Ambetter 90-Day-Maintenance Drug List

Transcription

1 Guide to this list: What is Ambetter 90 Day Maintenance Drug List? Ambetter 90 Day Supply Maintenance Drug List is a list of maintenance medications that are available for 90 day supply through mail order or through our Extended Day Supply Network. How do I find a pharmacy that is participating in Extended Day Supply Network? To find a retail pharmacy that is participating in our Extended Day Supply Network please consult information available under Pharmacy Resources tab on our webpage. Alternatively you can utilize our mail order pharmacy. Information on mail order pharmacy is available in Pharmacy Resources tab on our webpage. Are all formulary drugs covered for 90 day supply? No, certain specialty and non specialty drugs are excluded from 90 day supply. Please consult 90 Day Supply Maintenance Drug List for information if your drug is included. A Acamprosate Calcium Acarbose Acebutolol HCl AcetaZOLAMIDE AcetaZOLAMIDE ER Acid Control Maximum Strength Acid Controller Max St Acid Reducer Acid Reducer Maximum Strength Advair Diskus Advair HFA Albuterol Sulfate Albuterol Sulfate ER Alendronate Sodium Alfuzosin HCl ER Allopurinol Alora Alosetron HCl Altavera Alvesco Alyacen 1/35 Alyacen 7/7/7 Amantadine HCl Amethia Amethia Lo Amethyst AMILoride HCl Amiloride Hydrochlorothiazide Amiodarone HCl Amitiza Amitriptyline HCl Amlodipine Atorvastatin Amlodipine Besylate Benazepril HCl Amlodipine Besylate Olmesartan Amlodipine Besylate Valsartan Amlodipine Besylate Valsartan HCTZ AmLODIPine Besylate Amoxapine Anagrelide HCl Anastrozole Androderm Androxy Altoprev

2 Apidra ApidraSoloStar Apri Apriso Aptiom Aranelle Arcapta Neohaler ARIPiprazole Armodafanil Asacol Ashlyna Asmanex Aspirin Dipyridamole ER Atelvia Atenolol Atenolol Chlorthalidone Atomoxetine Atorvastatin Calcium Atrovent HFA Aubagio Aubra Avandia Aviane Avodart Aygestin Azasan Azathioprine Azopt Azurette B Baclofen Balziva Banzel Benazepril HCl Benazepril Hydrochlorothiazide Benztropine Mesylate Betaxolol HCl Beyaz BiDil Bimatoprost Bisoprolol Fumarate Bisoprolol HCTZ Breo Ellipta Brevicon (28) Briellyn Brilinta Brimonidine Tartrate Brintellix Bromocriptine Mesylate Brovana Budesonide Budesonide ER Bumetanide Buphenyl BuPROPion HCl BuPROPion HCl ER (SR) BuPROPion HCl ER (XL) BusPIRone HCl Byetta Bystolic C Calcitonin (Salmon) Calcitriol Calcium Acetate (Phos Binder) Camila Camrese Camrese Lo Candesartan Cilexetil Candesartan Cilexetil HCTZ Captopril Carafate CarBAMazepine CarBAMazepine ER Carbidopa Carbidopa Levodopa Carbidopa Levodopa ER

3 Carbidopa Levodopa Entacapone Carteolol HCl Carvedilol Caziant Celecoxib Celontin Cenestin Cesia Cevimeline HCl Chateal Chlordiazepoxide Clidinium Chloroquine Phosphate Chlorothiazide ChlorproMAZINE HCl ChlorproPAMIDE Chlorthalidone Cholestyramine Cholestyramine Light Cialis Cilostazol Cimetidine Ciprofloxacin HCl Citalopram HBr Climara Pro Clomipramine HCl Clonazepam Clonidine Clopidogrel Bisulfate Colchicine Probenecid Colestipol HCl Combigan Constulose Coumadin Creon Crestor Cromolyn Sodium Cryselle 28 CVS Acid Controller Max St CVS Acid Reducer Max St CVS Lansoprazole Cyclafem 1/35 Cyclafem 7/7/7 Cyclessa Cycloset CycloSPORINE CycloSPORINE Modified Cyred Cystagon D Daliresp Dapsone Darifenacin Dasetta 1/35 Dasetta 7/7/7 Daysee Deblitane Delyla Desipramine HCl Desmopressin Ace Spray Refrig Desmopressin Acetate Desogen Desogestrel Ethinyl Estradiol Desvenlafaxine Dexilant Diclofenac Potassium Diclofenac Sodium Diclofenac Sodium ER Diclofenac Misoprostol Diflunisal Digoxin Dilantin Dilantin Infatab Dilt CD Diltiazem CD Diltiazem HCl Diltiazem HCl ER Beads Diltiazem HCl ER Coated Beads Dipentum Dipyridamole Disopyramide Phos Disulfiram

4 Divalproex Sodium Divalproex Sodium ER Divigel Dofetilide Donepezil HCl Dorzolamide HCl Dorzolamide HCl Timolol Mal Doxazosin Mesylate Doxepin HCl Doxercalciferol Drisdol Drospirenone Ethinyl Estradiol Droxia DULoxetine HCl Duo Vil 2 25 Dutasteride Dyrenium E Edarbi Ethacrynic Acid Effer K Effervescent Potassium Chloride Effient Elestrin Eliquis Elixophyllin Emsam Enablex Enalapril Maleate Enalapril Hydrochlorothiazide Enjuvia Enpresse 28 Enskyce Entacapone Entresto Eplerenone Eprosartan Mesylate EQ Acid Reducer EQ Acid Reducer Max St EQ Lansoprazole EQL Heartburn Prevention EQL Heartburn Relief Max St Equetro Ergocalciferol Ergoloid Mesylates Errin Escitalopram Oxalate Esomeprazole Magnesium Estarylla Estrace Estraderm Estradiol Estrasorb Estrogel Estropipate Estrostep Fe Ethosuximide Etodolac Evamist Ezetimibe Ezetimibe Simvastatin F Falmina Famotidine Fareston Felbamate Felodipine Femcon Fe Femring Fenofibrate Fenofibrate Micronized Fenoprofen Calcium

5 Ferriprox Fetzima Fexofenadine HCl Finasteride FlavoxATE HCl Flecainide Acetate Flovent Diskus Flovent HFA Fludrocortisone FLUoxetine HCl FluPHENAZine HCl Flurbiprofen Fluticasone Fluvastatin Sodium FluvoxaMINE Maleate Folic Acid Foradil Aerolizer Fosamax Plus D Fosinopril Fosinopril Sodium HCTZ Fosrenol Furosemide Fycompa G Gabapentin Galantamine Hydrobromide Galantamine Hydrobromide ER Gel Kam Oral Care Rinse Gemfibrozil Generess FE Gianvi Gildagia Gildess 1.5/30 Gildess 1/20 Gildess 24 FE Gildess FE 1.5/30 Gildess FE 1/20 GlipiZIDE GlipiZIDE ER GlipiZIDE XL GlipiZIDE MetFORMIN HCl GlyBURIDE GlyBURIDE Micronized GlyBURIDE MetFORMIN Glycopyrrolate GNP Acid Control 150 Max St GNP Acid Reducer Max St GNP Lansoprazole GoodSense Acid Reducer Guanabenz Acetate GuanFACINE HCl GuanFACINE HCl ER H Haloperidol Heartburn Relief 150 Max St Heartburn Relief 24 Hour Heartburn Relief Max St Heartburn Treatment 24 Hour Heather HM AcidReducer HM Famotidine HMLansoprazole HumaLOG HumaLOG KwikPen HumaLOG Mix 50/50 HumaLOG Mix 50/50KwikPen HumaLOG Mix 50/50 Pen HumaLOG Mix 75/25 HumaLOG Mix 75/25KwikPen HumaLOG Mix 75/25 Pen HumaLOG Pen HumuLIN 70/30 HumuLIN 70/30 Pen Glimepiride

6 HumuLIN 70/30 Pen HumuLIN N HumuLIN N KwikPen HumuLIN N Pen HumuLIN R HumuLIN R U 500 (CONCENTRATED) HydrALAZINE HCl Hydrochlorothiazide Hydroxychloroquine Sulfate I Ibandronate Ibuprofen Imipramine HCl Imipramine Indapamide Indomethacin Indomethacin ER Invokamet Invokana Ipratropium Bromide Ipratropium Albuterol Irbesartan Irbesartan HCTZ Isoniazid Isosorbide Dinitrate Isosorbide Dinitrate ER Isosorbide Mononitrate Isosorbide Mononitrate ER Isradipine J Januvia Jardiance Jencycla Jolessa Jolivette Juleber Junel 1.5/30 Junel 1/20 Junel FE 1.5/30 Junel FE 1/20 Junel Fe 24 K Kariva K Effervescent Kelnor 1/35 Ketoprofen Klor Con Klor Con 10 Klor Con M10 Klor Con M15 Klor Con M20 Klor Con Sprinkle Klor Con/EF KLS Acid Controller Max St KLS Acid Reducer Max St KLS Lansoprazole K Prime K Sol Kurvelo K Vescent L Labetalol Lactulose Lamotrigine Lanoxin Lamotrigine Larin 1.5/30 Larin 1/20 Larin 24 FE Larin Fe

7 Latanoprost Latuda Layolis FE Leena Leflunomide Lessina Letrozole Levalbuterol HCl Levatol Levemir Levobunolol Levonest Levonorgest Eth Estrad 91 Day Levonorgestrel Ethinyl Estrad Levora 0.15/30 (28) Levothyroxine Sodium Linzess Liothyronine Sodium Lisinopril Lisinopril Hydrochlorothiazide Lithium Lithium Carbonate Lithium Carbonate ER Livalo Lo Loestrin Fe Lo/Ovral Lo/Ovral (28) Loestrin 1.5/30 (21) Loestrin 1/20 (21) Loestrin 24 Fe Loestrin Fe 1.5/30 Loestrin Fe 1/20 Lomedia 24 FE Loryna Losartan Potassium Losartan Potassium HCTZ LoSeasonique Lovastatin Low Ogestrel Loxapine Succinate Lumigan Lutera Lyrica Lyza M Maprotiline Marlissa Marplan Meclofenamate Sodium MedroxyPROGESTERone Acetate Mefenamic Acid Mefloquine HCl Megestrol Acetate Meloxicam Memantine HCl Menest Menostar Mesalamine Metaproterenol Sulfate MetFORMIN HCl MetFORMIN HCl ER MetFORMIN HCl ER (OSM) Methazolamide Methimazole Methitest Methotrexate Methyclothiazide Methyldopa Metipranolol Metoclopramide HCl Metolazone Metoprolol Succinate ER Metoprolol Tartrate Mexiletine HCL Microgestin 1.5/30

8 Microgestin 1/20 Microgestin FE 1.5/30 Microgestin FE 1/20 Micronized Colestipol HCl Miglitol Minastrin 24 Fe Minitran Minivelle Minoxidil Mircette Mirtazapine Misoprostol Modafinil Modicon (28) Moexipril HCl Mono Linyah MonoNessa Montelukast Sodium Multaq Mycophenolate Mofetil Mycophenolic Acid Myfortic Myrbetriq Myzilra N Nabumetone Nadolol Naproxen Naproxen DR Naproxen Kit Naproxen Sodium Natazia Nateglinide Necon 0.5/35 (28) Necon 1/35 (28) Necon 10/11 (28) Necon 7/7/7 Neupro Nexium 24HR Niacin ER Niacin ER (Antihyperlipidemic) NiCARdipine HCl Nifedical XL NIFEdipine NIFEdipine ER NIFEdipine ER Osmotic Nikki NiMODipine Nisoldipine Nitro Bid Nitroglycerin Nitrostat Nizatidine Nora BE Nordette Norethin Ace Eth Estrad FE Norethindrone Norethindrone Acetate Norethindrone Acet Ethinyl Est Norethin Eth Estradiol Fe Norgestimate Eth Estradiol Norgestim Eth Estrad Triphasic Norgestrel Ethinyl Estradiol Norinyl 1+35 (28) Norlyroc Nortrel 0.5/35 Nortrel Nortrel 7/7/7 Nortriptyline HCl NovoLIN 70/30 NovoLIN 70/30 ReliOn NovoLIN N NovoLIN N ReliOn NovoLIN R Nefazodone HCl NovoLIN R ReliOn

9 NovoLOG NovoLOG FlexPen NovoLOG Mix 70/30 NovoLOG Mix 70/30 FlexPen NovoLOG PenFill NuvaRing O Ocella Ogestrel OLANZapine Olmesartan Medoxomil Olmesartan Amlodipine HCTZ Olmesartan HCTZ Omega 3 acid Ethyl Esters Omeprazole Omeprazole Sodium Bicarbonate Onfi Onglyza Orenitram Orsythia Ortho Evra Ortho Micronor Ortho Tri Cyclen (28) Ortho Tri Cyclen Lo Ortho Cept (28) Ortho Cyclen (28) Ortho Novum 1/35 (28) Ortho Novum 7/7/7 (28) Osphena Ovcon 35 (28) Oxaprozin OXcarbazepine Oxybutynin Chloride Oxybutynin Chloride ER Paliperidone Pancreaze Pancrelipase (Lip Prot Amyl) Pantoprazole Sodium Paricalcitol PARoxetine HCl PARoxetine HCl ER Peganone Pentasa PentoxifyllineER Perindopril Erbumine Perphenazine Perphen Amitriptyline Phenelzine Sulfate PHENobarbital Phenytek Phenytoin Phenytoin Infatab Phenytoin Sodium Extended Philith Phoslyra Phospholine Iodide Pilocarpine HCl Pimtrea Pimozide Pindolol Pioglitazone HCl Pioglitazone HCl Metformin HCl Pirmella 1/3 Piroxicam Portia 28 Pot Bicarb Pot Chloride Potassium Bicarbonate Potassium Chloride Potassium Chloride Crys ER Potassium Chloride ER P Potiga Pradaxa

10 Pramipexole Dihydrochloride Prasugrel Pravastatin Sodium Prazosin HCl Premarin Premphase Prempro Prevacid 24HR Prevalite Previfem Primidone ProAir HFA Probenecid Prochlorperazine Maleate Progesterone Micronized Proglycem Prograf Propafenone HCl Propafenone HCl ER Propranolol HCl Propranolol HCl ER Propylthiouracil Protriptyline HCl Proventil HFA Pulmicort Pulmicort Flexhaler PX Acid Reducer Max St Q QC Acid Controller Max Quasense QUEtiapine Fumarate Quinapril HCl Quinapril HCTZ QuiNIDine Sulfate QuiNIDine Sulfate ER Qvar R RA Acid Reducer Max St RA Lansoprazole RA Omeprazole Na Bicarb RABEprazole Sodium Raloxifene HCl Ramipril Ranexa Ranitidine Rapaflo Rasagiline Reclipsen ReliOn 70/30 ReliOn N ReliOn R Renagel Repaglinide Rapaglinide metformin Restasis Rexulti Ridaura Rilutek Riluzole Risedronate Sodium RisperiDONE Rivastigmine Tartrate ROPINIRole HCl ROPINIRole HCl ER Rosuvastatin Rozerem S Safyral Salsalate Saphris Savella SB Acid Controller Max St Seasonale Seasonique

11 Selegiline HCl Serevent Diskus SEROquel XR Sertraline HCl Setlakin Sevelamer carbonate Sharobel Sildenafil Simvastatin Sirolimus SM Acid Reducer Max St SM Lansoprazole Sodium Phenylbutyrate Solia Sotalol HCl Spiriva HandiHaler Spironolactone Spironolactone HCTZ Sprintec 28 Sronyx Stannous Fluoride Conc. Striverdi Respimat Sucraid Sucralfate SulfaSALAzine Sulfazine Sulfazine EC Sulindac SW Acid Reducer 150 Max St Syeda Symbicort SymlinPen Synthroid T Tacrolimus Tamoxifen Citrate Tamsulosin HCl Tasmar TEGretol Tekturna Telmisartan Telmisartan Amlodipine Telmisartan HCTZ Terazosin Terbutaline Theochron Theophylline Theophylline ER Thioridazine HCl Thiothixene Thyrolar 1 Thyrolar 1/2 Thyrolar 1/4 Thyrolar 2 Thyrolar 3 TiaGABine HCl Tilia Fe Timolol Maleate TiZANidine HCl TOLAZamide TOLBUTamide Tolcapone Tolmetin Sodium Tolterodine Tartrate Tolterodine Tartrate ER Topiramate Torsemide Toviaz Tradjenta Trandolapril Trandolapril verapamil Tranexamic Acid Tranylcypromine Sulfate Travatan Z Tarina FE 1/20

12 TraZODone HCl Triamterene HCTZ Tri Estarylla Trifluoperazine HCl Trihexyphenidyl HCl Tri Legest Fe Tri Linyah Tri Lo Estarylla Tri Lo Sprintec Trimipramine Maleate TriNessa (28) TriNessa Lo Tri Norinyl (28) Trintellix Tri Previfem Tri Sprintec Trivora (28) Tropicamide Trospium Chloride Trospium Chloride ER Tudorza Pressair U Uloric Ursodiol Utibron Neohaler V ValGANciclovir HCl Valproic Acid Valsartan Valsartan Hydrochlorothiazide Vascepa Vecamyl Velphoro Velivet Venlafaxine HCl Venlafaxine HCl ER Ventolin HFA Verapamil HCl Verapamil HCl ER VESIcare Vestura Victoza Viibryd Vimpat Viorele Vitamin D (Ergocalciferol) Vitamin D2 Vivelle Dot Vyfemla Vytorin W Wal Zan 150 Maximum Strength Warfarin Sodium Welchol Wera Wymzya Fe X Xarelto Xifaxan Xopenex Xulane Y Yasmin 28 YAZ Z Zafirlukast Zaleplon

13 Zarah Zenchent Zenchent FE Zenpep Zeosa Zetia Zileuton Zioptan Ziprasidone HCl Zonisamide Zovia 1/35E Zovia 1/50E Zyflo CR