 300 MG/2ML, 600MG/4ML, 9 GM/60ML, 900MG/6ML (Use clindamycinphosphate)GlycopeptidesFIRVANQ SOLRDrug Name1B1BNFNF
Drug NameMACRODANTIN CAPS 50MG, 100 MG (Usenitrofurantoin macrocrystal)methenamine hippuratetabsMONUROL PACK (Usefosfomycin tromethamine)nitrofurantoin macrocrystalcaps 50 mg, 100 mgnitrofurantoin monohydmacro capsnitrofurantoin suspDrug Requirements/Tier LimitsNITROGLYCERIN SOLNIV 5 MG/MLnitroglycerin subl sl 0.3 mg,0.4 mg, 0.6 mgNITROSTAT SUBL (Usenitroglycerin)NF1BNFranolazine tb12 1000 mgranolazine tb12 500 mgNitratesISORDIL TITRADOSETABS 5 MG (Useisosorbide dinitrate)isosorbide dinitrate tabs 30mg, 10 mg, 20 mg, 5 mgisosorbide mononitratetabsisosorbide mononitratetb24NITRO-BID OINTNITRO-DUR PT24 0.1MG/HR, 0.2 MG/HR, 0.4MG/HR, 0.6 MG/HR (Usenitroglycerin)nitroglycerin cpcr or 2.5mg, 6.5 mg, 9 mgnitroglycerin pt24 td 0.1mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hrDrug Requirements/Tier Limits1B1BNFANTIANXIETY AGENTS - Drugs to Treat Anxiety1B1BAntianxiety Agents - Misc.buspirone hcl tabs 10 mg,30 mg, 7.5 mg, 15 mg1Bbuspirone hcl tabs 5 mgANTIANGINAL AGENTS - Drugs to Treat ChestPainAntianginals-OtherRANEXA TB12 1000 MG(Use ranolazine)RANEXA TB12 500 MG(Use ranolazine)Drug NameNF QL(2 ea daily)NF QL(3 ea daily)1BQL(2 ea daily)1BQL(3 ea daily)hydroxyzine hcl soln im 50mg/mlhydroxyzine hcl syrp or 10mg/5mlhydroxyzine hcl tabs or 10mg, 25 mg, 50 mg1BVISTARIL CAPS (Usehydroxyzine pamoate)NFalprazolam 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)QL(4 ea daily)1B1B1Balprazolam tabs 2 mgNF1Bmeprobamate tabs1B31B1BNF1B1Ahydroxyzine pamoate capsBenzodiazepinesalprazolam tabs 0.25 mg,0.5 mg, 1 mg1B1B1AQL(4 ea daily)1BQL(4 ea daily)1B1BNF QL(3 ea daily)NF QL(4 ea daily)chlordiazepoxide hcl caps1Bclorazepate dipotassiumtabs1Bdiazepam conc or 5 mg/ml1Bdiazepam soln or 5 mg/5ml1BAmbetter Formulary Updated June 1, 202212
Drug Namediazepam tabs or 10 mg, 2mg, 5 mgDrug Requirements/Tier Limits1A QL(4 ea daily)Drug Namedofetilide capsMULTAQ TABSDrug Requirements/Tier Limits1B3lorazepam conc or 2 mg/ml1Blorazepam tabs or 0.5 mg,2 mg1AQL(3 ea daily)TIKOSYN CAPS (Usedofetilide)lorazepam tabs or 1 mg1AQL(4 ea daily)ANTIASTHMATIC AND BRONCHODILATORAGENTS - Drugs to Treat Lung Conditionsoxazepam caps1BAnti-Inflammatory AgentsNFcromolyn sodium nebuNF QL(4 ea daily)Antiasthmatic - Monoclonal Antibodies4 PAFASENRA PEN SOAJTRANXENE T TABS (Useclorazepate dipotassium)VALIUM TABS (Usediazepam)XANAX TABS (Usealprazolam)XANAX XR TB24 (Usealprazolam)NF QL(4 ea daily)quinidine sulfate tabsPANUCALA SOAJ4PANUCALA SOLR4PANUCALA SOSY4PA1BXOLAIR SOLR 150 MG4PA; SPNFXOLAIR SOSY 150MG/ML, 75 MG/0.5ML4PA1BBronchodilators - Anticholinergics1BATROVENT HFA AERS3INCRUSE ELLIPTA AEPB2QL(0.44 gmdaily)QL(1 ea daily)1BQL(15 ml daily)2QL(1 ea daily)NF1Bipratropium bromide soln1BSPIRIVA HANDIHALERCAPSSPIRIVA RESPIMATAERSAntiarrhythmics Type I-Cflecainide acetate tabspropafenone hcl cp121Bpropafenone hcl tabs1BRYTHMOL SR CP12 (Usepropafenone hcl)Antiarrhythmics Type IIIamiodarone hcl soln iv 150mg/3ml, 50 mg/mlamiodarone hcl tabs or 100mg, 200 mg, 400 mgNF1B1BAmbetter Formulary Updated June 1, 202213QL(8 ml daily)4Antiarrhythmics Type I-Bmexiletine hcl caps1BFASENRA SOSYANTIARRHYTHMICS - Drugs to treat abnormalheart
A ,.aM I m gnolia - health. Ambetter.MagnoliaHealthPlan.com 2022Prescription Drug List Effective January 1, 2022
