Preferred Drug List
Blue Cross Complete participates in the Michigan Common Formulary
PH-ANR-13Rev122319
Preferred Drug List
Effective January 1, 2020
This Preferred Drug List is a list of medicines that are covered by your pharmacy benefit. The list includes prescription and non-prescription medicines. In addition to this list, you can use our online search tool. You’ll also find the Preferred Drug List Quick Reference on our website at mibluecrosscomplete.com. This is an easy-to-use summary of the medicines we cover.
If you have questions, please contact Blue Cross Complete of Michigan Pharmacy Services at 1-888-288-3231. You can call this number from 8:30 a.m. until 6 p.m., Monday through Friday.
Encl: Nondiscrimination Notice and Language Services
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
1
Tier Status Notes
Drug Tier Status Notes
Alternative Therapy
Alternative Therapy - Antioxidant
50 Plus Adult Eye Health F
Antioxidant A/C/E/Selenium F
Antioxidant Formula (selenium) F
E-400 C-500 and Beta Carotene F
Healthy Eyes SuperVision F
ICaps AREDS F
I-Vite Protect F
Multi-Betic F
PreserVision AREDS F
SAVision F
Super Antioxidant F
Analgesic, Anti-Inflammatory Or
Antipyretic
Analgesic Opioid Agonists
codeine sulfate oral tablet F QL; AL
fentanyl transdermal patch 72 hour 100 mcg/hr,
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr F PA; QL
hydromorphone oral liquid F QL
hydromorphone oral tablet 2 mg, 4 mg F QL
hydromorphone rectal F QL
meperidine oral F QL; AL
methadone oral concentrate F QL
methadone oral solution F QL
methadone oral tablet F QL
morphine concentrate oral solution F QL
morphine oral solution F QL
morphine oral tablet F QL
morphine oral tablet extended release F QL
oxycodone oral solution F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
2
Drug Tier Status Notes
oxycodone oral tablet 5 mg F QL
tramadol oral tablet F QL; AL
Analgesic Opioid Codeine
Combinations
acetaminophen-codeine oral solution 120-12 mg/5
mL F QL; AL
acetaminophen-codeine oral tablet F QL; AL
Butalbital Compound W/Codeine F QL; AL
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg F QL; AL
codeine-butalbital-ASA-caff F QL; AL
Analgesic Opioid Hydrocodone And
Non-Salicylate Combinations
hydrocodone-acetaminophen oral solution 7.5-
325 mg/15 mL F QL
hydrocodone-acetaminophen oral tablet 10-325
mg, 5-325 mg, 7.5-325 mg F QL
Analgesic Opioid Hydrocodone And
Nsaid Combinations
hydrocodone-ibuprofen oral tablet 5-200 mg, 7.5-
200 mg F QL
Analgesic Opioid Hydrocodone
Combinations
hydrocodone-acetaminophen oral solution 7.5-
325 mg/15 mL F QL
hydrocodone-acetaminophen oral tablet 10-325
mg, 5-325 mg, 7.5-325 mg F QL
hydrocodone-ibuprofen oral tablet 5-200 mg, 7.5-
200 mg F QL
Analgesic Opioid Oxycodone And Non-
Salicylate Combinations
oxycodone-acetaminophen oral tablet 10-325 mg,
5-325 mg, 7.5-325 mg F QL
Analgesic Opioid Oxycodone
Combinations
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
3
Drug Tier Status Notes
oxycodone-acetaminophen oral tablet 10-325 mg,
5-325 mg, 7.5-325 mg F QL
Analgesic Opioid Partial-Mixed
Agonists
pentazocine-naloxone F QL
Analgesic Or Antipyretic Non-Opioid
8 Hour Pain Reliever F OTC
Acetaminophen Extra Strength F OTC
acetaminophen oral elixir F OTC
acetaminophen oral liquid 160 mg/5 mL, 500
mg/5 mL F OTC
acetaminophen oral solution 160 mg/5 mL (5 mL) F OTC
acetaminophen oral suspension 160 mg/5 mL F OTC; QL
acetaminophen oral tablet F OTC
acetaminophen oral tablet extended release F OTC
acetaminophen oral tablet,disintegrating F OTC
Acetaminophen Pain Relief F OTC
acetaminophen rectal F OTC
Arthritis Pain Relief (acetam) F OTC
Arthritis Pain Reliever F OTC
Children's Acetaminophen oral suspension 160
mg/5 mL (5 mL) F OTC
Children's Acetaminophen oral
tablet,disintegrating F OTC
Children's Easy-Melts F OTC
Children's Pain-Fever Relief oral
tablet,disintegrating F OTC
Feverall rectal suppository 325 mg F OTC
Infant's Non-Aspirin oral drops F OTC
Jr. Acetaminophen F OTC
Jr. Str Non-Aspirin Pain F OTC
Jr. Strength Pain Reliever F OTC
Mapap (acetaminophen) oral capsule F OTC
Mapap Arthritis Pain F OTC
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
4
Drug Tier Status Notes
Non-Aspirin Extra Strength oral tablet F OTC
Non-Aspirin oral elixir F OTC
Pain Relief Extra Strength F OTC
Pain Relief oral tablet extended release F OTC
Tylenol Arthritis Pain F OTC
Tylenol Extra Strength oral tablet F OTC
Analgesic Or Antipyretic Non-
Opioid/Sedative Combinations
butalbital-acetaminophen oral tablet 50-325 mg F AL
butalbital-acetaminophen-caff oral tablet 50-325-
40 mg F AL
Anti-Inflammatory - Interleukin-1 Beta
Blockers
Ilaris (PF) subcutaneous solution State Carve Out
Anti-Inflammatory - Interleukin-1
Receptor Antagonist
Arcalyst State Carve Out
Anti-Inflammatory Tumor Necrosis
Factor Inhibiting Agnts,Non-Seiective
Enbrel F PA; QL
Enbrel Mini F PA; QL
Enbrel SureClick F PA; QL
Anti-Inflammatory Tumor Necrosis
Factor Inhibiting Agnts,Tnf-Alpha Sel
CIMZIA 2X200 MG/ML SYRINGE KIT F PA; QL
Cimzia Powder for Reconst F PA; QL
Cimzia Starter Kit F PA; QL
Humira F PA; QL
Humira Pediatric Crohns Start F PA; QL
Humira Pen F PA; QL
Humira Pen Crohns-UC-HS Start F PA; QL
Humira Pen Psor-Uveits-Adol HS F PA; QL
Humira(CF) F PA; QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
5
Drug Tier Status Notes
Humira(CF) Pedi Crohns Starter F PA; QL
Humira(CF) Pen F PA; QL
Humira(CF) Pen Crohns-UC-HS F PA; QL
Humira(CF) Pen Psor-Uv-Adol HS F PA; QL
Dmard - Anti-Inflammatory Tumor
Necrosis Factor Inhibiting Agents
CIMZIA 2X200 MG/ML SYRINGE KIT F PA; QL
Cimzia Powder for Reconst F PA; QL
Cimzia Starter Kit F PA; QL
Enbrel F PA; QL
Enbrel Mini F PA; QL
Enbrel SureClick F PA; QL
Humira F PA; QL
Humira Pediatric Crohns Start F PA; QL
Humira Pen F PA; QL
Humira Pen Crohns-UC-HS Start F PA; QL
Humira Pen Psor-Uveits-Adol HS F PA; QL
Humira(CF) F PA; QL
Humira(CF) Pedi Crohns Starter subcutaneous
syringe kit 80 mg/0.8 mL F PA; QL
Humira(CF) Pen F PA; QL
Humira(CF) Pen Crohns-UC-HS F PA; QL
Humira(CF) Pen Psor-Uv-Adol HS F PA; QL
Dmard - Antimalarials
hydroxychloroquine F
Dmard - Antimetabolites
methotrexate sodium oral F
Xatmep F PA
Dmard - Antinflammatory, Select.
Costimulation Modulator,T-Cell Inhib.
Orencia F PA; QL
Orencia ClickJect F PA; QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
6
Drug Tier Status Notes
Dmard - Immunosuppressives
azathioprine F QL
cyclophosphamide oral capsule F PA
cyclosporine modified oral capsule F
cyclosporine modified oral solution F AL
cyclosporine oral capsule F
mycophenolate mofetil oral capsule F
mycophenolate mofetil oral suspension for
reconstitution F AL
mycophenolate mofetil oral tablet F
Dmard - Interleukin-1 Receptor
Antagonist (Il-1Ra)
Kineret State Carve Out
Dmard - Interleukin-6 (Il-6) Receptor
Inhibitors, Monoclonal Antibody
Actemra ACTPen F PA; QL
Actemra subcutaneous F PA; QL
Dmard - Janus Kinase (Jak) Inhibitors
Olumiant oral tablet 2 mg F PA; QL
Xeljanz oral tablet 5 mg F PA; QL
Xeljanz XR F PA; QL
Dmard - Other
minocycline oral capsule F
sulfasalazine F
Dmard - Phosphodiesterase-4 (Pde4)
Inhibitors
Otezla F PA
Otezla Starter F PA; QL
Dmard - Pyrimidine Synthesis
Inhibitors
leflunomide F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
7
Drug Tier Status Notes
Nsaid Analgesic, Cyclooxygenase-2
(Cox-2) Selective Inhibitors
celecoxib F QL
Nsaid Analgesics (Cox Non-Specific) -
Other
ketorolac oral F AL
nabumetone F QL
sulindac F
Nsaid Analgesics (Cox Non-Specific) -
Oxicam Derivatives
meloxicam oral tablet F QL
piroxicam F QL
Nsaid Analgesics (Cox Non-Specific) -
Phenylacetic Acid Derivatives
diclofenac sodium oral F
Nsaid Analgesics (Cox Non-Specific) -
Propionic Acid Derivatives
Children's Ibuprofen F OTC; QL
flurbiprofen oral tablet 100 mg F
Ibuprofen IB oral tablet,chewable F OTC
Ibuprofen Jr Strength F OTC
ibuprofen oral capsule F OTC; QL
ibuprofen oral drops,suspension F OTC
ibuprofen oral suspension F OTC; QL
ibuprofen oral tablet 100 mg, 200 mg F OTC
ibuprofen oral tablet 400 mg, 600 mg, 800 mg F
ibuprofen oral tablet,chewable F OTC
Infant's Ibuprofen F OTC
Infant's Motrin F OTC
naproxen oral suspension F PA; AL
naproxen oral tablet F
naproxen oral tablet,delayed release (DR/EC) F
naproxen sodium oral capsule F OTC
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
8
Drug Tier Status Notes
naproxen sodium oral tablet 220 mg F OTC; QL
Nsaid Analgesics, (Cox Non-Specific) -
Indole Acetic Acid Derivatives
etodolac oral capsule F QL
etodolac oral tablet F QL
indomethacin oral F AL
Salicylate Analgesic And Sedative
Combinations
butalbital-aspirin-caffeine oral capsule F QL; AL
Salicylate Analgesic Combinations
choline,magnesium salicylate F
Salicylate Analgesics
aspirin oral tablet F OTC; QL; AL
aspirin oral tablet,chewable F OTC; QL
aspirin oral tablet,delayed release (DR/EC) 325
mg F OTC; QL; AL
aspirin oral tablet,delayed release (DR/EC) 81 mg F OTC; QL
aspirin rectal F OTC
Anesthetics
General Anesthetic - Parenteral,
Benzodiazepines
midazolam (PF) injection solution 5 mg/mL F QL
midazolam injection solution 5 mg/mL F QL
General Anesthetic Adjuncts -
Neuroleptic, Butyrophenone Derivative
droperidol injection solution State Carve Out
Antidotes And Other Reversal Agents
Antidote - Acetaminophen Poisoning
acetylcysteine F
Chelating Agents - Lead Poisoning
Chemet F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
9
Drug Tier Status Notes
Opioid Reversal Agents - Opioid
Antagonists
naloxone F QL
naltrexone State Carve Out
Narcan nasal spray,non-aerosol 4 mg/actuation F QL
Anti-Infective Agents
Amebicides
paromomycin F
Aminoglycoside Antibiotic
neomycin F
Aminopenicillin Antibiotic
amoxicillin oral capsule F
amoxicillin oral suspension for reconstitution F AL
amoxicillin oral tablet F
amoxicillin oral tablet,chewable 125 mg, 250 mg F AL
ampicillin oral capsule F
Aminopenicillin Antibiotic - Beta-
Lactamase Inhibitor Combinations
amoxicillin-pot clavulanate oral suspension for
reconstitution F AL
amoxicillin-pot clavulanate oral tablet F
amoxicillin-pot clavulanate oral tablet extended
release 12 hr F
amoxicillin-pot clavulanate oral tablet,chewable F AL
Anthelmintic Agents - Macrocyclic
Lactones
ivermectin oral F
Anthelmintic Agents Other
ivermectin oral F
Antibacterial Folate Antagonist - Other
Combinations
sulfamethoxazole-trimethoprim oral F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
10
Drug Tier Status Notes
Sulfatrim F
Antibacterial Folate Antagonist Others
trimethoprim F
Antibacterial Nitrofuran Derivatives
nitrofurantoin F AL
nitrofurantoin macrocrystal oral capsule 100 mg,
50 mg F QL; AL
nitrofurantoin monohyd/m-cryst F QL; AL
Antifungal - Allylamines
terbinafine HCl oral F QL
Antifungal - Amphoteric Polyene
Macrolides
nystatin oral tablet F
Antifungal - Imidazoles
ketoconazole oral F QL
Antifungal - Triazoles
fluconazole oral suspension for reconstitution F AL
fluconazole oral tablet F
itraconazole oral capsule F
Antifungal Other
griseofulvin microsize F
griseofulvin ultramicrosize F
Antileprotic - Immunomodulators
Thalomid F PA
Antileprotic - Sulfone Agents
dapsone oral F
Antimalarials
chloroquine phosphate F QL
Daraprim Specialty PA
hydroxychloroquine F
Krintafel F PA; QL; AL
mefloquine F PA; QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
11
Drug Tier Status Notes
primaquine F
Antiprotozoal Agents - Nitroimidazole
Derivatives
benznidazole F PA
Antiprotozoal Agents - Other
atovaquone F PA
Antiprotozoal-Antibacterial 1St
Generation 2-Methyl-5-Nitroimidazole
metronidazole oral tablet F
Antiprotozoal-Antibacterial 2Nd
Generation 2-Methyl-5-Nitroimidazole
tinidazole F
Antiretroviral - Anti-Cd4 Domain 2
Monoclonal Antibody
Trogarzo State Carve Out
Antiretroviral - Ccr5 Co-Receptor
Antagonist
Selzentry oral tablet 150 mg, 300 mg State Carve Out
Antiretroviral - Hiv-1 Fusion Inhibitors
Fuzeon subcutaneous recon soln State Carve Out
Antiretroviral - Hiv-1 Integrase Strand
Transfer Inhibitors
Isentress State Carve Out
Tivicay State Carve Out
Antiretroviral - Integrase Inhibitor And
Nnrti Combinations
Juluca State Carve Out
Antiretroviral - Integrase Inhibitor And
Nrti Combinations
Dovato State Carve Out
Antiretroviral - Non-Nucleoside Reverse
Transcriptase Inhib (Nnrti)
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
12
Drug Tier Status Notes
Edurant State Carve Out
Intelence State Carve Out
Rescriptor oral tablet State Carve Out
Sustiva State Carve Out
Viramune State Carve Out
Viramune XR oral tablet extended release 24 hr
400 mg State Carve Out
Antiretroviral - Nucleoside And
Nucleotide Analog Rtis Combinations
Descovy State Carve Out
Truvada State Carve Out
Antiretroviral - Nucleoside Reverse
Transcriptase Inhibitors (Nrti)
abacavir oral tablet State Carve Out
didanosine State Carve Out
Emtriva State Carve Out
Epivir oral solution State Carve Out
lamivudine oral tablet 150 mg, 300 mg State Carve Out
Retrovir intravenous State Carve Out
stavudine oral capsule State Carve Out
Videx 2 gram Pediatric State Carve Out
Zerit oral capsule 30 mg State Carve Out
Ziagen oral solution State Carve Out
zidovudine State Carve Out
Antiretroviral - Nucleotide Analog
Reverse Transcriptase Inhibitors
Viread State Carve Out
Antiretroviral Combinations - Protease
Inhibitors
Evotaz State Carve Out
Kaletra oral tablet State Carve Out
lopinavir-ritonavir State Carve Out
Prezcobix State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
13
Drug Tier Status Notes
Antiretroviral- Nucleoside And
Nucleotide Analogs,Integrase Inhibitors
Genvoya State Carve Out
Stribild State Carve Out
Antiretroviral- Nucleoside And
Nucleotide Analogs,Protease Inhibitors
Symtuza State Carve Out
Antiretroviral-Nucleoside Analogs And
Integrase Inhibitor Combinations
Triumeq State Carve Out
Antiretroviral-Nucleoside Reverse
Transcriptase Inhibitors (Nrti) Comb
abacavir-lamivudine-zidovudine State Carve Out
Epzicom State Carve Out
lamivudine-zidovudine State Carve Out
Antiretroviral-Nucleoside, Nucleotide
Analogs And Non-Nucleoside Rti
Atripla State Carve Out
Complera State Carve Out
Odefsey State Carve Out
Symfi State Carve Out
Symfi Lo State Carve Out
Antitubercular - D-Alanine Analogs
cycloserine F
Antitubercular - Isonicotinic Acid
Derivatives
isoniazid oral solution F AL
isoniazid oral tablet F
Antitubercular - Niacinamide
Derivatives
pyrazinamide F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
14
Drug Tier Status Notes
Antitubercular - Rifamycin And
Derivatives
rifabutin F
rifampin oral F
Antitubercular Agents Other
ethambutol F
Trecator F
Cephalosporin Antibiotics - 1St
Generation
cefadroxil oral capsule F
cefadroxil oral suspension for reconstitution 250
mg/5 mL, 500 mg/5 mL F AL
cefadroxil oral tablet F
cephalexin oral capsule 250 mg, 500 mg F
cephalexin oral suspension for reconstitution F AL
Cephalosporin Antibiotics - 2Nd
Generation
cefaclor oral capsule F
cefaclor oral suspension for reconstitution 125
mg/5 mL, 250 mg/5 mL, 375 mg/5 mL F AL
cefprozil oral suspension for reconstitution F AL
cefprozil oral tablet F
cefuroxime axetil oral tablet F
Cephalosporin Antibiotics - 3Rd
Generation
cefdinir oral capsule F
cefdinir oral suspension for reconstitution F AL
cefixime oral suspension for reconstitution F AL
cefpodoxime oral suspension for reconstitution F AL
cefpodoxime oral tablet F
Suprax oral capsule F
Suprax oral suspension for reconstitution 500
mg/5 mL F AL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
15
Drug Tier Status Notes
Cmv Antiviral Agent - Nucleoside
Analogs
valganciclovir oral tablet F PA; QL
Fluoroquinolone Antibiotics
ciprofloxacin F AL
ciprofloxacin HCl oral tablet 250 mg, 500 mg,
750 mg F
levofloxacin oral solution F AL
levofloxacin oral tablet F
moxifloxacin oral F
ofloxacin oral tablet 400 mg F
Glycopeptide Antibiotics
Firvanq F
vancomycin intravenous recon soln 1,000 mg, 10
gram, 5 gram, 500 mg, 750 mg Specialty
vancomycin oral capsule F
Hepatitis B Treatment- Nucleoside
Analogs (Antiviral)
entecavir F QL
lamivudine oral tablet 100 mg F QL
Hepatitis B Treatment- Nucleotide
Analogs (Antiviral)
adefovir Specialty QL
Vemlidy F PA; QL
Viread State Carve Out
Hepatitis C - Interferons
Pegasys State Carve Out QL
PegIntron subcutaneous kit 50 mcg/0.5 mL State Carve Out QL
Hepatitis C - Ns5a Inhibitor And
Ns3/4A Protease Inhibitor Combination
Mavyret State Carve Out
Zepatier State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
16
Drug Tier Status Notes
Hepatitis C - Ns5a, Ns3/4A Protease,
Nucleo.Ns5b Polymerase Inhib Comb
Vosevi State Carve Out
Hepatitis C - Ns5b Polymerase And
Ns5a Inhibitor Combinations
Harvoni oral tablet 90-400 mg State Carve Out
Hepatitis C - Nucleos(T)Ide Analog
Ns5b Polymerase Inhibitors
Sovaldi oral tablet 400 mg State Carve Out
Hepatitis C - Nucleoside Analogs
Ribasphere oral capsule State Carve Out
Ribasphere oral tablet 600 mg State Carve Out
Ribasphere RibaPak oral tablets,dose pack 600
mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7), 600-
400 mg (28)-mg (28), 600-600 mg (28)-mg (28)
State Carve Out
ribavirin oral capsule State Carve Out
ribavirin oral tablet 200 mg State Carve Out
Hepatitis C- Ns5a, Ns3/4A Protease
And Non-Nucleo.Ns5b Poly Inh. Comb
Viekira Pak State Carve Out
Herpes Antiviral Agent - Purine
Analogs
acyclovir oral capsule F QL
acyclovir oral suspension 200 mg/5 mL F AL
acyclovir oral tablet F QL
valacyclovir F QL
Herpes Antiviral Agent - Thymidine
Analogs
famciclovir F QL
Influenza Antiviral Agents -
Neuraminidase Inhibitors
oseltamivir oral capsule F QL
Relenza Diskhaler F QL; AL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
17
Drug Tier Status Notes
Tamiflu oral suspension for reconstitution F QL; AL
Influenza-A Antiviral Agents
rimantadine F
Lincosamide Antibiotics
clindamycin HCl F
clindamycin palmitate HCl F AL
Macrolide Antibiotics
azithromycin oral packet F QL
azithromycin oral suspension for reconstitution F AL
azithromycin oral tablet F
clarithromycin oral suspension for reconstitution F AL
clarithromycin oral tablet F
Dificid F PA
Misc Anti-Infective
methenamine hippurate F
methenamine mandelate F
Misc Anti-Infective Combinations
Uretron D-S oral tablet 81.6-10.8-40.8 mg F
Utira-C F
Oxazolidinone Antibiotics
linezolid F PA
Penicillin Antibiotic - Natural
penicillin V potassium oral recon soln F AL
penicillin V potassium oral tablet F
Penicillin Antibiotic - Penicillinase-
Resistant
dicloxacillin F
Protease Inhibitors (Non-Peptidic)
Antiretroviral
Aptivus State Carve Out
Prezcobix State Carve Out
Prezista oral suspension State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
18
Drug Tier Status Notes
Prezista oral tablet 150 mg, 600 mg, 75 mg, 800
mg State Carve Out
Protease Inhibitors (Peptidic)
Antiretroviral
Crixivan oral capsule 200 mg, 400 mg State Carve Out
Evotaz State Carve Out
Invirase oral tablet State Carve Out
Lexiva State Carve Out
Norvir State Carve Out
Reyataz oral capsule 150 mg, 200 mg, 300 mg State Carve Out
Reyataz oral powder in packet State Carve Out
Viracept oral tablet State Carve Out
Rifamycins And Related Derivative
Antibiotics
rifabutin F
rifampin oral F
Tetracycline Antibiotics
doxycycline hyclate oral capsule F
doxycycline hyclate oral tablet 100 mg F
doxycycline monohydrate oral capsule 100 mg,
50 mg F
doxycycline monohydrate oral suspension for
reconstitution F AL
doxycycline monohydrate oral tablet 100 mg, 50
mg F
minocycline oral capsule F
tetracycline F
Antineoplastics
Antineoplasic-Epiderm.Growth Factor-
Egfr (Erbb1),Her-2 (Erbb2)R.Inhib
Tykerb State Carve Out
Antineoplastic - Cyp17 (17 Alpha-
Hydroxylase/C17,20-Lyase) Inhibitor
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
19
Drug Tier Status Notes
Yonsa F PA
Zytiga Specialty PA; QL
Antineoplastic - 1St Generation Egfr
Tyrosine Kinase Inhibitor
Tarceva State Carve Out
Antineoplastic - 2Nd Generation Egfr
Tyrosine Kinase Inhibitor
Gilotrif State Carve Out
Antineoplastic - Alkylating Agent -
Alkyl Sulfonates
Myleran F PA
Antineoplastic - Alkylating Agent -
Methylhydrazines
Matulane F PA
Antineoplastic - Alkylating Agent -
Nitrogen Mustards
Alkeran F PA
cyclophosphamide oral capsule F PA
Leukeran F PA
Antineoplastic - Alkylating Agent -
Nitrosoureas
Gleostine oral capsule 10 mg, 100 mg, 40 mg Specialty PA
Antineoplastic - Alkylating Agent -
Triazenes
Temodar oral Specialty PA
temozolomide Specialty PA
Antineoplastic - Anaplastic Lymphoma
Kinase (Alk) Inhibitors
Alunbrig oral tablet 30 mg State Carve Out
Xalkori State Carve Out
Antineoplastic - Antiadrenals
Lysodren F PA
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
20
Drug Tier Status Notes
Antineoplastic - Antiandrogens
bicalutamide F PA
Erleada F PA; QL
flutamide F PA
nilutamide F PA
Nubeqa F PA
Xtandi Specialty PA; QL
Yonsa F PA
Zytiga Specialty PA; QL
Antineoplastic - Antimetabolite - Folic
Acid Analogs
methotrexate sodium F
methotrexate sodium (PF) injection solution F
Xatmep F PA
Antineoplastic - Antimetabolite - Purine
Analogs
mercaptopurine F
Tabloid F PA
Antineoplastic - Antimetabolite -
Pyrimidine Analogs
capecitabine F PA
Antineoplastic - Antimetabolite - Urea
Derivatives
hydroxyurea F
Antineoplastic - Antimetabolites -
Pyrimidine Analog Combinations
Lonsurf Specialty PA
Antineoplastic - Aromatase Inhibitors
anastrozole F
exemestane F
letrozole F QL; AL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
21
Drug Tier Status Notes
Antineoplastic - B-Cell Lymphoma-2
(Bcl-2) Inhibitors
Venclexta Specialty PA
Venclexta Starting Pack Specialty PA
Antineoplastic - Braf Kinase Inhibitors
Braftovi F PA
Tafinlar State Carve Out
Zelboraf State Carve Out
Antineoplastic - Bruton's Tyrosine
Kinase (Btk) Inhibitor
Imbruvica oral capsule 140 mg State Carve Out
Antineoplastic - Cyclin-Dependent
Kinase (Cdk) 4/6 Inhibitors
Ibrance State Carve Out
Kisqali State Carve Out
Verzenio State Carve Out
Antineoplastic - Epipodophyllotoxins
etoposide oral Specialty PA
Antineoplastic - Estrogens
Emcyt F PA
Antineoplastic - Exportin-1 (Xpo1)
Inhibitors
Xpovio F PA
Antineoplastic - Hedgehog Pathway
Inhibitor
Daurismo Specialty PA
Erivedge Specialty PA; QL
Odomzo F PA
Antineoplastic - Histone Deacetylase
(Hdac) Inhibitors
Farydak F PA
Zolinza Specialty PA
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
22
Drug Tier Status Notes
Antineoplastic - Interferons
Intron A injection Specialty PA
Antineoplastic - Janus Kinase (Jak)
Inhibitors
Jakafi Specialty PA; QL
Antineoplastic - Lhrh (Gnrh) Agonist
Analog Pituitary Suppressants
leuprolide subcutaneous kit F PA
Antineoplastic - Mek1 And Mek2
Kinase Inhibitors
Cotellic State Carve Out
Mekinist State Carve Out
Antineoplastic - Mtor Kinase Inhibitors
Afinitor Disperz Specialty PA; QL
Afinitor oral tablet 10 mg, 2.5 mg, 5 mg Specialty PA; QL
Afinitor oral tablet 7.5 mg Specialty PA
Antineoplastic - Multikinase Inhibitors
Cometriq State Carve Out
Iclusig State Carve Out
Nexavar State Carve Out
Antineoplastic - Mutant Isocitrate
Dehydrogenase 1 (Midh1) Inhibitors
Tibsovo F PA
Antineoplastic - Mutant Isocitrate
Dehydrogenase 2 (Midh2) Inhibitors
Idhifa F PA
Antineoplastic - Phosphatidylinositol 3-
Kinase (Pi3k) Inhibitors
Zydelig State Carve Out
Antineoplastic - Pi3k-Delta Inhibitors
Zydelig State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
23
Drug Tier Status Notes
Antineoplastic - Poly (Adp-Ribose)
Polymerase (Parp) Inhibitors
Rubraca oral tablet 250 mg State Carve Out
Zejula State Carve Out
Antineoplastic - Progestins
megestrol oral tablet F
Antineoplastic - Proteasome Enzyme
Inhibitors
Kyprolis intravenous recon soln 60 mg State Carve Out
Velcade State Carve Out
Antineoplastic - Protein-Tyrosine
Kinase Inhibitors
Bosulif oral tablet 500 mg State Carve Out
Caprelsa State Carve Out
Gleevec State Carve Out
Imbruvica oral capsule 140 mg State Carve Out
Inlyta State Carve Out
Lenvima oral capsule 10 mg/day (10 mg x 1), 14
mg/day(10 mg x 1-4 mg x 1), 20 mg/day (10 mg x
2), 24 mg/day(10 mg x 2-4 mg x 1)
State Carve Out
Sprycel State Carve Out
Sutent State Carve Out
Tasigna oral capsule 150 mg, 200 mg State Carve Out
Votrient State Carve Out
Antineoplastic - Retinoids
tretinoin (chemotherapy) Specialty PA
Antineoplastic - Selective Estrogen
Receptor Modulators (Serms)
tamoxifen F QL
toremifene F PA
Antineoplastic - Selective Inhibitiors Of
Nuclear Export (Sine)
Xpovio F PA
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
24
Drug Tier Status Notes
Antineoplastic - Selective Retinoid X
Receptor Agonists
bexarotene F PA
Targretin oral Specialty
Antineoplastic - Thalidomide Analogs
Pomalyst F PA
Revlimid oral capsule 10 mg, 15 mg, 25 mg, 5 mg Specialty PA; QL
Revlimid oral capsule 2.5 mg, 20 mg Specialty PA
Thalomid F PA
Antineoplastic - Topoisomerase I
Inhibitors
Hycamtin oral Specialty PA
Methotrexate Rescue Agents
leucovorin calcium oral F
Methotrexate Rescue Agents - Folic
Acid Antagonist Type
leucovorin calcium oral F
Urinary Tract Protective Agents Used
In Conjunction With Chemotherapy
Mesnex oral F PA
Antiseptics And Disinfectants
Antiseptic - Alcohols
alcohol swabs F OTC; QL
Biologicals
Antiviral Monoclonal Antibodies
Synagis F PA
Antiviral Monoclonal Antibodies -
Respiratory Syncytial Virus (Rsv)
Synagis F PA
Gene Therapy Agents - Smn Protein
Deficiency
Zolgensma State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
25
Drug Tier Status Notes
Hepatitis A Vaccine - Single Agents
Havrix (PF) intramuscular suspension 1,440
ELISA unit/mL F AL
Havrix (PF) intramuscular syringe F AL
Vaqta (PF) F AL
Live Vaccine And Live Virus
Formulations
M-M-R II (PF) F QL
Toxoid Vaccine Combinations
Adacel(Tdap Adolesn/Adult)(PF) F
Boostrix Tdap F
Vaccine Bacterial - Gram Positive Cocci
Pneumovax 23 injection solution F
Pneumovax 23 injection syringe F QL
Prevnar 13 (PF) F
Vaccine Viral - Influenza A And B
Afluria Qd 2019-20(3yr up)(PF) F QL; AL
Afluria Qd 2019-20(6-35mo)(PF) F QL; AL
Afluria Quad 2019-20(6mo up) F QL; AL
Fluarix Quad 2019-2020 (PF) F QL; AL
Flublok Quad 2019-2020 (PF) F QL; AL
Flulaval Quad 2019-2020 F QL; AL
Flulaval Quad 2019-2020 (PF) F QL; AL
Fluzone High-Dose 2019-20 (PF) F QL; AL
Fluzone Quad 2019-2020 F QL; AL
Fluzone Quad 2019-2020 (PF) F QL; AL
Fluzone Quad Pedi 2019-20 (PF) F QL; AL
Vaccine Viral - Measles
M-M-R II (PF) F QL
Vaccine Viral - Mumps And Related
M-M-R II (PF) F QL
Vaccine Viral - Rubella
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
26
Drug Tier Status Notes
M-M-R II (PF) F QL
Vaccine Viral - Varicella
Shingrix (PF) F QL; AL
Shingrix gE Antigen Component F QL; AL
Vaccine Viral Combinations
M-M-R II (PF) F QL
Cardiovascular Therapy Agents
Ace Inhibitor And Calcium Channel
Blocker Combinations
amlodipine-benazepril F
Ace Inhibitor And Diuretic
Combinations
enalapril-hydrochlorothiazide F
lisinopril-hydrochlorothiazide F
quinapril-hydrochlorothiazide F
Ace Inhibitors
benazepril F
enalapril maleate F
Epaned oral solution F
fosinopril F
lisinopril F
perindopril erbumine oral tablet 2 mg, 4 mg F
Qbrelis F AL
quinapril F
ramipril F
trandolapril F
Aldosterone Receptor Antagonists
spironolactone F
Alpha-Beta Blockers
carvedilol F
labetalol oral F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
27
Drug Tier Status Notes
Angiotensin Ii Receptor Blocker (Arb)-
Calcium Channel Blocker Comb.
amlodipine-valsartan F
Angiotensin Ii Receptor Blocker (Arb)-
Diuretic Combinations
irbesartan-hydrochlorothiazide F
losartan-hydrochlorothiazide F
valsartan-hydrochlorothiazide oral tablet 160-12.5
mg, 160-25 mg, 80-12.5 mg F QL
valsartan-hydrochlorothiazide oral tablet 320-12.5
mg, 320-25 mg F
Angiotensin Ii Receptor Blocker-
Neprilysin Inhibitor Comb. (Arni)
Entresto F QL; AL
Angiotensin Ii Receptor Blockers (Arbs)
irbesartan F
losartan F
valsartan F QL
Antianginal - Coronary Vasodilators
(Nitrates)
isosorbide dinitrate oral F
isosorbide mononitrate oral tablet F
isosorbide mononitrate oral tablet extended
release 24 hr F QL
Nitro-Bid F
nitroglycerin oral capsule, extended release 2.5
mg, 6.5 mg F
nitroglycerin sublingual tablet 0.4 mg F
nitroglycerin transdermal patch 24 hour F QL
nitroglycerin translingual spray,non-aerosol F ST
Nitrostat F
Nitro-Time oral capsule, extended release 9 mg F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
28
Drug Tier Status Notes
Antianginal And Anti-Ischemic Agents,
Non-Hemodynamic
Ranexa F PA
Antiarrhythmic - Class Ia
disopyramide phosphate oral capsule F AL
quinidine sulfate oral tablet F
Antiarrhythmic - Class Ib
mexiletine F
phenytoin sodium State Carve Out
Antiarrhythmic - Class Ic
flecainide F
propafenone oral tablet F
Antiarrhythmic - Class Ii
Sotalol AF F
sotalol oral F QL
Antiarrhythmic - Class Iii
amiodarone oral F
Antiarrhythmic - Class Iv
verapamil oral tablet F
Antihyperlipidemic - Bile Acid
Sequestrants
cholestyramine (with sugar) oral powder F QL
cholestyramine (with sugar) oral powder in packet F
Cholestyramine Light F
colestipol oral granules F
colestipol oral tablet F
Antihyperlipidemic - Fibric Acid
Derivatives
fenofibrate micronized oral capsule 134 mg, 200
mg, 43 mg, 67 mg F QL
fenofibrate nanocrystallized oral tablet 145 mg,
48 mg F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
29
Drug Tier Status Notes
fenofibrate oral capsule 50 mg F QL
fenofibrate oral tablet 160 mg, 54 mg F QL
fenofibric acid (choline) F QL
gemfibrozil F QL
Antihyperlipidemic - Hmg Coa
Reductase Inhibitors (Statins)
atorvastatin F QL
lovastatin F QL
pravastatin F QL
rosuvastatin F QL
simvastatin F QL
Antihyperlipidemic - Omega-3 Fatty
Acid Type
omega-3 acid ethyl esters F PA
Antihyperlipidemic - Selective
Cholesterol Absorption Inhibitor
ezetimibe F PA; QL
Antihyperlipidemic Agents - Dietary
Source
choline bitartrate F
omega-3 acid ethyl esters F PA
omega-3 fatty acids oral capsule F
Prenatal DHA oral capsule 200 mg F
Antihyperlipidemic Agents - Dietary
Source Combinations
Fish Oil Extra Strength F
Fish Oil oral capsule 100-160-1,000 mg, 120-180-
500 mg, 183.3 mg-75 mg -91.6 mg-306 mg, 300-
500 mg, 340-1,000 mg
F
omega 3-dha-epa-fish oil oral capsule 1,000 mg
(120 mg-180 mg), 1,200 (144-216) mg, 300-1,000
mg, 500-1,000 mg, 60-90-500 mg
F
omega 3-dha-epa-fish oil oral capsule,delayed
release(DR/EC) 300-1,000 mg F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
30
Drug Tier Status Notes
omega-3 fatty acids-fish oil oral capsule 300-
1,000 mg, 360-1,200 mg F
vitamin E oral capsule 100 unit, 400 unit F
Beta Blockers Cardiac Selective
atenolol F
betaxolol oral F
bisoprolol fumarate F QL
metoprolol succinate F QL
metoprolol tartrate oral tablet 100 mg, 25 mg, 50
mg F QL
Beta Blockers Cardiac Selective,
Intrinsic Sympathomimetic Activity
acebutolol F
Beta Blockers Non-Cardiac Selective
Hemangeol F AL
nadolol F
propranolol oral capsule,extended release 24 hr F QL
propranolol oral solution F
propranolol oral tablet F
Sotalol AF F
sotalol oral F QL
Calcium Channel Blockers -
Benzothiazepines
diltiazem HCl oral capsule,ext.rel 24h degradable F QL
diltiazem HCl oral capsule,extended release 24 hr F QL
diltiazem HCl oral capsule,extended release 24hr
120 mg, 180 mg, 240 mg, 300 mg F QL
diltiazem HCl oral tablet F
diltiazem HCl oral tablet extended release 24 hr
180 mg, 300 mg F QL
Calcium Channel Blockers -
Dihydropyridines
amlodipine F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
31
Drug Tier Status Notes
felodipine F QL
isradipine F QL
nicardipine oral F QL
nifedipine oral capsule F QL; AL
nifedipine oral tablet extended release F QL
nifedipine oral tablet extended release 24hr F QL
Calcium Channel Blockers -
Dihydropyridines - Cerebrovascular
Specific
nimodipine F QL
Calcium Channel Blockers -
Phenylakylamines
verapamil oral capsule, 24 hr ER pellet CT F QL
verapamil oral capsule,ext rel. pellets 24 hr 120
mg, 180 mg, 240 mg F QL
verapamil oral tablet F
verapamil oral tablet extended release F QL
Cardiac Selective Beta Blocker-Thiazide
Diuretic And Related Comb.
atenolol-chlorthalidone F
bisoprolol-hydrochlorothiazide F QL
Cardiovascular Sympathomimetic -
Anaphylaxis Therapy Single Agents
epinephrine injection auto-injector F QL
Symjepi injection syringe 0.3 mg/0.3 mL F QL
Cardiovascular Sympathomimetics
midodrine F QL
Central Alpha-2 Agonists-Thiazide
Diuretic And Related Comb.
methyldopa-hydrochlorothiazide F
Central Alpha-2 Receptor Agonists
clonidine F QL
clonidine HCl oral tablet F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
32
Drug Tier Status Notes
guanfacine oral tablet F QL
methyldopa F AL
Digitalis Glycosides
digoxin oral tablet F
Direct Acting Vasodilators
hydralazine injection F
hydralazine oral F QL
minoxidil oral F
Diuretic - Aldosterone Receptor
Antagonist, Non-Selective
spironolactone F
Diuretic - Carbonic Anhydrase
Inhibitors
acetazolamide F
Diuretic - Loop
bumetanide oral F
furosemide oral solution 10 mg/mL, 40 mg/5 mL
(8 mg/mL) F AL
furosemide oral tablet F
torsemide oral F
Diuretic - Potassium Sparing
amiloride F QL
Diuretic - Potassium Sparing-Thiazide
And Related Combinations
amiloride-hydrochlorothiazide F QL
spironolacton-hydrochlorothiaz F QL
triamterene-hydrochlorothiazid oral capsule 37.5-
25 mg F
triamterene-hydrochlorothiazid oral tablet F
Diuretic - Thiazides And Related
chlorothiazide oral tablet 500 mg F
chlorthalidone oral tablet 25 mg, 50 mg F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
33
Drug Tier Status Notes
Diuril F AL
hydrochlorothiazide F
indapamide F QL
metolazone F QL
Peripheral Alpha-1 Receptor Blockers
doxazosin F QL
prazosin F QL
terazosin F QL
Plasma Kallikrein Inhibitor Agents
Kalbitor State Carve Out
Plasma Kallikrein Inhibitor Agents,
Recombinant Protein
Kalbitor State Carve Out
Pulmonary Antihypertensive Agents-
Soluble Guanylate Cyclase Stimulator
Adempas Specialty PA; QL
Pulmonary Arterial Hypertension -
Endothelin Receptor Antagonists
Letairis Specialty PA; QL
Tracleer oral tablet Specialty PA; QL
Tracleer oral tablet for suspension F PA; AL
Pulmonary Arterial Hypertension
Agents-Selective Cgmp-Pde5 Inhibitors
sildenafil (pulm.hypertension) oral tablet F PA
tadalafil (pulm. hypertension) F PA; QL
Renin Inhibitor, Direct
Tekturna F PA; QL
Renin Inhibitor, Direct And Diuretic
Combinations
Tekturna HCT oral tablet 300-12.5 mg, 300-25
mg F PA; QL
Central Nervous System Agents
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
34
Drug Tier Status Notes
Antianxiety Agent - Antihistamine Type
hydroxyzine HCl oral solution 10 mg/5 mL F AL
hydroxyzine HCl oral tablet F AL
hydroxyzine pamoate oral capsule 25 mg, 50 mg F AL
Antianxiety Agent - Benzodiazepines
Alprazolam Intensol State Carve Out
alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg State Carve Out
alprazolam oral tablet extended release 24 hr 0.5
mg, 1 mg, 2 mg State Carve Out
alprazolam oral tablet,disintegrating State Carve Out
chlordiazepoxide HCl State Carve Out
clonazepam oral tablet 1 mg, 2 mg State Carve Out
clonazepam oral tablet,disintegrating State Carve Out
clorazepate dipotassium State Carve Out
diazepam injection State Carve Out
Diazepam Intensol State Carve Out
diazepam oral solution State Carve Out
diazepam oral tablet State Carve Out
Klonopin oral tablet 0.5 mg State Carve Out
Lorazepam Intensol State Carve Out
lorazepam oral tablet State Carve Out
oxazepam State Carve Out
Xanax oral tablet 2 mg State Carve Out
Xanax XR oral tablet extended release 24 hr 3 mg State Carve Out
Antianxiety Agent - Dicarbamate Type
meprobamate State Carve Out
Antianxiety Agent - Non-
Benzodiazepine
buspirone State Carve Out
Anticonvulsant - Ampa-Type Glutamate
Receptor Antagonists
Fycompa oral tablet State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
35
Drug Tier Status Notes
Anticonvulsant - Barbiturates And
Derivatives
phenobarbital State Carve Out
phenobarbital sodium injection solution State Carve Out
primidone State Carve Out
Anticonvulsant - Benzodiazepines
clonazepam oral tablet 1 mg, 2 mg State Carve Out
clonazepam oral tablet,disintegrating State Carve Out
Diastat AcuDial State Carve Out
diazepam rectal kit 2.5 mg State Carve Out
Klonopin oral tablet 0.5 mg State Carve Out
Onfi oral suspension State Carve Out
Onfi oral tablet 10 mg, 20 mg State Carve Out
Anticonvulsant - Cannabinoid Type
Epidiolex State Carve Out
Anticonvulsant - Carbamates
Felbatol State Carve Out
Anticonvulsant - Carboxylic Acid
Derivatives
Depacon State Carve Out
Depakote ER oral tablet extended release 24 hr
250 mg State Carve Out
Depakote Sprinkles State Carve Out
divalproex oral tablet extended release 24 hr 500
mg State Carve Out
divalproex oral tablet,delayed release (DR/EC) State Carve Out
valproic acid State Carve Out
Anticonvulsant - Functionalized Amino
Acid
Vimpat State Carve Out
Anticonvulsant - Gaba Analogs
gabapentin oral capsule 300 mg State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
36
Drug Tier Status Notes
gabapentin oral solution 250 mg/5 mL (5 mL),
300 mg/6 mL (6 mL) State Carve Out
gabapentin oral tablet 600 mg, 800 mg State Carve Out
Lyrica State Carve Out
Neurontin oral capsule 100 mg, 400 mg State Carve Out
Neurontin oral solution State Carve Out
Anticonvulsant - Gaba Re-Uptake
Inhibitor, Nipecotic Acid Derivatives
Gabitril oral tablet 12 mg, 16 mg, 4 mg State Carve Out
tiagabine oral tablet 2 mg, 4 mg State Carve Out
Anticonvulsant - Gaba Transaminase
(Gaba-T) Inhibitor
Sabril State Carve Out
vigabatrin oral tablet State Carve Out
Anticonvulsant - Hydantoins
Cerebyx State Carve Out
Dilantin State Carve Out
Dilantin Extended State Carve Out
Dilantin Infatabs State Carve Out
Peganone State Carve Out
Phenytek State Carve Out
phenytoin oral suspension State Carve Out
phenytoin sodium State Carve Out
Anticonvulsant - Iminostilbene
Derivatives
Aptiom State Carve Out
carbamazepine oral capsule, ER multiphase 12 hr State Carve Out
carbamazepine oral tablet,chewable State Carve Out
Equetro State Carve Out
oxcarbazepine State Carve Out
Oxtellar XR State Carve Out
Tegretol oral suspension State Carve Out
Tegretol oral tablet State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
37
Drug Tier Status Notes
Tegretol XR State Carve Out
Anticonvulsant - Monosaccharide
Derivatives
Qudexy XR State Carve Out
topiramate oral capsule, sprinkle State Carve Out
topiramate oral tablet State Carve Out
Trokendi XR State Carve Out
Anticonvulsant - Phenyltriazine
Derivatives
Lamictal ODT State Carve Out
Lamictal ODT Starter (Blue) State Carve Out
Lamictal ODT Starter (Green) State Carve Out
Lamictal ODT Starter (Orange) State Carve Out
Lamictal oral tablet State Carve Out
Lamictal oral tablet, chewable dispersible 25 mg State Carve Out
Lamictal Starter (Blue) Kit State Carve Out
Lamictal Starter (Green) Kit State Carve Out
Lamictal Starter (Orange) Kit State Carve Out
Lamictal XR oral tablet extended release 24hr
200 mg, 250 mg, 300 mg State Carve Out
Lamictal XR Starter (Blue) State Carve Out
Lamictal XR Starter (Green) State Carve Out
Lamictal XR Starter (Orange) State Carve Out
lamotrigine oral tablet extended release 24hr 100
mg, 25 mg, 50 mg State Carve Out
lamotrigine oral tablet, chewable dispersible 5 mg State Carve Out
Anticonvulsant - Pyrrolidine
Derivatives
levetiracetam in NaCl (iso-os) State Carve Out
levetiracetam intravenous State Carve Out
levetiracetam oral solution 100 mg/mL State Carve Out
levetiracetam oral tablet State Carve Out
levetiracetam oral tablet extended release 24 hr State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
38
Drug Tier Status Notes
Anticonvulsant - Succinimides
Celontin oral capsule 300 mg State Carve Out
ethosuximide State Carve Out
Anticonvulsant - Sulfonamide
Derivatives
zonisamide State Carve Out
Anticonvulsant - Triazole Derivatives
Banzel State Carve Out
Antidepressant - Alpha-2 Receptor
Antagonists (Nassa)
mirtazapine State Carve Out
Antidepressant - Mao Inhibitor
Nonselective And Irreversible-Types
A,B
Emsam State Carve Out
Marplan State Carve Out
phenelzine State Carve Out
tranylcypromine State Carve Out
Antidepressant - N-Methyl D-Aspartate
(Nmda) Receptor Antagonist
Spravato State Carve Out
Antidepressant - Selective Serotonin
Reuptake Inhibitors (Ssris)
citalopram State Carve Out
escitalopram oxalate State Carve Out
fluoxetine oral capsule 10 mg, 40 mg State Carve Out
fluoxetine oral solution State Carve Out
fluoxetine oral tablet 10 mg, 60 mg State Carve Out
fluvoxamine State Carve Out
paroxetine HCl oral tablet State Carve Out
paroxetine HCl oral tablet extended release 24 hr State Carve Out
Paxil oral suspension State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
39
Drug Tier Status Notes
Pexeva State Carve Out
Prozac oral capsule 20 mg State Carve Out
Sarafem oral tablet 20 mg State Carve Out
sertraline oral concentrate State Carve Out
sertraline oral tablet 25 mg, 50 mg State Carve Out
Zoloft oral tablet 100 mg State Carve Out
Antidepressant - Serotonin-2
Antagonist-Reuptake Inhibitors (Saris)
nefazodone State Carve Out
trazodone State Carve Out
Antidepressant - Serotonin-
Norepinephrine Reuptake Inhibitors
(Snris)
Cymbalta oral capsule,delayed release(DR/EC)
60 mg State Carve Out
desvenlafaxine State Carve Out
duloxetine oral capsule,delayed release(DR/EC)
20 mg, 30 mg State Carve Out
Effexor XR oral capsule,extended release 24hr
150 mg State Carve Out
Fetzima State Carve Out
Pristiq State Carve Out
venlafaxine oral capsule,extended release 24hr
37.5 mg, 75 mg State Carve Out
venlafaxine oral tablet State Carve Out
venlafaxine oral tablet extended release 24hr State Carve Out
Antidepressant - Ssri And 5Ht1a Partial
Agonist
Viibryd oral tablet State Carve Out
Viibryd oral tablets,dose pack 10 mg (7)- 20 mg
(23) State Carve Out
Antidepressant - Ssri And Serotonin (5-
Ht) Receptor Modulator
Trintellix State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
40
Drug Tier Status Notes
Antidepressant - Tricyclic And
Antipsychotic, Phenothiazine Comb
perphenazine-amitriptyline State Carve Out
Antidepressant - Tricyclic-
Benzodiazepine Combinations
amitriptyline-chlordiazepoxide State Carve Out
Antidepressant- Ssri And Atypical
Antipsych,Dopamine,Serotonin
Antagon
olanzapine-fluoxetine oral capsule 12-25 mg, 12-
50 mg, 3-25 mg, 6-25 mg State Carve Out
Symbyax oral capsule 6-50 mg State Carve Out
Antidepressant-Norepinephrine And
Dopamine Reuptake Inhibitors (Ndris)
Aplenzin State Carve Out
bupropion HCl oral tablet State Carve Out
bupropion HCl oral tablet extended release 24 hr
150 mg, 300 mg State Carve Out
bupropion HCl oral tablet sustained-release 12 hr
150 mg F QL
bupropion HCl oral tablet sustained-release 12 hr
200 mg State Carve Out
Forfivo XL State Carve Out
Wellbutrin SR oral tablet sustained-release 12 hr
100 mg, 150 mg State Carve Out
Antidepressant-Tricyclics And Related
(Non-Select Reuptake Inhibitors)
amitriptyline State Carve Out
amoxapine State Carve Out
clomipramine State Carve Out
desipramine State Carve Out
doxepin oral State Carve Out
imipramine HCl State Carve Out
imipramine pamoate State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
41
Drug Tier Status Notes
maprotiline State Carve Out
nortriptyline State Carve Out
protriptyline State Carve Out
trimipramine oral capsule 100 mg, 50 mg State Carve Out
Antiparkinson - Dopaminerg-Peripheral
Dopa-Decarboxylase Inhibit Comb
carbidopa-levodopa F
Antiparkinson Therapy -
Anticholinergic Agents
benztropine State Carve Out
trihexyphenidyl State Carve Out
Antiparkinson Therapy - Ergot
Alkaloids And Derivatives
bromocriptine F QL
Antiparkinson Therapy - Monoamine
Oxidase Inhibitor(Mao-B)
selegiline HCl oral capsule F QL
Antiparkinson Therapy - Non-Ergot
Dopamine Agonist Agents
amantadine HCl oral capsule F QL
amantadine HCl oral solution F QL
pramipexole oral tablet F QL
ropinirole oral tablet F QL
Antipsychotic - Atyp Dopamine-
Serotonin Antag Dibenzo-Oxepino
Pyrroles
Saphris sublingual tablet 2.5 mg State Carve Out
Antipsychotic - Atypical Dopamine-
Serotonin Antag- Benzisothiazolones
Geodon intramuscular State Carve Out
Geodon oral capsule 20 mg, 40 mg, 80 mg State Carve Out
Latuda State Carve Out
ziprasidone HCl oral capsule 60 mg State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
42
Drug Tier Status Notes
Antipsychotic - Atypical Dopamine-
Serotonin Antag- Benzisoxazole Deriv
Fanapt State Carve Out
Invega State Carve Out
Invega Sustenna State Carve Out
Invega Trinza State Carve Out
Risperdal Consta State Carve Out
risperidone oral solution State Carve Out
risperidone oral tablet State Carve Out
risperidone oral tablet,disintegrating State Carve Out
Antipsychotic - Atypical Dopamine-
Serotonin Antag-Dibenzodiazepine Der
clozapine oral tablet State Carve Out
clozapine oral tablet,disintegrating 100 mg, 12.5
mg, 200 mg, 25 mg State Carve Out
Versacloz State Carve Out
Antipsychotic - Butyrophenone
Derivatives
haloperidol State Carve Out
haloperidol decanoate State Carve Out
haloperidol lactate injection State Carve Out
haloperidol lactate oral State Carve Out
Antipsychotic - Dibenzoxazepine
Derivatives
Adasuve State Carve Out
loxapine succinate State Carve Out
Antipsychotic - Phenothiazines,
Aliphatic
chlorpromazine State Carve Out
Antipsychotic - Phenothiazines,
Piperazine
fluphenazine decanoate State Carve Out
fluphenazine HCl State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
43
Drug Tier Status Notes
perphenazine State Carve Out
prochlorperazine maleate F QL
trifluoperazine State Carve Out
Antipsychotic - Phenothiazines,
Piperidine
thioridazine State Carve Out
Antipsychotic - Thioxanthenes
thiothixene State Carve Out
Antipsychotic -Atypical Dopamine-
Serotonin Antag-Dibenzothiazepine Der
quetiapine State Carve Out
Seroquel XR oral tablet, Ext Rel 24hr dose pack State Carve Out
Antipsychotic -Atypical Dopamine-
Serotonin Antag-
Thienobenzodiazepines
olanzapine intramuscular State Carve Out
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20
mg, 7.5 mg State Carve Out
olanzapine oral tablet,disintegrating State Carve Out
olanzapine-fluoxetine oral capsule 12-25 mg, 12-
50 mg, 3-25 mg, 6-25 mg State Carve Out
Symbyax oral capsule 6-50 mg State Carve Out
Zyprexa oral tablet 5 mg State Carve Out
Zyprexa Relprevv State Carve Out
Antipsychotic-Atypical,D2 Receptor
Partial Agonist-5Ht Serotonin Mixed
Abilify Maintena State Carve Out
Abilify oral tablet State Carve Out
aripiprazole oral tablet State Carve Out
Aristada intramuscular suspension,extended rel
syring 1,064 mg/3.9 mL State Carve Out
Rexulti State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
44
Drug Tier Status Notes
Antipsychotic-Atypical,D3/D2 Receptor
Partial Agonist-Serotonin Mixed
Vraylar State Carve Out
Attention Deficit-Hyperact. Disorder
(Adhd)- Alpha-2 Receptor Agonist
clonidine HCl oral tablet extended release 12 hr State Carve Out
guanfacine oral tablet extended release 24 hr State Carve Out
Intuniv ER State Carve Out
Kapvay State Carve Out
Attention Deficit-Hyperactivity (Adhd)
Therapy, Stimulant-Type
Adderall State Carve Out
Adderall XR State Carve Out
Adzenys ER State Carve Out
Adzenys XR-ODT State Carve Out
amphetamine sulfate oral tablet 5 mg State Carve Out
Aptensio XR State Carve Out
Concerta State Carve Out
Cotempla XR-ODT State Carve Out
Daytrana State Carve Out
dexmethylphenidate State Carve Out
dextroamphetamine oral capsule, extended release State Carve Out
dextroamphetamine oral tablet State Carve Out
dextroamphetamine-amphetamine State Carve Out
Dyanavel XR State Carve Out
Evekeo State Carve Out
Focalin State Carve Out
Focalin XR State Carve Out
Metadate ER State Carve Out
methamphetamine State Carve Out
Methylin oral solution State Carve Out
methylphenidate HCl State Carve Out
Mydayis State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
45
Drug Tier Status Notes
QuilliChew ER State Carve Out
Quillivant XR State Carve Out
Relexxii State Carve Out
Ritalin State Carve Out
Ritalin LA oral capsule,ER biphasic 50-50 10 mg,
20 mg, 30 mg, 40 mg State Carve Out
Vyvanse State Carve Out
Zenzedi oral tablet 15 mg, 2.5 mg, 20 mg, 30 mg,
7.5 mg State Carve Out
Attention Deficit-Hyperactivity
Disorder (Adhd) Therapy, Nri-Type
atomoxetine State Carve Out
Strattera State Carve Out
Benzodiazepines
Alprazolam Intensol State Carve Out
alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg State Carve Out
alprazolam oral tablet extended release 24 hr 0.5
mg, 1 mg, 2 mg State Carve Out
alprazolam oral tablet,disintegrating State Carve Out
amitriptyline-chlordiazepoxide State Carve Out
chlordiazepoxide HCl State Carve Out
clonazepam oral tablet 1 mg, 2 mg State Carve Out
clonazepam oral tablet,disintegrating State Carve Out
clorazepate dipotassium State Carve Out
Diastat AcuDial State Carve Out
diazepam injection State Carve Out
Diazepam Intensol State Carve Out
diazepam oral solution State Carve Out
diazepam oral tablet State Carve Out
diazepam rectal kit 2.5 mg State Carve Out
estazolam State Carve Out
flurazepam State Carve Out
Klonopin oral tablet 0.5 mg State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
46
Drug Tier Status Notes
lorazepam injection State Carve Out
Lorazepam Intensol State Carve Out
lorazepam oral tablet State Carve Out
midazolam (PF) injection solution 5 mg/mL F QL
midazolam injection solution 5 mg/mL F QL
midazolam oral syrup 2 mg/mL State Carve Out
Onfi oral suspension State Carve Out
Onfi oral tablet 10 mg, 20 mg State Carve Out
oxazepam State Carve Out
temazepam State Carve Out
triazolam State Carve Out
Xanax oral tablet 2 mg State Carve Out
Xanax XR oral tablet extended release 24 hr 3 mg State Carve Out
Bipolar Therapy Agents -
Anticonvulsant Type
carbamazepine oral capsule, ER multiphase 12 hr State Carve Out
carbamazepine oral tablet,chewable State Carve Out
Depakote ER oral tablet extended release 24 hr
250 mg State Carve Out
Depakote Sprinkles State Carve Out
divalproex oral tablet extended release 24 hr 500
mg State Carve Out
divalproex oral tablet,delayed release (DR/EC) State Carve Out
Equetro State Carve Out
Lamictal ODT State Carve Out
Lamictal ODT Starter (Blue) State Carve Out
Lamictal ODT Starter (Green) State Carve Out
Lamictal ODT Starter (Orange) State Carve Out
Lamictal Starter (Blue) Kit State Carve Out
Lamictal Starter (Green) Kit State Carve Out
Lamictal Starter (Orange) Kit State Carve Out
Tegretol oral suspension State Carve Out
Tegretol oral tablet State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
47
Drug Tier Status Notes
Tegretol XR oral tablet extended release 12 hr
200 mg, 400 mg State Carve Out
valproic acid State Carve Out
Bipolar Therapy Agents - Atypical
Antipsychotics
Abilify oral tablet State Carve Out
aripiprazole oral tablet State Carve Out
Geodon intramuscular State Carve Out
Geodon oral capsule 20 mg, 40 mg, 80 mg State Carve Out
olanzapine intramuscular State Carve Out
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20
mg, 7.5 mg State Carve Out
olanzapine oral tablet,disintegrating State Carve Out
olanzapine-fluoxetine oral capsule 12-25 mg, 12-
50 mg, 3-25 mg, 6-25 mg State Carve Out
quetiapine State Carve Out
risperidone oral solution State Carve Out
risperidone oral tablet State Carve Out
risperidone oral tablet,disintegrating State Carve Out
Saphris sublingual tablet 2.5 mg State Carve Out
Symbyax oral capsule 6-50 mg State Carve Out
Vraylar State Carve Out
ziprasidone HCl oral capsule 60 mg State Carve Out
Zyprexa oral tablet 5 mg State Carve Out
Bipolar Therapy Agents - Lithium
lithium carbonate State Carve Out
lithium citrate oral solution 8 mEq/5 mL State Carve Out
Cannabis And Cannabinoid Receptor
Agonists
dronabinol F PA
Cns And Respiratory Stimulant
Dopram State Carve Out
doxapram State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
48
Drug Tier Status Notes
Cns Stimulant - Amphetamine
Combinations
Adderall State Carve Out
Adderall XR State Carve Out
Adzenys ER State Carve Out
Adzenys XR-ODT State Carve Out
dextroamphetamine-amphetamine State Carve Out
Dyanavel XR State Carve Out
Mydayis State Carve Out
Cns Stimulant - Amphetamines
amphetamine sulfate oral tablet 5 mg State Carve Out
dextroamphetamine State Carve Out
Evekeo State Carve Out
methamphetamine State Carve Out
Zenzedi oral tablet 15 mg, 2.5 mg, 20 mg, 30 mg,
7.5 mg State Carve Out
Cns Stimulant - Analeptics
caffeine citrate oral F AL
Dopram State Carve Out
doxapram State Carve Out
Cns Stimulant - Analeptics,
Methylxanthine-Type
caffeine citrate oral F AL
Cns Stimulant Others
ammonia aromatic inhalation spirit State Carve Out OTC
Diabetic Peripheral Neuropathy Agents
Lyrica CR State Carve Out
Fibromyalgia Agents - Gaba Analogs
Lyrica State Carve Out
Fibromyalgia Agents - Serotonin-
Norepinephrine Reuptake-Inhib (Snris)
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
49
Drug Tier Status Notes
Cymbalta oral capsule,delayed release(DR/EC)
60 mg State Carve Out
duloxetine oral capsule,delayed release(DR/EC)
20 mg, 30 mg State Carve Out
Hypnotics - Melatonin M1/M2 Receptor
Agonists
Hetlioz State Carve Out
Rozerem State Carve Out
Migraine Therapy - Calcitonin Gene-
Related Peptide Inhibitors
Aimovig Autoinjector F PA; QL; AL
Migraine Therapy - Carboxylic Acid
Derivatives
Depakote ER oral tablet extended release 24 hr
250 mg State Carve Out
divalproex oral tablet extended release 24 hr 500
mg State Carve Out
Migraine Therapy - Cgrp Receptor
Blockers, Monoclonal Antibody
Aimovig Autoinjector F PA; QL; AL
Migraine Therapy - Selective Serotonin
Agonists 5-Ht(1)
naratriptan F QL
rizatriptan F QL
sumatriptan F PA; QL
sumatriptan succinate oral F QL
sumatriptan succinate subcutaneous cartridge F PA; QL
sumatriptan succinate subcutaneous pen injector F PA; QL
sumatriptan succinate subcutaneous solution F PA; QL
zolmitriptan F ST; QL
Narcolepsy And Cataplexy Therapy
Agents - Sedative-Type
Xyrem F PA; QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
50
Drug Tier Status Notes
Narcolepsy Therapy Agents - Non-
Sympathomimetic
armodafinil oral tablet 200 mg State Carve Out
modafinil State Carve Out
Nuvigil oral tablet 150 mg, 250 mg, 50 mg State Carve Out
Narcolepsy Therapy Agents - Stimulant-
Type, Piperadine Derivative
Methylin oral solution State Carve Out
methylphenidate HCl oral solution State Carve Out
methylphenidate HCl oral tablet State Carve Out
methylphenidate HCl oral tablet,chewable State Carve Out
Ritalin State Carve Out
Narcolepsy Therapy Agents- Stimulant-
Type,Sympathomimetic,Amphetamines
Adderall State Carve Out
amphetamine sulfate oral tablet 5 mg State Carve Out
dextroamphetamine oral capsule, extended release State Carve Out
dextroamphetamine oral tablet State Carve Out
dextroamphetamine-amphetamine oral tablet State Carve Out
Evekeo State Carve Out
Zenzedi oral tablet 15 mg, 2.5 mg, 20 mg, 30 mg,
7.5 mg State Carve Out
Neuropathic Pain Therapy
Lyrica CR State Carve Out
Postherpetic Neuralgia Agents
Lyrica CR State Carve Out
Sedative-Hypnotic - Antihistamines
diphenhydramine HCl oral capsule F OTC; AL
diphenhydramine HCl oral tablet 25 mg F OTC; AL
Unisom (doxylamine) State Carve Out OTC
Unisom SleepGels State Carve Out OTC
Unisom SleepMelts State Carve Out OTC
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
51
Drug Tier Status Notes
Sedative-Hypnotic - Barbiturates
Amytal State Carve Out
pentobarbital sodium injection solution State Carve Out
phenobarbital State Carve Out
phenobarbital sodium injection solution State Carve Out
Seconal Sodium State Carve Out
Sedative-Hypnotic - Benzodiazepines
estazolam State Carve Out
flurazepam State Carve Out
lorazepam injection State Carve Out
midazolam oral syrup 2 mg/mL State Carve Out
temazepam State Carve Out
triazolam State Carve Out
Sedative-Hypnotic - Gaba-Receptor
Modulators
Edluar State Carve Out
eszopiclone State Carve Out
zaleplon State Carve Out
zolpidem oral State Carve Out
Sedative-Hypnotic - Orexin Receptor
Antagonist
Belsomra State Carve Out
Sedative-Hypnotic - Selective Alpha2-
Adrenoreceptor Agonists
Precedex State Carve Out
Precedex in 0.9 % sodium chlor State Carve Out
Sedative-Hypnotic - Tricyclic
Antidepressant Type
Silenor State Carve Out
Chemical Dependency, Agents To Treat
Agents For Opioid Withdrawal, Central
Alpha-2 Adrenergic Agonist-Type
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
52
Drug Tier Status Notes
Lucemyra F PA; QL; AL
Agents For Opioid Withdrawal, Opioid-
Type
Bunavail State Carve Out
buprenorphine HCl sublingual State Carve Out
buprenorphine-naloxone State Carve Out
Sublocade State Carve Out
Suboxone State Carve Out
Zubsolv sublingual tablet 0.7-0.18 mg State Carve Out QL
Zubsolv sublingual tablet 1.4-0.36 mg, 11.4-2.9
mg, 2.9-0.71 mg, 5.7-1.4 mg, 8.6-2.1 mg State Carve Out
Alcohol Abstinence Therapy -
Glutamate And Gaba System Type
acamprosate State Carve Out
Alcohol Abstinence Therapy - Opioid
Receptor Antagonist-Type
Vivitrol State Carve Out
Alcohol Deterrents
Antabuse oral tablet 500 mg State Carve Out
disulfiram oral tablet 250 mg State Carve Out
Smoking Deterrents - Ne And
Dopamine Reuptake Inhibitor (Ndri)-
Type
bupropion HCl oral tablet sustained-release 12 hr
150 mg F QL
Smoking Deterrents - Nicotine-Type
nicotine (polacrilex) F OTC
nicotine transdermal patch 24 hour 14 mg/24 hr,
21 mg/24 hr, 7 mg/24 hr F OTC
nicotine transdermal patch, TD daily, sequential F OTC; QL
Nicotrol F
Nicotrol NS F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
53
Drug Tier Status Notes
Smoking Deterrents - Nicotinic
Receptor Partial Agonist, Alpha4beta2
Chantix F QL
Chantix Continuing Month Box F QL
Chantix Starting Month Box F QL
Chemicals-Pharmaceutical Adjuvants
Pharmaceutical Adjuvant - Inhalation
Vehicles
sodium chloride inhalation solution for
nebulization 0.9 %, 3 %, 7 % F
Cognitive Disorder Therapy
Alzheimer's Disease Therapy -
Cholinesterase Inhibitors
donepezil oral tablet 10 mg, 5 mg F QL; AL
donepezil oral tablet 23 mg F QL
galantamine F QL
rivastigmine tartrate F QL; AL
Alzheimer's Disease Therapy - Nmda
Receptor Antagonists
memantine oral tablet F QL; AL
memantine oral tablets,dose pack F QL; AL
Contraceptives
Contraceptive Injectable - Progestin
medroxyprogesterone intramuscular F QL
Contraceptive Oral - Biphasic
desog-e.estradiol/e.estradiol F
Contraceptive Oral - Monophasic
Alyacen 1/35 (28) F
Aubra F
Aubra EQ F
Aviane F
Balziva (28) F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
54
Drug Tier Status Notes
Blisovi 24 Fe F
Blisovi Fe 1.5/30 (28) F
Blisovi Fe 1/20 (28) F
Briellyn F
Cyclafem 1/35 (28) F
Dasetta 1/35 (28) F
desogestrel-ethinyl estradiol F
drospirenone-ethinyl estradiol F
Falmina (28) F
Hailey 24 Fe F
Junel 1/20 (21) F
Junel FE 1.5/30 (28) F
Junel FE 1/20 (28) F
Junel Fe 24 F
Kaitlib Fe F
Larin 1/20 (21) F
Larin 24 Fe F
Larin Fe 1.5/30 (28) F
Larin Fe 1/20 (28) F
Larissia F
Lessina F
levonorgestrel-ethinyl estrad F
Low-Ogestrel (28) F
Lutera (28) F
Mibelas 24 Fe F
Microgestin 1.5/30 (21) F
Microgestin 1/20 (21) F
Microgestin Fe 1.5/30 (28) F
Microgestin FE 1/20 (28) F
Necon 0.5/35 (28) F
noreth-ethinyl estradiol-iron F
norethindrone ac-eth estradiol oral tablet 1-20
mg-mcg F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
55
Drug Tier Status Notes
norethindrone-e.estradiol-iron oral tablet 1 mg-20
mcg (21)/75 mg (7) F
norethindrone-e.estradiol-iron oral
tablet,chewable F
norgestimate-ethinyl estradiol oral tablet 0.25-35
mg-mcg F
norgestrel-ethinyl estradiol F
Nortrel 0.5/35 (28) F
Nortrel 1/35 (21) F
Ocella F
Orsythia F
Philith F
Pirmella oral tablet 1-35 mg-mcg F
Sronyx F
Syeda F
Tarina Fe 1/20 (28) F
Tarina Fe 1-20 EQ (28) F
Vienva F
Vyfemla (28) F
Wera (28) F
Wymzya Fe F
Zarah F
Zovia 1/35E (28) F
Contraceptive Oral - Progestin
norethindrone (contraceptive) F
Contraceptive Oral - Triphasic
Aranelle (28) F
Caziant (28) F
Leena 28 F
levonorg-eth estrad triphasic F
norgestimate-ethinyl estradiol oral tablet
0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-
35 mcg (28)
F
Nortrel 7/7/7 (28) F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
56
Drug Tier Status Notes
Tilia Fe F
Tri Femynor F
Tri-Estarylla F
Tri-Legest Fe F
Tri-Linyah F
Tri-Lo-Estarylla F
Tri-Lo-Marzia F
Tri-Lo-Sprintec F
Tri-Previfem (28) F
Tri-Sprintec (28) F
Velivet Triphasic Regimen (28) F
Contraceptive Transdermal
Combinations
Xulane F QL
Contraceptive Transdermal
Combinations - Estrogen And Progestin
Comb.
Xulane F QL
Contraceptives - Intravaginal, Systemic
NuvaRing F
Contraceptives - Intravaginal, Systemic
- Estrogen And Progestin Comb.
NuvaRing F
Emergency Contraceptives
Aftera F OTC; QL
EContra EZ F OTC; QL
Econtra One-Step F OTC; QL
levonorgestrel oral tablet 1.5 mg F OTC; QL
My Choice F OTC; QL
My Way F OTC; QL
New Day F OTC; QL
Opcicon One-Step F OTC; QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
57
Drug Tier Status Notes
Option-2 F OTC; QL
Emergency Contraceptives - Progestin
Type
Aftera F OTC; QL
EContra EZ F OTC; QL
Econtra One-Step F OTC; QL
levonorgestrel oral tablet 1.5 mg F OTC; QL
My Choice F OTC; QL
My Way F OTC; QL
New Day F OTC; QL
Opcicon One-Step F OTC; QL
Option-2 F OTC; QL
Spermicides
Gynol II F OTC
Today Contraceptive Sponge F OTC
Vaginal Contraceptive Foam F OTC
Dermatological
Acne Therapy Systemic - Retinoids And
Derivatives
Amnesteem F PA; QL
Claravis F PA; QL
isotretinoin F PA; QL
Myorisan F PA; QL
Zenatane F PA; QL
Acne Therapy Topical - Anti-Infective
clindamycin phosphate topical gel F
clindamycin phosphate topical lotion F
clindamycin phosphate topical solution F
clindamycin phosphate topical swab F
erythromycin with ethanol topical solution F
metronidazole topical cream F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
58
Drug Tier Status Notes
Acne Therapy Topical - Anti-Infective-
Keratolytic Combinations
clindamycin-benzoyl peroxide topical gel 1.2 %(1
% base) -5 % F QL; AL
sulfacetamide sodium-sulfur topical cleanser 10-5
% (w/w) F
Acne Therapy Topical - Keratolytic
benzoyl peroxide topical cleanser 5 % F OTC
benzoyl peroxide topical gel 10 % F OTC; QL
benzoyl peroxide topical gel 5 % F OTC
Acne Therapy Topical - Retinoids And
Derivatives
Differin topical gel 0.1 % F OTC; QL
tretinoin topical cream 0.025 % F ST; QL; AL
Antipsoriatic Agents-Interleukin-17 (Il-
17) Antagonist, Mc Antibody
Siliq F PA; QL
Dermatological - Antibacterial
Aminoglycosides
gentamicin topical F
Dermatological - Antibacterial Mixtures
Triple Antibiotic topical ointment F OTC
Triple Antibiotic topical ointment in packet F OTC
Dermatological - Antibacterial Other
mupirocin F QL
Dermatological - Antibacterial
Polymyxins And Derivatives
bacitracin topical F OTC
bacitracin zinc F OTC
Dermatological - Antibacterial-Local
Anesthetic Combinations
Neosporin Plus PainRelief(bac) F OTC
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
59
Drug Tier Status Notes
Dermatological - Antifungal
Allylamines
terbinafine HCl topical F OTC
Dermatological - Antifungal
Amphoteric Polyene Macrolides
nystatin topical cream F
nystatin topical ointment F
nystatin topical powder F QL
Dermatological - Antifungal
Hydroxypyridinone
ciclopirox topical solution F QL
Dermatological - Antifungal Imidazole
And Related Agents
clotrimazole topical F OTC
econazole F QL
ketoconazole topical cream F QL
ketoconazole topical shampoo F QL
miconazole nitrate topical cream F OTC
Dermatological - Antifungal
Thiocarbamate
Antifungal (tolnaftate) topical cream F OTC
tolnaftate topical aerosol powder F OTC
tolnaftate topical powder F OTC
Dermatological - Antifungal-
Glucocorticoid Combinations
clotrimazole-betamethasone topical cream F
clotrimazole-betamethasone topical lotion F QL
nystatin-triamcinolone F QL
Dermatological - Antineoplastic
Antimetabolites
fluorouracil topical cream F PA
Dermatological - Antineoplastic Or
Premalignant Lesions - Nsaid's
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
60
Drug Tier Status Notes
diclofenac sodium topical gel 3 % F PA
Dermatological - Antipsoriatic Agents
Systemic, Vitamin A Derivatives
acitretin F PA; QL
Dermatological - Antipsoriatic Agents
Topical
calcipotriene F PA; QL
Dermatological - Antipsoriatics
Systemic, Phosphodiesterase 4 Inhib.
Otezla F PA
Otezla Starter F PA; QL
Dermatological - Antiseborrheic
selenium sulfide topical lotion F
Dermatological - Antiviral, Herpes
Abreva F OTC
Dermatological - Burn Products Anti-
Infective
silver sulfadiazine F
SSD F
Dermatological - Calcineurin Inhibitors
Elidel F PA; QL
tacrolimus topical F PA; QL
Dermatological - Emollients
ammonium lactate F OTC; QL
Dermatological - Enzymes
Santyl F QL
Dermatological - Glucocorticoid
Anti-Itch (HC) topical ointment F OTC
betamethasone dipropionate F QL
betamethasone valerate topical cream F QL
betamethasone valerate topical lotion F QL
betamethasone valerate topical ointment F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
61
Drug Tier Status Notes
betamethasone, augmented F QL
clobetasol scalp F PA; QL
clobetasol topical cream F PA; QL
clobetasol topical ointment F PA; QL
Cortizone-10 topical ointment F OTC
fluocinonide topical cream 0.05 % F QL
fluocinonide topical ointment F QL
fluocinonide topical solution F QL
Fluocinonide-E F QL
fluticasone propionate topical cream F QL
fluticasone propionate topical ointment F QL
halobetasol propionate topical cream F QL
halobetasol propionate topical ointment F QL
hydrocortisone acetate topical cream F OTC
hydrocortisone acetate topical ointment F OTC
hydrocortisone topical cream 0.5 %, 1 % F OTC
hydrocortisone topical cream 2.5 % F
hydrocortisone topical lotion 2.5 % F
hydrocortisone topical ointment 0.5 %, 1 % F OTC
hydrocortisone topical ointment 2.5 % F
hydrocortisone valerate topical cream F QL
mometasone topical F QL
Noble Formula HC topical cream F OTC
Soothing Care (hydrocortisone) F OTC
triamcinolone acetonide topical cream F QL
triamcinolone acetonide topical lotion 0.025 % F
triamcinolone acetonide topical lotion 0.1 % F QL
triamcinolone acetonide topical ointment 0.025
%, 0.1 % F QL
triamcinolone acetonide topical ointment 0.5 % F
Dermatological - Immunomodulator -
Imidazoquinolinamines
imiquimod topical cream in packet F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
62
Drug Tier Status Notes
Dermatological - Keratolytic-
Antimitotic Single Agents
podofilox F
Dermatological - Local Anesthetic
Combinations
lidocaine-prilocaine topical cream F QL
Dermatological - Nsaid Single Agents
diclofenac sodium topical gel 1 % F QL
Dermatological - Rosacea Therapy,
Topical
metronidazole topical cream F
metronidazole topical gel 0.75 % F
Dermatological - Topical Local
Anesthetic Amides
Aspercreme (lidocaine) topical adhesive
patch,medicated F OTC; QL
ASPERCREME LIDOCAINE 4% CREAM F OTC; QL
lidocaine HCl mucous membrane jelly F
lidocaine HCl mucous membrane jelly in
applicator F
lidocaine topical adhesive patch,medicated 5 % F PA; QL
Dermatological Irritants-Counter-
Irritant Single Agents
capsaicin topical cream 0.025 % F OTC
Scabicide And Pediculicide
Combinations
Lice Killing F OTC; QL
Scabicide And Pediculicide Single
Agents
lindane topical shampoo F QL
malathion F ST; QL
permethrin topical cream F QL
Diagnostic Agents
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
63
Drug Tier Status Notes
Diagnostic Drugs - Pituitary Function
Acthrel State Carve Out
cosyntropin State Carve Out
Eating Disorder Therapy
Appetite Stimulants - Cannabinoids
dronabinol F PA
Appetite Stimulants - Progestin
Hormone Type
megestrol oral suspension 400 mg/10 mL (10
mL), 400 mg/10 mL (40 mg/mL) F
Electrolyte Balance-Nutritional
Products
Amino Acid - Carnitine Derivatives
levocarnitine oral tablet State Carve Out OTC
Amino Acids, Single Ingredient, Oral
(Non-Injectable)
Endari F PA
B-Complex Vitamin Combinations
Alba-Lybe F
Apetex F
Apetigen F
B Complex Plus Vitamin C F
B complex-vitamin C-folic acid oral tablet F
B-100 Complex oral tablet extended release F
Balanced B-100 Complex oral tablet extended
release 100 mg F
B-Complex Plus Vit C (calcium) F
B-complex with vitamin C oral tablet F
B-complex with vitamin C oral tablet 400-500
mcg-mg F
B-complex with vitamin C oral tablet extended
release F
Biopetit F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
64
Drug Tier Status Notes
Complex B-100 oral tablet extended release 400
mcg F
Complex B-50 F
DIALYVITE 3000 F
Dialyvite 800 oral tablet F
Dialyvite 800 Plus D F
Dialyvite 800 with Zinc 15 F
Dialyvite 800 with Zinc 50 F
Dialyvite 800-Ultra D F
Dialyvite oral tablet 100-1 mg F
Dialyvite Supreme D F
Folbee AR F
Folbee Plus F
Lysiplex Plus oral tablet F
Medtycholl-B Complex-Liver F
Natural B-100 Complex F
Nephronex F
Nephronex-SL F
ProRenal F
Quin B Strong F
Renal Caps F
Reno Caps F
Stress B Plus Zinc F
Stress B With Zinc F
Stress Formula 600 C F
Stress Formula With Iron(sulf) F
Stress Formula with Zinc F
Super B Complex-Vitamin C F
Superplex-T F
Supervite F
Total B/C F
Triphrocaps F
Virt-Vite Plus F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
65
Drug Tier Status Notes
Vita-Bee with C F
vitamin B complex-folic acid F
Vitamins B Complex oral tablet 500 mg-400
mcg- 18 mg iron F
Vitamins for Hair oral tablet F
B-Complex Vitamins
B Complex 100 injection F
B Complex sublingual F
B Complex-Vitamin B12 F
Balanced B-50 oral tablet F
Complex B-100 oral tablet extended release F
Folgard F
PoDiaPN F
Super B-50 Complex F
Super B-50 Complex Plus F
Super Quints B-50 F
Ultra B-100 Complex oral tablet extended release F
vitamin B complex F
Vitamins B Complex oral capsule F
Vitamins B Complex oral tablet F
B-Complex Vitamins And
Combinations
Apetigen Plus oral liquid F
Dialyvite oral tablet 1-100-300-50 mg-mg-mcg-
mg F
Nephplex Rx F
Rena-Vite Rx F
Brewers Yeast
Brewer's Yeast oral tablet 500 mg (7.5 gr) F OTC
Brewer's Yeast oral tablet 680 mg F
yeast F OTC
Dietary Product - Dietary Supplements
choline dihydrogen citrate F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
66
Drug Tier Status Notes
NicAzel Forte F
Electrolyte Depleters - Ion Exchange
Resin
sodium polystyrene sulfonate oral powder F
sodium polystyrene sulfonate rectal F
Geriatric Vitamins
Central-Vite Select F OTC
Centravites 50 Plus oral tablet F
Complete Senior oral tablet F
Daily Multivitamin-Minerals F
Multivitamin 50 Plus F
multivitamin with minerals oral tablet F
REQ49+ F
Minerals And Electrolytes - Calcium
Replacement
Calcitrate F
calcium acetate oral tablet 667 mg F OTC
calcium carbonate oral suspension F OTC
calcium carbonate oral tablet 500 mg calcium
(1,250 mg), 600 mg calcium (1,500 mg) F
calcium carbonate oral tablet,chewable 260 mg
calcium (650 mg) F
calcium carbonate oral tablet,chewable 300 mg
(750 mg) F OTC
calcium citrate oral tablet 200 mg (950 mg) F
Minerals And Electrolytes - Calcium
Replacement Combinations
Biocal F
Calcium 600 + Minerals oral tablet 600 mg
calcium- 400 unit F
Calcium 600-D3 Plus (mag-zinc) F
calcium carbonate-vit D3-min oral tablet F
Calcium Magnesium + D oral tablet 400-167-133
mg-mg-unit F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
67
Drug Tier Status Notes
Pro-Cal oral tablet F
Minerals And Electrolytes - Calcium
Replacement/Vitamin D Combinations
Calcet Petites F
Cal-Citrate F
Calcium 500 + D oral tablet 500 mg(1,250mg) -
200 unit F
Calcium 600 + D(3) oral tablet 600-125 mg-unit F
calcium carbonate-vitamin D3 oral capsule 600
mg(1,500mg) -400 unit F
calcium carbonate-vitamin D3 oral tablet 500
mg(1,250mg) -125 unit, 500mg (1,250mg) -600
unit, 600 mg(1,500mg) -200 unit, 600
mg(1,500mg) -400 unit, 600 mg(1,500mg) -800
unit
F
calcium carbonate-vitamin D3 oral
tablet,chewable 500-100 mg-unit F
calcium citrate-vitamin D3 oral tablet 200 mg
calcium -250 unit, 315 mg- 250 unit, 315-200 mg-
unit
F
calcium phosphate-vitamin D3 oral
tablet,chewable 200 mg calcium- 200 unit, 250
mg calcium -200 unit
F
Caltrate with Vitamin D3 F
Citracal + D Maximum F
Hi-Cal Plus Vit D F
Os-Cal 500 + D3 F
Oysco 500/D oral tablet F
Oyster Shell Calcium-Vit D2 oral tablet 250
(625)-125 mg-unit F OTC
Oyster Shell Calcium-Vit D3 oral tablet F
Minerals And Electrolytes - Iron
Auryxia F
Feosol oral tablet 325 mg (65 mg iron) F
FeroSul oral tablet F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
68
Drug Tier Status Notes
ferrous gluconate oral tablet 236 mg (27 mg iron),
240 mg (27 mg iron), 324 mg (37.5 mg iron), 324
mg (38 mg iron)
F
ferrous sulfate oral drops F AL
ferrous sulfate oral elixir F
ferrous sulfate oral liquid F AL
ferrous sulfate oral solution F AL
ferrous sulfate oral tablet 325 mg (65 mg iron) F
ferrous sulfate oral tablet,delayed release
(DR/EC) F
FerrouSul F
Iron (dried) F
Iron 100 Plus F AL
iron oral tablet extended release 159 mg (45 mg
iron) F
Slow Release Iron oral tablet extended release
142 mg (45 mg iron), 159 mg (45 mg iron), 160
mg (50 mg iron)
F
Minerals And Electrolytes - Iron
Combinations
Parvlex F
Siderol oral tablet F
Minerals And Electrolytes - Magnesium
Mag 64 F
Mag Glycinate F
Mag-G F
Maginex F
magnesium F
Magnesium (oxide/AA chelate) F
magnesium amino acid chelate oral tablet 100 mg F
magnesium chloride injection F
magnesium chloride oral tablet,delayed release
(DR/EC) 64 mg F
magnesium citrate oral tablet F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
69
Drug Tier Status Notes
magnesium gluconate F
magnesium oxide oral capsule F
magnesium oxide oral tablet 250 mg magnesium,
420 mg, 500 mg F
magnesium oxide oral tablet 400 mg (241.3 mg
magnesium) F OTC
magnesium sulfate in D5W intravenous
piggyback 1 gram/100 mL F
magnesium sulfate in water F
magnesium sulfate injection Specialty
Magonate (magnesium carb) F
MagOx F
Magtab F
Phillips F
Slow-Mag F
Uro-Mag F
Minerals And Electrolytes - Magnesium
Combinations
Beelith F
Minerals And Electrolytes - Oral
Electrolytes
Oralyte F
Pediatric Electrolyte oral solution F
Pediatric Freezer Pops F
PediaVance F
Minerals And Electrolytes - Phosphate
Glycophos F
Phos-NaK F
potassium phosphate m-/d-basic F
sodium phosphate F
Minerals And Electrolytes - Potassium,
Oral
potassium chloride oral capsule, extended release F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
70
Drug Tier Status Notes
potassium chloride oral tablet extended release 10
mEq, 8 mEq F
potassium chloride oral tablet,ER
particles/crystals F
Multivitamin And Mineral
Combinations
50 Plus Adult Eye Health F
A Thru Z F
A Thru Z Men's Ultimate F
A Thru Z Select oral tablet 300-600-300 mcg,
500-300-250 mcg F
A Thru Z Select Women's F
Actical F
Adult Multivitamin Gummies F
Adult One Daily Gummies F
Antioxidant A/C/E/Selenium F
Antioxidant Formula (selenium) F
AquADEKs oral tablet,chewable F
Bacmin F
Bio-35, Gluten Free F
Biocel (with Lutein) F
Biotin Plus-Calcium and Vit D3 F
Body, Hair, Skin and Nails F
Central-Vite Cardio F OTC
Central-Vite Select F OTC
Central-Vite Women's Mature F
Centravites F
Centrum Men F
Centrum Silver oral tablet,chewable F
Centrum Silver Ultra Men's F
Centrum Silver Women F
Centrum Specialist Heart F
Centrum Ultra Men's F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
71
Drug Tier Status Notes
Century Cardio F
Century Ultimate Men's F
Century Ultimate Women's oral tablet 8 mg iron-
400 mcg-300 mcg F
Certa Plus F
Compete F OTC
Complete Multi F
Complete Multi 50+ F
Complete Multivitamin oral tablet F
Complete oral tablet 18-500-300-250 mg-mcg-
mcg-mcg F
Complete Premium Vitamin F
Corvite Free F
Daily Gummies F
Daily Multiple oral tablet , 400-120 mcg-mg F
Daily Multivitamin F
Daily Multivitamin-Minerals F
Daily Multi-Vitamins/Iron F OTC
DAILY VITAMIN FORMULA-MINERALS F
Daily Vitamin with Iron F
Daily Vites/Iron F
Daily-Vite F
Diabetes Health Formula F
Dialyvite 5000 F
ESSENTIAL Balance with Lutein F
ESSENTIAL Daily F
ESSENTIAL Man F
ESSENTIAL Man 50+ F
Essential Woman 50+ F
Fosfree F
Freedavite F
Hair Vitamins F
Hair, Skin and Nails-Argan Oil F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
72
Drug Tier Status Notes
Hair,Skin and Nails F
Hair,Skin and Nails(FA-biotin) oral tablet 66.7-
1,000 mcg F
Healthy Eyes SuperVision F
I-Caps F
ICaps AREDS F
Icaps MV F
Icaps Plus F OTC
I-Vite Protect F
K-Pax Immune Support F
K-PAX oral capsule F OTC
Macuvite Eye Care F
MAXIMUM DAILY GREEN F OTC
Maximum Daily Multivitamin F
Mega Multi for Women F
Mega Multiple/Chelated Mineral F
Mega Multivitamin For Men F
Mega Multivitamin with Mineral oral tablet 13.5-
200-250 mg-mcg-mcg F
Men's Daily F
Men's Daily Multivit-Mineral F
Men's Multivitamin Gummies F
Men's One Daily F
Monocaps F
Multi For Her oral tablet F
Multi-Betic F
Multi-Delyn with Iron F
Multiple Vitamin-Minerals F
multivitamin with iron F
multivitamin with minerals oral tablet F
mv-min-folic acid-lutein F
My-Vitalife F
Ocutabs F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
73
Drug Tier Status Notes
Omnicap F
One Daily Calcium/Iron F
One Daily Complete F
One Daily Energy oral tablet F
One Daily Essential oral tablet 0.4 mg F
One Daily For Men F
One Daily For Women F
One Daily Healthy Weight F
One Daily Maximum F
One Daily Mens 50 Plus(ginkgo) F OTC
One Daily Multi-Vit w-Mineral oral tablet F
One Daily oral tablet 0.4-600 mg-mcg F
One Daily Plus Minerals F
One Daily With Iron F
One Daily Women 50 Plus F
One Daily Womens 50 Plus F
One Daily Women's oral tablet 27-0.4 mg F
One-A-Day Cholesterol Plus F
One-A-Day Maximum Formula F
One-A-Day Men VitaCraves F
One-A-Day Menopause Formula F
One-A-Day Men's 50 Plus F
One-A-Day Men's Multivitamin F
One-A-Day Teen Advantage oral tablet 9 mg
iron-400 mcg F
One-A-Day VitaCraves F
One-A-Day Vitacraves Immunity F
One-A-Day Vitacraves Omega-3 F
One-A-Day WeightSmart F
One-A-Day Women VitaCraves F
One-A-Day Women's Active F
One-A-Day Women's Healthy Skin F
Optisource F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
74
Drug Tier Status Notes
Opurity Multivitamin F
PreserVision AREDS F
PreserVision Lutein F
Prevent F
ProCerv HP F
ProRenal QD F
Prosight with Lutein F
Protect Cardio AF F
Protect Plus SO F
Quintabs-M F
Quintabs-M Iron Free F
REQ49+ F
SAVision F
Sentry Senior oral tablet 500-300-250 mcg F
Solo F
Spectravite Adult 50 Plus(lut) F
Spectravite Men's F
Spectravite Senior oral tablet 500-300-250 mcg F
Spectravite Ultra Men 50+ F
Spectravite Ultra Men's Sr F
Spectravite Ultra Women's Sr F
Strovite Forte F
Strovite One F
Sunvite F
Super Antioxidant F
Super Ginseng Multivitamin F
Super Multiple F
Super Multiple - Low Iron F
Super Thera Vite M F
Tab-A-Vite/Iron F
Thera M Plus (ferrous fumarat) F
Theragran-M Premier 50 Plus F
Theralogix Companion F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
75
Drug Tier Status Notes
Thera-M F
Therapeutic-M oral tablet 9 mg iron-400 mcg F
Thera-Tabs M F
Theratrum Complete with Lutein F
Therems F
Therems-H F
Therems-M F
Thrivite-19 F OTC
TRUEplus Diabetic Multivitamin F
Ultimate Men's Complete 50+ F
Ultimate Women's Complete 50+ F
Ultra Freeda F
Unicomplex-M F
V-C Forte F
VIC-Forte F
Vision F
Vitacel (with Lutein) F
Vital-D Rx F
Vitalee F
Vitamins A-D-E selenium F
Vitamins and Minerals F
Vitatrum F
Vitrum Senior oral tablet 500-300-250 mcg F
Women's Complex F
Women's Daily Caplet F
Women's Daily Formula oral tablet 27-0.4 mg F
Women's Daily Multivitamin F OTC
Women's Multivitamin Gummies F
Multivitamins
A Thru Z Advanced Formula F
Centrum Complete F
Century oral tablet 18-400 mg-mcg F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
76
Drug Tier Status Notes
Century Ultimate Women's oral tablet 18-400
mg-mcg F
Cerefolin F
Cerovite Advanced Formula F
Certavite-Antioxidant F
Chewable-Vite F
Complete Multivitamin-Mineral oral tablet F
Daily Multiple For Women F
Daily Multiple oral tablet , 18-400 mg-mcg F
Daily Multi-Vitamin F
Daily Multivitamin with Iron F
Daily Value F
Daily Vitamin Formula F
Daily Vitamin Formula-Iron F
Daily-Vite F
Decubi Vite F
E-400 C-500 and Beta Carotene F
Essentia F
ESSENTIAL Balance with Lutein F
Fortavit F
L-Methyl-MC F
Metafolbic F
Multi Complete with Iron F
Multi-Day with Iron F
Multiple Vitamins F
multivitamin F
Multi-Vite (with folic acid) F OTC
Once Daily F
Oncovite F
One Daily Energy oral tablet 9 mg iron-400 mcg-
200 mg F
One Daily Essential oral tablet , 400 mcg F
One Daily For Men 50+ Advanced F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
77
Drug Tier Status Notes
One Daily Men's 50 Plus Memory F
One Daily Multivitamin oral tablet F
One Daily Multivit-Iron(folic) F
One Daily Plus Iron oral tablet 18-400 mg-mcg F
One Daily Women's Health F
One Daily Women's oral tablet 18 mg iron-400
mcg-450 mg Ca F
One-A-Day Energy F
One-A-Day Essential F
One-A-Day Maximum Formula F
One-A-Day Men 50 Plus (ginkgo) F
One-A-Day Teen Advantage oral tablet 18-400
mg-mcg F
One-A-Day Womens Formula oral tablet 18 mg
iron-400 mcg-500 mg Ca F
One-A-Day Women's Petites F
Quintabs F
Sentry F
Spectravite Advanced Formula oral tablet 18-400
mg-mcg F
Spectravite Ultra Women F
Super Multivitamin F
Tab-A-Vite F
Thera F
Thera-Tabs F
Therems F
Vitamins for Hair oral tablet F
Women's One Daily F
Yelets F
Nutritional Product - Medical Condition
Specific Formulation
Endari F PA
Pediatric Vitamins
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
78
Drug Tier Status Notes
ANIMAL CHEWS F
Animal Shape Vitamins F
Chewable-Vite F
Child Multivitamins F
Children's Chewable F OTC
Children's Chewable Multivitmn F
Children's Chewable Vitamin F
Children's Chewables F
Children's Chewables Extra C F
Children's Chewables with Iron F
Childs Chew Vite F
Dino-Life F
Dino-Life with Extra C F
Dino-Life with Iron-Zinc F
Flintstones Gummies F
Flintstones Gummies Omega-3 F
Flintstones Multivitamin F
Flintstones/Extra C oral tablet,chewable F
Honey Bears with Iron-Zinc F
MVW Complete Formul Multivit oral capsule
1,500-800 unit-mcg F QL
MVW Complete Formul Pediatric F
MVW Complete Formulation D3000 oral capsule F QL
One-A-Day Teen Him VitaCraves F
Poly-Vitamins F
Tri-Vi-Sol F
Zoo Friends oral tablet,chewable F
Zoo Friends Plus Iron F OTC
Pediatric Vitamins And Mineral
Combinations
Animal Shapes Complete oral tablet,chewable 18
mg iron F
AquADEKs Pediatric F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
79
Drug Tier Status Notes
Cerovite Jr oral tablet,chewable F OTC
Chewable-Vite with Iron F
Child Complete Multivitamin F
Children's Chew Multivit-Iron F
Children's Complete Vitamin F OTC
Child's Chewable Vitamins/Iron oral
tablet,chewable F
Childs/Iron F
Dino-Life with Iron-Zinc F
Flintstones Complete (iron) F
Flintstones Plus Calcium F
Flintstones with Iron F
Honey Bears with Iron-Zinc F
NovaFerrum Pediatric F
Poly-Vi-Sol oral drops F
Poly-Vi-Sol with Iron F
Polyvitamin with Iron F
Scooby-Doo One A Day F
Pediatric Vitamins With Fluoride And
Minerals Combinations
Multi-Vit with Fluoride-Iron F QL; AL
Pediatric Vitamins With Fluoride
Combinations
Multi-Vit with Fluoride-Iron F QL; AL
Multivitamin With Fluoride F QL; AL
Multi-Vitamin With Fluoride F QL; AL
Multivitamins With Fluoride oral tablet,chewable
1 mg F QL; AL
Mvc-Fluoride F QL; AL
Quflora Pediatric F
Triple Vitamin with Fluoride F OTC; QL; AL
Tri-Vitamin With Fluoride oral drops 0.25 mg
fluor. (0.55 mg)/mL F QL; AL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
80
Drug Tier Status Notes
Vitamins A,C,D and Fluoride oral drops 0.25 mg
fluor. (0.55 mg)/mL F QL
Prenatal Vitamins And Minerals
CompleteNate F QL; AL
Mynatal Advance F QL; AL
Mynatal oral tablet F QL; AL
Mynatal Plus F QL; AL
Mynatal-Z F QL; AL
Mynate 90 Plus F QL; AL
Nestabs F QL; AL
Nestabs DHA F QL; AL
NewGen F QL; AL
Obstetrix DHA F QL; AL
Obstetrix EC F QL; AL
PNV 29-1 F QL; AL
Prenatabs FA F QL; AL
Prenatabs Rx F QL; AL
Prenatal 19 F QL; AL
Prenatal Complete F QL; AL
Prenatal Gummy F QL; AL
Prenatal Low Iron F QL; AL
Prenatal oral tablet 28 mg iron- 800 mcg F QL; AL
Prenatal Plus F QL; AL
Prenatal Plus (calcium carb) F QL; AL
Prenatal Tablet F QL; AL
Prenatal Vitamin oral tablet 27 mg iron- 0.8 mg F QL; AL
Prenatal Vitamin Plus Low Iron F QL; AL
Prenatal Vitamin with Minerals F QL; AL
prenatal vit-iron fum-folic ac F QL; AL
Prenatal-U F QL; AL
PrePlus F QL; AL
PreTAB F QL; AL
TheraNatal oral tablet F QL; AL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
81
Drug Tier Status Notes
Thrivite-19 F OTC
TriAdvance F QL; AL
TriCare F QL; AL
Trinatal Rx 1 F QL; AL
Trinate F QL; AL
Vinate GT F QL; AL
Vinate II F QL; AL
Vinate M F QL; AL
Vinate One F QL; AL
Vinate Ultra F QL; AL
Vitamins - B Preparation Combinations
B Complex w-Vit C F
B-Complex With B-12 F
Cerefolin NAC (algal oil) F
FaBB F
Folbee F
Folbic F
Folgard RX F
Folinic-Plus F
Folplex 2.2 F
Foltabs 800 F
Foltanx F
Homocysteine Formula F
Lmefol Ca-acetyl-meB12-algal F
L-Methyl-B6-B12 F
Metafolbic Plus RF F
Niva-Fol F
Virt-Vite F
Vita-Respa F
Vitamins - B-1, Thiamine And
Derivatives
Arkaliox F
thiamine HCl (vitamin B1) oral tablet 100 mg F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
82
Drug Tier Status Notes
Vitamin B-1 (mononitrate) F
Vitamin B-1 oral tablet 100 mg, 50 mg F
Vitamins - B-12, Cyanocobalamin And
Derivatives
cyanocobalamin (vitamin B-12) injection F
Vitamins - B-2, Riboflavin And
Derivatives
Vitamin B-2 oral tablet 25 mg F
Vitamins - B-3, Niacin And Derivatives
Endur-Acin oral tablet extended release 500 mg F
niacin (inositol niacinate) oral capsule 400 mg
niacin (500 mg), 500 mg F
niacin (inositol niacinate) oral tablet F
Niacin Flush Free oral capsule 750 mg F
niacin oral capsule, extended release 125 mg F OTC
niacin oral capsule, extended release 250 mg F
niacin oral tablet 100 mg, 250 mg, 50 mg F
niacin oral tablet extended release 1,000 mg, 250
mg, 500 mg F
niacinamide oral tablet 500 mg F
niacinamide oral tablet extended release F
Slo-Niacin oral tablet extended release 500 mg,
750 mg F
Vitamins - B-6, Pyridoxine And
Derivatives
pyridoxine (vitamin B6) oral tablet 100 mg, 25
mg, 50 mg F
Vitamins - Biotin
biotin oral capsule 1 mg, 2,500 mcg, 5 mg F
biotin oral tablet F
Cyto B7 F
Hard Nails F
Mega Biotin F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
83
Drug Tier Status Notes
Meribin F
Vitamins - D Derivatives
calcitriol oral capsule F QL
calcitriol oral solution F AL
cholecalciferol (vitamin D3) oral capsule 1,250
mcg (50,000 unit), 125 mcg (5,000 unit), 25 mcg
(1,000 unit)
F
cholecalciferol (vitamin D3) oral drops 10
mcg/mL (400 unit/mL) F
cholecalciferol (vitamin D3) oral tablet 125 mcg
(5,000 unit), 2,000 unit, 25 mcg (1,000 unit) F
cholecalciferol (vitamin D3) oral tablet,chewable
400 unit F
D3-2000 F
Delta D3 F
Dialyvite Vitamin D F
Dialyvite Vitamin D3 Max F
ergocalciferol (vitamin D2) oral capsule 1,250
mcg (50,000 unit) F
Thera-D F
Vital-D Rx F
Vitamin D3 oral capsule 25 mcg (1,000 unit), 400
unit, 50 mcg (2,000 unit) F
Vitamin D3 oral tablet 10 mcg (400 unit), 125
mcg (5,000 unit), 2,000 unit F
Vitamins - E
Aqua-E F
vitamin E (dl, acetate) oral capsule 1,000 unit,
200 unit, 400 unit F
vitamin E (dl, acetate) oral drops 100 unit/0.25
mL F
vitamin E acetate F
vitamin E mixed F
vitamin E oral F
vitamin E succinate F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
84
Drug Tier Status Notes
wheat germ oil oral capsule F OTC
wheat germ oil oral oil F
Vitamins - Folic Acid And Derivatives
folic acid oral tablet 1 mg F OTC
folic acid oral tablet 400 mcg, 800 mcg F
Vitamins - Folic Acid Combinations
FaBB F
Folbee F
Folbic F
Folgard RX F
Folplex 2.2 F
Niva-Fol F
Virt-Vite F
Vita-Respa F
Vitamins - K, Phytonadione And
Derivatives
phytonadione (vitamin K1) oral tablet 5 mg F QL
Endocrine
Agents To Treat Hypoglycemia
(Hyperglycemics)
Dex4 Glucose oral tablet,chewable F
dextrose oral liquid F
GlucaGen HypoKit F QL
Glucagon Emergency Kit (human) F QL
Glucose Gel F
glucose oral tablet,chewable F OTC
glucose oral tablet,chewable 4 gram F
Proglycem F
Amyloidosis Agents- Transthyretin
(Ttr) Stabilizer
Vyndamax F PA; QL; AL
Vyndaqel F PA; QL; AL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
85
Drug Tier Status Notes
Androgen - Single Agents
testosterone cypionate intramuscular oil 100
mg/mL, 200 mg/mL Specialty
testosterone transdermal gel in packet 1 % (25
mg/2.5gram), 1 % (50 mg/5 gram) F PA; QL
testosterone transdermal solution in metered
pump w/app F PA; QL
Antidiuretic And Vasopressor
Hormones
desmopressin nasal spray with pump F PA
desmopressin nasal spray,non-aerosol F PA
desmopressin oral F QL
Stimate F PA
Antihyperglycemic - Alpha-Glucosidase
Inhibitors
acarbose F QL
Antihyperglycemic - Dipeptidyl
Peptidase-4 (Dpp-4) Inhibitors
alogliptin F ST
Januvia F PA; QL
Tradjenta F PA; QL
Antihyperglycemic - Meglitinide
Analogs
nateglinide F QL
repaglinide F QL
Antihyperglycemic - Sglt-2 Inhibitor
And Biguanide Combinations
Invokamet F PA; QL
Invokamet XR F PA; QL
Segluromet F PA
Synjardy F PA; QL
Synjardy XR F PA; QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
86
Drug Tier Status Notes
Antihyperglycemic - Sglt-2 Inhibitor
And Dpp-4 Inhibitor Combinations
Steglujan F PA; AL
Antihyperglycemic - Sodium Glucose
Cotransporter-2 (Sglt2) Inhibitors
Invokana F PA; QL
Jardiance F PA; QL
Steglatro F PA
Antihyperglycemic - Sulfonylurea And
Biguanide Combinations
glipizide-metformin F
glyburide-metformin F
Antihyperglycemic - Sulfonylurea
Derivatives
glimepiride F
glipizide F
glyburide F
glyburide micronized oral tablet 1.5 mg, 3 mg F
glyburide micronized oral tablet 6 mg F QL
Antihyperglycemic, Incretin
Mimetic,Glp-1 Receptor Agonist
Analog-Type
Ozempic F PA; QL
Trulicity subcutaneous pen injector 0.75 mg/0.5
mL F PA; QL
Trulicity subcutaneous pen injector 1.5 mg/0.5
mL F PA
Victoza 2-Pak F PA; QL
Victoza 3-Pak F PA; QL
Antihyperglycemic-Dipeptidyl
Peptidase-4 Inhibit And
Thiazolidinedione
alogliptin-pioglitazone F ST; QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
87
Drug Tier Status Notes
Antihyperglycemic-Dipeptidyl
Peptidase-4(Dpp-4)Inhibitor And
Biguanide
alogliptin-metformin oral tablet 12.5-1,000 mg F ST
alogliptin-metformin oral tablet 12.5-500 mg F PA
Janumet F PA; QL
Janumet XR F PA; QL
Jentadueto F PA; QL
Antithyroid Agents, Thionamides -
Imidazole Derivatives
methimazole oral tablet 10 mg, 5 mg F
Antithyroid Agents, Thionamides -
Thiouracil Derivatives
propylthiouracil F
Bone Formation Stimulating Agents -
Parathyroid Hormone Rel Peptides
Tymlos F PA
Bone Formation Stimulating Agents -
Parathyroid Hormone-Type
Forteo F PA; QL
Bone Resorption Inhibitors -
Bisphosphonates
alendronate oral tablet 10 mg, 35 mg, 5 mg, 70
mg F QL
ibandronate oral F QL
Calcimimetic, Parathyroid Calcium
Receptor Sensitivity Enhancer
Sensipar F PA; QL
Calcitonins
calcitonin (salmon) F QL
Estrogen-Progestin
estradiol-norethindrone acet F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
88
Drug Tier Status Notes
norethindrone ac-eth estradiol oral tablet 0.5-2.5
mg-mcg, 1-5 mg-mcg F QL
Premphase F QL
Prempro F QL
Estrogens
estradiol oral F
estradiol transdermal patch semiweekly 0.025
mg/24 hr, 0.0375 mg/24 hr, 0.075 mg/24 hr, 0.1
mg/24 hr
F QL
estradiol transdermal patch semiweekly 0.05
mg/24 hr F
estradiol transdermal patch weekly F QL
Menest oral tablet 0.3 mg, 0.625 mg, 1.25 mg F
Premarin oral F QL
Glucocorticoids
dexamethasone oral elixir F
dexamethasone oral solution F
dexamethasone oral tablet F
hydrocortisone oral F
methylprednisolone F
prednisolone oral solution 15 mg/5 mL F
prednisolone sodium phosphate oral solution 15
mg/5 mL (3 mg/mL), 5 mg base/5 mL (6.7 mg/5
mL)
F
prednisone F
Gonadotropin Inhibitor Pituitary
Suppressants
danazol F
Growth Hormones
Norditropin FlexPro F PA
Human Insulins - Fixed Combinations
Humulin 70/30 U-100 Insulin F OTC; QL
Humulin 70/30 U-100 KwikPen F OTC; QL; AL
Novolin 70/30 U-100 Insulin F OTC; QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
89
Drug Tier Status Notes
Human Insulins - Intermediate Acting
Humulin N NPH Insulin KwikPen F OTC; QL; AL
Humulin N NPH U-100 Insulin F OTC; QL
Novolin N NPH U-100 Insulin F OTC; QL
Human Insulins - Short Acting
Humulin R Regular U-100 Insuln F OTC; QL
Humulin R U-500 (Conc) Insulin F PA
Novolin R Regular U-100 Insuln F OTC; QL
Insulin Analogs - Fixed Combinations
Humalog Mix 50-50 Insuln U-100 F QL
Humalog Mix 50-50 KwikPen F QL; AL
Humalog Mix 75-25 KwikPen F QL; AL
Humalog Mix 75-25(U-100)Insuln F QL
Novolog Mix 70-30 U-100 Insuln F QL
Novolog Mix 70-30FlexPen U-100 F QL; AL
Insulin Analogs - Long Acting
Basaglar KwikPen U-100 Insulin F QL
Insulin Analogs - Rapid Acting
Admelog SoloStar U-100 Insulin F QL; AL
Admelog U-100 Insulin lispro F QL
Humalog U-100 Insulin subcutaneous solution F PA
Insulin Response Enhancers -
Biguanides
metformin oral tablet F QL
metformin oral tablet extended release 24 hr F
Insulin Response Enhancers -
Thiazolidinediones (Ppar-Gamma
Agonists)
pioglitazone F QL
Insulin-Like Growth Factor-1 (Igf-1)
Increlex Specialty PA
Leptin Hormone Analogs
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
90
Drug Tier Status Notes
Myalept State Carve Out
Lhrh (Gnrh) Antagonists
Orilissa F PA
Menopausal Symptoms Suppressant-
Ssri Antidepressant Type
Brisdelle State Carve Out
Mineralocorticoids
fludrocortisone F
Oxytocic - Ergot Alkaloids
Methergine F QL; AL
Progestins
medroxyprogesterone oral F
norethindrone acetate F QL
progesterone micronized F QL
Prolactin Inhibitor - Ergot Derivative
Dopamine Receptor Agonists
cabergoline F
Selective Estrogen Receptor Modulators
(Serms)
raloxifene F QL; AL
Somatostatic Agents
octreotide acetate injection solution 1,000
mcg/mL, 100 mcg/mL, 200 mcg/mL, 50 mcg/mL Specialty PA
Thyroid Hormones - Animal Source
(Porcine)
Armour Thyroid oral tablet 180 mg, 240 mg, 30
mg, 300 mg, 60 mg, 90 mg F
Nature-Throid F
NP Thyroid F
thyroid (pork) oral tablet 120 mg, 15 mg F
Westhroid oral tablet 130 mg, 195 mg, 32.5 mg,
65 mg, 97.5 mg F
WP Thyroid F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
91
Drug Tier Status Notes
Thyroid Hormones - Synthetic T3
(Triiodothyronine)
liothyronine oral F
Thyroid Hormones - Synthetic T4
(Thyroxine)
levothyroxine oral F
Levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,
137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg,
50 mcg, 75 mcg, 88 mcg
F
Gastrointestinal Therapy Agents
Antacid - Alginate Combinations
Foaming Antacid oral tablet,chewable F OTC
Antacid - Aluminum
aluminum hydroxide gel oral suspension 320
mg/5 mL F OTC
Antacid - Antacid Combinations
Acid Gone Antacid F OTC
Acid Gone Antacid E.Strength F OTC
Antacid ExSt (mag carb-Al hyd) F OTC
Foaming Antacid oral suspension F OTC
Gaviscon Extra Strength F OTC
Heartburn Antacid F OTC
Heartburn Relief oral tablet,chewable F OTC
Antacid - Bicarbonate
sodium bicarbonate oral F OTC
Antacid - Calcium
Antacid (calcium carbonate) oral tablet,chewable
200 mg calcium (500 mg) F OTC
Antacid Calcium oral tablet,chewable 215 mg
calcium (500 mg) F OTC
Calcium Antacid oral tablet,chewable 200 mg
calcium (500 mg), 320 mg calcium (750 mg) F OTC
calcium carbonate oral suspension F OTC
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
92
Drug Tier Status Notes
calcium carbonate oral tablet,chewable 200 mg
calcium (500 mg), 300 mg (750 mg), 400 mg
calcium (1,000 mg)
F OTC
Cal-Gest Antacid F OTC
Tums Freshers F OTC
Tums oral tablet,chewable 200 mg calcium (500
mg) F OTC
Antacid - Magnesium
magnesium oxide oral tablet 400 mg (241.3 mg
magnesium) F OTC
Antacid - Simethicone Combinations
Antacid Anti-Gas (ca carb-sim) F OTC
Antacid Anti-Gas oral suspension 200-200-20
mg/5 mL F OTC
Antacid-Simethicone F OTC
Maalox Advanced oral tablet,chewable F OTC
Antidiarrheal - Antiperistaltic Agents
Diamode F OTC
loperamide oral capsule F OTC
loperamide oral liquid 1 mg/7.5 mL F OTC
loperamide oral tablet F OTC
Antidiarrheal - Bismuth Agents
Bismatrol oral suspension 525 mg/15 mL F OTC
Bismatrol oral tablet,chewable F OTC
Bismuth oral tablet F OTC
bismuth subsalicylate oral suspension F OTC
Diotame F OTC
Kaopectate Ex Str (bismuth ss) F OTC
Peptic Relief oral tablet,chewable F OTC
Pepto-Bismol Max St F OTC
Pink Bismuth Maximum Strength F OTC
Pink Bismuth oral suspension 525 mg/15 mL F OTC
Pink Bismuth oral tablet F OTC
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
93
Drug Tier Status Notes
Pink Bismuth oral tablet,chewable F OTC
Soothe (bismuth subsalicylate) oral tablet F OTC
Stomach Relief Max Strength F OTC
Stomach Relief oral suspension 525 mg/15 mL F OTC
Stomach Relief oral tablet F OTC
Stomach Relief oral tablet,chewable F OTC
Antidiarrheal Antiperistaltic-
Anticholinergic Combinations
diphenoxylate-atropine oral tablet F
Antiemetic - Anticholinergics
scopolamine base F QL
Antiemetic - Antihistamines
dimenhydrinate oral F OTC
meclizine oral tablet 12.5 mg, 25 mg F OTC
meclizine oral tablet,chewable F OTC
Motion Sickness (meclizine) F OTC
Motion Sickness Relief(mecliz) F OTC
Travel Sickness (meclizine) F OTC
Antiemetic - Cannabinoid Type
dronabinol F PA
Antiemetic - Dopamine (D2)/5-Ht3
Antagonists
trimethobenzamide oral F
Antiemetic - Phenothiazines
prochlorperazine F QL
prochlorperazine maleate F QL
promethazine oral F AL
promethazine rectal suppository 12.5 mg, 25 mg F AL
Antiemetic - Selective Serotonin 5-Ht3
Antagonists
granisetron HCl oral F ST; QL
ondansetron F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
94
Drug Tier Status Notes
ondansetron HCl oral solution F QL; AL
ondansetron HCl oral tablet F QL
Colonic Acidifier (Ammonia Inhibitor)
Enulose State Carve Out
Generlac State Carve Out
lactulose oral solution 10 gram/15 mL (15 mL) F
Digestive Enzyme Mixtures
Creon F QL
Pancreaze oral capsule,delayed release(DR/EC)
10,500-35,500- 61,500 unit, 16,800-56,800-
98,400 unit, 2,600-6,200- 10,850 unit, 21,000-
54,700- 83,900 unit, 4,200-14,200- 24,600 unit
F QL
Pertzye oral capsule,delayed release(DR/EC)
16,000-57,500- 60,500 unit, 24,000-86,250-
90,750 unit, 8,000-28,750- 30,250 unit
F QL
Viokace F QL
Zenpep oral capsule,delayed release(DR/EC)
10,000-32,000 -42,000 unit, 15,000-47,000 -
63,000 unit, 20,000-63,000- 84,000 unit, 25,000-
79,000- 105,000 unit, 3,000-10,000 -14,000-unit,
40,000-126,000- 168,000 unit, 5,000-17,000-
24,000 unit
F QL
Digestive Enzymes
lactase State Carve Out
Lactase Fast Acting oral tablet State Carve Out
Gallstone Solubilizing (Litholysis)
Agents
ursodiol oral capsule F QL
ursodiol oral tablet F
Gastric Acid Secretion Reducers -
Histamine H2-Receptor Antagonists
Acid Controller F OTC
Acid Reducer (famotidine) F OTC
cimetidine oral tablet 200 mg F OTC
cimetidine oral tablet 300 mg, 400 mg, 800 mg F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
95
Drug Tier Status Notes
famotidine oral tablet 10 mg, 20 mg F OTC
famotidine oral tablet 40 mg F
Heartburn Prevention F OTC
Heartburn Relief (cimetidine) F OTC
Heartburn Relief (famotidine) F OTC
ranitidine HCl oral syrup F QL
ranitidine HCl oral tablet 150 mg, 75 mg F OTC
ranitidine HCl oral tablet 300 mg F
Gastric Acid Secretion Reducing Agents
- Proton Pump Inhibitors (Ppis)
lansoprazole oral capsule,delayed release(DR/EC)
15 mg F ST; OTC; QL
lansoprazole oral capsule,delayed release(DR/EC)
30 mg F ST; QL
Nexium 24HR oral capsule,delayed
release(DR/EC) F OTC
omeprazole magnesium F OTC; QL
omeprazole oral capsule,delayed release(DR/EC) F QL
pantoprazole oral F QL
Prevacid SoluTab F QL; AL
Gastric Mucosa - Cytoprotective
Prostaglandin Analogs
misoprostol F QL
Gastrointestinal - Prokinetic Agents - 5-
Ht4 Receptor Agonists
Motegrity F PA; QL; AL
Gastrointestinal Antiflatulents
Gas Relief 80 F OTC
Gas Relief Extra Strength oral tablet,chewable F OTC
Gas Relief oral drops,suspension F OTC
Gas Relief oral tablet,chewable F OTC
Gas-X Extra Strength oral tablet,chewable F OTC
Infants Gas Relief F OTC
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
96
Drug Tier Status Notes
Mi-Acid Gas Relief F OTC
simethicone oral drops,suspension F OTC
simethicone oral tablet,chewable F OTC
Gastrointestinal Prokinetic Agents - D2
Antagonist/5-Ht4 Agonists
metoclopramide HCl oral solution F
metoclopramide HCl oral tablet F
Gi Antispasmodic - Belladonna
Alkaloids
hyoscyamine sulfate oral F AL
hyoscyamine sulfate sublingual F
Gi Antispasmodic - Quaternary
Ammonium Compounds
glycopyrrolate oral tablet 1 mg, 2 mg F
propantheline F
Gi Antispasmodic - Synthetic Tertiary
Amines
dicyclomine oral capsule F AL
dicyclomine oral solution F AL
dicyclomine oral tablet F AL
Ibs Agent - Gastrointestinal Chloride
Channel Activator Agents
Amitiza F PA; QL; AL
Inflammatory Bowel Agent -
Aminosalicylates And Related Agents
Apriso F ST
balsalazide F
Canasa F
Delzicol oral capsule (with del rel tablets) F ST; QL
Dipentum F QL
mesalamine oral tablet,delayed release (DR/EC) F ST; QL
mesalamine rectal enema F
Pentasa F ST; QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
97
Drug Tier Status Notes
sulfasalazine F
Inflammatory Bowel Agent -
Glucocorticoids
hydrocortisone rectal F
Inflammatory Bowel Agent - Janus
Kinase (Jak) Inhibitors
XELJANZ 10 MG TABLET F PA; QL
Xeljanz oral tablet 5 mg F PA; QL
Inflammatory Bowel Agent - Tumor
Necrosis Factor Alpha Blockers
CIMZIA 2X200 MG/ML SYRINGE KIT F PA; QL
Cimzia Powder for Reconst F PA; QL
Cimzia Starter Kit F PA; QL
Humira F PA; QL
Humira Pediatric Crohns Start F PA; QL
Humira Pen F PA; QL
Humira Pen Crohns-UC-HS Start F PA; QL
Humira Pen Psor-Uveits-Adol HS F PA; QL
Humira(CF) F PA; QL
Humira(CF) Pedi Crohns Starter F PA; QL
Humira(CF) Pen F PA; QL
Humira(CF) Pen Crohns-UC-HS F PA; QL
Humira(CF) Pen Psor-Uv-Adol HS F PA; QL
Irritable Bowel Syndrome (Ibs) Agents
Amitiza F PA; QL; AL
Laxative - Bulk Forming
Daily Fiber F OTC
Fiber (psyllium husk/sugar) oral powder 3.4
gram/11 gram, 3.4 gram/12 gram F OTC
Fiber (with aspartame) oral powder 3.4 gram/5.8
gram F OTC
Fiber Laxative (ca polycarbo) F OTC
fiber oral powder F OTC
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
98
Drug Tier Status Notes
Fiber Smooth F OTC
Fiber Smooth (sucrose) F OTC
Fiber Supplement (inulin) F OTC
Fiber-Tabs F OTC
Hydrocil F OTC
Konsyl (sugar) oral powder 3.4 gram/12 gram F OTC
Metamucil (sugar) F OTC
Metamucil (with sugar) oral powder 3.4 gram/12
gram F OTC
Metamucil MultiHealth Fiber F OTC
Metamucil Sugar-Free (aspart) oral powder 3.4
gram/5.8 gram F OTC
Natural Fiber Laxative F OTC
Natural Fiber Laxative (sugar) oral powder 3.4
gram/12 gram, 3.4 gram/7 gram F OTC
Natural Fiber Laxative Therapy F OTC
Natural Fiber Laxative(aspart) oral powder F OTC
Natural Vegetable F OTC
Natural Vegetable (psyllium) F OTC
Natural Vegetable Powder F OTC
psyllium husk oral capsule 0.52 gram F OTC
Reguloid, Sugar Free F OTC
Wal-Mucil Natural Fiber Lax F OTC
Laxative - Lubricant
Mineral Oil Extra Heavy F OTC
Mineral Oil Heavy oral F OTC
mineral oil oral F OTC
mineral oil rectal F OTC
Ready-To-Use Enema (min oil) F OTC
Laxative - Saline And Osmotic
Fleet Glycerin (Adult) F OTC
Fleet Glycerin (Child) F OTC
glycerin (adult) F OTC
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
99
Drug Tier Status Notes
glycerin (child) F OTC
Laxative (glycerin-pediatric) F OTC
magnesium citrate oral solution F OTC
Milk of Magnesia F OTC
Milk Of Magnesia Concentrated F OTC
Pedia-Lax rectal F OTC
polyethylene glycol 3350 oral powder F OTC
Laxative - Saline/Osmotic Mixtures
Enema Disposable F OTC
Enema rectal enema 19-7 gram/118 mL F OTC
Fleet Enema F OTC
Fleet Enema Extra F OTC
Fleet Pediatric F OTC
Gavilyte-C F
GaviLyte-G F
GaviLyte-N F
Golytely oral recon soln F
peg 3350-electrolytes oral recon soln 236-22.74-
6.74 -5.86 gram F
PEG-3350 with flavor packs F
peg-electrolyte soln F
Ready-To-Use Enema F OTC
TriLyte With Flavor Packets F
Laxative - Stimulant
bisacodyl F OTC; QL
Correctol F OTC
Ex-Lax (sennosides) oral tablet F OTC
Ex-Lax Maximum Strength F OTC
Fleet Bisacodyl F OTC
Geri-kot F OTC
Laxative (bisacodyl) oral tablet F OTC
Laxative (sennosides) oral tablet 25 mg F OTC
Laxative Feminine F OTC
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
100
Drug Tier Status Notes
Laxative Maximum Strength F OTC
Laxative Pills F OTC
Laxative Pills Regular F OTC
Natural Veg Laxative(sennosid) F OTC
Perdiem Overnight Relief F OTC
Senna Lax F OTC
Senna Laxative oral tablet 8.6 mg F OTC
senna oral syrup 8.8 mg/5 mL F OTC
senna oral tablet F OTC
Senno F OTC
Senokot F OTC
Sen-O-Tab F OTC
Vegetable Laxative F OTC
Woman's Laxative oral tablet F OTC
Women's Laxative (bisacodyl) oral tablet F OTC
Laxative - Stimulant And Surfactant
Combinations
sennosides-docusate sodium F OTC
Laxative - Surfactant
Colace Clear F OTC
Col-Rite oral capsule 100 mg F OTC
Diocto oral syrup F OTC
Dioctyl F OTC
Docuprene F OTC
docusate calcium F OTC
docusate sodium oral F OTC
Docusil F OTC; QL
DOK F OTC
Dulcolax Stool Softener (dss) F OTC
Enemeez F OTC
Enemeez Plus F OTC
Pedia-Lax Stool Softener F OTC
Phillips' Liqui-Gels F OTC
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
101
Drug Tier Status Notes
Promolaxin F OTC
Silace oral syrup F OTC
Stool Softener (docusate cal) F OTC
Stool Softener oral capsule F OTC
Stool Softener oral syrup F OTC
Stool Softener oral tablet F OTC
Surfak F OTC
Peptic Ulcer - Gastric Lumen Adherent
Cytoprotectives
sucralfate oral tablet F QL
Short Bowel Syndrome (Sbs) Agents
Endari F PA
octreotide acetate injection solution 1,000
mcg/mL, 100 mcg/mL, 200 mcg/mL, 50 mcg/mL Specialty PA
Genitourinary Therapy
Interstitial Cystitis Agents
Elmiron F PA; QL
Phosphate Binders
Auryxia F
calcium acetate oral capsule F
calcium acetate oral tablet 667 mg F OTC
Calphron F
Fosrenol oral powder in packet F
Fosrenol oral tablet,chewable F PA
lanthanum F PA
sevelamer carbonate oral tablet F PA
sevelamer HCl oral tablet 800 mg F PA
Velphoro F
Phosphate Binders - Calcium-Based
calcium acetate oral capsule F
calcium acetate oral tablet 667 mg F OTC
Calphron F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
102
Drug Tier Status Notes
Phosphate Binders - Iron-Based
Auryxia F
Velphoro F
Prostatic Hypertrophy Agent - Alpha-1-
Adrenoceptor Antagonists
alfuzosin F
tamsulosin F QL
Prostatic Hypertrophy Agent - Type Ii
5-Alpha Reductase Inhibitors
finasteride oral tablet 5 mg F QL
Urinary Acidifier - Bacterial Urease
Inhibitor
Lithostat State Carve Out
Urinary Acidifier - Phosphates
K-Phos No 2 F
K-Phos Original F
Urinary Alkalinizer - Citrates
Cytra K Crystals F
Cytra-2 F
potassium citrate oral tablet extended release 10
mEq (1,080 mg), 5 mEq (540 mg) F
potassium citrate-citric acid oral solution F
sodium citrate-citric acid F
Tricitrates F
Urocit-K 10 F
Urocit-K 5 F
Virtrate-3 F
Urinary Analgesics
phenazopyridine oral tablet 100 mg, 200 mg F
Urinary Antibacterial - Methenamine
And Salts
methenamine hippurate F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
103
Drug Tier Status Notes
methenamine mandelate F
Urinary Antibacterial - Nitrofuran
Derivatives
nitrofurantoin F AL
nitrofurantoin macrocrystal oral capsule 100 mg,
50 mg F QL; AL
nitrofurantoin monohyd/m-cryst F QL; AL
Urinary Anti-Infective Methenamine-
Antispas-Analg Combinations
Uretron D-S oral tablet 81.6-10.8-40.8 mg F
Utira-C F
Urinary Antispasmodic -
Anticholinergics, Non-Selective
hyoscyamine sulfate oral F AL
hyoscyamine sulfate sublingual F
Urinary Antispasmodic - Smooth
Muscle Relaxants
flavoxate F
oxybutynin chloride F QL
Oxytrol For Women F OTC
tolterodine F ST; QL
trospium F ST; QL
Urinary Retention Therapy -
Parasympathomimetic Agents
bethanechol chloride F QL
Gout And Hyperuricemia Therapy
Gout Acute Therapy - Antimitotics
colchicine F QL
Gout And Hyperuricemia - Antimitotic-
Uricosuric Combinations
probenecid-colchicine F
Hyperuricemia Therapy - Uricosurics
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
104
Drug Tier Status Notes
probenecid F
Hyperuricemia Therapy - Xanthine
Oxidase Inhibitors
allopurinol F QL
febuxostat F PA; QL
Hematological Agents
Anticoagulants - Coumarin
warfarin F
Anti-Inhibitor Coagulation Complex
Feiba NF intravenous recon soln 1,750-3,250
unit, 350-650 unit, 700-1,300 unit State Carve Out
C1 Esterase Inhibitor Agents
Berinert State Carve Out
Cinryze State Carve Out
Ruconest State Carve Out
Direct Factor Xa Inhibitors
Eliquis F QL; AL
Eliquis DVT-PE Treat 30D Start F QL; AL
Xarelto oral tablet 10 mg, 15 mg, 20 mg F QL; AL
Xarelto oral tablets,dose pack F QL; AL
Erythropoietins
Aranesp (in polysorbate) F PA
Epogen injection solution 10,000 unit/mL, 2,000
unit/mL, 20,000 unit/2 mL, 20,000 unit/mL, 3,000
unit/mL, 4,000 unit/mL
F PA
Procrit F PA
Retacrit Specialty PA
Factor Ix Complex (Prothrombin
Complex Concentrate) Preparations
Kcentra State Carve Out
Factor Ix Preparations
AlphaNine SD intravenous recon soln 1,500 (+/-)
unit, 500 (+/-) unit State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
105
Drug Tier Status Notes
Alprolix intravenous recon soln 1,000 unit, 2,000
unit, 3,000 unit, 500 unit State Carve Out
Ixinity State Carve Out
Mononine State Carve Out
Profilnine State Carve Out
Rixubis State Carve Out
Factor Vii Preparations
Novoseven RT State Carve Out
Factor Viii Preparations (Ahf)
Advate intravenous recon soln 1,500 (+/-) unit,
4,000 (+/-) unit State Carve Out
Adynovate intravenous solution 1,500 (+/-) unit,
3,000 (+/-) unit, 750 (+/-) unit State Carve Out
Afstyla intravenous recon soln 1,500 (+/-) unit
range State Carve Out
Alphanate State Carve Out
Eloctate State Carve Out
Hemofil M High State Carve Out
Hemofil M Low State Carve Out
Hemofil M Mid State Carve Out
Hemofil M Super High State Carve Out
Humate-P State Carve Out
Koate intravenous recon soln 250 (+/-) unit, 500
(+/-) unit State Carve Out
Kogenate FS State Carve Out
Novoeight State Carve Out
Obizur State Carve Out
Recombinate State Carve Out
Wilate intravenous recon soln 450-450 unit, 900-
900 unit State Carve Out
Xyntha State Carve Out
Xyntha Solofuse State Carve Out
Factor Viii-Mimetic Agent, Monoclonal
Antibody
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
106
Drug Tier Status Notes
Hemlibra State Carve Out
Factor Xiii Preparations
Corifact State Carve Out
Tretten State Carve Out
Granulocyte Colony-Stimulating Factor
(G-Csf)
Fulphila Specialty PA
Granix Specialty PA
Neupogen F PA
Nivestym subcutaneous F PA
Zarxio F PA
Hematorheologic Agents
pentoxifylline F
Hemostatic Systemic - Antifibrinolytic
Agents
aminocaproic acid intravenous State Carve Out
Cyklokapron State Carve Out
RiaSTAP State Carve Out
tranexamic acid oral State Carve Out
Heparins
heparin (porcine) injection solution 10,000
unit/mL, 5,000 unit/mL F
Human Albumin
Albuminar 25 % State Carve Out
Albuminar 5 % State Carve Out
Buminate 25 % State Carve Out
Plasbumin 5 % State Carve Out
Human Monoclonal Antibody
Complement (C5) Inhibitors
Soliris State Carve Out
Low Molecular Weight Heparins
enoxaparin subcutaneous syringe F PA
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
107
Drug Tier Status Notes
Plasma Fractions
Octaplas (Blood Group A) State Carve Out
Octaplas (Blood Group AB) State Carve Out
Octaplas (Blood Group B) State Carve Out
Octaplas (Blood Group O) State Carve Out
Plasmanate State Carve Out
Plasma Proteins Which Facilitate
Anticoagulation
ATryn State Carve Out
Thrombate III State Carve Out
Platelet Aggregation Inhibitors -
Phosphodiesterase Iii Inhibitors
cilostazol F QL
Platelet Aggregation Inhibitors -
Quinazoline Agents
anagrelide F
Platelet Aggregation Inhibitors -
Salicylates
aspirin oral tablet F OTC; QL; AL
aspirin oral tablet,chewable F OTC; QL
aspirin oral tablet,delayed release (DR/EC) 325
mg F OTC; QL; AL
aspirin oral tablet,delayed release (DR/EC) 81 mg F OTC; QL
Platelet Aggregation Inhibitors -
Thienopyridine Agents
clopidogrel F QL
Platelet Aggregation Inhib-Pdesterase
And Adenosine Deaminase Inhibitr
dipyridamole oral F QL
Protein C Preparations
Ceprotin (Blue Bar) State Carve Out
Ceprotin (Green Bar) State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
108
Drug Tier Status Notes
Sickle Cell Anemia Agents
Droxia F
Endari F PA
Sickle Cell Anemia Agents, Others
Droxia F
Endari F PA
Thrombin Inhibitor - Selective Direct
And Reversible
Pradaxa oral capsule 150 mg, 75 mg F QL
Immunosuppressive Agents
Immunosuppressive - Calcineurin
Inhibitors
cyclosporine modified oral capsule F
cyclosporine modified oral solution F AL
cyclosporine oral capsule F
tacrolimus oral F
Immunosuppressive - Inosine
Monophosphate Dehydrogenase
Inhibitors
mycophenolate mofetil oral capsule F
mycophenolate mofetil oral suspension for
reconstitution F AL
mycophenolate mofetil oral tablet F
mycophenolate sodium F ST
Immunosuppressive - Mammalian
Target Of Rapamycin (Mtor) Inhibitors
sirolimus oral tablet F
Immunosuppressive - Purine Analogs
azathioprine F QL
Locomotor System
Als Agents - Benzathiazoles
riluzole F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
109
Drug Tier Status Notes
Antimyasthenic Agent - Reversible
Cholinesterase Inhibitors
pyridostigmine bromide oral tablet 60 mg F
pyridostigmine bromide oral tablet extended
release F
Duchenne Muscular Dystrophy - Exon
Skipping Antisense Oligonucleotide
Exondys 51 State Carve Out
Skeletal Muscle Relaxant - Central
Muscle Relaxants
baclofen oral tablet 10 mg, 20 mg F
chlorzoxazone oral tablet 500 mg F AL
cyclobenzaprine oral tablet 10 mg, 5 mg F AL
methocarbamol oral F AL
orphenadrine citrate oral F QL; AL
tizanidine oral tablet F AL
Skeletal Muscle Relaxant - Direct
Muscle Relaxants
dantrolene oral F QL
Spinal Muscular Atrophy - Exon
Inclusion Antisense Oligonucleotide
Spinraza (PF) State Carve Out
Medical Supplies And Durable Medical
Equipment (Dme)
Medical Supplies And Dme - Blood
Glucose Tests
Accu-Chek Aviva Plus test strp F OTC; QL
Accu-Chek Guide F OTC; QL
Accu-Chek SmartView Test Strip F OTC; QL
Medical Supplies And Dme - Cervical
Caps
FemCap vaginal device 26 mm, 30 mm F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
110
Drug Tier Status Notes
Medical Supplies And Dme -
Diaphragms
Caya Contoured F
Wide-Seal Diaphragm 60 F
Wide-Seal Diaphragm 65 F
Wide-Seal Diaphragm 70 F
Wide-Seal Diaphragm 75 F
Wide-Seal Diaphragm 80 F
Wide-Seal Diaphragm 85 F
Wide-Seal Diaphragm 90 F
Wide-Seal Diaphragm 95 F
Medical Supplies And Dme - Female
Condoms
FC2 Female Condom F OTC; QL
Medical Supplies And Dme - Glucose
Monitoring Test Supplies
Accu-Chek Aviva Control Soln F OTC
Accu-Chek FastClix Lancing Dev F OTC
Accu-Chek Guide Glucose Meter F OTC; QL
Accu-Chek Guide L1-L2 Ctrl Sol F OTC
Accu-Chek Guide Me Glucose Mtr F OTC; QL
Accu-Chek Multiclix Lancet F OTC; QL
Accu-Chek Multiclix Lancet kit F OTC
Accu-Chek SmartView Contrl Sol F OTC
Accu-Chek Soft Dev Lancets F OTC
Accu-Chek Softclix Lancet Dev F OTC
Accu-Chek Softclix Lancets F OTC; QL
Smart Sense Lancets 26 gauge F OTC
Soft Touch Lancets F OTC; QL
Medical Supplies And Dme - Hearing
Aid Supplies And Batteries
Hearing Aid Batteries F OTC; QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
111
Drug Tier Status Notes
Medical Supplies And Dme - Insulin
Needles-Syringes And Admin Supplies
Advocate Syringes syringe 1 mL 30 gauge x 5/16 F OTC
BD AutoShield Duo Pen Needle F OTC
BD INS SYR 0.3 ML 8MMX31G(1/2) F OTC
BD INS SYR UF 0.3 ML 12.7MMX30G F OTC
BD INS SYR UF 0.5 ML 12.7MMX30G F OTC
BD INS SYRN UF 1 ML 12.7MMX30G F OTC
BD INS SYRNG UF 0.3 ML 8MMX31G F OTC
BD INS SYRNG UF 0.5 ML 8MMX31G F OTC
BD INSULIN SYR UF 1 ML 8MMX31G F OTC
BD Insulin Syringe Half Unit syringe 0.3 mL 31
gauge x 5/16" F OTC; QL
BD Insulin Syringe Micro-Fine syringe 1 mL 28
gauge x 1/2" F OTC; QL
BD Insulin Syringe syringe 1 mL 28 gauge x 1/2" F OTC; QL
BD Insulin Syringe U-500 F
BD Insulin Syringe Ultra-Fine syringe 0.3 mL 30
gauge x 1/2", 0.3 mL 31 gauge x 5/16", 0.5 mL
30 gauge x 1/2", 0.5 mL 31 gauge x 5/16", 1 mL
30 gauge x 1/2", 1 mL 31 gauge x 5/16
F OTC; QL
BD Nano 2nd Gen Pen Needle F OTC
BD UF MICRO PEN NEEDLE 6MMX32G F OTC
BD UF MINI PEN NEEDLE 5MMX31G F OTC
BD UF NANO PEN NEEDLE 4MMX32G F OTC
BD UF ORIG PEN NDL 12.7MMX29G F OTC
BD UF SHORT PEN NEEDLE 8MMX31G F OTC
BD Ultra-Fine Micro Pen Needle needle 32 gauge
x 1/4" F OTC; QL
BD Ultra-Fine Mini Pen Needle needle 31 gauge
x 3/16" F OTC; QL
BD Ultra-Fine Nano Pen Needle needle 32 gauge
x 5/32" F OTC; QL
BD Ultra-Fine Orig Pen Needle needle 29 gauge
x 1/2" F OTC; QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
112
Drug Tier Status Notes
BD Ultra-Fine Short Pen Needle needle 31 gauge
x 5/16" F OTC; QL
BD VEO INS SYRING 1 ML 6MMX31G F OTC
BD VEO INS SYRN 0.3 ML 6MMX31G F OTC
BD VEO INS SYRN 0.5 ML 6MMX31G F OTC
BD Veo Insulin Syr Half Unit F OTC
Easy Comfort Insulin Syringe syringe 1 mL 30
gauge x 5/16 F OTC
Easy Touch Insulin Syringe syringe 1 mL 28
gauge x 1/2", 1 mL 31 gauge x 5/16 F OTC; QL
insulin syringe-needle U-100 syringe 1 mL 29
gauge x 1/2", 1 mL 30 gauge x 3/8", 1 mL 31
gauge x 5/16
F OTC; QL
Sure-Ject Insulin Syringe syringe 1 mL 28 gauge
x 1/2" F OTC; QL
UltiCare syringe 1 mL 30 gauge x 1/2" F OTC; QL
Ultra Comfort Insulin Syringe syringe 1 mL 28
gauge F OTC
Medical Supplies And Dme - Male
Condoms
Aimsco Latex Condom F OTC; QL
Condoms-Prem Lubricated F OTC; QL
Durex Avanti Bare Real Feel F OTC; QL
Fantasy Condom F OTC; QL
Kimono Condoms(Non-lubricated) F OTC; QL
Kimono Maxx Condoms F OTC; QL
Kimono MicroThin Aqua Lube Con F OTC; QL
Kimono MicroThin Condoms F OTC; QL
Kimono MicroThin Large Condoms F OTC; QL
Kimono Textured Condoms F OTC; QL
Trustex Latex Condom F OTC; QL
Trustex Lubricated Condoms F OTC; QL
Trustex Non-Lub Condoms F OTC; QL
Trustex-RIA Lub/Spermicide F OTC; QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
113
Drug Tier Status Notes
Trustex-RIA Lubricated Condoms F OTC; QL
Trustex-RIA Non-Lub Condoms F OTC; QL
Medical Supplies And Dme -
Miscellaneous Other
blood pressure test kit-large F OTC; QL
blood pressure test kit-medium F OTC
blood pressure test kit-wrist F OTC
Sharps Container F OTC
Medical Supplies And Dme - Needles
And Syringes
SafeSnap Syringe syringe 1 mL 25 gauge x 5/8",
1 mL 27 gauge x 1/2", 3 mL F OTC
Medical Supplies And Dme - Peak Flow
Meters
Aerogear Action Asthma Kit F QL
Airzone Peak Flow Meter F OTC; QL
Asthma Check Meter F OTC; QL
Asthmapack Children's F QL
In-Check Nasal With Mask F OTC; QL
In-Check Oral Flow Meter F OTC; QL
Microlife Peak Flow Meter F OTC; QL
Mini Wright Peak Flow Meter F QL
Peak Air Peak Flow Meter F OTC
Personal Best Full Range F OTC; QL
Piko 1 F OTC; QL
Pocket Peak Flow Meter F OTC; QL
Truzone Peak Flow Meter F QL
Medical Supplies And Dme -
Respiratory Therapy Supplies
Ace Aerosol Cloud Enhancer F QL
Aerochamber Mini F QL
Aerochamber MV F QL
Aerochamber Plus Flow-Vu F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
114
Drug Tier Status Notes
Aerochamber Plus Flow-Vu,L Msk F QL
Aerochamber Plus Flow-Vu,M Msk F QL
Aerochamber Plus Flow-Vu,S Msk F QL
Aerochamber Plus Z Stat F QL
AeroChamber Plus Z Stat Lg Msk F QL
AeroChamber Plus Z Stat Md Msk F QL
AeroChamber Plus Z Stat Sm Msk F QL
Aerochamber with Flowsignal F QL
AeroChamber Z-Stat Plus-Flw Sg F QL
AeroTrach Plus F QL
BreatheRite MDI Spacer F QL
BreatheRite Spacer-Mask, Neo. F QL
BreatheRite Spacer-Mask,Adult F QL
BreatheRite Spacer-Mask,Child F QL
BreatheRite Spacer-Mask,Infant F QL
BreatheRite Spacer-Mask,S.Chld F QL
BreatheRite Valved MDI Chamber F QL
BreatheRite Valved MDI Spacer F QL
Clever Choice Chamber-Lrg Mask F QL
Clever Choice Chamber-Med Mask F QL
Clever Choice Chamber-Sm Mask F QL
Compact Space Chamber Plus F QL
Compact Space Chamber-Lrg Mask F QL
Compact Space Chamber-Med Mask F QL
Compact Space Chamber-Sm Mask F QL
EasiVent Holding Chamber F QL
EasiVent Mask Large F QL
EasiVent Mask Medium F QL
EasiVent Mask Small F QL
Flexichamber-Lg Child Mask F QL
Flexichamber-Sm Adult Mask F QL
Flexichamber-Sm Child Mask F QL
InspiraChamber F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
115
Drug Tier Status Notes
InspiraChamber with Mask-Large F QL
InspiraChamber with Mask-Med F QL
InspiraChamber with Mask-Small F QL
Lite Touch-Medium Mask F QL
LiteAire MDI Chamber F QL
LiteTouch-Large Mask F QL
LiteTouch-Small Mask F QL
Microchamber F QL
Microspacer F QL
Mouthpiece F OTC; QL
One Way Valved Mouthpiece F OTC; QL
Optichamber Adult Mask-Large F QL
OptiChamber Diamond Lg Mask F QL
OptiChamber Diamond VHC F QL
OptiChamber Diamond-Med Msk F QL
OptiChamber Diamond-Sml Mask F QL
Panda Mask F OTC; QL
Pediatric Medium Mask F OTC; QL
Pediatric Panda Mask F OTC; QL
Pediatric Small Mask F OTC; QL
POCKET CHAMBER F QL
PrimeAire F QL
Pro Comfort Spacer-Adult Mask F QL
Pro Comfort Spacer-Child Mask F QL
ProChamber F QL
RiteFlo Aerochamber F QL
Sidestream Pediatric Face Mask F OTC; QL
Silicone Mask - Infant F QL
Silicone Mask - Pediatric F OTC; QL
Space Chamber Plus F QL
Vortex Adult Mask F OTC; QL
Vortex Frog Mask-Child F OTC; QL
Vortex Holding Chamber F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
116
Drug Tier Status Notes
Vortex Holding Chamber Child F QL
Vortex Holding Chamber Toddler F QL
Vortex Ladybug Mask-Toddler F OTC; QL
Vortex VHC Frog Mask-Child F QL
Vortex VHC Ladybug Mask-Toddlr F QL
Medical Supplies And Dme - Urine
Ketone Tests
Ketone Care F OTC
Ketone Urine Test F OTC
Ketostix F OTC
TRUEplus Ketone F OTC
Medical Supply, Fdb Superset
Medical Supply, Fdb Superset
Accu-Chek Aviva Control Soln F OTC
Accu-Chek Aviva Plus test strp F OTC; QL
Accu-Chek FastClix Lancing Dev F OTC
Accu-Chek Guide F OTC; QL
Accu-Chek Guide Glucose Meter F OTC; QL
Accu-Chek Guide L1-L2 Ctrl Sol F OTC
Accu-Chek Guide Me Glucose Mtr F OTC; QL
Accu-Chek Multiclix Lancet F OTC; QL
Accu-Chek Multiclix Lancet kit F OTC
Accu-Chek SmartView Contrl Sol F OTC
Accu-Chek SmartView Test Strip F OTC; QL
Accu-Chek Soft Dev Lancets F OTC
Accu-Chek Softclix Lancet Dev F OTC
Accu-Chek Softclix Lancets F OTC; QL
Ace Aerosol Cloud Enhancer F QL
Advocate Syringes syringe 1 mL 30 gauge x 5/16 F OTC
Aerochamber Mini F QL
Aerochamber MV F QL
Aerochamber Plus Flow-Vu F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
117
Drug Tier Status Notes
Aerochamber Plus Flow-Vu,L Msk F QL
Aerochamber Plus Flow-Vu,M Msk F QL
Aerochamber Plus Flow-Vu,S Msk F QL
Aerochamber Plus Z Stat F QL
AeroChamber Plus Z Stat Lg Msk F QL
AeroChamber Plus Z Stat Md Msk F QL
AeroChamber Plus Z Stat Sm Msk F QL
Aerochamber with Flowsignal F QL
AeroChamber Z-Stat Plus-Flw Sg F QL
Aerogear Action Asthma Kit F QL
AeroTrach Plus F QL
Aimsco Latex Condom F OTC; QL
Airzone Peak Flow Meter F OTC; QL
Asthma Check Meter F OTC; QL
Asthmapack Children's F QL
BD AutoShield Duo Pen Needle F OTC
BD INS SYR 0.3 ML 8MMX31G(1/2) F OTC
BD INS SYR UF 0.3 ML 12.7MMX30G F OTC
BD INS SYR UF 0.5 ML 12.7MMX30G F OTC
BD INS SYRN UF 1 ML 12.7MMX30G F OTC
BD INS SYRNG UF 0.3 ML 8MMX31G F OTC
BD INS SYRNG UF 0.5 ML 8MMX31G F OTC
BD INSULIN SYR UF 1 ML 8MMX31G F OTC
BD Insulin Syringe Half Unit syringe 0.3 mL 31
gauge x 5/16" F OTC; QL
BD Insulin Syringe Micro-Fine syringe 1 mL 28
gauge x 1/2" F OTC; QL
BD Insulin Syringe syringe 1 mL 28 gauge x 1/2" F OTC; QL
BD Insulin Syringe U-500 F
BD Insulin Syringe Ultra-Fine syringe 0.3 mL 30
gauge x 1/2", 0.3 mL 31 gauge x 5/16", 0.5 mL
30 gauge x 1/2", 0.5 mL 31 gauge x 5/16", 1 mL
30 gauge x 1/2", 1 mL 31 gauge x 5/16
F OTC; QL
BD Nano 2nd Gen Pen Needle F OTC
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
118
Drug Tier Status Notes
BD UF MICRO PEN NEEDLE 6MMX32G F OTC
BD UF MINI PEN NEEDLE 5MMX31G F OTC
BD UF NANO PEN NEEDLE 4MMX32G F OTC
BD UF ORIG PEN NDL 12.7MMX29G F OTC
BD UF SHORT PEN NEEDLE 8MMX31G F OTC
BD Ultra-Fine Micro Pen Needle needle 32 gauge
x 1/4" F OTC; QL
BD Ultra-Fine Mini Pen Needle needle 31 gauge
x 3/16" F OTC; QL
BD Ultra-Fine Nano Pen Needle needle 32 gauge
x 5/32" F OTC; QL
BD Ultra-Fine Orig Pen Needle needle 29 gauge
x 1/2" F OTC; QL
BD Ultra-Fine Short Pen Needle needle 31 gauge
x 5/16" F OTC; QL
BD VEO INS SYRING 1 ML 6MMX31G F OTC
BD VEO INS SYRN 0.3 ML 6MMX31G F OTC
BD VEO INS SYRN 0.5 ML 6MMX31G F OTC
BD Veo Insulin Syr Half Unit F OTC
blood pressure test kit-large F OTC; QL
blood pressure test kit-medium F OTC
blood pressure test kit-wrist F OTC
BreatheRite MDI Spacer F QL
BreatheRite Spacer-Mask, Neo. F QL
BreatheRite Spacer-Mask,Adult F QL
BreatheRite Spacer-Mask,Child F QL
BreatheRite Spacer-Mask,Infant F QL
BreatheRite Spacer-Mask,S.Chld F QL
BreatheRite Valved MDI Chamber F QL
BreatheRite Valved MDI Spacer F QL
Caya Contoured F
Clever Choice Chamber-Lrg Mask F QL
Clever Choice Chamber-Med Mask F QL
Clever Choice Chamber-Sm Mask F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
119
Drug Tier Status Notes
Compact Space Chamber Plus F QL
Compact Space Chamber-Lrg Mask F QL
Compact Space Chamber-Med Mask F QL
Compact Space Chamber-Sm Mask F QL
Condoms-Prem Lubricated F OTC; QL
Durex Avanti Bare Real Feel F OTC; QL
EasiVent Holding Chamber F QL
EasiVent Mask Large F QL
EasiVent Mask Medium F QL
EasiVent Mask Small F QL
Easy Comfort Insulin Syringe syringe 1 mL 30
gauge x 5/16 F OTC
Easy Touch Insulin Syringe syringe 1 mL 28
gauge x 1/2", 1 mL 31 gauge x 5/16 F OTC; QL
Fantasy Condom F OTC; QL
FC2 Female Condom F OTC; QL
FemCap vaginal device 26 mm, 30 mm F QL
Flexichamber-Lg Child Mask F QL
Flexichamber-Sm Adult Mask F QL
Flexichamber-Sm Child Mask F QL
Hearing Aid Batteries F OTC; QL
In-Check Nasal With Mask F OTC; QL
In-Check Oral Flow Meter F OTC; QL
InspiraChamber F QL
InspiraChamber with Mask-Large F QL
InspiraChamber with Mask-Med F QL
InspiraChamber with Mask-Small F QL
insulin syringe-needle U-100 syringe 1 mL 29
gauge x 1/2", 1 mL 30 gauge x 3/8", 1 mL 31
gauge x 5/16
F OTC; QL
Ketone Care F OTC
Ketone Urine Test F OTC
Ketostix F OTC
Kimono Condoms(Non-lubricated) F OTC; QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
120
Drug Tier Status Notes
Kimono Maxx Condoms F OTC; QL
Kimono MicroThin Aqua Lube Con F OTC; QL
Kimono MicroThin Condoms F OTC; QL
Kimono MicroThin Large Condoms F OTC; QL
Kimono Textured Condoms F OTC; QL
Lite Touch-Medium Mask F QL
LiteAire MDI Chamber F QL
LiteTouch-Large Mask F QL
LiteTouch-Small Mask F QL
Microchamber F QL
Microlife Peak Flow Meter F OTC; QL
Microspacer F QL
Mini Wright Peak Flow Meter F QL
Mouthpiece F OTC; QL
One Way Valved Mouthpiece F OTC; QL
Optichamber Adult Mask-Large F QL
OptiChamber Diamond Lg Mask F QL
OptiChamber Diamond VHC F QL
OptiChamber Diamond-Med Msk F QL
OptiChamber Diamond-Sml Mask F QL
Panda Mask F OTC; QL
Peak Air Peak Flow Meter F OTC
Pediatric Medium Mask F OTC; QL
Pediatric Panda Mask F OTC; QL
Pediatric Small Mask F OTC; QL
Personal Best Full Range F OTC; QL
Piko 1 F OTC; QL
POCKET CHAMBER F QL
Pocket Peak Flow Meter F OTC; QL
PrimeAire F QL
Pro Comfort Spacer-Adult Mask F QL
Pro Comfort Spacer-Child Mask F QL
ProChamber F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
121
Drug Tier Status Notes
RiteFlo Aerochamber F QL
SafeSnap Syringe syringe 1 mL 25 gauge x 5/8",
1 mL 27 gauge x 1/2", 3 mL F OTC
Sharps Container F OTC
Sidestream Pediatric Face Mask F OTC; QL
Silicone Mask - Infant F QL
Silicone Mask - Pediatric F OTC; QL
Smart Sense Lancets 26 gauge F OTC
Soft Touch Lancets F OTC; QL
Space Chamber Plus F QL
Sure-Ject Insulin Syringe syringe 1 mL 28 gauge
x 1/2" F OTC; QL
TRUEplus Ketone F OTC
Trustex Latex Condom F OTC; QL
Trustex Lubricated Condoms F OTC; QL
Trustex Non-Lub Condoms F OTC; QL
Trustex-RIA Lub/Spermicide F OTC; QL
Trustex-RIA Lubricated Condoms F OTC; QL
Trustex-RIA Non-Lub Condoms F OTC; QL
Truzone Peak Flow Meter F QL
UltiCare syringe 1 mL 30 gauge x 1/2" F OTC; QL
Ultra Comfort Insulin Syringe syringe 1 mL 28
gauge F OTC
Vortex Adult Mask F OTC; QL
Vortex Frog Mask-Child F OTC; QL
Vortex Holding Chamber F QL
Vortex Holding Chamber Child F QL
Vortex Holding Chamber Toddler F QL
Vortex Ladybug Mask-Toddler F OTC; QL
Vortex VHC Frog Mask-Child F QL
Vortex VHC Ladybug Mask-Toddlr F QL
Wide-Seal Diaphragm 60 F
Wide-Seal Diaphragm 65 F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
122
Drug Tier Status Notes
Wide-Seal Diaphragm 70 F
Wide-Seal Diaphragm 75 F
Wide-Seal Diaphragm 80 F
Wide-Seal Diaphragm 85 F
Wide-Seal Diaphragm 90 F
Wide-Seal Diaphragm 95 F
Metabolic Disease Enzyme Replacement
Agents
Metabolic Disease Enzyme
Replacement, Fabry's Disease
Fabrazyme State Carve Out
Metabolic Disease Enzyme
Replacement, Gaucher's Disease
Cerezyme intravenous recon soln 400 unit State Carve Out
Elelyso State Carve Out
VPRIV State Carve Out
Metabolic Disease Enzyme
Replacement, Mucopolysaccharidosis
Aldurazyme State Carve Out
Elaprase State Carve Out
Naglazyme State Carve Out
Vimizim State Carve Out
Metabolic Disease Enzyme
Replacement, Pompe Disease
Lumizyme State Carve Out
Metabolic Modifiers
Hyperparathyroid Treatment Agents -
Vitamin D Analog-Type
calcitriol oral capsule F QL
calcitriol oral solution F AL
Metabolic Modifier - Carnitine
Replenisher Agents
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
123
Drug Tier Status Notes
Carnitor (sugar-free) State Carve Out
Carnitor intravenous State Carve Out
levocarnitine (with sugar) State Carve Out
levocarnitine oral tablet State Carve Out OTC
Metabolic Modifier - Gaucher's Disease,
Type-1, Substrate Reduction Tx
Cerdelga State Carve Out
Zavesca State Carve Out
Metabolic Modifier - Hereditary
Tyrosinemia Treatment Agents
Orfadin oral capsule 10 mg, 2 mg, 5 mg State Carve Out
Metabolic Modifier - Homocystinuria
Treatment Agents
Cystadane State Carve Out
Metabolic Modifier - Urea Cycle
Disorder Agents-Conjugating Agents
Ammonul State Carve Out
Buphenyl oral tablet State Carve Out
Ravicti State Carve Out
sodium phenylbutyrate oral powder State Carve Out
Metabolic Modifier-Carbamoyl
Phosphate Synthetase 1 (Cps 1)
Activator
Carbaglu State Carve Out
Pharmacoenhancer - Cytochrome P450
Inhibitors
Tybost State Carve Out
Pharmacological Chaperone Tx -
Alpha-Galactosidase A Enzyme
Stabilizer
Galafold State Carve Out
Phenylketonuria(Pku) Tx Agents -
Cofactor Of Phenylalanine Hydroxylase
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
124
Drug Tier Status Notes
Kuvan State Carve Out
Mouth-Throat-Dental - Preparations
Dental Product - Fluoride Preparations
Denta 5000 Plus F
DentaGel F AL
fluoride (sodium) oral drops F QL; AL
fluoride (sodium) oral tablet,chewable 0.25
mg(0.55 mg sod. fluoride) F AL
fluoride (sodium) oral tablet,chewable 0.5 mg
(1.1 mg sodium fluorid), 1 mg (2.2 mg sod.
fluoride)
F QL; AL
Fluoritab oral tablet,chewable 1 mg (2.2 mg sod.
fluoride) F AL
Ludent Fluoride F AL
Perio Med F OTC; QL
PreviDent 5000 Plus F
PreviDent dental gel F AL
SF F AL
SF 5000 Plus F
Mouth And Throat - Antifungals
clotrimazole mucous membrane F QL
nystatin oral suspension F QL
Mouth And Throat - Antiseptics
chlorhexidine gluconate mucous membrane F QL
Mouth And Throat - Glucocorticoids
triamcinolone acetonide dental F QL
Mouth And Throat - Local Anesthetic
Amides
lidocaine HCl mucous membrane jelly F
Lidocaine Viscous F
Mouth And Throat - Saliva Stimulants
pilocarpine HCl oral F
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
125
Drug Tier Status Notes
Periodontal Product - Tetracycline-
Type, Collagenase Inhibitors
doxycycline hyclate oral tablet 20 mg F QL
Multiple Sclerosis Agents
Multiple Sclerosis Agent - Interferons
Avonex (with albumin) Specialty PA; QL
Avonex intramuscular pen injector kit Specialty PA; QL
Avonex intramuscular syringe kit Specialty PA; QL
Multiple Sclerosis Agent - Others
glatiramer Specialty PA; QL
Glatopa subcutaneous syringe 20 mg/mL Specialty PA; QL
Tecfidera Specialty PA; QL
Multiple Sclerosis Agent - Potassium
Channel Blocker
dalfampridine F PA; QL; AL
Firdapse State Carve Out
Multiple Sclerosis Agent - Sphingosine
1-Phosphate Receptor Modulator
Gilenya oral capsule 0.5 mg Specialty PA; QL
Ophthalmic Agents
Artificial Tears And Lubricant
Combinations
Artificial Tears (PF) F OTC
Artificial Tears(dext70-hypro) F OTC
Artificial Tears(glycerin-peg) F OTC
Artificial Tears(pvalch-povid) F OTC
Bion Tears (PF) F OTC
Lubricant (p-glycol-glycerin) F OTC
Lubricant Eye (PG-PEG 400) F OTC
Lubricant Eye ophthalmic (eye) ointment 57.3-
42.5 % F OTC
Lubricant Eye(dextran70-hypml) F OTC
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
126
Drug Tier Status Notes
Lubricating Relief F OTC
Natural Tears (PF) F OTC
Refresh Lacri-Lube F OTC
Refresh P.M. F OTC
Systane (propylene glycol) F OTC
Systane Gel ophthalmic (eye) drops,gel F OTC
Systane Ultra F OTC
Ultra Lubricant Eye F OTC
Artificial Tears And Lubricant Single
Agents
Artificial Tears (polyvin alc) F OTC
Lubricant Eye Drops ophthalmic (eye)
dropperette F OTC
Lubricant Eye Drops ophthalmic (eye) drops 0.5
% F OTC
polyvinyl alcohol F OTC
Refresh Celluvisc F OTC
Refresh Liquigel F OTC
Refresh Plus F OTC
Refresh Tears F OTC
TheraTears ophthalmic (eye) dropperette,gel F OTC
Miotics - Cholinesterase Inhibitors
Phospholine Iodide F
Miotics - Direct Acting
pilocarpine HCl ophthalmic (eye) drops 1 %, 2 %,
4 % F
Ophthalmic - Antibacterial-
Glucocorticoid Combinations
neomycin-bacitracin-poly-HC F
neomycin-polymyxin B-dexameth F
sulfacetamide-prednisolone F
tobramycin-dexamethasone F
Ophthalmic - Anticholinergics
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
127
Drug Tier Status Notes
atropine ophthalmic (eye) drops F
atropine ophthalmic (eye) ointment F
cyclopentolate ophthalmic (eye) drops 1 %, 2 % F
homatropine HBr F
tropicamide F
Ophthalmic - Antihistamine-
Decongestant Combinations
Allergy Eye (naphazoline-phen) F OTC
Eye Allergy Relief F OTC
Ophthalmic - Antihistamines
azelastine ophthalmic (eye) F QL
ketotifen fumarate F OTC; QL
Ophthalmic - Anti-Inflammatory,
Glucocorticoids
dexamethasone sodium phosphate ophthalmic
(eye) F
fluorometholone F QL
FML Forte F QL
FML S.O.P. F QL
Pred Mild F QL
prednisolone acetate F
prednisolone sodium phosphate ophthalmic (eye) F
Ophthalmic - Anti-Inflammatory,
Nsaids
diclofenac sodium ophthalmic (eye) F
flurbiprofen sodium F
ketorolac ophthalmic (eye) drops 0.5 % F QL
Ophthalmic - Beta Blockers-Carbonic
Anhydrase Inhibitor Combinations
dorzolamide-timolol F QL
Ophthalmic - Carbonic Anhydrase
Inhibitors
dorzolamide F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
128
Drug Tier Status Notes
Ophthalmic - Decongestants
phenylephrine HCl ophthalmic (eye) drops 2.5 % F
Ophthalmic - Hyperosmolar Agents
Artificial Tears(dext70-hypro) ophthalmic (eye)
drops F OTC
sodium chloride ophthalmic (eye) F OTC
Ophthalmic - Intraocular Pressure
Reducing Agents, Beta-Blockers
betaxolol ophthalmic (eye) F
carteolol F
levobunolol ophthalmic (eye) drops 0.5 % F
metipranolol F
timolol maleate ophthalmic (eye) drops F
Ophthalmic - Local Anesthetic Esters
proparacaine F
Ophthalmic - Mast Cell Stabilizers
cromolyn ophthalmic (eye) F
Ophthalmic Antibacterial Mixtures
bacitracin-polymyxin B ophthalmic (eye) F
neomycin-bacitracin-polymyxin F
neomycin-polymyxin-gramicidin F
polymyxin B sulf-trimethoprim F
Ophthalmic Antibiotic -
Aminoglycosides
gentamicin ophthalmic (eye) F
tobramycin F
Ophthalmic Antibiotic -
Dehydropeptidase Inhibitors
bacitracin ophthalmic (eye) F
Ophthalmic Antibiotic -
Fluoroquinolones
ciprofloxacin HCl ophthalmic (eye) F QL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
129
Drug Tier Status Notes
levofloxacin ophthalmic (eye) F
ofloxacin ophthalmic (eye) F
Ophthalmic Antibiotic - Macrolides
erythromycin ophthalmic (eye) F
Ophthalmic Antibiotic - Sulfonamides
sulfacetamide sodium ophthalmic (eye) F
Ophthalmic Antivirals
trifluridine F
Ophthalmic-Intraocular Press.
Reducing, Sel. Alpha Adrenergic
Agonists
apraclonidine F QL
brimonidine ophthalmic (eye) drops 0.2 % F
Ophthalmic-Intraocular Pressure
Reducing Agents, Prostaglandin
Analogs
latanoprost F QL
Otic (Ear)
Otic (Ear) - Anti-Infective-
Glucocorticoid Combinations
Ciprodex F QL
neomycin-polymyxin-HC otic (ear) F
Otic (Ear) - Anti-Infectives Other
acetic acid otic (ear) F
Otic (Ear) - Fluoroquinolones
ciprofloxacin HCl otic (ear) F QL
ofloxacin otic (ear) F QL
Otic (Ear) - Glucocorticoids
hydrocortisone-acetic acid F
Respiratory Therapy Agents
2Nd Generation Antihistamine-
Decongestant Combinations
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
130
Drug Tier Status Notes
All Day Allergy-D F OTC; QL
AllerClear D-24hr F OTC; QL
Allergy and Congestion Relief oral tablet
extended release 24 hr F OTC; QL
Allergy Complete-D F OTC; QL
Allergy Relief D-24hr F OTC; QL
Allergy Relief,Nasal Decongest F OTC; QL
Allergy Relief-D (cetirizine) F OTC; QL
Allergy-Congestion Relief-D oral tablet extended
release 24 hr F OTC; QL
Aller-Tec D F OTC; QL
cetirizine-pseudoephedrine F OTC; QL
Lorata-D F OTC; QL
lorata-dine D F OTC; QL
Loratadine-D oral tablet extended release 24 hr F OTC; QL
Wal-itin D F OTC; QL
Wal-Zyr D F OTC; QL
Antihistamine - 1St Generation -
Alkylamines
chlorpheniramine maleate oral tablet F OTC
chlorpheniramine maleate oral tablet extended
release F OTC
Antihistamine - 1St Generation -
Ethanolamines
carbinoxamine maleate oral liquid F
carbinoxamine maleate oral tablet 4 mg F
clemastine oral tablet F
diphenhydramine HCl injection solution 50
mg/mL F AL
diphenhydramine HCl injection syringe F AL
diphenhydramine HCl oral capsule F OTC; AL
diphenhydramine HCl oral elixir F OTC
diphenhydramine HCl oral liquid F OTC
diphenhydramine HCl oral syrup F OTC
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
131
Drug Tier Status Notes
diphenhydramine HCl oral tablet 25 mg F OTC; AL
Antihistamine - 1St Generation -
Phenothiazines
promethazine oral F AL
promethazine rectal suppository 12.5 mg, 25 mg F AL
Antihistamine - 1St Generation -
Piperidines
cyproheptadine F AL
Antihistamines - 1St Generation
carbinoxamine maleate oral liquid F
carbinoxamine maleate oral tablet 4 mg F
chlorpheniramine maleate oral tablet F OTC
chlorpheniramine maleate oral tablet extended
release F OTC
clemastine oral tablet F
cyproheptadine F AL
diphenhydramine HCl injection solution 50
mg/mL F AL
diphenhydramine HCl injection syringe F AL
diphenhydramine HCl oral capsule F OTC; AL
diphenhydramine HCl oral elixir F OTC
diphenhydramine HCl oral liquid F OTC
diphenhydramine HCl oral syrup F OTC
diphenhydramine HCl oral tablet 25 mg F OTC; AL
promethazine oral F AL
promethazine rectal suppository 12.5 mg, 25 mg F AL
Unisom SleepGels State Carve Out OTC
Unisom SleepMelts State Carve Out OTC
Antihistamines - 2Nd Generation
cetirizine oral solution F OTC; QL; AL
cetirizine oral tablet F OTC; QL
Children's Allergy Relief(fex) F OTC
fexofenadine oral suspension F OTC
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
132
Drug Tier Status Notes
fexofenadine oral tablet 180 mg, 60 mg F OTC
loratadine oral solution F OTC; QL; AL
loratadine oral tablet F OTC; QL
loratadine oral tablet,disintegrating F OTC
Antihistamines - 2Nd Generation -
Piperazines
cetirizine oral solution F OTC; QL; AL
cetirizine oral tablet F OTC; QL
Antihistamines - 2Nd Generation -
Piperidines
Children's Allergy Relief(fex) F OTC
fexofenadine oral suspension F OTC
fexofenadine oral tablet 180 mg, 60 mg F OTC
loratadine oral solution F OTC; QL; AL
loratadine oral tablet F OTC; QL
loratadine oral tablet,disintegrating F OTC
Antitussives - Non-Opioid
benzonatate oral capsule 100 mg, 200 mg F AL
Asthma Therapy - Inhaled
Corticosteroids (Glucocorticoids)
ArmonAir RespiClick inhalation aerosol powdr
breath activated 232 mcg/actuation, 55
mcg/actuation
F QL
budesonide inhalation F QL; AL
Flovent HFA F QL; AL
Pulmicort Flexhaler F QL
Qvar RediHaler F QL
Asthma Therapy - Leukotriene
Receptor Antagonists
montelukast oral granules in packet F QL; AL
montelukast oral tablet F QL
montelukast oral tablet,chewable F QL
Asthma Therapy - Mast Cell Stabilizers
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
133
Drug Tier Status Notes
cromolyn inhalation F
Asthma Therapy - Xanthines
theophylline oral elixir F
theophylline oral solution F
theophylline oral tablet extended release 12 hr F
theophylline oral tablet extended release 24 hr F
Asthma/Copd - Anticholinergic Agents,
Inhaled Long Acting
Incruse Ellipta F QL
Spiriva Respimat inhalation mist 1.25
mcg/actuation F PA; QL; AL
Asthma/Copd - Anticholinergic Agents,
Inhaled Short Acting
Atrovent HFA F QL
ipratropium bromide inhalation F
Asthma/Copd Therapy - Beta 2-
Adrenergic Agents, Inhaled, Long
Acting
Serevent Diskus F QL
Asthma/Copd Therapy - Beta 2-
Adrenergic Agents, Inhaled, Short
Acting
albuterol sulfate inhalation HFA aerosol inhaler F QL
albuterol sulfate inhalation solution for
nebulization 0.63 mg/3 mL, 1.25 mg/3 mL F QL
albuterol sulfate inhalation solution for
nebulization 2.5 mg /3 mL (0.083 %), 2.5 mg/0.5
mL, 5 mg/mL
F
levalbuterol HCl inhalation solution for
nebulization 0.31 mg/3 mL, 0.63 mg/3 mL, 1.25
mg/3 mL
F
levalbuterol tartrate F ST; QL
Asthma/Copd Therapy - Beta
Adrenergic Agents
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
134
Drug Tier Status Notes
albuterol sulfate oral syrup F
terbutaline oral F
Asthma/Copd Therapy - Beta
Adrenergic-Anticholinergic
Combinations
Bevespi Aerosphere F ST
Combivent Respimat F QL
ipratropium-albuterol F QL
Asthma/Copd Therapy - Beta
Adrenergic-Glucocorticoid
Combinations
Dulera F QL; AL
fluticasone propion-salmeterol inhalation aerosol
powdr breath activated F QL
fluticasone propion-salmeterol inhalation blister
with device 100-50 mcg/dose, 250-50 mcg/dose,
500-50 mcg/dose
F QL; AL
Symbicort inhalation HFA aerosol inhaler 160-4.5
mcg/actuation, 80-4.5 mcg/actuation F QL; AL
Wixela Inhub inhalation blister with device 100-
50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose F QL; AL
Cystic Fibrosis - Inhaled
Aminoglycosides
Bethkis F PA
Kitabis Pak Specialty
Tobi Podhaler Specialty PA
tobramycin in 0.225 % NaCl Specialty PA
tobramycin with nebulizer Specialty PA
Cystic Fibrosis - Inhaled Monobactams
Cayston Specialty PA
Cystic Fibrosis-Transmembrane
Conductance Regulator (Cftr)
Potentiator
Kalydeco oral granules in packet 50 mg, 75 mg State Carve Out
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
135
Drug Tier Status Notes
Kalydeco oral tablet State Carve Out
Cystic Fib-Transmemb Conduct.
Reg.(Cftr) Potentiator And Corrector
Cmb
Orkambi oral tablet 200-125 mg State Carve Out
Mucolytics
acetylcysteine F
Pulmozyme Specialty PA; QL
Nasal Anticholinergics
ipratropium bromide nasal F
Nasal Antihistamines
azelastine nasal aerosol,spray F QL
Nasal Corticosteroids
Allergy Relief (fluticasone) F OTC; QL
Flonase Allergy Relief F OTC; QL
flunisolide nasal spray,non-aerosol 25 mcg (0.025
%) F QL
fluticasone propionate nasal F OTC; QL
Nasacort F OTC; QL
Nasal Mast Cell Stabilizers
cromolyn nasal F OTC
Nasalcrom F OTC
Nasal Moisturizers
Baby Ayr Saline F OTC
Nasal Spray (sodium chloride) F OTC
Opioid Antitussive-Expectorant
Combinations
codeine-guaifenesin F OTC; QL; AL
Virtussin AC F OTC; QL; AL
Systemic Sympathomimetic
Decongestants
pseudoephedrine HCl oral tablet 30 mg, 60 mg F OTC; QL; AL
AL = Age Limit F = Formulary OTC = Over The Counter
PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call
the Magellan Clinical Call Center at 877-864-9014.
Reviewed and Updated December 2019
136
Drug Tier Status Notes
Vaginal Products
Vaginal Antibacterial - Lincosamides
clindamycin phosphate vaginal F
Vaginal Antifungal - Imidazoles
Clotrimazole 3 Day F OTC
clotrimazole vaginal cream F OTC
miconazole nitrate vaginal comb pack,prefill appl,
cream F OTC
miconazole nitrate vaginal cream F OTC
Miconazole-3 prefil,cream,wipe F OTC
Miconazole-3 vaginal kit F OTC
Monistat 7 vaginal comb pack,prefill appl, cream F OTC
Vaginal Antifungal - Triazoles
terconazole vaginal cream F
Vaginal Antiprotozoal-Antibacterial -
Nitroimidazole Derivatives
metronidazole vaginal F
Vaginal Estrogens
estradiol vaginal cream F QL
estradiol vaginal tablet F
Yuvafem F
137
Index
INDEX \e " " \c "3" \h "A" \z "1033"
50 Plus Adult Eye Health, 1, 70
8 Hour Pain Reliever, 3
A Thru Z, 70
A Thru Z Advanced Formula, 75
A Thru Z Men's Ultimate, 70
A Thru Z Select, 70
A Thru Z Select Women's, 70
abacavir, 12
abacavir-lamivudine-zidovudine, 13
Abilify, 43, 47
Abilify Maintena, 43
Abreva, 60
acamprosate, 52
acarbose, 85
Accu-Chek Aviva Control Soln, 110, 116
Accu-Chek Aviva Plus test strp, 109, 116
Accu-Chek FastClix Lancing Dev, 110, 116
Accu-Chek Guide, 109, 116
Accu-Chek Guide Glucose Meter, 110, 116
Accu-Chek Guide L1-L2 Ctrl Sol, 110, 116
Accu-Chek Guide Me Glucose Mtr, 110, 116
Accu-Chek Multiclix Lancet, 110, 116
Accu-Chek SmartView Contrl Sol, 110, 116
Accu-Chek SmartView Test Strip, 109, 116
Accu-Chek Soft Dev Lancets, 110, 116
Accu-Chek Softclix Lancet Dev, 110, 116
Accu-Chek Softclix Lancets, 110, 116
Ace Aerosol Cloud Enhancer, 113, 116
acebutolol, 30
acetaminophen, 3
Acetaminophen Extra Strength, 3
Acetaminophen Pain Relief, 3
acetaminophen-codeine, 2
acetazolamide, 32
acetic acid, 129
acetylcysteine, 8, 135
Acid Controller, 94
Acid Gone Antacid, 91
Acid Gone Antacid E.Strength, 91
Acid Reducer (famotidine), 94
acitretin, 60
Actemra, 6
Actemra ACTPen, 6
Acthrel, 63
Actical, 70
acyclovir, 16
Adacel(Tdap Adolesn/Adult)(PF), 25
Adasuve, 42
Adderall, 44, 48, 50
Adderall XR, 44, 48
adefovir, 15
Adempas, 33
Admelog SoloStar U-100 Insulin, 89
Admelog U-100 Insulin lispro, 89
Adult Multivitamin Gummies, 70
Adult One Daily Gummies, 70
Advate, 105
Advocate Syringes, 111, 116
Adynovate, 105
Adzenys ER, 44, 48
Adzenys XR-ODT, 44, 48
Aerochamber Mini, 113, 116
Aerochamber MV, 113, 116
Aerochamber Plus Flow-Vu, 113, 116
Aerochamber Plus Flow-Vu,L Msk, 114, 117
Aerochamber Plus Flow-Vu,M Msk, 114, 117
Aerochamber Plus Flow-Vu,S Msk, 114, 117
Aerochamber Plus Z Stat, 114, 117
AeroChamber Plus Z Stat Lg Msk, 114, 117
AeroChamber Plus Z Stat Md Msk, 114, 117
AeroChamber Plus Z Stat Sm Msk, 114, 117
Aerochamber with Flowsignal, 114, 117
AeroChamber Z-Stat Plus-Flw Sg, 114, 117
Aerogear Action Asthma Kit, 113, 117
AeroTrach Plus, 114, 117
Afinitor, 22
Afinitor Disperz, 22
Afluria Qd 2019-20(3yr up)(PF), 25
Afluria Qd 2019-20(6-35mo)(PF), 25
Afluria Quad 2019-20(6mo up), 25
Afstyla, 105
Aftera, 56, 57
Aimovig Autoinjector, 49
Aimsco Latex Condom, 112, 117
Airzone Peak Flow Meter, 113, 117
Alba-Lybe, 63
Albuminar 25 %, 106
Albuminar 5 %, 106
albuterol sulfate, 133, 134
alcohol swabs, 24
Aldurazyme, 122
alendronate, 87
alfuzosin, 102
Alkeran, 19
All Day Allergy-D, 130
AllerClear D-24hr, 130
138
Allergy and Congestion Relief, 130
Allergy Complete-D, 130
Allergy Eye (naphazoline-phen), 127
Allergy Relief (fluticasone), 135
Allergy Relief D-24hr, 130
Allergy Relief,Nasal Decongest, 130
Allergy Relief-D (cetirizine), 130
Allergy-Congestion Relief-D, 130
Aller-Tec D, 130
allopurinol, 104
alogliptin, 85
alogliptin-metformin, 87
alogliptin-pioglitazone, 86
Alphanate, 105
AlphaNine SD, 104
alprazolam, 34, 45
Alprazolam Intensol, 34, 45
Alprolix, 105
aluminum hydroxide gel, 91
Alunbrig, 19
Alyacen 1/35 (28), 53
amantadine HCl, 41
amiloride, 32
amiloride-hydrochlorothiazide, 32
aminocaproic acid, 106
amiodarone, 28
Amitiza, 96, 97
amitriptyline, 40
amitriptyline-chlordiazepoxide, 40, 45
amlodipine, 30
amlodipine-benazepril, 26
amlodipine-valsartan, 27
ammonia aromatic, 48
ammonium lactate, 60
Ammonul, 123
Amnesteem, 57
amoxapine, 40
amoxicillin, 9
amoxicillin-pot clavulanate, 9
amphetamine sulfate, 44, 48, 50
ampicillin, 9
Amytal, 51
anagrelide, 107
anastrozole, 20
ANIMAL CHEWS, 78
Animal Shape Vitamins, 78
Animal Shapes Complete, 78
Antabuse, 52
Antacid (calcium carbonate), 91
Antacid Anti-Gas, 92
Antacid Anti-Gas (ca carb-sim), 92
Antacid Calcium, 91
Antacid ExSt (mag carb-Al hyd), 91
Antacid-Simethicone, 92
Antifungal (tolnaftate), 59
Anti-Itch (HC), 60
Antioxidant A/C/E/Selenium, 1, 70
Antioxidant Formula (selenium), 1, 70
Apetex, 63
Apetigen, 63
Apetigen Plus, 65
Aplenzin, 40
apraclonidine, 129
Apriso, 96
Aptensio XR, 44
Aptiom, 36
Aptivus, 17
AquADEKs, 70
AquADEKs Pediatric, 78
Aqua-E, 83
Aranelle (28), 55
Aranesp (in polysorbate), 104
Arcalyst, 4
aripiprazole, 43, 47
Aristada, 43
Arkaliox, 81
armodafinil, 50
ArmonAir RespiClick, 132
Armour Thyroid, 90
Arthritis Pain Relief (acetam), 3
Arthritis Pain Reliever, 3
Artificial Tears (PF), 125
Artificial Tears (polyvin alc), 126
Artificial Tears(dext70-hypro), 125, 128
Artificial Tears(glycerin-peg), 125
Artificial Tears(pvalch-povid), 125
Aspercreme (lidocaine), 62
aspirin, 8, 107
Asthma Check Meter, 113, 117
Asthmapack Children's, 113, 117
atenolol, 30
atenolol-chlorthalidone, 31
atomoxetine, 45
atorvastatin, 29
atovaquone, 11
Atripla, 13
atropine, 127
Atrovent HFA, 133
ATryn, 107
Aubra, 53
139
Aubra EQ, 53
Auryxia, 67, 101, 102
Aviane, 53
Avonex, 125
Avonex (with albumin), 125
azathioprine, 6, 108
azelastine, 127, 135
azithromycin, 17
B Complex, 65
B Complex 100, 65
B Complex Plus Vitamin C, 63
B Complex w-Vit C, 81
B Complex-Vitamin B12, 65
B complex-vitamin C-folic acid, 63
B-100 Complex, 63
Baby Ayr Saline, 135
bacitracin, 58, 128
bacitracin zinc, 58
bacitracin-polymyxin B, 128
baclofen, 109
Bacmin, 70
Balanced B-100 Complex, 63
Balanced B-50, 65
balsalazide, 96
Balziva (28), 53
Banzel, 38
Basaglar KwikPen U-100 Insulin, 89
B-Complex Plus Vit C (calcium), 63
B-Complex With B-12, 81
B-complex with vitamin C, 63
BD AutoShield Duo Pen Needle, 111, 117
BD Insulin Syringe, 111, 117
BD Insulin Syringe Half Unit, 111, 117
BD Insulin Syringe Micro-Fine, 111, 117
BD Insulin Syringe U-500, 111, 117
BD Insulin Syringe Ultra-Fine, 111, 117
BD Nano 2nd Gen Pen Needle, 111, 117
BD Ultra-Fine Micro Pen Needle, 111, 118
BD Ultra-Fine Mini Pen Needle, 111, 118
BD Ultra-Fine Nano Pen Needle, 111, 118
BD Ultra-Fine Orig Pen Needle, 111, 118
BD Ultra-Fine Short Pen Needle, 111, 112, 118
BD Veo Insulin Syr Half Unit, 112, 118
BD Veo Insulin Syringe UF, 112, 118
Beelith, 69
Belsomra, 51
benazepril, 26
benznidazole, 11
benzonatate, 132
benzoyl peroxide, 58
benztropine, 41
Berinert, 104
betamethasone dipropionate, 60
betamethasone valerate, 60
betamethasone, augmented, 61
betaxolol, 30, 128
bethanechol chloride, 103
Bethkis, 134
Bevespi Aerosphere, 134
bexarotene, 24
bicalutamide, 20
Bio-35, Gluten Free, 70
Biocal, 66
Biocel (with Lutein), 70
Bion Tears (PF), 125
Biopetit, 63
biotin, 82
Biotin Plus-Calcium and Vit D3, 70
bisacodyl, 99
Bismatrol, 92
Bismuth, 92
bismuth subsalicylate, 92
bisoprolol fumarate, 30
bisoprolol-hydrochlorothiazide, 31
Blisovi 24 Fe, 54
Blisovi Fe 1.5/30 (28), 54
Blisovi Fe 1/20 (28), 54
blood pressure test kit-large, 113, 118
blood pressure test kit-medium, 113, 118
blood pressure test kit-wrist, 113, 118
Body, Hair, Skin and Nails, 70
Boostrix Tdap, 25
Bosulif, 23
Braftovi, 21
BreatheRite MDI Spacer, 114, 118
BreatheRite Spacer-Mask, Neo., 114, 118
BreatheRite Spacer-Mask,Adult, 114, 118
BreatheRite Spacer-Mask,Child, 114, 118
BreatheRite Spacer-Mask,Infant, 114, 118
BreatheRite Spacer-Mask,S.Chld, 114, 118
BreatheRite Valved MDI Chamber, 114, 118
BreatheRite Valved MDI Spacer, 114, 118
Brewer's Yeast, 65
Briellyn, 54
brimonidine, 129
Brisdelle, 90
bromocriptine, 41
budesonide, 132
bumetanide, 32
Buminate 25 %, 106
140
Bunavail, 52
Buphenyl, 123
buprenorphine HCl, 52
buprenorphine-naloxone, 52
bupropion HCl, 40, 52
buspirone, 34
Butalbital Compound W/Codeine, 2
butalbital-acetaminop-caf-cod, 2
butalbital-acetaminophen, 4
butalbital-acetaminophen-caff, 4
butalbital-aspirin-caffeine, 8
cabergoline, 90
caffeine citrate, 48
Calcet Petites, 67
calcipotriene, 60
calcitonin (salmon), 87
Calcitrate, 66
Cal-Citrate, 67
calcitriol, 83, 122
Calcium 500 + D, 67
Calcium 600 + D(3), 67
Calcium 600 + Minerals, 66
Calcium 600-D3 Plus (mag-zinc), 66
calcium acetate, 66, 101
Calcium Antacid, 91
calcium carbonate, 66, 91, 92
calcium carbonate-vit D3-min, 66
calcium carbonate-vitamin D3, 67
calcium citrate, 66
calcium citrate-vitamin D3, 67
Calcium Magnesium + D, 66
calcium phosphate-vitamin D3, 67
Cal-Gest Antacid, 92
Calphron, 101
Caltrate with Vitamin D3, 67
Canasa, 96
capecitabine, 20
Caprelsa, 23
capsaicin, 62
Carbaglu, 123
carbamazepine, 36, 46
carbidopa-levodopa, 41
carbinoxamine maleate, 130, 131
Carnitor, 123
Carnitor (sugar-free), 123
carteolol, 128
carvedilol, 26
Caya Contoured, 110, 118
Cayston, 134
Caziant (28), 55
cefaclor, 14
cefadroxil, 14
cefdinir, 14
cefixime, 14
cefpodoxime, 14
cefprozil, 14
cefuroxime axetil, 14
celecoxib, 7
Celontin, 38
Central-Vite Cardio, 70
Central-Vite Select, 66, 70
Central-Vite Women's Mature, 70
Centravites, 70
Centravites 50 Plus, 66
Centrum Complete, 75
Centrum Men, 70
Centrum Silver, 70
Centrum Silver Ultra Men's, 70
Centrum Silver Women, 70
Centrum Specialist Heart, 70
Centrum Ultra Men's, 70
Century, 75
Century Cardio, 71
Century Ultimate Men's, 71
Century Ultimate Women's, 71, 76
cephalexin, 14
Ceprotin (Blue Bar), 107
Ceprotin (Green Bar), 107
Cerdelga, 123
Cerebyx, 36
Cerefolin, 76
Cerefolin NAC (algal oil), 81
Cerezyme, 122
Cerovite Advanced Formula, 76
Cerovite Jr, 79
Certa Plus, 71
Certavite-Antioxidant, 76
cetirizine, 131, 132
cetirizine-pseudoephedrine, 130
Chantix, 53
Chantix Continuing Month Box, 53
Chantix Starting Month Box, 53
Chemet, 8
Chewable-Vite, 76, 78
Chewable-Vite with Iron, 79
Child Complete Multivitamin, 79
Child Multivitamins, 78
Children's Acetaminophen, 3
Children's Allergy Relief(fex), 131, 132
Children's Chew Multivit-Iron, 79
141
Children's Chewable, 78
Children's Chewable Multivitmn, 78
Children's Chewable Vitamin, 78
Children's Chewables, 78
Children's Chewables Extra C, 78
Children's Chewables with Iron, 78
Children's Complete Vitamin, 79
Children's Easy-Melts, 3
Children's Ibuprofen, 7
Children's Pain-Fever Relief, 3
Childs Chew Vite, 78
Child's Chewable Vitamins/Iron, 79
Childs/Iron, 79
chlordiazepoxide HCl, 34, 45
chlorhexidine gluconate, 124
chloroquine phosphate, 10
chlorothiazide, 32
chlorpheniramine maleate, 130, 131
chlorpromazine, 42
chlorthalidone, 32
chlorzoxazone, 109
cholecalciferol (vitamin D3), 83
cholestyramine (with sugar), 28
Cholestyramine Light, 28
choline bitartrate, 29
choline dihydrogen citrate, 65
choline,magnesium salicylate, 8
ciclopirox, 59
cilostazol, 107
cimetidine, 94
Cimzia, 4, 5, 97
Cimzia Powder for Reconst, 4, 5, 97
Cimzia Starter Kit, 4, 5, 97
Cinryze, 104
Ciprodex, 129
ciprofloxacin, 15
ciprofloxacin HCl, 15, 128, 129
citalopram, 38
Citracal + D Maximum, 67
Claravis, 57
clarithromycin, 17
clemastine, 130, 131
Clever Choice Chamber-Lrg Mask, 114, 118
Clever Choice Chamber-Med Mask, 114, 118
Clever Choice Chamber-Sm Mask, 114, 118
clindamycin HCl, 17
clindamycin palmitate HCl, 17
clindamycin phosphate, 57, 136
clindamycin-benzoyl peroxide, 58
clobetasol, 61
clomipramine, 40
clonazepam, 34, 35, 45
clonidine, 31
clonidine HCl, 31, 44
clopidogrel, 107
clorazepate dipotassium, 34, 45
clotrimazole, 59, 124, 136
Clotrimazole 3 Day, 136
clotrimazole-betamethasone, 59
clozapine, 42
codeine sulfate, 1
codeine-butalbital-ASA-caff, 2
codeine-guaifenesin, 135
Colace Clear, 100
colchicine, 103
colestipol, 28
Col-Rite, 100
Combivent Respimat, 134
Cometriq, 22
Compact Space Chamber Plus, 114, 119
Compact Space Chamber-Lrg Mask, 114, 119
Compact Space Chamber-Med Mask, 114, 119
Compact Space Chamber-Sm Mask, 114, 119
Compete, 71
Complera, 13
Complete, 71
Complete Multi, 71
Complete Multi 50+, 71
Complete Multivitamin, 71
Complete Multivitamin-Mineral, 76
Complete Premium Vitamin, 71
Complete Senior, 66
CompleteNate, 80
Complex B-100, 64, 65
Complex B-50, 64
Concerta, 44
Condoms-Prem Lubricated, 112, 119
Corifact, 106
Correctol, 99
Cortizone-10, 61
Corvite Free, 71
cosyntropin, 63
Cotellic, 22
Cotempla XR-ODT, 44
Creon, 94
Crixivan, 18
cromolyn, 128, 133, 135
cyanocobalamin (vitamin B-12), 82
Cyclafem 1/35 (28), 54
cyclobenzaprine, 109
142
cyclopentolate, 127
cyclophosphamide, 6, 19
cycloserine, 13
cyclosporine, 6, 108
cyclosporine modified, 6, 108
Cyklokapron, 106
Cymbalta, 39, 49
cyproheptadine, 131
Cystadane, 123
Cyto B7, 82
Cytra K Crystals, 102
Cytra-2, 102
D3-2000, 83
Daily Fiber, 97
Daily Gummies, 71
Daily Multiple, 71, 76
Daily Multiple For Women, 76
Daily Multivitamin, 71
Daily Multi-Vitamin, 76
Daily Multivitamin with Iron, 76
Daily Multivitamin-Minerals, 66, 71
Daily Multi-Vitamins/Iron, 71
Daily Value, 76
Daily Vitamin Formula, 76
Daily Vitamin Formula-Iron, 76
DAILY VITAMIN FORMULA-MINERALS, 71
Daily Vitamin with Iron, 71
Daily Vites/Iron, 71
Daily-Vite, 71, 76
dalfampridine, 125
danazol, 88
dantrolene, 109
dapsone, 10
Daraprim, 10
Dasetta 1/35 (28), 54
Daurismo, 21
Daytrana, 44
Decubi Vite, 76
Delta D3, 83
Delzicol, 96
Denta 5000 Plus, 124
DentaGel, 124
Depacon, 35
Depakote ER, 35, 46, 49
Depakote Sprinkles, 35, 46
Descovy, 12
desipramine, 40
desmopressin, 85
desog-e.estradiol/e.estradiol, 53
desogestrel-ethinyl estradiol, 54
desvenlafaxine, 39
Dex4 Glucose, 84
dexamethasone, 88
dexamethasone sodium phosphate, 127
dexmethylphenidate, 44
dextroamphetamine, 44, 48, 50
dextroamphetamine-amphetamine, 44, 48, 50
dextrose, 84
Diabetes Health Formula, 71
Dialyvite, 64, 65
DIALYVITE 3000, 64
Dialyvite 5000, 71
Dialyvite 800, 64
Dialyvite 800 Plus D, 64
Dialyvite 800 with Zinc 15, 64
Dialyvite 800 with Zinc 50, 64
Dialyvite 800-Ultra D, 64
Dialyvite Supreme D, 64
Dialyvite Vitamin D, 83
Dialyvite Vitamin D3 Max, 83
Diamode, 92
Diastat AcuDial, 35, 45
diazepam, 34, 35, 45
Diazepam Intensol, 34, 45
diclofenac sodium, 7, 60, 62, 127
dicloxacillin, 17
dicyclomine, 96
didanosine, 12
Differin, 58
Dificid, 17
digoxin, 32
Dilantin, 36
Dilantin Extended, 36
Dilantin Infatabs, 36
diltiazem HCl, 30
dimenhydrinate, 93
Dino-Life, 78
Dino-Life with Extra C, 78
Dino-Life with Iron-Zinc, 78, 79
Diocto, 100
Dioctyl, 100
Diotame, 92
Dipentum, 96
diphenhydramine HCl, 50, 130, 131
diphenoxylate-atropine, 93
dipyridamole, 107
disopyramide phosphate, 28
disulfiram, 52
Diuril, 33
divalproex, 35, 46, 49
143
Docuprene, 100
docusate calcium, 100
docusate sodium, 100
Docusil, 100
DOK, 100
donepezil, 53
Dopram, 47, 48
dorzolamide, 127
dorzolamide-timolol, 127
Dovato, 11
doxapram, 47, 48
doxazosin, 33
doxepin, 40
doxycycline hyclate, 18, 125
doxycycline monohydrate, 18
dronabinol, 47, 63, 93
droperidol, 8
drospirenone-ethinyl estradiol, 54
Droxia, 108
Dulcolax Stool Softener (dss), 100
Dulera, 134
duloxetine, 39, 49
Durex Avanti Bare Real Feel, 112, 119
Dyanavel XR, 44, 48
E-400 C-500 and Beta Carotene, 1, 76
EasiVent Holding Chamber, 114, 119
EasiVent Mask Large, 114, 119
EasiVent Mask Medium, 114, 119
EasiVent Mask Small, 114, 119
Easy Comfort Insulin Syringe, 112, 119
Easy Touch Insulin Syringe, 112, 119
econazole, 59
EContra EZ, 56, 57
Econtra One-Step, 56, 57
Edluar, 51
Edurant, 12
Effexor XR, 39
Elaprase, 122
Elelyso, 122
Elidel, 60
Eliquis, 104
Eliquis DVT-PE Treat 30D Start, 104
Elmiron, 101
Eloctate, 105
Emcyt, 21
Emsam, 38
Emtriva, 12
enalapril maleate, 26
enalapril-hydrochlorothiazide, 26
Enbrel, 4, 5
Enbrel Mini, 4, 5
Enbrel SureClick, 4, 5
Endari, 63, 77, 101, 108
Endur-Acin, 82
Enema, 99
Enema Disposable, 99
Enemeez, 100
Enemeez Plus, 100
enoxaparin, 106
entecavir, 15
Entresto, 27
Enulose, 94
Epaned, 26
Epidiolex, 35
epinephrine, 31
Epivir, 12
Epogen, 104
Epzicom, 13
Equetro, 36, 46
ergocalciferol (vitamin D2), 83
Erivedge, 21
Erleada, 20
erythromycin, 129
erythromycin with ethanol, 57
escitalopram oxalate, 38
Essentia, 76
ESSENTIAL Balance with Lutein, 71, 76
ESSENTIAL Daily, 71
ESSENTIAL Man, 71
ESSENTIAL Man 50+, 71
Essential Woman 50+, 71
estazolam, 45, 51
estradiol, 88, 136
estradiol-norethindrone acet, 87
eszopiclone, 51
ethambutol, 14
ethosuximide, 38
etodolac, 8
etoposide, 21
Evekeo, 44, 48, 50
Evotaz, 12, 18
exemestane, 20
Ex-Lax (sennosides), 99
Ex-Lax Maximum Strength, 99
Exondys 51, 109
Eye Allergy Relief, 127
ezetimibe, 29
FaBB, 81, 84
Fabrazyme, 122
Falmina (28), 54
144
famciclovir, 16
famotidine, 95
Fanapt, 42
Fantasy Condom, 112, 119
Farydak, 21
FC2 Female Condom, 110, 119
febuxostat, 104
Feiba NF, 104
Felbatol, 35
felodipine, 31
FemCap, 109, 119
fenofibrate, 29
fenofibrate micronized, 28
fenofibrate nanocrystallized, 28
fenofibric acid (choline), 29
fentanyl, 1
Feosol, 67
FeroSul, 67
ferrous gluconate, 68
ferrous sulfate, 68
FerrouSul, 68
Fetzima, 39
Feverall, 3
fexofenadine, 131, 132
fiber, 97
Fiber (psyllium husk/sugar), 97
Fiber (with aspartame), 97
Fiber Laxative (ca polycarbo), 97
Fiber Smooth, 98
Fiber Smooth (sucrose), 98
Fiber Supplement (inulin), 98
Fiber-Tabs, 98
finasteride, 102
Firdapse, 125
Firvanq, 15
Fish Oil, 29
Fish Oil Extra Strength, 29
flavoxate, 103
flecainide, 28
Fleet Bisacodyl, 99
Fleet Enema, 99
Fleet Enema Extra, 99
Fleet Glycerin (Adult), 98
Fleet Glycerin (Child), 98
Fleet Pediatric, 99
Flexichamber-Lg Child Mask, 114, 119
Flexichamber-Sm Adult Mask, 114, 119
Flexichamber-Sm Child Mask, 114, 119
Flintstones Complete (iron), 79
Flintstones Gummies, 78
Flintstones Gummies Omega-3, 78
Flintstones Multivitamin, 78
Flintstones Plus Calcium, 79
Flintstones with Iron, 79
Flintstones/Extra C, 78
Flonase Allergy Relief, 135
Flovent HFA, 132
Fluarix Quad 2019-2020 (PF), 25
Flublok Quad 2019-2020 (PF), 25
fluconazole, 10
fludrocortisone, 90
Flulaval Quad 2019-2020, 25
Flulaval Quad 2019-2020 (PF), 25
flunisolide, 135
fluocinonide, 61
Fluocinonide-E, 61
fluoride (sodium), 124
Fluoritab, 124
fluorometholone, 127
fluorouracil, 59
fluoxetine, 38
fluphenazine decanoate, 42
fluphenazine HCl, 42
flurazepam, 45, 51
flurbiprofen, 7
flurbiprofen sodium, 127
flutamide, 20
fluticasone propionate, 61, 135
fluticasone propion-salmeterol, 134
fluvoxamine, 38
Fluzone High-Dose 2019-20 (PF), 25
Fluzone Quad 2019-2020, 25
Fluzone Quad 2019-2020 (PF), 25
Fluzone Quad Pedi 2019-20 (PF), 25
FML Forte, 127
FML S.O.P., 127
Foaming Antacid, 91
Focalin, 44
Focalin XR, 44
Folbee, 81, 84
Folbee AR, 64
Folbee Plus, 64
Folbic, 81, 84
Folgard, 65
Folgard RX, 81, 84
folic acid, 84
Folinic-Plus, 81
Folplex 2.2, 81, 84
Foltabs 800, 81
Foltanx, 81
145
Forfivo XL, 40
Fortavit, 76
Forteo, 87
Fosfree, 71
fosinopril, 26
Fosrenol, 101
Freedavite, 71
Fulphila, 106
furosemide, 32
Fuzeon, 11
Fycompa, 34
gabapentin, 35, 36
Gabitril, 36
Galafold, 123
galantamine, 53
Gas Relief, 95
Gas Relief 80, 95
Gas Relief Extra Strength, 95
Gas-X Extra Strength, 95
Gavilyte-C, 99
GaviLyte-G, 99
GaviLyte-N, 99
Gaviscon Extra Strength, 91
gemfibrozil, 29
Generlac, 94
gentamicin, 58, 128
Genvoya, 13
Geodon, 41, 47
Geri-kot, 99
Gilenya, 125
Gilotrif, 19
glatiramer, 125
Glatopa, 125
Gleevec, 23
Gleostine, 19
glimepiride, 86
glipizide, 86
glipizide-metformin, 86
GlucaGen HypoKit, 84
Glucagon Emergency Kit (human), 84
glucose, 84
Glucose Gel, 84
glyburide, 86
glyburide micronized, 86
glyburide-metformin, 86
glycerin (adult), 98
glycerin (child), 99
Glycophos, 69
glycopyrrolate, 96
Golytely, 99
granisetron HCl, 93
Granix, 106
griseofulvin microsize, 10
griseofulvin ultramicrosize, 10
guanfacine, 32, 44
Gynol II, 57
Hailey 24 Fe, 54
Hair Vitamins, 71
Hair, Skin and Nails-Argan Oil, 71
Hair,Skin and Nails, 72
Hair,Skin and Nails(FA-biotin), 72
halobetasol propionate, 61
haloperidol, 42
haloperidol decanoate, 42
haloperidol lactate, 42
Hard Nails, 82
Harvoni, 16
Havrix (PF), 25
Healthy Eyes SuperVision, 1, 72
Hearing Aid Batteries, 110, 119
Heartburn Antacid, 91
Heartburn Prevention, 95
Heartburn Relief, 91
Heartburn Relief (cimetidine), 95
Heartburn Relief (famotidine), 95
Hemangeol, 30
Hemlibra, 106
Hemofil M High, 105
Hemofil M Low, 105
Hemofil M Mid, 105
Hemofil M Super High, 105
heparin (porcine), 106
Hetlioz, 49
Hi-Cal Plus Vit D, 67
homatropine HBr, 127
Homocysteine Formula, 81
Honey Bears with Iron-Zinc, 78, 79
Humalog Mix 50-50 Insuln U-100, 89
Humalog Mix 50-50 KwikPen, 89
Humalog Mix 75-25 KwikPen, 89
Humalog Mix 75-25(U-100)Insuln, 89
Humalog U-100 Insulin, 89
Humate-P, 105
Humira, 4, 5, 97
Humira Pediatric Crohns Start, 4, 5, 97
Humira Pen, 4, 5, 97
Humira Pen Crohns-UC-HS Start, 4, 5, 97
Humira Pen Psor-Uveits-Adol HS, 4, 5, 97
Humira(CF), 4, 5, 97
Humira(CF) Pedi Crohns Starter, 5, 97
146
Humira(CF) Pen, 5, 97
Humira(CF) Pen Crohns-UC-HS, 5, 97
Humira(CF) Pen Psor-Uv-Adol HS, 5, 97
Humulin 70/30 U-100 Insulin, 88
Humulin 70/30 U-100 KwikPen, 88
Humulin N NPH Insulin KwikPen, 89
Humulin N NPH U-100 Insulin, 89
Humulin R Regular U-100 Insuln, 89
Humulin R U-500 (Conc) Insulin, 89
Hycamtin, 24
hydralazine, 32
hydrochlorothiazide, 33
Hydrocil, 98
hydrocodone-acetaminophen, 2
hydrocodone-ibuprofen, 2
hydrocortisone, 61, 88, 97
hydrocortisone acetate, 61
hydrocortisone valerate, 61
hydrocortisone-acetic acid, 129
hydromorphone, 1
hydroxychloroquine, 5, 10
hydroxyurea, 20
hydroxyzine HCl, 34
hydroxyzine pamoate, 34
hyoscyamine sulfate, 96, 103
ibandronate, 87
Ibrance, 21
ibuprofen, 7
Ibuprofen IB, 7
Ibuprofen Jr Strength, 7
I-Caps, 72
ICaps AREDS, 1, 72
Icaps MV, 72
Icaps Plus, 72
Iclusig, 22
Idhifa, 22
Ilaris (PF), 4
Imbruvica, 21, 23
imipramine HCl, 40
imipramine pamoate, 40
imiquimod, 61
In-Check Nasal With Mask, 113, 119
In-Check Oral Flow Meter, 113, 119
Increlex, 89
Incruse Ellipta, 133
indapamide, 33
indomethacin, 8
Infants Gas Relief, 95
Infant's Ibuprofen, 7
Infant's Motrin, 7
Infant's Non-Aspirin, 3
Inlyta, 23
InspiraChamber, 114, 119
InspiraChamber with Mask-Large, 115, 119
InspiraChamber with Mask-Med, 115, 119
InspiraChamber with Mask-Small, 115, 119
insulin syringe-needle U-100, 112, 119
Intelence, 12
Intron A, 22
Intuniv ER, 44
Invega, 42
Invega Sustenna, 42
Invega Trinza, 42
Invirase, 18
Invokamet, 85
Invokamet XR, 85
Invokana, 86
ipratropium bromide, 133, 135
ipratropium-albuterol, 134
irbesartan, 27
irbesartan-hydrochlorothiazide, 27
iron, 68
Iron (dried), 68
Iron 100 Plus, 68
Isentress, 11
isoniazid, 13
isosorbide dinitrate, 27
isosorbide mononitrate, 27
isotretinoin, 57
isradipine, 31
itraconazole, 10
ivermectin, 9
I-Vite Protect, 1, 72
Ixinity, 105
Jakafi, 22
Janumet, 87
Janumet XR, 87
Januvia, 85
Jardiance, 86
Jentadueto, 87
Jr. Acetaminophen, 3
Jr. Str Non-Aspirin Pain, 3
Jr. Strength Pain Reliever, 3
Juluca, 11
Junel 1/20 (21), 54
Junel FE 1.5/30 (28), 54
Junel FE 1/20 (28), 54
Junel Fe 24, 54
Kaitlib Fe, 54
Kalbitor, 33
147
Kaletra, 12
Kalydeco, 134, 135
Kaopectate Ex Str (bismuth ss), 92
Kapvay, 44
Kcentra, 104
ketoconazole, 10, 59
Ketone Care, 116, 119
Ketone Urine Test, 116, 119
ketorolac, 7, 127
Ketostix, 116, 119
ketotifen fumarate, 127
Kimono Condoms(Non-lubricated), 112, 119
Kimono Maxx Condoms, 112, 120
Kimono MicroThin Aqua Lube Con, 112, 120
Kimono MicroThin Condoms, 112, 120
Kimono MicroThin Large Condoms, 112, 120
Kimono Textured Condoms, 112, 120
Kineret, 6
Kisqali, 21
Kitabis Pak, 134
Klonopin, 34, 35, 45
Koate, 105
Kogenate FS, 105
Konsyl (sugar), 98
K-PAX, 72
K-Pax Immune Support, 72
K-Phos No 2, 102
K-Phos Original, 102
Krintafel, 10
Kuvan, 124
Kyprolis, 23
labetalol, 26
lactase, 94
Lactase Fast Acting, 94
lactulose, 94
Lamictal, 37
Lamictal ODT, 37, 46
Lamictal ODT Starter (Blue), 37, 46
Lamictal ODT Starter (Green), 37, 46
Lamictal ODT Starter (Orange), 37, 46
Lamictal Starter (Blue) Kit, 37, 46
Lamictal Starter (Green) Kit, 37, 46
Lamictal Starter (Orange) Kit, 37, 46
Lamictal XR, 37
Lamictal XR Starter (Blue), 37
Lamictal XR Starter (Green), 37
Lamictal XR Starter (Orange), 37
lamivudine, 12, 15
lamivudine-zidovudine, 13
lamotrigine, 37
lansoprazole, 95
lanthanum, 101
Larin 1/20 (21), 54
Larin 24 Fe, 54
Larin Fe 1.5/30 (28), 54
Larin Fe 1/20 (28), 54
Larissia, 54
latanoprost, 129
Latuda, 41
Laxative (bisacodyl), 99
Laxative (glycerin-pediatric), 99
Laxative (sennosides), 99
Laxative Feminine, 99
Laxative Maximum Strength, 100
Laxative Pills, 100
Laxative Pills Regular, 100
Leena 28, 55
leflunomide, 6
Lenvima, 23
Lessina, 54
Letairis, 33
letrozole, 20
leucovorin calcium, 24
Leukeran, 19
leuprolide, 22
levalbuterol HCl, 133
levalbuterol tartrate, 133
levetiracetam, 37
levetiracetam in NaCl (iso-os), 37
levobunolol, 128
levocarnitine, 63, 123
levocarnitine (with sugar), 123
levofloxacin, 15, 129
levonorgestrel, 56, 57
levonorgestrel-ethinyl estrad, 54
levonorg-eth estrad triphasic, 55
levothyroxine, 91
Levoxyl, 91
Lexiva, 18
Lice Killing, 62
lidocaine, 62
lidocaine HCl, 62, 124
Lidocaine Viscous, 124
lidocaine-prilocaine, 62
lindane, 62
linezolid, 17
liothyronine, 91
lisinopril, 26
lisinopril-hydrochlorothiazide, 26
Lite Touch-Medium Mask, 115, 120
148
LiteAire MDI Chamber, 115, 120
LiteTouch-Large Mask, 115, 120
LiteTouch-Small Mask, 115, 120
lithium carbonate, 47
lithium citrate, 47
Lithostat, 102
Lmefol Ca-acetyl-meB12-algal, 81
L-Methyl-B6-B12, 81
L-Methyl-MC, 76
Lonsurf, 20
loperamide, 92
lopinavir-ritonavir, 12
Lorata-D, 130
loratadine, 132
lorata-dine D, 130
Loratadine-D, 130
lorazepam, 34, 46, 51
Lorazepam Intensol, 34, 46
losartan, 27
losartan-hydrochlorothiazide, 27
lovastatin, 29
Low-Ogestrel (28), 54
loxapine succinate, 42
Lubricant (p-glycol-glycerin), 125
Lubricant Eye, 125
Lubricant Eye (PG-PEG 400), 125
Lubricant Eye Drops, 126
Lubricant Eye(dextran70-hypml), 125
Lubricating Relief, 126
Lucemyra, 52
Ludent Fluoride, 124
Lumizyme, 122
Lutera (28), 54
Lyrica, 36, 48
Lyrica CR, 48, 50
Lysiplex Plus, 64
Lysodren, 19
Maalox Advanced, 92
Macuvite Eye Care, 72
Mag 64, 68
Mag Glycinate, 68
Mag-G, 68
Maginex, 68
magnesium, 68
Magnesium (oxide/AA chelate), 68
magnesium amino acid chelate, 68
magnesium chloride, 68
magnesium citrate, 68, 99
magnesium gluconate, 69
magnesium oxide, 69, 92
magnesium sulfate, 69
magnesium sulfate in D5W, 69
magnesium sulfate in water, 69
Magonate (magnesium carb), 69
MagOx, 69
Magtab, 69
malathion, 62
Mapap (acetaminophen), 3
Mapap Arthritis Pain, 3
maprotiline, 41
Marplan, 38
Matulane, 19
Mavyret, 15
MAXIMUM DAILY GREEN, 72
Maximum Daily Multivitamin, 72
meclizine, 93
medroxyprogesterone, 53, 90
Medtycholl-B Complex-Liver, 64
mefloquine, 10
Mega Biotin, 82
Mega Multi for Women, 72
Mega Multiple/Chelated Mineral, 72
Mega Multivitamin For Men, 72
Mega Multivitamin with Mineral, 72
megestrol, 23, 63
Mekinist, 22
meloxicam, 7
memantine, 53
Menest, 88
Men's Daily, 72
Men's Daily Multivit-Mineral, 72
Men's Multivitamin Gummies, 72
Men's One Daily, 72
meperidine, 1
meprobamate, 34
mercaptopurine, 20
Meribin, 83
mesalamine, 96
Mesnex, 24
Metadate ER, 44
Metafolbic, 76
Metafolbic Plus RF, 81
Metamucil (sugar), 98
Metamucil (with sugar), 98
Metamucil MultiHealth Fiber, 98
Metamucil Sugar-Free (aspart), 98
metformin, 89
methadone, 1
methamphetamine, 44, 48
methenamine hippurate, 17, 102
149
methenamine mandelate, 17, 103
Methergine, 90
methimazole, 87
methocarbamol, 109
methotrexate sodium, 5, 20
methotrexate sodium (PF), 20
methyldopa, 32
methyldopa-hydrochlorothiazide, 31
Methylin, 44, 50
methylphenidate HCl, 44, 50
methylprednisolone, 88
metipranolol, 128
metoclopramide HCl, 96
metolazone, 33
metoprolol succinate, 30
metoprolol tartrate, 30
metronidazole, 11, 57, 62, 136
mexiletine, 28
Mi-Acid Gas Relief, 96
Mibelas 24 Fe, 54
miconazole nitrate, 59, 136
Miconazole-3, 136
Miconazole-3 prefil,cream,wipe, 136
Microchamber, 115, 120
Microgestin 1.5/30 (21), 54
Microgestin 1/20 (21), 54
Microgestin Fe 1.5/30 (28), 54
Microgestin FE 1/20 (28), 54
Microlife Peak Flow Meter, 113, 120
Microspacer, 115, 120
midazolam, 8, 46, 51
midazolam (PF), 8, 46
midodrine, 31
Milk of Magnesia, 99
Milk Of Magnesia Concentrated, 99
mineral oil, 98
Mineral Oil Extra Heavy, 98
Mineral Oil Heavy, 98
Mini Wright Peak Flow Meter, 113, 120
minocycline, 6, 18
minoxidil, 32
mirtazapine, 38
misoprostol, 95
M-M-R II (PF), 25, 26
modafinil, 50
mometasone, 61
Monistat 7, 136
Monocaps, 72
Mononine, 105
montelukast, 132
morphine, 1
morphine concentrate, 1
Motegrity, 95
Motion Sickness (meclizine), 93
Motion Sickness Relief(mecliz), 93
Mouthpiece, 115, 120
moxifloxacin, 15
Multi Complete with Iron, 76
Multi For Her, 72
Multi-Betic, 1, 72
Multi-Day with Iron, 76
Multi-Delyn with Iron, 72
Multiple Vitamin-Minerals, 72
Multiple Vitamins, 76
Multi-Vit with Fluoride-Iron, 79
multivitamin, 76
Multivitamin 50 Plus, 66
Multivitamin With Fluoride, 79
Multi-Vitamin With Fluoride, 79
multivitamin with iron, 72
multivitamin with minerals, 66, 72
Multivitamins With Fluoride, 79
Multi-Vite (with folic acid), 76
mupirocin, 58
Mvc-Fluoride, 79
mv-min-folic acid-lutein, 72
MVW Complete Formul Multivit, 78
MVW Complete Formul Pediatric, 78
MVW Complete Formulation D3000, 78
My Choice, 56, 57
My Way, 56, 57
Myalept, 90
mycophenolate mofetil, 6, 108
mycophenolate sodium, 108
Mydayis, 44, 48
Myleran, 19
Mynatal, 80
Mynatal Advance, 80
Mynatal Plus, 80
Mynatal-Z, 80
Mynate 90 Plus, 80
Myorisan, 57
My-Vitalife, 72
nabumetone, 7
nadolol, 30
Naglazyme, 122
naloxone, 9
naltrexone, 9
naproxen, 7
naproxen sodium, 7, 8
150
naratriptan, 49
Narcan, 9
Nasacort, 135
Nasal Spray (sodium chloride), 135
Nasalcrom, 135
nateglinide, 85
Natural B-100 Complex, 64
Natural Fiber Laxative, 98
Natural Fiber Laxative (sugar), 98
Natural Fiber Laxative Therapy, 98
Natural Fiber Laxative(aspart), 98
Natural Tears (PF), 126
Natural Veg Laxative(sennosid), 100
Natural Vegetable, 98
Natural Vegetable (psyllium), 98
Natural Vegetable Powder, 98
Nature-Throid, 90
Necon 0.5/35 (28), 54
nefazodone, 39
neomycin, 9
neomycin-bacitracin-poly-HC, 126
neomycin-bacitracin-polymyxin, 128
neomycin-polymyxin B-dexameth, 126
neomycin-polymyxin-gramicidin, 128
neomycin-polymyxin-HC, 129
Neosporin Plus PainRelief(bac), 58
Nephplex Rx, 65
Nephronex, 64
Nephronex-SL, 64
Nestabs, 80
Nestabs DHA, 80
Neupogen, 106
Neurontin, 36
New Day, 56, 57
NewGen, 80
Nexavar, 22
Nexium 24HR, 95
niacin, 82
niacin (inositol niacinate), 82
Niacin Flush Free, 82
niacinamide, 82
nicardipine, 31
NicAzel Forte, 66
nicotine, 52
nicotine (polacrilex), 52
Nicotrol, 52
Nicotrol NS, 52
nifedipine, 31
nilutamide, 20
nimodipine, 31
Nitro-Bid, 27
nitrofurantoin, 10, 103
nitrofurantoin macrocrystal, 10, 103
nitrofurantoin monohyd/m-cryst, 10, 103
nitroglycerin, 27
Nitrostat, 27
Nitro-Time, 27
Niva-Fol, 81, 84
Nivestym, 106
Noble Formula HC, 61
Non-Aspirin, 4
Non-Aspirin Extra Strength, 4
Norditropin FlexPro, 88
noreth-ethinyl estradiol-iron, 54
norethindrone (contraceptive), 55
norethindrone acetate, 90
norethindrone ac-eth estradiol, 54, 88
norethindrone-e.estradiol-iron, 55
norgestimate-ethinyl estradiol, 55
norgestrel-ethinyl estradiol, 55
Nortrel 0.5/35 (28), 55
Nortrel 1/35 (21), 55
Nortrel 7/7/7 (28), 55
nortriptyline, 41
Norvir, 18
NovaFerrum Pediatric, 79
Novoeight, 105
Novolin 70/30 U-100 Insulin, 88
Novolin N NPH U-100 Insulin, 89
Novolin R Regular U-100 Insuln, 89
Novolog Mix 70-30 U-100 Insuln, 89
Novolog Mix 70-30FlexPen U-100, 89
Novoseven RT, 105
NP Thyroid, 90
Nubeqa, 20
NuvaRing, 56
Nuvigil, 50
nystatin, 10, 59, 124
nystatin-triamcinolone, 59
Obizur, 105
Obstetrix DHA, 80
Obstetrix EC, 80
Ocella, 55
Octaplas (Blood Group A), 107
Octaplas (Blood Group AB), 107
Octaplas (Blood Group B), 107
Octaplas (Blood Group O), 107
octreotide acetate, 90, 101
Ocutabs, 72
Odefsey, 13
151
Odomzo, 21
ofloxacin, 15, 129
olanzapine, 43, 47
olanzapine-fluoxetine, 40, 43, 47
Olumiant, 6
omega 3-dha-epa-fish oil, 29
omega-3 acid ethyl esters, 29
omega-3 fatty acids, 29
omega-3 fatty acids-fish oil, 30
omeprazole, 95
omeprazole magnesium, 95
Omnicap, 73
Once Daily, 76
Oncovite, 76
ondansetron, 93
ondansetron HCl, 94
One Daily, 73
One Daily Calcium/Iron, 73
One Daily Complete, 73
One Daily Energy, 73, 76
One Daily Essential, 73, 76
One Daily For Men, 73
One Daily For Men 50+ Advanced, 76
One Daily For Women, 73
One Daily Healthy Weight, 73
One Daily Maximum, 73
One Daily Men's 50 Plus Memory, 77
One Daily Mens 50 Plus(ginkgo), 73
One Daily Multi-Vit w-Mineral, 73
One Daily Multivitamin, 77
One Daily Multivit-Iron(folic), 77
One Daily Plus Iron, 77
One Daily Plus Minerals, 73
One Daily With Iron, 73
One Daily Women 50 Plus, 73
One Daily Women's, 73, 77
One Daily Womens 50 Plus, 73
One Daily Women's Health, 77
One Way Valved Mouthpiece, 115, 120
One-A-Day Cholesterol Plus, 73
One-A-Day Energy, 77
One-A-Day Essential, 77
One-A-Day Maximum Formula, 73, 77
One-A-Day Men 50 Plus (ginkgo), 77
One-A-Day Men VitaCraves, 73
One-A-Day Menopause Formula, 73
One-A-Day Men's 50 Plus, 73
One-A-Day Men's Multivitamin, 73
One-A-Day Teen Advantage, 73, 77
One-A-Day Teen Him VitaCraves, 78
One-A-Day VitaCraves, 73
One-A-Day Vitacraves Immunity, 73
One-A-Day Vitacraves Omega-3, 73
One-A-Day WeightSmart, 73
One-A-Day Women VitaCraves, 73
One-A-Day Women's Active, 73
One-A-Day Womens Formula, 77
One-A-Day Women's Healthy Skin, 73
One-A-Day Women's Petites, 77
Onfi, 35, 46
Opcicon One-Step, 56, 57
Optichamber Adult Mask-Large, 115, 120
OptiChamber Diamond Lg Mask, 115, 120
OptiChamber Diamond VHC, 115, 120
OptiChamber Diamond-Med Msk, 115, 120
OptiChamber Diamond-Sml Mask, 115, 120
Option-2, 57
Optisource, 73
Opurity Multivitamin, 74
Oralyte, 69
Orencia, 5
Orencia ClickJect, 5
Orfadin, 123
Orilissa, 90
Orkambi, 135
orphenadrine citrate, 109
Orsythia, 55
Os-Cal 500 + D3, 67
oseltamivir, 16
Otezla, 6, 60
Otezla Starter, 6, 60
oxazepam, 34, 46
oxcarbazepine, 36
Oxtellar XR, 36
oxybutynin chloride, 103
oxycodone, 1, 2
oxycodone-acetaminophen, 2, 3
Oxytrol For Women, 103
Oysco 500/D, 67
Oyster Shell Calcium-Vit D2, 67
Oyster Shell Calcium-Vit D3, 67
Ozempic, 86
Pain Relief, 4
Pain Relief Extra Strength, 4
Pancreaze, 94
Panda Mask, 115, 120
pantoprazole, 95
paromomycin, 9
paroxetine HCl, 38
Parvlex, 68
152
Paxil, 38
Peak Air Peak Flow Meter, 113, 120
Pedia-Lax, 99
Pedia-Lax Stool Softener, 100
Pediatric Electrolyte, 69
Pediatric Freezer Pops, 69
Pediatric Medium Mask, 115, 120
Pediatric Panda Mask, 115, 120
Pediatric Small Mask, 115, 120
PediaVance, 69
peg 3350-electrolytes, 99
PEG-3350 with flavor packs, 99
Peganone, 36
Pegasys, 15
peg-electrolyte soln, 99
PegIntron, 15
penicillin V potassium, 17
Pentasa, 96
pentazocine-naloxone, 3
pentobarbital sodium, 51
pentoxifylline, 106
Peptic Relief, 92
Pepto-Bismol Max St, 92
Perdiem Overnight Relief, 100
perindopril erbumine, 26
Perio Med, 124
permethrin, 62
perphenazine, 43
perphenazine-amitriptyline, 40
Personal Best Full Range, 113, 120
Pertzye, 94
Pexeva, 39
phenazopyridine, 102
phenelzine, 38
phenobarbital, 35, 51
phenobarbital sodium, 35, 51
phenylephrine HCl, 128
Phenytek, 36
phenytoin, 36
phenytoin sodium, 28, 36
Philith, 55
Phillips, 69
Phillips' Liqui-Gels, 100
Phos-NaK, 69
Phospholine Iodide, 126
phytonadione (vitamin K1), 84
Piko 1, 113, 120
pilocarpine HCl, 124, 126
Pink Bismuth, 92, 93
Pink Bismuth Maximum Strength, 92
pioglitazone, 89
Pirmella, 55
piroxicam, 7
Plasbumin 5 %, 106
Plasmanate, 107
Pneumovax 23, 25
PNV 29-1, 80
POCKET CHAMBER, 115, 120
Pocket Peak Flow Meter, 113, 120
PoDiaPN, 65
podofilox, 62
polyethylene glycol 3350, 99
polymyxin B sulf-trimethoprim, 128
polyvinyl alcohol, 126
Poly-Vi-Sol, 79
Poly-Vi-Sol with Iron, 79
Polyvitamin with Iron, 79
Poly-Vitamins, 78
Pomalyst, 24
potassium chloride, 69, 70
potassium citrate, 102
potassium citrate-citric acid, 102
potassium phosphate m-/d-basic, 69
Pradaxa, 108
pramipexole, 41
pravastatin, 29
prazosin, 33
Precedex, 51
Precedex in 0.9 % sodium chlor, 51
Pred Mild, 127
prednisolone, 88
prednisolone acetate, 127
prednisolone sodium phosphate, 88, 127
prednisone, 88
Premarin, 88
Premphase, 88
Prempro, 88
Prenatabs FA, 80
Prenatabs Rx, 80
Prenatal, 80
Prenatal 19, 80
Prenatal Complete, 80
Prenatal DHA, 29
Prenatal Gummy, 80
Prenatal Low Iron, 80
Prenatal Plus, 80
Prenatal Plus (calcium carb), 80
Prenatal Tablet, 80
Prenatal Vitamin, 80
Prenatal Vitamin Plus Low Iron, 80
153
Prenatal Vitamin with Minerals, 80
prenatal vit-iron fum-folic ac, 80
Prenatal-U, 80
PrePlus, 80
PreserVision AREDS, 1, 74
PreserVision Lutein, 74
PreTAB, 80
Prevacid SoluTab, 95
Prevent, 74
PreviDent, 124
PreviDent 5000 Plus, 124
Prevnar 13 (PF), 25
Prezcobix, 12, 17
Prezista, 17, 18
primaquine, 11
PrimeAire, 115, 120
primidone, 35
Pristiq, 39
Pro Comfort Spacer-Adult Mask, 115, 120
Pro Comfort Spacer-Child Mask, 115, 120
probenecid, 104
probenecid-colchicine, 103
Pro-Cal, 67
ProCerv HP, 74
ProChamber, 115, 120
prochlorperazine, 93
prochlorperazine maleate, 43, 93
Procrit, 104
Profilnine, 105
progesterone micronized, 90
Proglycem, 84
promethazine, 93, 131
Promolaxin, 101
propafenone, 28
propantheline, 96
proparacaine, 128
propranolol, 30
propylthiouracil, 87
ProRenal, 64
ProRenal QD, 74
Prosight with Lutein, 74
Protect Cardio AF, 74
Protect Plus SO, 74
protriptyline, 41
Prozac, 39
pseudoephedrine HCl, 135
psyllium husk, 98
Pulmicort Flexhaler, 132
Pulmozyme, 135
pyrazinamide, 13
pyridostigmine bromide, 109
pyridoxine (vitamin B6), 82
Qbrelis, 26
Qudexy XR, 37
quetiapine, 43, 47
Quflora Pediatric, 79
QuilliChew ER, 45
Quillivant XR, 45
Quin B Strong, 64
quinapril, 26
quinapril-hydrochlorothiazide, 26
quinidine sulfate, 28
Quintabs, 77
Quintabs-M, 74
Quintabs-M Iron Free, 74
Qvar RediHaler, 132
raloxifene, 90
ramipril, 26
Ranexa, 28
ranitidine HCl, 95
Ravicti, 123
Ready-To-Use Enema, 99
Ready-To-Use Enema (min oil), 98
Recombinate, 105
Refresh Celluvisc, 126
Refresh Lacri-Lube, 126
Refresh Liquigel, 126
Refresh P.M., 126
Refresh Plus, 126
Refresh Tears, 126
Reguloid, Sugar Free, 98
Relenza Diskhaler, 16
Relexxii, 45
Renal Caps, 64
Rena-Vite Rx, 65
Reno Caps, 64
repaglinide, 85
REQ49+, 66, 74
Rescriptor, 12
Retacrit, 104
Retrovir, 12
Revlimid, 24
Rexulti, 43
Reyataz, 18
RiaSTAP, 106
Ribasphere, 16
Ribasphere RibaPak, 16
ribavirin, 16
rifabutin, 14, 18
rifampin, 14, 18
154
riluzole, 108
rimantadine, 17
Risperdal Consta, 42
risperidone, 42, 47
Ritalin, 45, 50
Ritalin LA, 45
RiteFlo Aerochamber, 115, 121
rivastigmine tartrate, 53
Rixubis, 105
rizatriptan, 49
ropinirole, 41
rosuvastatin, 29
Rozerem, 49
Rubraca, 23
Ruconest, 104
Sabril, 36
SafeSnap Syringe, 113, 121
Santyl, 60
Saphris, 41, 47
Sarafem, 39
SAVision, 1, 74
Scooby-Doo One A Day, 79
scopolamine base, 93
Seconal Sodium, 51
Segluromet, 85
selegiline HCl, 41
selenium sulfide, 60
Selzentry, 11
senna, 100
Senna Lax, 100
Senna Laxative, 100
Senno, 100
sennosides-docusate sodium, 100
Senokot, 100
Sen-O-Tab, 100
Sensipar, 87
Sentry, 77
Sentry Senior, 74
Serevent Diskus, 133
Seroquel XR, 43
sertraline, 39
sevelamer carbonate, 101
sevelamer HCl, 101
SF, 124
SF 5000 Plus, 124
Sharps Container, 113, 121
Shingrix (PF), 26
Shingrix gE Antigen Component, 26
Siderol, 68
Sidestream Pediatric Face Mask, 115, 121
Silace, 101
sildenafil (pulm.hypertension), 33
Silenor, 51
Silicone Mask - Infant, 115, 121
Silicone Mask - Pediatric, 115, 121
Siliq, 58
silver sulfadiazine, 60
simethicone, 96
simvastatin, 29
sirolimus, 108
Slo-Niacin, 82
Slow Release Iron, 68
Slow-Mag, 69
Smart Sense Lancets, 110, 121
sodium bicarbonate, 91
sodium chloride, 53, 128
sodium citrate-citric acid, 102
sodium phenylbutyrate, 123
sodium phosphate, 69
sodium polystyrene sulfonate, 66
Soft Touch Lancets, 110, 121
Soliris, 106
Solo, 74
Soothe (bismuth subsalicylate), 93
Soothing Care (hydrocortisone), 61
sotalol, 28, 30
Sotalol AF, 28, 30
Sovaldi, 16
Space Chamber Plus, 115, 121
Spectravite Adult 50 Plus(lut), 74
Spectravite Advanced Formula, 77
Spectravite Men's, 74
Spectravite Senior, 74
Spectravite Ultra Men 50+, 74
Spectravite Ultra Men's Sr, 74
Spectravite Ultra Women, 77
Spectravite Ultra Women's Sr, 74
Spinraza (PF), 109
Spiriva Respimat, 133
spironolactone, 26, 32
spironolacton-hydrochlorothiaz, 32
Spravato, 38
Sprycel, 23
Sronyx, 55
SSD, 60
stavudine, 12
Steglatro, 86
Steglujan, 86
Stimate, 85
Stomach Relief, 93
155
Stomach Relief Max Strength, 93
Stool Softener, 101
Stool Softener (docusate cal), 101
Strattera, 45
Stress B Plus Zinc, 64
Stress B With Zinc, 64
Stress Formula 600 C, 64
Stress Formula With Iron(sulf), 64
Stress Formula with Zinc, 64
Stribild, 13
Strovite Forte, 74
Strovite One, 74
Sublocade, 52
Suboxone, 52
sucralfate, 101
sulfacetamide sodium, 129
sulfacetamide sodium-sulfur, 58
sulfacetamide-prednisolone, 126
sulfamethoxazole-trimethoprim, 9
sulfasalazine, 6, 97
Sulfatrim, 10
sulindac, 7
sumatriptan, 49
sumatriptan succinate, 49
Sunvite, 74
Super Antioxidant, 1, 74
Super B Complex-Vitamin C, 64
Super B-50 Complex, 65
Super B-50 Complex Plus, 65
Super Ginseng Multivitamin, 74
Super Multiple, 74
Super Multiple - Low Iron, 74
Super Multivitamin, 77
Super Quints B-50, 65
Super Thera Vite M, 74
Superplex-T, 64
Supervite, 64
Suprax, 14
Sure-Ject Insulin Syringe, 112, 121
Surfak, 101
Sustiva, 12
Sutent, 23
Syeda, 55
Symbicort, 134
Symbyax, 40, 43, 47
Symfi, 13
Symfi Lo, 13
Symjepi, 31
Symtuza, 13
Synagis, 24
Synjardy, 85
Synjardy XR, 85
Systane (propylene glycol), 126
Systane Gel, 126
Systane Ultra, 126
Tab-A-Vite, 77
Tab-A-Vite/Iron, 74
Tabloid, 20
tacrolimus, 60, 108
tadalafil (pulm. hypertension), 33
Tafinlar, 21
Tamiflu, 17
tamoxifen, 23
tamsulosin, 102
Tarceva, 19
Targretin, 24
Tarina Fe 1/20 (28), 55
Tarina Fe 1-20 EQ (28), 55
Tasigna, 23
Tecfidera, 125
Tegretol, 36, 46
Tegretol XR, 37, 47
Tekturna, 33
Tekturna HCT, 33
temazepam, 46, 51
Temodar, 19
temozolomide, 19
terazosin, 33
terbinafine HCl, 10, 59
terbutaline, 134
terconazole, 136
testosterone, 85
testosterone cypionate, 85
tetracycline, 18
Thalomid, 10, 24
theophylline, 133
Thera, 77
Thera M Plus (ferrous fumarat), 74
Thera-D, 83
Theragran-M Premier 50 Plus, 74
Theralogix Companion, 74
Thera-M, 75
TheraNatal, 80
Therapeutic-M, 75
Thera-Tabs, 77
Thera-Tabs M, 75
TheraTears, 126
Theratrum Complete with Lutein, 75
Therems, 75, 77
Therems-H, 75
156
Therems-M, 75
thiamine HCl (vitamin B1), 81
thioridazine, 43
thiothixene, 43
Thrivite-19, 75, 81
Thrombate III, 107
thyroid (pork), 90
tiagabine, 36
Tibsovo, 22
Tilia Fe, 56
timolol maleate, 128
tinidazole, 11
Tivicay, 11
tizanidine, 109
Tobi Podhaler, 134
tobramycin, 128
tobramycin in 0.225 % NaCl, 134
tobramycin with nebulizer, 134
tobramycin-dexamethasone, 126
Today Contraceptive Sponge, 57
tolnaftate, 59
tolterodine, 103
topiramate, 37
toremifene, 23
torsemide, 32
Total B/C, 64
Tracleer, 33
Tradjenta, 85
tramadol, 2
trandolapril, 26
tranexamic acid, 106
tranylcypromine, 38
Travel Sickness (meclizine), 93
trazodone, 39
Trecator, 14
tretinoin, 58
tretinoin (chemotherapy), 23
Tretten, 106
Tri Femynor, 56
TriAdvance, 81
triamcinolone acetonide, 61, 124
triamterene-hydrochlorothiazid, 32
triazolam, 46, 51
TriCare, 81
Tricitrates, 102
Tri-Estarylla, 56
trifluoperazine, 43
trifluridine, 129
trihexyphenidyl, 41
Tri-Legest Fe, 56
Tri-Linyah, 56
Tri-Lo-Estarylla, 56
Tri-Lo-Marzia, 56
Tri-Lo-Sprintec, 56
TriLyte With Flavor Packets, 99
trimethobenzamide, 93
trimethoprim, 10
trimipramine, 41
Trinatal Rx 1, 81
Trinate, 81
Trintellix, 39
Triphrocaps, 64
Triple Antibiotic, 58
Triple Vitamin with Fluoride, 79
Tri-Previfem (28), 56
Tri-Sprintec (28), 56
Triumeq, 13
Tri-Vi-Sol, 78
Tri-Vitamin With Fluoride, 79
Trogarzo, 11
Trokendi XR, 37
tropicamide, 127
trospium, 103
TRUEplus Diabetic Multivitamin, 75
TRUEplus Ketone, 116, 121
Trulicity, 86
Trustex Latex Condom, 112, 121
Trustex Lubricated Condoms, 112, 121
Trustex Non-Lub Condoms, 112, 121
Trustex-RIA Lub/Spermicide, 112, 121
Trustex-RIA Lubricated Condoms, 113, 121
Trustex-RIA Non-Lub Condoms, 113, 121
Truvada, 12
Truzone Peak Flow Meter, 113, 121
Tums, 92
Tums Freshers, 92
Tybost, 123
Tykerb, 18
Tylenol Arthritis Pain, 4
Tylenol Extra Strength, 4
Tymlos, 87
UltiCare, 112, 121
Ultimate Men's Complete 50+, 75
Ultimate Women's Complete 50+, 75
Ultra B-100 Complex, 65
Ultra Comfort Insulin Syringe, 112, 121
Ultra Freeda, 75
Ultra Lubricant Eye, 126
Unicomplex-M, 75
Unisom (doxylamine), 50
157
Unisom SleepGels, 50, 131
Unisom SleepMelts, 50, 131
Uretron D-S, 17, 103
Urocit-K 10, 102
Urocit-K 5, 102
Uro-Mag, 69
ursodiol, 94
Utira-C, 17, 103
Vaginal Contraceptive Foam, 57
valacyclovir, 16
valganciclovir, 15
valproic acid, 35, 47
valsartan, 27
valsartan-hydrochlorothiazide, 27
vancomycin, 15
Vaqta (PF), 25
V-C Forte, 75
Vegetable Laxative, 100
Velcade, 23
Velivet Triphasic Regimen (28), 56
Velphoro, 101, 102
Vemlidy, 15
Venclexta, 21
Venclexta Starting Pack, 21
venlafaxine, 39
verapamil, 28, 31
Versacloz, 42
Verzenio, 21
VIC-Forte, 75
Victoza 2-Pak, 86
Victoza 3-Pak, 86
Videx 2 gram Pediatric, 12
Viekira Pak, 16
Vienva, 55
vigabatrin, 36
Viibryd, 39
Vimizim, 122
Vimpat, 35
Vinate GT, 81
Vinate II, 81
Vinate M, 81
Vinate One, 81
Vinate Ultra, 81
Viokace, 94
Viracept, 18
Viramune, 12
Viramune XR, 12
Viread, 12, 15
Virtrate-3, 102
Virtussin AC, 135
Virt-Vite, 81, 84
Virt-Vite Plus, 64
Vision, 75
Vita-Bee with C, 65
Vitacel (with Lutein), 75
Vital-D Rx, 75, 83
Vitalee, 75
vitamin B complex, 65
vitamin B complex-folic acid, 65
Vitamin B-1, 82
Vitamin B-1 (mononitrate), 82
Vitamin B-2, 82
Vitamin D3, 83
vitamin E, 30, 83
vitamin E (dl, acetate), 83
vitamin E acetate, 83
vitamin E mixed, 83
vitamin E succinate, 83
Vitamins A,C,D and Fluoride, 80
Vitamins A-D-E selenium, 75
Vitamins and Minerals, 75
Vitamins B Complex, 65
Vitamins for Hair, 65, 77
Vita-Respa, 81, 84
Vitatrum, 75
Vitrum Senior, 75
Vivitrol, 52
Vortex Adult Mask, 115, 121
Vortex Frog Mask-Child, 115, 121
Vortex Holding Chamber, 115, 121
Vortex Holding Chamber Child, 116, 121
Vortex Holding Chamber Toddler, 116, 121
Vortex Ladybug Mask-Toddler, 116, 121
Vortex VHC Frog Mask-Child, 116, 121
Vortex VHC Ladybug Mask-Toddlr, 116, 121
Vosevi, 16
Votrient, 23
VPRIV, 122
Vraylar, 44, 47
Vyfemla (28), 55
Vyndamax, 84
Vyndaqel, 84
Vyvanse, 45
Wal-itin D, 130
Wal-Mucil Natural Fiber Lax, 98
Wal-Zyr D, 130
warfarin, 104
Wellbutrin SR, 40
Wera (28), 55
Westhroid, 90
158
wheat germ oil, 84
Wide-Seal Diaphragm 60, 110, 121
Wide-Seal Diaphragm 65, 110, 121
Wide-Seal Diaphragm 70, 110, 122
Wide-Seal Diaphragm 75, 110, 122
Wide-Seal Diaphragm 80, 110, 122
Wide-Seal Diaphragm 85, 110, 122
Wide-Seal Diaphragm 90, 110, 122
Wide-Seal Diaphragm 95, 110, 122
Wilate, 105
Wixela Inhub, 134
Woman's Laxative, 100
Women's Complex, 75
Women's Daily Caplet, 75
Women's Daily Formula, 75
Women's Daily Multivitamin, 75
Women's Laxative (bisacodyl), 100
Women's Multivitamin Gummies, 75
Women's One Daily, 77
WP Thyroid, 90
Wymzya Fe, 55
Xalkori, 19
Xanax, 34, 46
Xanax XR, 34, 46
Xarelto, 104
Xatmep, 5, 20
Xeljanz, 6, 97
Xeljanz XR, 6
Xpovio, 21, 23
Xtandi, 20
Xulane, 56
Xyntha, 105
Xyntha Solofuse, 105
Xyrem, 49
yeast, 65
Yelets, 77
Yonsa, 19, 20
Yuvafem, 136
zaleplon, 51
Zarah, 55
Zarxio, 106
Zavesca, 123
Zejula, 23
Zelboraf, 21
Zenatane, 57
Zenpep, 94
Zenzedi, 45, 48, 50
Zepatier, 15
Zerit, 12
Ziagen, 12
zidovudine, 12
ziprasidone HCl, 41, 47
Zolgensma, 24
Zolinza, 21
zolmitriptan, 49
Zoloft, 39
zolpidem, 51
zonisamide, 38
Zoo Friends, 78
Zoo Friends Plus Iron, 78
Zovia 1/35E (28), 55
Zubsolv, 52
Zydelig, 22
Zyprexa, 43, 47
Zyprexa Relprevv, 43
Zytiga, 19, 20
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