MAGELLAN Rx STANDARD FORMULARY

Magellan Rx Standard Formulary

Welcome to Magellan Rx Management's Standard Formulary. A formulary is a list of covered prescription drugs. Please use this formulary drug list when you receive a prescription from your doctor. This formulary list is not intended to imply coverage and may change over time. Please refer to your plan document for detailed information about your drug benefit coverage.

The formulary is organized by categories depending on the type of medical conditions that they are used to treat. Medications are listed as Tier 1 Generic, Tier 2 preferred Brand, and Tier 3 non-preferred Brand. Medications listed as "Specialty Drugs" are used to treat complex medical conditions that require special handling, administration, and member care management. Depending on your pharmacy benefit design, specialty drugs may be part of a specialty benefit with specific coverage and copay requirements that differ from drugs in Tiers 1 ? 3. If you do not have a defined specialty benefit, your copay may be based on whether the drug is Generic or Brand, therefore Tier 1 or Tier 3 copays may apply.

Our Pharmacy and Therapeutics Committee (P&T) and Value Assessment Committee (VAC) dedicates many hours to the clinical analysis and evaluation of peer reviewed literature and medical care guidelines to determine a drug's safety and efficacy. After this rigorous clinical evaluation, the committee weighs the financial implications of a drug compared to other similar drugs and selects appropriate Tier placement based on the drugs' safety, efficacy and cost- effectiveness. Please note all drugs on the Formulary Drug List are subjected to periodic review and amendment without notice.

Please keep in mind when a generic medication is chosen, patients pay the lowest copay available under their pharmacy benefit plan. When clinically appropriate, please consider choosing a generic product. If a preferred brand drug from the formulary is prescribed, your copay may be less than if a non-preferred brand drug is prescribed for you.

For the most up-to-date Formulary Drug list visit our website at .

TIER

1

Generics

2 Preferred Brands

3 Non-Preferred Brands

TYPE

QL Quantity Limit

ST Step Therapy GL Gender Limit AL Age Limit C Custom

S Specialty Drug

MED Medical Drug

PR Preventive Medication

DESCRIPTION

DESCRIPTION

There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. In some cases, you may be required to first try certain drugs to treat your medical condition before you move up a "step" to other drug options.

This prescription drug is restricted for a single gender.

This prescription drug may only be covered if you meet the minimum or maximum age limit.

This drug has unique restrictions.

Specialty drugs are high-cost drugs used to treat complex or rare conditions. Some examples of the diseases include; multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. This medication is not on our drug list. Click on the THERAPEUTIC CLASS or sub class to find covered alternative medications. If you have questions, please contact member services. Preventive health drugs can help prevent, treat, and manage several health concerns that can lead to serious illness or complications in the future. The copays for these products may vary so check with your plan for further information.

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LAST UPDATED 01/2021

HCR Health Care Reform Products

NTI Narrow Therapeutic Indicator

PS Preferred Specialty

PA PA Applies

B4G Brand For Generic HCG High Cost Generic MVB Minimal Value Brand MV Minimal Value Generic NFD Non-FDA Approved BSP Benefit Shift Program SBA Select Brand Alternative PS1 Preferred 1st line PS2 Preferred 2nd line

The Affordable Care Act (ACA) requires certain preventive generic products to be covered at zero dollar copay. This does not include plans that are grandfathered. NTI products may have to be monitored by your doctor or pharmacist more frequently because small changes in doses can have harmful impacts.

Preferred Specialty.

Your provider is required to get prior authorization before you fill your prescription, which ensures appropriate use of the selected drug. Without prior approval, we may not cover this drug. Brand products that would bypass the DAW penalty. The strategy prefers brands over generics.

High Cost Generic.

Minimal Value Brand.

Minimal Value Generic.

Non-FDA Approved.

Benefit Shift Program.

Select Brand Alternative

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LAST UPDATED 01/2021

PRODUCT DESCRIPTION

TIER

ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)

NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS

CAFERGOT

3

D.H.E.45

3

DIBENZYLINE

3

dihydroergotamine 1 mg/ml amp

1

dihydroergotamine 4 mg/ml spry

1

ergoloid mesylates

1

ERGOMAR

3

ergotamine-caffeine

1

MIGERGOT

3

MIGRANAL

3

phenoxybenzamine hcl

1

LIMITS & RESTRICTIONS

SBA

Select Brand Alternative

QL 10 / 30 days MED Medical Drug PA

PR

MVB

MINIMAL VALUE BRAND

SBA

SELECT BRAND ALTERNATIVE

PA

BSP

BENEFIT SHIFT PROGRAM

QL 8 / 30 days PA

QL MVB

QL PA MVB

HCG

MVG

0.72 / day MINIMAL VALUE BRAND 8 / 30 days

MINIMAL VALUE BRAND

MINIMAL VALUE GENERIC

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LAST UPDATED 01/2021

PRODUCT DESCRIPTION phentolamine mesylate SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT alfuzosin hcl er FLOMAX

RAPAFLO

silodosin tamsulosin hcl

UROXATRAL

ANALGESICS AND ANTIPYRETICS ANALGESICS AND ANTIPYRETICS, MISC.

acetaminophen (325mg/32.5ml syr, 500 mg/50 ml syr, 650 mg/65 ml bag)

ALLZITAL

BUPAP

butalbital-acetaminophn 50-300

TIER LIMITS & RESTRICTIONS

1

MED Medical Drug

QL 1 / day 1

GL Male

QL 2 / day 3

ST

QL 1 / day

3

GL Male

SBA

Select Brand Alternative

QL 1 / day 1

GL Male

1

QL 2 / day

QL 1 / day

3

GL Male

SBA

Select Brand Alternative

1

MED Medical Drug

QL 12 / day

3

HCG

MVB

Minimal Value Brand

1

QL 6 / day

QL 6 / day

HCG

1

MINIMAL

MVG VALUE

GENERIC

PAGE 5

LAST UPDATED 01/2021

PRODUCT DESCRIPTION butalbital-acetaminophn 25-325 butalbital-acetaminophn 50-325 butalbital-acetaminophen-caffe clonidine hcl (1,000 mcg/10 ml vial, 5,000 mcg/10 ml vial) CORICIDIN HBP COLD AND FLU DURACLON

ESGIC CAPSULE

ESGIC 50-325-40 MG TABLET

FIORICET GRALISE 30-DAY STARTER PACK GRALISE ER 300 MG TABLET GRALISE ER 600 MG TABLET

LYRICA CR (CR 82.5 MG TABLET, CR 165 MG TABLET)

LYRICA CR 330 MG TABLET

TIER LIMITS & RESTRICTIONS

1

QL 12 / day

1

QL 6 / day

1

QL 6 / day

1

MED Medical Drug

3

3

MED Medical Drug

QL 6 / day

HCG

1

MINIMAL

MVG VALUE

GENERIC

QL 6 / day

3

SBA

Select Brand Alternative

QL 6 / day

3

ST

SBA

Select Brand Alternative

3

ST

QL 1 / day 3

ST

QL 3 / day 3

ST

QL 3 / day

3

PA

MVB

MINIMAL VALUE BRAND

QL 2 / day

3

PA

MVB

MINIMAL VALUE BRAND

PAGE 6

LAST UPDATED 01/2021

PRODUCT DESCRIPTION PHRENILIN FORTE PRIALT TENCON VANATOL LQ VTOL LQ ZEBUTAL OPIATE AGONISTS

ABSTRAL

acetamn-caf-dihydrcodein 320.5

acetamin-caf-dihydrocodein 325

acetamin-codein 300-30 mg/12.5 acetaminop-codeine 120-12 mg/5

TIER LIMITS & RESTRICTIONS

1

QL 6 / day

S 3

MED Medical Drug

1

QL 6 / day

3

1

1

QL 6 / day

QL 4 / day

3

AL

At least 18 yrs old

PA

MVB

MINIMAL VALUE BRAND

QL 10 / day

1

AL

At least 18 yrs old

QL 10 / day

AL

At least 18 yrs old

1

HCG

MINIMAL MVG VALUE

GENERIC

QL 139 / day

1

AL

At least 12 yrs old

QL 140 / day

1

AL

At least 12 yrs old

PAGE 7

LAST UPDATED 01/2021

PRODUCT DESCRIPTION acetaminophen-cod #2 tablet acetaminophen-cod #3 tablet acetaminophen-cod #4 tablet

ACTIQ

APADAZ ARYMO ER asa-butalb-caffeine-codeine ASCOMP WITH CODEINE belladonna-opium 16.2-30 supp belladonna-opium 16.2-60 supp benzhydrocodone-acetaminophen

PAGE 8

TIER LIMITS & RESTRICTIONS

QL 22 / day

1

AL

At least 12 yrs old

QL 12 / day

1

AL

At least 12 yrs old

QL 6 / day

1

AL

At least 12 yrs old

QL 4 / day

3

AL

At least 18 yrs old

PA

SBA

Select Brand Alternative

QL 12 / day

3

AL

At least 18 yrs old

SBA

Select Brand Alternative

QL 3 / day 3

PA

QL 6 / day

1

AL

At least 18 yrs old

QL 6 / day

1

AL

At least 18 yrs old

1

QL 2 / day

1

QL 1 / day

QL 12 / day

1

AL

At least 18 yrs old

LAST UPDATED 01/2021

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