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@ .FROMI superiorhealthplan.2022Prescription Drug ListEffective January 1, 2022Ambetter.SuperiorHealthPlan.com
Formulary IntroductionSUMMARY OF FORMULARY BENEFITSThe information in this document is designed to help you understand the prescription drug benefits offered under this plan an d tocompare these benefits to those offered by other plans. Information contained in this summary is designed to help you compare boththe value and scope of formulary benefits.HOW TO FIND INFORMATION ON THE COST OF PRESCRIPTION DRUGSTo find the cost of your prescription please visit pharmacy- resources.html.In the Drug Cost Tool please select the plan in which you are participating (planning to pa rticipate) and enter medicationsthat you are taking. The tool will provide you an approximate cost of your prescriptions, excluding any deductible ormaximum out of pocket requirements. The tool uses median cost for generic prescriptions and actual allowe d cost forbranded products. If the total medication cost is less than the co-pay that you would pay for that Tier you will beresponsible only for the lesser of amount.FORMULARY BY HEALTH BENEFIT PLANPlanAmbetter Balanced Care 11(2022)Ambetter Balanced Care 12(2022)Ambetter Balanced Care 201HSA (2022)Ambetter Balanced Care 203(2022)Ambetter Balanced Care 207(2022)Ambetter Balanced Care 209(2022)Ambetter Balanced Care 210(2022)Ambetter Balanced Care 29(2022)Ambetter Balanced Care 30(2022)Ambetter Balanced Care 31(2022)Ambetter Balanced Care 32(2022)Ambetter Balanced Care 5(2022)Ambetter Value Silver laryStandardFormularyStandardFormularySummary of Benefits and 22brochures.html?plan m/2022brochures.html?plan m/2022brochures.html?plan m/2022brochures.html?plan m/2022brochures.html?plan m/2022brochures.html?plan m/2022brochures.html?plan m/2022brochures.html?plan m/2022brochures.html?plan m/2022brochures.html?plan m/2022brochures.html?plan m/2022brochures.html?plan m/2022brochures.html?plan ValueSilver
Ambetter Value Silver 30(2022)Ambetter Value Silver 31(2022)Ambetter Value Silver 32(2022)Ambetter Virtual AccessSilver (2022)Ambetter Essential Care 1(2022)Ambetter Essential Care 10(2022)Ambetter Essential Care 2(2022)Ambetter Essential Care 2HSA (2022)Ambetter Essential Care 22HSA (2022)Ambetter Essential Care: 0Medical DeductibleAmbetter Essential Care: 1,500 Medical DeductibleAmbetter Virtual AccessBronze (2022)Ambetter Secure Care 201HSA (2022)Ambetter Secure Care 202(2022)Ambetter Secure Care 5 rdFormularyAmbetter Secure Care 20 (2022) StandardFormularyAmbetter Secure Care 203 (2022) StandardFormularyAmbetter Value Gold 20 (2022)StandardFormularyAmbetter Virtual Access orhealthplan.com/2022brochures.html?plan /2022brochures.html?plan /2022brochures.html?plan /2022brochures.html?plan om/2022brochures.html?plan om/2022brochures.html?plan om/2022brochures.html?plan om/2022brochures.html?plan om/2022brochures.html?plan om/2022brochures.html?plan om/2022brochures.html?plan om/2022brochures.html?plan om/2022brochures.html?plan 2022brochures.html?plan 2022brochures.html?plan 2022brochures.html?plan 2022brochures.html?plan 2022brochures.html?plan 022brochures.html?plan VirtualAccessDRUG BY COST-SHARING TIERTier01a1b234Percent of drugs in eachcost -sharing tier:6.5%5.1%77.6%1.8%2.6%6.4%
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 lowest cost. With that in mi nd, westart with the Affordable Care Act mandated benchmark. We then review the formulary for addition of other clinically necessa ryand appropriate drugs. Ambetter’s formulary is considered a closed formulary. This means that any drug not found in theformulary requires prior authorization. To make sure that our members have access to appropriate drugs, we review and updateour formulary on a monthly basisB) RIGHT TO APPEALa. If we deny your request for Prior Authorization you have 180 days from being denied coverage for a drug to file an appeal and your appealwill be resolved within 30 days. In the event that your appeal is successful, non-specialty non-formulary drugs will be covered at your Tier 3cost-share (co-pay or co-insurance) and specialty non-formulary drugs will be covered at your Tier 4 cost-share (co-pay or co-insurance).Please consult your individual Summary of Benefits and Coverage for additional information on your cost-share. All other provisions of yourbenefit, such as deductibles and maximum out of pockets, apply to formulary and non-formulary drugs that have been provided throughan appeal.C) CONTINUATION OF COVERAGEa. Ambetter does not make changes to our formulary requiring a continuation of coverage. However if a formulary change is maderequiring continuation of coverage, you would have the right to continue taking the drug at the coverage level or tier at which thedrug was covered at the beginning of the plan year until your plan is renewedD) OFF-LABEL DRUG USEa. We provide coverage for off-label drug use. Off-label use indicates medications use that has not been FDA approved for that condition.Coverage of a product under off-label use policy requires that the following 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 published in a reputable medicaljournal, peer reviewed specialty medical journal, or listed in reputable compendia.E) COSTSHARINGa. Cost sharing is your monetary participation in your care. You will need to know few items to determine the cost-share you are responsiblefor. Knowing the following items will help you estimate the cost you’ll be responsible for at any given time: how much of your deductible youhave already paid, how much deductible remains, what drug you are prescribed, and your maximum out of pocket allowance. All t hoseitems, with the exception of the tier, can be obtained from the Summary of Benefits and Coverage (see links above). To obtain the tier foryour drug please consult the Formulary. To determine your cost share please 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-sharewill apply to your selected drug/productiii. If you have not met your deductible, you will be responsible for the full cost of the drug until you meet your deductibleiv. If you have met your deductible, but not your Maximum Out of Pocket, you will be charged a copay for drugs that are assigned acopay under your SBC and co-insurance for drugs that are assigned a co-insurance under your SBC. Generally, you will pay one (1)co-pay for each 30 day supply of medication. Two co-pays will be charged for 2 month supply and three co-pays for 3 monthsupply of your medication, respectivelyv. To determine the cost for co-insurance drugs/products, please utilize or online drug sear tool. Please see section: “HOW TO FINDINFORMATION ON THE COST OF PRESCRIPTION DRUGS ” above.
b.Please be aware that pharmacy claims will only process if you present your prescription to an in-network pharmacy. Out-ofnetwork claims will not be covered. To find an in-network-pharmacy close to you please consult our Find a Provider toolavailable on our website under Pharmacy Resources.c.Your cost share for maintenance medications obtained through either Mail Order or at retail pharmacies participating in ourExtended Day supply retail network will be calculated based on the day supply that you obtain. For up to 30 day supply youwill be charged one (1) copay or co-insurance, 31-60 day supply you will be responsible for two (2) copays or co-insuranceand for day supply greater than 60 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 providerhave to request an authorization from us to use this drug/product prior to be able to fill a prescription for the drug/product.b. Step Therapy (ST) – Drugs that have ST indication on the Formulary require that you try and fail other formulary productsbefore you can obtain drug/product. When your provider does not feel that trying another product is appropriate yourprovider or you can submit a regular Prior Authorization to obtain the Step Therapy drug/product.c. Quantity Limit (QL) – Drugs that have QL indication on the Formulary are limited to the quantity indicated. Those quantitylimits are based on FDA approved maximum doses. If your provider would like to request exception to those limits, he/shemay submit a Prior Authorization request. All requests for quantity limit exceptions will be processed under our Off-Labelpolicy.d. Non-Formulary Drugs – Drugs not found on this formulary are considered non-formulary drugs. To obtain non-formularydrugs you provider would have to submit a regular Prior Authorization request. All requests for Non-Formulary Drugs will bereviewed under our Non-Formulary Drug Request Policy.
STANDARD FORMULARYThe Ambetter from Superior Healthplan Formulary or Prescription 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 be consideredthe first line of treatment. The FDA requires generics to be safe and work the same as brand name drugs. If there is nogeneric 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, ifa 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. Notall dosage forms or strengths of a drug may be covered. This list is periodically reviewed and updated and may besubject 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 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 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 similarconditions. Select over-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 preferredcompared to other drugs to treat the same conditions.Tier 3 -High copayment covers higher cost brand name and non-preferred generic drugs. This tier may also covernon-specialty 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 requirefulfillment at a pharmacy that participates in Ambetter’s “specialty” or “hemophilia” networks. For additionalinformation on which pharmacies are within our “specialty” or “hemophilia” networks, please consultAmbetter 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.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.
AMB21-TX-C-00639Ambetter from Superior HealthPlan is underwritten by Celtic InsuranceCompany. 2022 Celtic Insurance Company. All rights reserved.
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)NFNF1BDrug 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 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)NFNF1B1B1B3PAmethamphetamine hcl tabs1BVYVANSE CAPS 10 MG,20 MG, 30 MG, 40 MG, 50MG, 60 MG, 70 MG3QL(1 ea daily)1B1BQL(4 ea daily)QL(4 ea daily)PAQL(5 ea daily);AL(At least 6yrs old)ST; QL(1 eadaily)Anorexiants Non-AmphetamineADIPEX-P CAPS (UseNF PAphentermine hcl)Ambetter Formulary Updated July 1, 20221
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)Ambetter Formulary Updated July 1, 20222methylphenidate hcl tbcr 18mg, 27 mgmethylphenidate hcl tbcr 36mg, 54 mgmodafinil tabs 100 mgmodafinil tabs 200 mg
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)1B4PA1BDrug 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)HUMIRA PEN PNKT 804 PAMG/0.8MLHUMIRA 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),1BNFAmbetter Formulary Updated July 1, 20223
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)Ambetter Formulary Updated July 1, 20224Drug 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/OTCPA
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 LimitsDrug Name1B1BQL(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)Analgesic 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 FAmbetter Formulary Updated July 1, 20225
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 2MG/ML, 1 MG/ML (Usehydromorphone hcl)NF PA; QL(4 eadaily)New starts1B limited to 7 daysupplyNew starts1B limited to 7 daysupplyNFNFNew startsNF limited to 7 daysupplyNFAmbetter Formulary Updated July 1, 20226Drug 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 Namehydromorphone 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 daysupply
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)Drug 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
The Ambetter from Superior Healthplan Formulary or Prescription 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 active ingredients as their brand name counterparts and should be considered
