Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health...

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Prescription Drug List Effective January 1, 2014 FROM superiorhealthplan.com

Transcript of Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health...

Page 1: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Prescription Drug ListEffective January 1, 2014

FROM superiorhealthplan.com

Page 2: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Formulary IntroductionPREFERRED DRUG LIST

The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription drug benefit. Generic drugs have the same active ingredient as their brand name counterpart and should be considered the first line of treatment. If there is no generic available, there may be more than one brand name drug to treat a condition. The preferred brand name drugs are listed to help identify prescription drugs that are clinically appropriate, safe and cost effective treatment options.

Please note, the Preferred Drug List 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 may be subject to change. Drugs may be added or removed or additional requirements added in order to approve continued usage of a specific drug.

Specific prescription benefit plan designs may not cover certain products or categories, regardless of their appearance in 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 1 - Lowest copayment for those drugs that offer the greatest value compared to other drugs used to treat similarconditions. Select generic or brand name drugs may be covered under this tier.

Tier 2 - Medium copayment covers brand name drugs that are generally more affordable, or may be preferred comparedto other drugs to treat the same conditions.

Tier 3 - Highest copayment covers higher cost brand name drugs. This tier may also cover those brand name drugs thathave a generic alternative.

Tier 4 - Coverage for this tier is for “specialty” drugs used to treat complex, chronic conditions that may requirespecial handling, storage or clinical management. For members who do not have a 4 Tier plan, these drugs may be found under Tier 1, 2 or 3.

Page 3: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

CELEBREX 2 ST

diclofenac 1

diclofenac w/ misoprostol 1

diflunisal 1

etodolac 1

fenoprofen 1 QLL

flurbiprofen 1

ibuprofen 1

indomethacin 1

ketoprofen 1

ketorolac 1 QLL

meclofenamate 1

mefenamic acid 1

meloxicam 1

nabumetone 1

naproxen 1

oxaprozin 1

oxycodone-ibuprofen 1

piroxicam 1

sulindac 1

tolmetin 1

Drug Name Tier QLL ST PA

EMBEDA 3

EXALGO 2

fentanyl 1 QLL

levorphanol 1

METHADONE 3

morphine 1 QLL

NUCYNTA 2 QLL PA

NUCYNTA ER 2 QLL PA

OXYCONTIN 2 QLL PA

OXYMORPHONE 1 PA

tramadol 1 QLL

Drug Name Tier QLL ST PA

acetaminophen w/ codeine 1 QLL

butalbital-aspirin-caff w/ codeine 1 QLL

butorphanol 1

codeine sulfate 1

fentanyl 1 QLL

hydrocodone-acetaminophen 1 QLL

hydromorphone 1

meperidine 1

morphine 1

Analgesics, Nonsteroidal Anti-inflammatory Drugs

Analgesics, Opioid Analgesics, Long-Acting

Analgesics, Opioid Analgesics, Short-Acting

PA = Prior Authorization May Be Required QLL = Quantity Limit May Apply ST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless of their appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 4: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

nalbuphine 1

oxycodone 1 QLL PA

oxycodone w/ acetaminophen 1 QLL

oxymorphone 3 PA

TALWIN 3

tramadol 1 QLL

tramadol-acetaminophen 1 QLL

Drug Name Tier QLL ST PA

lidocaine 1

lidocaine-prilocaine 1

LIDODERM 2 PA

SYNERA 3

XYLOCAINE 3

Drug Name Tier QLL ST PA

CAMPRAL 2

disulfiram 1

naltrexone 1

Drug Name Tier QLL ST PA

buprenorphine 1 QLL

naloxone 1

SUBOXONE 3 QLL PA

Drug Name Tier QLL ST PA

BUPROBAN 0 QLL

CHANTIX 0 QLL

COMMIT 0 QLL

NICOTINE 0 QLL

NICOTINE POL 0 QLL

NICOTROL 0 QLL

NICOTROL NS 0 QLL

Anti-Addiction/Substance Abuse Treatment Agents, Opioid

Antagonists

Anti-Addiction/Substance Abuse Treatment Agents, Smoking

Cessation Agents

Anesthetics, Local Anesthetics

Anti-Addiction/Substance Abuse Treatment Agents, Alcohol

Deterrents/Anti-craving

Analgesics, Opioid Analgesics, Short-Acting

PA = Prior Authorization May Be Required QLL = Quantity Limit May Apply ST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless of their appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 5: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

amikacin sulfate 1

gentamicin 1

KANAMYCIN 3

neomycin 1

paromomycin 1

STREPTOMYCIN 3

TOBI 4 PA

TOBRA/NACL 4

TOBRADEX 3 PA

tobramycin 4 PA

Drug Name Tier QLL ST PA

ALTABAX 2

BACITRACIN 3

clindamycin 1

CUBICIN 3

LINCOCIN 3

methenamine 1

metronidazole 1

MONUROL 3

mupirocin 1

neomycin-bacitrac zn-polymyx 1

nitrofurantoin 1

polymyxin b-trimethoprim 1

trimethoprim 1

TYGACIL 3 PA

vancomycin 1 QLL PA

VIBATIV 3

XIFAXAN 3 PA

ZYVOX 2 QLL PA

Drug Name Tier QLL ST PA

CEDAX 3

cefaclor 1

cefadroxil 1

cefazolin 1

cefdinir 1

CEFDITOREN 3

cefepime 1

cefotaxime 1

cefoxitin 1

cefpodoxime 1

cefprozil 1

ceftazidime 1

Antibacterials, Aminoglycosides

Antibacterials, Antibacterials, Other

Antibacterials, Beta-lactam, Cephalosporins

PA = Prior Authorization May Be Required QLL = Quantity Limit May Apply ST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless of their appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 6: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

ceftriaxone 1

cefuroxime 1

cephalexin 1

SUPRAX 2

Drug Name Tier QLL ST PA

aztreonam 1

DORIBAX 3

imipenem-cilastatin 1

INVANZ 3

Drug Name Tier QLL ST PA

amoxicillin & k clavulanate 1

amoxicillin 1

ampicillin & sulbactam 1

ampicillin 1

dicloxacillin 1

nafcillin 1

oxacillin 1

PEN G PROC 3

PEN G SOD 3

penicillin g potassium 1

penicillin v potassium 1

piperacillin sodium-tazobactam 1

TIMENTIN 3

Drug Name Tier QLL ST PA

AZASITE 3

azithromycin 1 QLL

clarithromycin 1

DIFICID 2

ERY-TAB 3

erythromycin 1

KETEK 3 QLL

Drug Name Tier QLL ST PA

AVELOX 2

BESIVANCE 3

CIPRO I.V. 3

ciprofloxacin 1

FACTIVE 3

gatifloxacin 1

levofloxacin 1

NOROXIN 3

ofloxacin 1

Antibacterials, Beta-lactam, Other

Antibacterials, Beta-lactam, Cephalosporins

Antibacterials, Beta-lactam, Penicillins

Antibacterials, Macrolides

Antibacterials, Quinolones

PA = Prior Authorization May Be Required QLL = Quantity Limit May Apply ST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless of their appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 7: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

silver sulfadiazine 1

sulfacetamide 1

sulfadiazine 1

sulfamethoxazole-trimethoprim 1

Drug Name Tier QLL ST PA

demeclocycline 1

doxycycline 1 QLL

minocycline 1 QLL

tetracycline 1 QLL

Drug Name Tier QLL ST PA

levetiracetam 1

POTIGA 3

Drug Name Tier QLL ST PA

CELONTIN 3

ethosuximide 1

LYRICA 2 QLL PA

zonisamide 1

Drug Name Tier QLL ST PA

clonazepam 1 QLL

DIAZEPAM 3 QLL

gabapentin 1

primidone 1

SABRIL 4 QLL PA

tiagabine 1

valproate 1

valproic 1

Drug Name Tier QLL ST PA

felbamate 1

lamotrigine 1

topiramate 1

Drug Name Tier QLL ST PA

BANZEL 2

carbamazepine 1

DILANTIN 2

fosphenytoin 1

oxcarbazepine 1

PEGANONE 3

PHENYTEK 2

phenytoin 1

VIMPAT 3

Anticonvulsants, Glutamate Reducing Agents

Anticonvulsants, Sodium Channel Agents

Anticonvulsants, Calcium Channel Modifying Agents

Anticonvulsants, Gamma-aminobutyric Acid (GABA) Augmenting

Antibacterials, Sulfonamides

Antibacterials, Tetracyclines

Anticonvulsants, Anticonvulsants, Other

PA = Prior Authorization May Be Required QLL = Quantity Limit May Apply ST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless of their appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 8: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

ERGOLOID 3

Drug Name Tier QLL ST PA

donepezil 1 QLL

galantamine 1 QLL

rivastigmine 1 QLL

Drug Name Tier QLL ST PA

NAMENDA 2 QLL

Drug Name Tier QLL ST PA

ABILIFY 2 PA

bupropion 1

MAPROTILINE 3

mirtazapine 1

NEFAZODONE 3

OLEPTRO 3

SEROQUEL XR 2 PA

trazodone 1

VIIBRYD 2 ST

Drug Name Tier QLL ST PA

EMSAM 3

MARPLAN 2

phenelzine 1

tranylcypromine 1

Drug Name Tier QLL ST PA

citalopram 1

CYMBALTA 2 QLL ST

escitalopram 1 QLL

fluoxetine 1

fluvoxamine 1

paroxetine 1 QLL

PAXIL 3

PRISTIQ 2 QLL ST

sertraline 1 QLL

venlafaxine 1 QLL

Drug Name Tier QLL ST PA

amitriptyline 1

AMOXAPINE 3

clomipramine 1

desipramine 1

doxepin 1

Antidementia Agents, Antidementia Agents, Other

Antidementia Agents, Cholinesterase Inhibitors

Antidementia Agents, N-methyl-D-aspartate (NMDA) Receptor

Antagonist

Antidepressants, Antidepressants, Other

Antidepressants, Monoamine Oxidase Inhibitors

Antidepressants, Serotonin/Norepinephrine Reuptake Inhibitors

Antidepressants, Tricyclics

PA = Prior Authorization May Be Required QLL = Quantity Limit May Apply ST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless of their appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 9: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

imipramine 1

nortriptyline 1

perphenazine-amitriptyline 3

protriptyline 1

trimipramine 1

Drug Name Tier QLL ST PA

chlorpromazine 1

diphenhydramine 1

hydroxyzine 1

meclizine 1

metoclopramide 1

perphenazine 1

promethazine 1

trimethobenzamide 1

Drug Name Tier QLL ST PA

ALOXI 3 PA

ANZEMET 3 PA

CESAMET 3

dronabinol 1

EMEND 2 QLL

granisetron 1

ondansetron 1

Drug Name Tier QLL ST PA

CICLOPIROX 1

clotrimazole 1

econazole nitrate 1

ERAXIS 3

ERTACZO 3

EXELDERM 3

fluconazole 1

flucytosine 1

griseofulvin 1

GYNAZOLE-1 3

itraconazole 1 PA

ketoconazole 1

MICONAZOLE 3 3

MYCAMINE 3

NAFTIN 3

NATACYN 2

NOXAFIL 3

NYSTATIN 1

SPORANOX 3 PA

terbinafine 1

terconazole 1 QLL

voriconazole 1

Antiemetics, Antiemetics, Other

Antiemetics, Emetogenic Therapy Adjuncts

Antifungals, Antifungals

Antidepressants, Tricyclics

PA = Prior Authorization May Be Required QLL = Quantity Limit May Apply ST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless of their appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 10: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

allopurinol 1

colchicine w/ probenecid 1

COLCRYS 2 QLL

probenecid 1

ULORIC 3

Drug Name Tier QLL ST PA

dihydroergotamine mesylate 2

ERGOMAR 3

MIGRANAL 2

Drug Name Tier QLL ST PA

BOTOX 3 PA

divalproex 1

topiramate 1

Drug Name Tier QLL ST PA

AXERT 3 QLL

FROVA 3 QLL

naratriptan 1 QLL

RELPAX 3 QLL

rizatriptan 1 QLL

sumatriptan 1 QLL

ZOMIG 2 QLL

Drug Name Tier QLL ST PA

GUANIDINE 2

MESTINON 2

MYTELASE 3

pyridostigmine 1

Drug Name Tier QLL ST PA

DAPSONE 3

MYCOBUTIN 3 PA

Drug Name Tier QLL ST PA

CAPASTAT 3

ethambutol 1

isoniazid 1

PASER 3

PRIFTIN 3

pyrazinamide 1

RIFAMATE 3

rifampin 1

RIFATER 3

TRECATOR 3

Antigout Agents, Antigout Agents

Antimigraine Agents, Ergot Alkaloids

Antimigraine Agents, Prophylactic

Antimigraine Agents, Serotonin (5-HT) 1b/1d Receptor Agonists

Antimyasthenic Agents, Parasympathomimetics

Antimycobacterials, Antimycobacterials, Other

Antimycobacterials, Antituberculars

PA = Prior Authorization May Be Required QLL = Quantity Limit May Apply ST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless of their appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 11: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

ALKERAN 2

BUSULFEX 4

CEENU 4

CYCLOPHOSPH 4

HEXALEN 4

LEUKERAN 4

MATULANE 4

melphalan 1

MYLERAN 4

SEROMYCIN 3

ZANOSAR 4

Drug Name Tier QLL ST PA

REVLIMID 4 PA

THALOMID 4 PA

Drug Name Tier QLL ST PA

EMCYT 4 PA

FARESTON 2

SOLTAMOX 3

tamoxifen citrate 1

Drug Name Tier QLL ST PA

DROXIA 4 PA

HYDROXYUREA 4

TABLOID 4 PA

Drug Name Tier QLL ST PA

ABRAXANE 4 PA

ADCETRIS 4 PA

ALIMTA 4 PA

ARIMIDEX 4 PA

AROMASIN 4 PA

ARRANON 4

ARZERRA 4

BEXXAR 4 PA

BICNU 4

bleomycin 4

BOSULIF 4 PA

CAMPATH 4

CAMPTOSAR 4

carboplatin 4

CASODEX 4

CERUBIDINE 4

cisplatin 4

cladribine 4 PA

CLOLAR 4

COMETRIQ 4 PA

Antineoplastics, Antiangiogenic Agents

Antineoplastics, Antiestrogens/Modifiers

Antineoplastics, Antimetabolites

Antineoplastics, Antineoplastics, Other

Antineoplastics, Alkylating Agents

PA = Prior Authorization May Be Required QLL = Quantity Limit May Apply ST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless of their appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 12: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

COSMEGEN 4

cytarabine 4 PA

dacarbazine 4

DACOGEN 4

dactinomycin 4

daunorubicin 4

DAUNOXOME 4

DEPOCYT 4

DOCEFREZ 4

DOCETAXEL 4

DOXIL 4

doxorubicin 4

ELLENCE 4

ELOXATIN 4

ELSPAR 4

epirubicin 4 PA

ERBITUX 4 PA

ERIVEDGE 4 PA

ERWINAZE 4 PA

FASLODEX 4

FEMARA 4 PA

floxuridine 4

FLUDARA 4

fludarabine 4

fluorouracil 4

FOLOTYN 4

FUDR 4

gemcitabine 4

GEMZAR 4

HALAVEN 4

HYCAMTIN 4 PA

HYDREA 4

IDAMYCIN PFS 4

idarubicin 4

IFEX 4

IFOSFAMIDE 4

irinotecan 4

ISTODAX 4

IXEMPRA KIT 4 PA

JAKAFI 4 PA

JEVTANA 4 PA

KYPROLIS 4 PA

leucovorin 1

MEGACE 4 PA

mitomycin 4

mitoxantrone 4

MOZOBIL 4 PA

MUSTARGEN 4

NAVELBINE 4

Antineoplastics, Antineoplastics, Other

PA = Prior Authorization May Be Required QLL = Quantity Limit May Apply ST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless of their appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 13: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

NIPENT 4

OFORTA 4 PA

ONCASPAR 4

ONTAK 4

oxaliplatin 4

paclitaxel 4

pentostatin 4

PERJETA 4 PA

PHOTOFRIN 4

PROLEUKIN 4

PURINETHOL 4

RHEUMATREX 4

RITUXAN 4 PA

STIVARGA 4 PA

SYNRIBO 4

TAXOTERE 4

TEMODAR 4 PA

THIOTEPA 4

TORISEL 4

TREANDA 4

TREXALL 4 PA

TRISENOX 4

VALSTAR 4

VECTIBIX 4 PA

VELCADE 4

VIDAZA 4

VINBLASTINE 4

vincristine 4

vinorelbine 4

VORAXAZE 4 PA

VUMON 4

XELODA 4 PA

XTANDI 4 PA

YERVOY 4 PA

ZALTRAP 4 PA

ZOLADEX 4 PA

ZOLINZA 4 PA

ZYTIGA 4 PA

Drug Name Tier QLL ST PA

anastrozole 4 PA

exemestane 4 PA

letrozole 4 PA

Drug Name Tier QLL ST PA

ETOPOPHOS 4

ETOPOSIDE 4

topotecan 4

Antineoplastics, Aromatase Inhibitors, 3rd Generation

Antineoplastics, Enzyme Inhibitors

Antineoplastics, Antineoplastics, Other

PA = Prior Authorization May Be Required QLL = Quantity Limit May Apply ST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless of their appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 14: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

AFINITOR 4 PA

CAPRELSA 4 PA

GLEEVEC 4 PA

INLYTA 4 PA

NEXAVAR 4 PA

SPRYCEL 4 PA

SUTENT 4 PA

TARCEVA 4 PA

TASIGNA 4 PA

TYKERB 4 PA

VOTRIENT 4 PA

XALKORI 4 PA

ZELBORAF 4 PA

ZORTRESS 4

Drug Name Tier QLL ST PA

AVASTIN 4 PA

HERCEPTIN 4 PA

RITUXAN 4 PA

Drug Name Tier QLL ST PA

PANRETIN 3

TARGRETIN 4 PA

tretinoin 1

Drug Name Tier QLL ST PA

ALBENZA 3

BILTRICIDE 3

MEBENDAZOLE 3 PA

STROMECTOL 3

Drug Name Tier QLL ST PA

ALINIA 2

atovaquone-proguanil 1

chloroquine 1

COARTEM 2

DARAPRIM 3

hydroxychloroquine 1

LACRISERT 3

mefloquine 1

MEPRON 3

NEBUPENT 3

PENTAM 300 3

PRIMAQUINE 3

quinine sulfate 1

Drug Name Tier QLL ST PA

EURAX 3

Antineoplastics, Molecular Target Inhibitors

Antineoplastics, Monoclonal Antibodies

Antineoplastics, Retinoids

Antiparasitics, Anthelmintics

Antiparasitics, Antiprotozoals

Antiparasitics, Pediculicides/Scabicides

PA = Prior Authorization May Be Required QLL = Quantity Limit May Apply ST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 15: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

lindane 3

malathion 1

permethrin 1

SKLICE 3

ULESFIA 3

Drug Name Tier QLL ST PA

benztropine mesylate 1

diphenhydramine 1

trihexyphenidyl 1

Drug Name Tier QLL ST PA

amantadine 1

COMTAN 2 QLL

TASMAR 3

Drug Name Tier QLL ST PA

APOKYN 4 PA

NEUPRO 2

pramipexole dihydrochloride 1

ropinirole 1

Drug Name Tier QLL ST PA

carbidopa & levodopa 1

carbidopa-levodopa-entacapone 1

LODOSYN 3

Drug Name Tier QLL ST PA

AZILECT 2 QLL PA

selegiline 1

Drug Name Tier QLL ST PA

CHLORPROMAZ 3

chlorpromazine 1

fluphenazine 1

haloperidol 1

loxapine 1

ORAP 3

prochlorperazine 1

thioridazine 1

thiothixene 1

trifluoperazine 1

Antiparkinson Agents, Anticholinergics

Antiparkinson Agents, Antiparkinson Agents, Other

Antiparkinson Agents, Dopamine Agonists

Antiparkinson Agents, Dopamine Precursors/L-Amino Acid

Decarboxylase Inhibitors

Antiparkinson Agents, Monomine Oxidase B (MAO-B) Inhibitors

Antipsychotics, 1st Generation/Typical

Antiparasitics, Pediculicides/Scabicides

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 16: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

ABILIFY 2 PA

FANAPT 2

INVEGA 2 QLL

LATUDA 3

olanzapine 1

quetiapine 1

RISPERDAL 2

risperidone 1

SAPHRIS 2

ziprasidone 1

Drug Name Tier QLL ST PA

clozapine 1

Drug Name Tier QLL ST PA

baclofen 1

clonazepam 1 QLL

dantrolene 1

diazepam 1 QLL

tizanidine 1

XEOMIN 3

Drug Name Tier QLL ST PA

ganciclovir 1

VALCYTE 2 PA

VISTIDE 3

Drug Name Tier QLL ST PA

BARACLUDE 4 PA

EPIVIR HBV 4 PA

HEPSERA 4 PA

INCIVEK 4 PA

INFERGEN 4 PA

INTRON-A 4 PA

PEGASYS 4 PA

PEG-INTRON 4 PA

REBETOL 4 PA

ribavirin 1

SYLATRON 4 PA

TYZEKA 4 PA

VICTRELIS 4 PA

VIREAD 2

Drug Name Tier QLL ST PA

acyclovir 1

DENAVIR 3

famciclovir 1 QLL

FOSCARNET 3

Antipsychotics, 2nd Generation/Atypical

Antipsychotics, Treatment-Resistant

Antispasticity Agents, Antispasticity Agents

Antivirals, Anti-cytomegalovirus (CMV) Agents

Antivirals, Antihepatitis Agents

Antivirals, Antiherpetic Agents

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 17: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

trifluridine 1

valacyclovir 1 QLL

ZOVIRAX 3 QLL

Drug Name Tier QLL ST PA

ATRIPLA 2

EDURANT 2

INTELENCE 2

nevirapine 1

RESCRIPTOR 2

SUSTIVA 2

VIRAMUNE XR 2

Drug Name Tier QLL ST PA

abacavir sulfate 1

didanosine 1

EMTRIVA 2

EPIVIR 4

EPZICOM 2

lamivudine 4

lamivudine-zidovudine 1

stavudine 1

TRIZIVIR 2

TRUVADA 2

VIREAD 2

zidovudine 1

Drug Name Tier QLL ST PA

FUZEON 4 PA

ISENTRESS 2

SELZENTRY 2

Drug Name Tier QLL ST PA

APTIVUS 2

CRIXIVAN 2

INVIRASE 2

KALETRA 2

LEXIVA 2

NORVIR 2

PREZISTA 2

REYATAZ 2

VIRACEPT 2

Drug Name Tier QLL ST PA

RELENZA 2 QLL

Antivirals, Anti-HIV Agents, Non-nucleoside Reverse Transcriptase

Inhibitors

Antivirals, Anti-HIV Agents, Nucleoside and Nucleotide Reverse

Transcriptase Inhibitors

Antivirals, Anti-HIV Agents, Other

Antivirals, Anti-HIV Agents, Protease Inhibitors

Antivirals, Anti-influenza Agents

Antivirals, Antiherpetic Agents

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 18: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

rimantadine 1

TAMIFLU 2 QLL

Drug Name Tier QLL ST PA

alprazolam 1 QLL

buspirone 1

doxepin 1

lorazepam 1 QLL

meprobamate 1

Drug Name Tier QLL ST PA

sertraline 1 QLL

Drug Name Tier QLL ST PA

SAPHRIS 2

SEROQUEL XR 2 PA

ziprasidone 1

EQUETRO 3

lithium 1

Drug Name Tier QLL ST PA

acarbose 1 QLL

ACTOPLUS MET 2 QLL

ACTOS 2 QLL

BYETTA 2 QLL

chlorpropamide 1 QLL

CYCLOSET 3 QLL

glimepiride 1 QLL

glipizide 1 QLL

glipizide-metformin 1 QLL

glyburide 1 QLL

glyburide-metformin 1 QLL

GLYSET 3 QLL

JANUVIA 2 QLL ST

metformin 1 QLL

nateglinide 1 QLL

ONGLYZA 3 QLL ST

PRANDIMET 3 QLL

PRANDIN 2 QLL

SYMLIN PEN 2 QLL PA

tolazamide 1 QLL

tolbutamide 1 QLL

TRADJENTA 2 QLL ST

VICTOZA 2 QLL ST

WELCHOL 2 QLL

Drug Name Tier QLL ST PA

GLUCAGEN 3 QLL

Anxiolytics, Anxiolytics, Other

Antivirals, Anti-influenza Agents

Anxiolytics, SSRI/SNRI

Bipolar Agents, Mood Stabilizers

Blood Glucose Regulators, Antidiabetic Agents

Blood Glucose Regulators, Glycemic Agents

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 19: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

GLUCAGON 3 QLL

PROGLYCEM 3 QLL

Drug Name Tier QLL ST PA

APIDRA 3 QLL

HUMALOG 2 QLL

HUMULIN 2 QLL

LANTUS 2 QLL

LEVEMIR 2 QLL

NOVOLIN 2 QLL

NOVOLOG 2 QLL

Drug Name Tier QLL ST PA

COUMADIN 3

enoxaparin 4 QLL PA

fondaparinux 4 QLL PA

FRAGMIN 4 PA

heparin sodium (porcine) 1

PRADAXA 2 QLL PA

warfarin 1

XARELTO 2 PA

Drug Name Tier QLL ST PA

anagrelide 1

ARANESP 4 PA

EPOGEN 4 PA

LEUKINE 4 PA

NEULASTA 4 PA

NEUPOGEN 4 QLL PA

NPLATE 4 PA

PROCRIT 4 PA

PROMACTA 4 PA

Drug Name Tier QLL ST PA

tranexamic acid 1

Drug Name Tier QLL ST PA

AGGRENOX 2

cilostazol 1

clopidogrel 1

dipyridamole 1

EFFIENT 2

REOPRO 3

ticlopidine 1

Blood Products/Modifiers/Volume Expanders, Blood Formation

Modifiers

Blood Products/Modifiers/Volume Expanders, Coagulants

Blood Products/Modifiers/Volume Expanders, Platelet Modifying

Agents

Blood Glucose Regulators, Insulins

Blood Products/Modifiers/Volume Expanders, Anticoagulants

Blood Glucose Regulators, Glycemic Agents

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 20: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

clonidine 1 QLL

GUANABENZ 3

guanfacine 1 QLL

methyldopa 1 QLL

METHYLDOPATE 3

midodrine 1

Drug Name Tier QLL ST PA

DIBENZYLINE 3 QLL

doxazosin 1

terazosin 1

Drug Name Tier QLL ST PA

ATACAND 3 QLL ST

BENICAR 2 QLL ST

DIOVAN 2 QLL ST

EDARBI 3 QLL ST

irbesartan 1 QLL

losartan 1 QLL

MICARDIS 3 QLL ST

TEVETEN 3 QLL ST

Drug Name Tier QLL ST PA

benazepril 1

captopril 1

enalapril 1

fosinopril 1

lisinopril 1

moexipril 1

perindopril 1

quinapril 1

ramipril 1

trandolapril 1

Drug Name Tier QLL ST PA

amiodarone 1

disopyramide 1

flecainide 1

mexiletine 1

MULTAQ 4

PACERONE 2

procainamide 1 QLL

propafenone 1 QLL

quinidine 1 QLL

sotalol 1 QLL

TIKOSYN 2

Cardiovascular Agents, Alpha-adrenergic Agonists

Cardiovascular Agents, Alpha-adrenergic Blocking Agents

Cardiovascular Agents, Angiotensin II Receptor Antagonists

Cardiovascular Agents, Angiotensin-converting Enzyme (ACE)

Inhibitors

Cardiovascular Agents, Antiarrhythmics

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 21: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

acebutolol 1

atenolol 1

betaxolol 1

bisoprolol 1

BYSTOLIC 2 QLL ST

carvedilol 1

labetalol 1

LEVATOL 3

metoprolol 1

nadolol 1

pindolol 1

propranolol 1

timolol maleate 1

Drug Name Tier QLL ST PA

amlodipine 1

diltiazem 1

felodipine 1

isradipine 1

nicardipine 1

nifedipine 1

nimodipine 1

nisoldipine 1

verapamil 1

Drug Name Tier QLL ST PA

digoxin 1

pentoxifylline 1 QLL

RANEXA 2 QLL

TEKTURNA 2 QLL ST

Drug Name Tier QLL ST PA

acetazolamide 1 QLL

methazolamide 1 QLL

Drug Name Tier QLL ST PA

bumetanide 1 QLL

EDECRIN 3 QLL

furosemide 1

torsemide 1

Drug Name Tier QLL ST PA

amiloride 1

DYRENIUM 3 QLL

eplerenone 1

spironolactone 1

Cardiovascular Agents, Diuretics, Carbonic Anhydrase Inhibitors

Cardiovascular Agents, Diuretics, Loop

Cardiovascular Agents, Diuretics, Potassium-sparing

Cardiovascular Agents, Beta-adrenergic Blocking Agents

Cardiovascular Agents, Calcium Channel Blocking Agents

Cardiovascular Agents, Cardiovascular Agents, Other

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 22: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

chlorothiazide 1

chlorthalidone 1

hydrochlorothiazide 1 QLL

indapamide 1 QLL

methyclothiazide 1

metolazone 1 QLL

Drug Name Tier QLL ST PA

fenofibrate 1 QLL

gemfibrozil 1

Drug Name Tier QLL ST PA

atorvastatin 1 QLL

CRESTOR 2 QLL ST

fluvastatin 2 QLL

LIVALO 3 QLL

lovastatin 1 QLL

pravastatin 1 QLL

simvastatin 1 QLL

Drug Name Tier QLL ST PA

ADVICOR 3

cholestyramine light 1

cholestyramine 1

colestipol 1

LOVAZA 2

NIASPAN 2

SIMCOR 2

VYTORIN 2 ST

ZETIA 2 ST

Drug Name Tier QLL ST PA

BIDIL 2

hydralazine 1

minoxidil 1

RECTIV 3

Drug Name Tier QLL ST PA

isosorbide 1

NITRO-BID 3

nitroglycerin 1

NITROSTAT 2

Cardiovascular Agents, Diuretics, Thiazide

Cardiovascular Agents, Dyslipidemics, Fibric Acid Derivatives

Cardiovascular Agents, Dyslipidemics, HMG CoA Reductase Inhibitors

Cardiovascular Agents, Dyslipidemics, Other

Cardiovascular Agents, Vasodilators, Direct-acting Arterial

Cardiovascular Agents, Vasodilators, Direct-acting Arterial/Venous

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 23: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

amphetamine-dextroamphetamine 1

dextroamphetamine 1

methamphetamine 3 QLL

VYVANSE 2 QLL

Drug Name Tier QLL ST PA

dexmethylphenidate 1

INTUNIV 2 QLL

methylphenidate 1

STRATTERA 2 QLL

Drug Name Tier QLL ST PA

butalbital-acetaminophen-caff w/ cod 1

HORIZANT 3

NUEDEXTA 3

RILUTEK 3

XENAZINE 4 PA

CYMBALTA 2 ST

Drug Name Tier QLL ST PA

SAVELLA 2 PA

Drug Name Tier QLL ST PA

AMPYRA 4 PA

AVONEX 4 PA

BETASERON 4 PA

COPAXONE 4 PA

EXTAVIA 4 PA

GILENYA 4 PA

REBIF 4 PA

TYSABRI 4 PA

Drug Name Tier QLL ST PA

ARESTIN 4 PA

cevimeline 1

chlorhexidine 1

KEPIVANCE 4

pilocarpine 1

triamcinolone 1

Drug Name Tier QLL ST PA

adapalene 1

AMEVIVE 4 PA

Central Nervous System Agents, Fibromyalgia Agents

Central Nervous System Agents, Multiple Sclerosis Agents

Dental and Oral Agents, Dental and Oral Agents

Dermatological Agents, Dermatological Agents

Central Nervous System Agents, Attention Deficit Hyperactivity

Disorder Agents, Amphetamines

Central Nervous System Agents, Attention Deficit Hyperactivity

Disorder Agents, Non-amphetamines

Central Nervous System Agents, Central Nervous System, Other

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 24: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

AZELEX 3

bacitracin-polymyxin-neomycin hc 1

benzoyl peroxide 1

benzoyl peroxide-erythromycin 1 QLL

calcipotriene 1 QLL

calcitriol 1 QLL

clindamycin 1

clotrimazole w/ betamethasone 1

DIFFERIN 2 PA

erythromycin 1

FINACEA 2

fluorouracil 1 QLL

hexachlorophene 1

imiquimod 1

isotretinoin 1 QLL

lactic acid 1

LAVOCLEN-4 3

neomycin-polymyxin-hc 1

nystatin-triamcinolone 1

OXSORALEN 2 QLL

PICATO 2

podofilox 1

prednicarbate 1

PROTOPIC 2 ST

REGRANEX 3 PA

SANTYL 3

selenium sulfide 1 QLL

SOLARAZE 2 QLL

SORIATANE 2 QLL

spinosad 1

STELARA 4 PA

sulfacetamide 1 QLL

TACLONEX 3

TAZORAC 2 PA

tretinoin 1 PA

UVADEX 4

VEREGEN 3

VOLTAREN 2

ZONALON 3

Drug Name Tier QLL ST PA

ADAGEN 4 QLL PA

ALDURAZYME 4 QLL PA

BUPHENYL 3

CREON 2 QLL

CYSTADANE 4 QLL PA

CYSTAGON 3 QLL

ELAPRASE 4 QLL PA

KUVAN 4 QLL PA

ORFADIN 4 QLL PA

Enzyme Replacement/Modifiers, Enzyme Replacement/Modifiers

Dermatological Agents, Dermatological Agents

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 25: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

atropine 1

CANTIL 3

dicyclomine 1

glycopyrrolate 1

methscopolamine 1

TRANSDERM-SC 2

Drug Name Tier QLL ST PA

diphenoxylate w/ atropine 1

ENTEREG 3 PA

loperamide 1

metoclopramide 1 QLL

RELISTOR 2 PA

ursodiol 1

XIFAXAN 3 PA

Drug Name Tier QLL ST PA

cimetidine 1

famotidine 1

nizatidine 1

ranitidine 1

Drug Name Tier QLL ST PA

AMITIZA 2

LOTRONEX 2

Drug Name Tier QLL ST PA

lactulose 1

MOVIPREP 2

OSMOPREP 3

PREPOPIK 3

Drug Name Tier QLL ST PA

CARAFATE 2

misoprostol 1

sucralfate 1

Drug Name Tier QLL ST PA

ACIPHEX 3 QLL ST

DEXILANT 2 QLL ST

lansoprazole 1 QLL

NEXIUM 2 QLL ST

omeprazole 1 QLL

pantoprazole 1 QLL

Drug Name Tier QLL ST PA

DETROL LA 3 ST

ENABLEX 3 ST

Gastrointestinal Agents, Antispasmodics, Gastrointestinal

Genitourinary Agents, Antispasmodics, Urinary

Gastrointestinal Agents, Gastrointestinal Agents, Other

Gastrointestinal Agents, Histamine2 (H2) receptor Antagonists

Gastrointestinal Agents, Irritable Bowel Syndrome Agents

Gastrointestinal Agents, Laxatives

Gastrointestinal Agents, Protectants

Gastrointestinal Agents, Proton Pump Inhibitors

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 26: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

flavoxate 1

oxybutynin 1

tolterodine 1

TOVIAZ 3 ST

trospium chloride 1

VESICARE 2 ST

Drug Name Tier QLL ST PA

alfuzosin 1

AVODART 2 QLL

CIALIS 3 PA

prazosin 1 QLL

RAPAFLO 2

tamsulosin 1

Drug Name Tier QLL ST PA

bethanechol 1 QLL

CUPRIMINE 3

ELMIRON 2

Drug Name Tier QLL ST PA

calcium acetate 1

FOSRENOL 2

PHOSLYRA 2

RENAGEL 3

Drug Name Tier QLL ST PA

alclometasone 1

AMCINONIDE 3

betamethasone dipropionate 1

betamethasone valerate 1

clobetasol 1

CLODERM 3

CORDRAN 3

cortisone 1

DEPO-MEDROL 3

desonide 1

desoximetasone 1

dexamethasone 1

diflorasone 1

fludrocortisone 1

fluocinolone 1

fluticasone 1

halobetasol 1

HALOG 3

hydrocortisone 1

methylprednisolone 1

MILLIPRED 3

Genitourinary Agents, Benign Prostatic Hypertrophy Agents

Genitourinary Agents, Genitourinary Agents, Other

Genitourinary Agents, Phosphate Binders

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal),

Glucocorticoids/Mineralocorticoids

Genitourinary Agents, Antispasmodics, Urinary

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 27: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

mometasone 1

ORAPRED ODT 3

prednicarbate 1

prednisolone 1

prednisone 1

SOLU-CORTEF 3

SOLU-MEDROL 3

triamcinolone 1

VERIPRED 20 3

Drug Name Tier QLL ST PA

chorionic gonadotropin 4 PA

desmopressin 1

GENOTROPIN 4 PA

HUMATROPE 4 PA

INCRELEX 4 PA

NORDITROPIN 4 PA

NUTROPIN 4 PA

OMNITROPE 4 PA

SAIZEN 4 PA

SEROSTIM 4 PA

STIMATE 4 PA

TEV-TROPIN 4 PA

ZORBTIVE 4 PA

Drug Name Tier QLL ST PA

ANADROL-50 3

oxandrolone 1

Drug Name Tier QLL ST PA

ANDRODERM 2 PA

ANDROXY 3 PA

danazol 1 PA

METHITEST 3 PA

Drug Name Tier QLL ST PA

AMETHIA 0

AMETHYST 0

APRI 0

ARANELLE 0

AVIANE 0

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary),

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal),

Glucocorticoids/Mineralocorticoids

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers), Anabolic Steroids

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers), Androgens

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers), Estrogens

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 28: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

AZURETTE 0

BALZIVA 0

BRIELLYN 0

CAMRESE 0

CAZIANT 0

CENESTIN 3

CESIA 0

CLIMARA PRO 3

CRYSELLE-28 0

CYCLAFEM 0

DASETTA 0

DEPO-ESTRADI 3

DIVIGEL 3

ELESTRIN 3

ELINEST 0

EMOQUETTE 0

ENJUVIA 3

ENPRESSE-28 0

ESTRACE VAG 3

estradiol 1

ESTRASORB 3

ESTROGEL 3

estropipate 1

EVAMIST 3

FEMRING 3

GIANVI 0

JOLESSA 0

JUNEL 0

KARIVA 0

KELNOR 0

KURVELO 0

LEENA 0

LESSINA 0

LEVONEST 0

LEVORA-28 0

LOESTRIN 24 0

LORYNA 0

LOW-OGESTREL 0

LUTERA 0

MENEST 3

MENOSTAR 3

MICROGESTIN 0

MONO-LINYAH 0

MONONESSA 0

MYZILRA 0

NATAZIA 0

NECON 0

NORTREL 0

NUVARING 0

OCELLA 0

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers), Estrogens

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 29: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

OGESTREL 0

ORTHO EVRA 0

ORTHO TRI-CYCLN LO 0

PHILITH 0

PORTIA-28 0

PREMARIN 2

PREMARIN VAG 2

PREMPHASE 2

PREMPRO 2

PREVIFEM 0

QUASENSE 0

RECLIPSEN 0

SAFYRAL 0

SPRINTEC 28 0

SRONYX 0

SYEDA 0

TILIA FE 0

TRI-LEGEST FE 0

TRINESSA 0

TRI-PREVIFEM 0

TRI-SPRINTEC 0

TRIVORA-28 0

VELIVET 0

VESTURA 0

VIVELLE-DOT 3

WERA 0

ZARAH 0

ZENCHENT 0

ZEOSA 0

ZOVIA 0

Drug Name Tier QLL ST PA

CAMILA 0

CRINONE 3

ELLA 0

ENDOMETRIN 2

HEATHER 0

JOLIVETTE 0

levonorgestrel 0

medroxyprogesterone 4 PA

MEGACE ES 4 PA

megestrol 1

NORETHIN ACE 0

NORETHINDRON 0

PROCHIEVE 3

progesterone 1

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers), Estrogens

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers), Progestins

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 30: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

EVISTA 2 QLL

Drug Name Tier QLL ST PA

levothyroxine 1

liothyronine 1

THYROLAR 3

Drug Name Tier QLL ST PA

LYSODREN 4 PA

Drug Name Tier QLL ST PA

SENSIPAR 4 PA

Drug Name Tier QLL ST PA

bromocriptine 1

cabergoline 1

ELIGARD 4 PA

FIRMAGON 4 PA

leuprolide 4 PA

LUPR DEP-PED 4 PA

LUPRON DEPOT 4 PA

octreotide 4 PA

SOMATULINE 4 PA

SOMAVERT 4 PA

SYNAREL 4 PA

TRELSTAR 4 PA

Drug Name Tier QLL ST PA

bicalutamide 4

finasteride 1

flutamide 4

NILANDRON 3 QLL

Drug Name Tier QLL ST PA

methimazole 1

propylthiouracil 1

Hormonal Agents, Suppressant (Parathyroid), Hormonal Agents,

Suppressant (Parathyroid)

Hormonal Agents, Suppressant (Pituitary), Hormonal Agents,

Suppressant (Pituitary)

Hormonal Agents, Suppressant (Sex Hormones/Modifiers),

Antiandrogens

Hormonal Agents, Suppressant (Thyroid), Antithyroid Agents

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers), Selective Estrogen Receptor Modifying

Agents

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid),

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Suppressant (Adrenal), Hormonal Agents,

Suppressant (Adrenal)

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 31: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

AZASAN 3

azathioprine 1

CIMZIA 4 PA

cyclosporine 1

ELIDEL 2 QLL ST

ENBREL 4 PA

HUMIRA 4 PA

KINERET 4 PA

mercaptopurine 4

methotrexate 1

mycophenolate 1

MYFORTIC 2

NULOJIX 4 PA

ORENCIA 4 PA

PROGRAF 2

RAPAMUNE 2

REMICADE 4 PA

SIMPONI 4 PA

tacrolimus 1

Drug Name Tier QLL ST PA

CARIMUNE NF 4 PA

GAMMAGARD SD 4 PA

GAMUNEX-C 4 PA

HIZENTRA 4 PA

THYMOGLOBULN 3

Drug Name Tier QLL ST PA

ACTEMRA 4 PA

ACTIMMUNE 4 PA

ARCALYST 4 PA

AVONEX 4 PA

leflunomide 1 QLL

RIDAURA 3

Drug Name Tier QLL ST PA

APRISO 2

ASACOL 2 QLL

balsalazide 1

CANASA 2

DIPENTUM 2

LIALDA 2

mesalamine 1

PENTASA 2

Drug Name Tier QLL ST PA

budesonide 1

dexamethasone 1

hydrocortisone 1

Inflammatory Bowel Disease Agents, Glucocorticoids

Immunological Agents, Immune Suppressants

Immunological Agents, Immunizing Agents, Passive

Immunological Agents, Immunomodulators

Inflammatory Bowel Disease Agents, Aminosalicylates

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 32: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

KENALOG-40 3

MEDROL 3

methylprednisolone 1

Drug Name Tier QLL ST PA

sulfasalazine 1

Drug Name Tier QLL ST PA

ACTONEL 2 QLL

alendronate 1 QLL

ATELVIA 2

BONIVA 4

calcitonin 1 QLL

etidronate 1

FORTEO 4 PA

FOSAMAX + D 3

HECTOROL 2

ibandronate 1

PAMIDRONATE 4 PA

PROLIA 4 PA

SKELID 3

XGEVA 4 PA

ZEMPLAR 4

Drug Name Tier QLL ST PA

latanoprost 1

LUMIGAN 3

TRAVATAN Z 2

Drug Name Tier QLL ST PA

naphazoline 1

proparacaine 1

RESTASIS 2 PA

tropicamide 1

Drug Name Tier QLL ST PA

ALOCRIL 3

ALOMIDE 3

azelastine 1

BEPREVE 3

cromolyn 1

EMADINE 3 PA

epinastine 1

LASTACAFT 2

PATADAY 2

PATANOL 3

Inflammatory Bowel Disease Agents, Sulfonamides

Metabolic Bone Disease Agents, Metabolic Bone Disease Agents

Inflammatory Bowel Disease Agents, Glucocorticoids

Ophthalmic Agents, Ophthalmic Prostaglandin and Prostamide

Analogs

Ophthalmic Agents, Ophthalmic Agents, Other

Ophthalmic Agents, Ophthalmic Anti-Allergy Agents

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 33: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

apraclonidine 1

AZOPT 2 QLL

betaxolol 1 QLL

brimonidine 1 QLL

carteolol 1

COMBIGAN 2

dorzolamide 1 QLL

dorzolamide -timolol maleate 1 QLL

IOPIDINE 3

levobunolol 1 QLL

metipranolol 1

PHOSPHOLINE 3

pilocarpine 1

timolol maleate 1 QLL

Drug Name Tier QLL ST PA

ALREX 2

BROMDAY 2

BROMFENAC 3

DUREZOL 2

fluorometholone 1

flurbiprofen 1

FML 3

FML FORTE 3

ILEVRO 3

LOTEMAX 2

MAXIDEX 3

neomycin-polymyxin-dexamethasone 1

NEVANAC 3

PRED MILD 3

PRED SOD PHO 3

prednisolone 1

VEXOL 3

Drug Name Tier QLL ST PA

acetic acid 1

antipyrine-benzocaine 1

CIPRO HC 3

CIPRODEX 2

COLY-MYCIN S 3

CORTISPORIN 3

dexamethasone 1

hydrocortisone w/ acetic acid 1

neomycin-polymyxin-hc 1

Drug Name Tier QLL ST PA

ASTEPRO 2

azelastine 1 QLL

carbinoxamine 1

clemastine fumarate 1

Respiratory Tract Agents, Antihistamines

Ophthalmic Agents, Ophthalmic Antiglaucoma Agents

Ophthalmic Agents, Ophthalmic Anti-inflammatories

Otic Agents, Otic Agents

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 34: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

cyproheptadine 1

desloratadine 1 ST

DEXCHLORPHEN 3

hydroxyzine 1

levocetirizine 1 QLL ST

PATANASE 3

Drug Name Tier QLL ST PA

ADVAIR 2 QLL

ALVESCO 3

ASMANEX 2

budesonide 3

FLOVENT HFA 3 QLL

flunisolide 1 QLL

NASONEX 2

PULMICORT 2

QVAR 2

RHINOCORT AQUA 2

Drug Name Tier QLL ST PA

montelukast 1

zafirlukast 1 QLL

ZYFLO CR 3 QLL

Drug Name Tier QLL ST PA

ATROVENT HFA 3 QLL

ipratropium 1 QLL

SPIRIVA 2 QLL

Drug Name Tier QLL ST PA

aminophylline 1

LUFYLLIN 3

theophylline 1

Drug Name Tier QLL ST PA

albuterol sulfate 1 QLL

ARCAPTA 2

BROVANA 3

epinephrine 1

EPIPEN 2 QLL

FORADIL 2

levalbuterol 1

MAXAIR AUTOH 3

metaproterenol 1

PROVENTIL 2

SEREVENT DIS 2 QLL

terbutaline 1

Respiratory Tract Agents, Antihistamines

Respiratory Tract Agents, Anti-inflammatories, Inhaled

Corticosteroids

Respiratory Tract Agents, Antileukotrienes

Respiratory Tract Agents, Bronchodilators, Anticholinergic

Respiratory Tract Agents, Bronchodilators, Phosphodiesterase

Inhibitors (Xanthines)

Respiratory Tract Agents, Bronchodilators, Sympathomimetic

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 35: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

VENTOLIN HFA 3 QLL

XOPENEX HFA 3 QLL

Drug Name Tier QLL ST PA

cromolyn 1 QLL

Drug Name Tier QLL ST PA

ADCIRCA 4 PA

LETAIRIS 4 PA

REMODULIN 4 PA

REVATIO 4 PA

sildenafil citrate 4 PA

TRACLEER 4 QLL PA

VENTAVIS 4 PA

Drug Name Tier QLL ST PA

acetylcysteine 1

ARALAST NP 4 PA

DALIRESP 3

PULMOZYME 4 PA

TYZINE 3

XOLAIR 4 PA

Drug Name Tier QLL ST PA

carisoprodol 1

chlorzoxazone 1

cyclobenzaprine 1 QLL

metaxalone 1 QLL

methocarbamol 1

orphenadrine citrate 1

Drug Name Tier QLL ST PA

LUNESTA 3 QLL ST

zaleplon 1 QLL

zolpidem 1 QLL

Drug Name Tier QLL ST PA

modafinil 1 QLL PA

NUVIGIL 2 QLL PA

phenobarbital 1

ROZEREM 3 QLL ST

XYREM 4 QLL PA

Drug Name Tier QLL ST PA

CHEMET 3

EXJADE 4 PA

FERRIPROX 3

KIONEX 1

Respiratory Tract Agents, Bronchodilators, Sympathomimetic

Sleep Disorder Agents, Sleep Disorders, Other

Therapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral

Modifiers

Respiratory Tract Agents, Mast Cell Stabilizers

Respiratory Tract Agents, Pulmonary Antihypertensives

Respiratory Tract Agents, Respiratory Tract Agents, Other

Skeletal Muscle Relaxants, Skeletal Muscle Relaxants

Sleep Disorder Agents, GABA Receptor Modulators

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 36: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

Drug Name Tier QLL ST PA

SAMSCA 4 PA

sodium polystyrene sulfonate 1

SYPRINE 3

Drug Name Tier QLL ST PA

acetic acid 1

AMMONIUM CHL 3

calcium chloride 1

calcium gluconate 1

CLINIMIX 3

D5W/LYTES 1

dextrose 5% 1

DIANEAL 1

glycine 1

IONOSOL 1

ISOLYTE 1

kcl 1

lactated ringer's 1

magnesium 1

mannitol irrigation 1

NORMOSOL 1

PHYSIOLYTE 1

PHYSIOSOL 1

PLASMA-LYTE 1

PLASMALYTE-M 1

pot bicarbonate & chloride 1

potassium acetate 1

potassium bicarbonate 1

potassium chloride 1

potassium citrate 1

potassium phosphate 1

ringer's solution 1

sodium acetate 1

sodium chloride 1

sodium citrate & citric acid 1

sodium fluoride 1

sodium phosphate 1

sorbitol irrigation 1

sorbitol-mannitol 1

TPN ELECTROL 1

ULTRABAG/DIANEAL 1

water for irrigation, sterile irrigation 1

Therapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral

Modifiers

Therapeutic Nutrients/Minerals/Electrolytes, Electrolyte/Mineral

Replacement

PA = Prior Authorization May Be RequiredQLL = Quantity Limit May ApplyST = Step Therapy May Be Required

Your specific prescription benefit plan may not cover certain products or categories, regardless oftheir appearance in this document. Please refer to your health plan's website for

the most current information about your plan benefits.

Page 37: Prescription Drug ListFormulary Introduction PREFERRED DRUG LIST The Ambetter from Superior Health Plan Preferred Drug List is a guide to available brand and generic drugs that are

MO HealthNet Preferred Drug List Effective November 1 ...MO HealthNet Preferred Drug List Effective November 1, 2018 All Therapeutic Classes The MO HealthNet Preferred Drug List is

MO HealthNet Preferred Drug List Effective November 1 ...MO HealthNet Preferred Drug List Effective November 1, 2018 All Therapeutic Classes The MO HealthNet Preferred Drug List is

TennCare Preferred Drug List (PDL)

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EFFECTIVE PREFERRED DRUG LISTS

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CareFirst Preferred Drug List - Formulary 1...CareFirst Preferred Drug List - Formulary 1. The . CareFirst Preferred Drug List . is a guide to help you identify products that are both

CareFirst Preferred Drug List - Formulary 1...CareFirst Preferred Drug List - Formulary 1. The . CareFirst Preferred Drug List . is a guide to help you identify products that are both

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Louisiana Medicaid Preferred Drug List (PDL)/Non-Preferred Drug … · 2020-07-01 · Louisiana Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) • The PDL is a

Louisiana Medicaid Preferred Drug List (PDL)/Non-Preferred Drug … · 2020-07-01 · Louisiana Medicaid Preferred Drug List (PDL)/Non-Preferred Drug List (NPDL) • The PDL is a

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PREFERRED DRUG LIST - DVHA Vermont - …dvha.vermont.gov/administration/preferred-drug-list-and-clinical...• The therapeutic classes of drugs subject to the Preferred Drug List,

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Preferred Drug List - bcbsm.com...Preferred Drug List Effective July 1, 2018 This Preferred Drug List is a list of medicines that are covered by your pharmacy benefit. The list includes

Preferred Drug List - bcbsm.com...Preferred Drug List Effective July 1, 2018 This Preferred Drug List is a list of medicines that are covered by your pharmacy benefit. The list includes

State Employees’ Prescription Drug Plan Preferred Drug List€¦ · State Employees’ Prescription Drug Plan Preferred Drug List is a guide that includes medications that may be

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Dual Eligible Preferred Drug List · 2021. 1. 14. · PH-ANR-31Rev120920 Dual Eligible Preferred Drug List This is a supplemental preferred drug list and only applies to members who

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2021 Preferred Drug List (PDL)

THERAPEUTIC DRUG CLASS - dhhr.wv.gov Pharmacy/Documents/Preferred Drug L… · NR – New drug has not been reviewed by P & T Committee AP – Non -preferred drugs and selected preferred

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Illinois Medicaid Preferred Drug List...Illinois Medicaid Preferred Drug List Effective January 1, 2020 The Preferred Drug List (PDL) has products listed in groups by drug class, drug

Utah Medicaid Preferred Drug List Archive... · 2019-10-30 · Utah Medicaid Preferred Drug List Effective September 15, 2015 Preferred Drugs Date Comments Non Preferred Drugs Date

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Utah Medicaid Preferred Drug List...Dec 01, 2017  · Utah Medicaid Preferred Drug List Effective December 1, 2017 Preferred Drugs Date Comments Non Preferred Drugs Date G glimepiride