Magellan Rx Precision Formulary
Magellan Rx Precision Formulary
Welcome to Magellan Rx Management¡¯s Precision Formulary. A formulary is a list of covered
prescription drugs. The Precision Formulary excludes certain drugs in order to reduce the cost of your
prescriptions. For every excluded drug there is a preferred alternative available at a lower cost. 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, Tier 3 Non-Preferred
Brand, and Excluded Products. 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 ¨C 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. Excluded products are not covered by your plan; however, a
preferred alternative is available at a lower cost.
Our Pharmacy and Therapeutics Committee (P&T) and Value Assessment Committee (VAC) dedicate
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 drug¡¯s safety, efficacy and cost-effectiveness. Please note all
drugs on the Formulary Drug List are subjected to periodic review and amendment without notice.
Drug exception requests must have clinical information submitted by a prescriber. For excluded drug
products, members or prescribers may request a medical exception review if the prescriber feels that
the formulary does not adequately cover your clinical needs. If the request is initiated by the member
using the online tool or via a telephone request to our offices, Magellan will contact the physician for
the necessary clinical information to support this exception. If the request is initiated by the prescriber,
he or she may submit it by fax, phone, or mail. They will be required to submit supporting clinical
documentation to justify Magellan¡¯s approval.
For the most up-to-date Formulary Drug list visit our website at .
TIER
DESCRIPTION
1
Generics
2
Pref erred Brands
3
Non-Pref erred Brands
NF
Non Formulary
TYPE
QL
DESCRIPTION
Quantity Limit
There is a limit on the amount of this drug that is covered per
prescription, or within a specif ic time f rame.
In some cases, you may be required to f irst try certain drugs to treat
ST
Step Therapy
your medical condition bef ore you move up a ¡° step¡± to other drug
options.
GL
Gender Limit
AL
Age Limit
S
Specialty Drug
This prescription drug is restricted f or a single gender.
This prescription drug may only be covered if you meet the
minimum or maximum age limit.
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
MED
Medical Drug
CLASS or sub class to f ind covered alternative medications. If you
have questions, please contact member services.
Preventive health drugs can help prevent, treat, and manage
PR
Preventive Medication
several health concerns that can lead to serious illness or
complications in the f uture. The copays f or these products may vary
so check with your plan f or f urther inf ormation.
The Af f ordable Care Act (ACA) requires certain preventive generic
HCR
Health Care Ref orm Products
products to be covered at zero dollar copay. This does not include
plans that are grandf athered.
NTI products may have to be monitored by your doctor or
NTI
Narrow Therapeutic Indicator
pharmacist more f requently because small changes in doses can
have harmf ul impacts.
PAGE 2
LAST UPDATED 01/2022
PS
Pref erred Specialty
Pref erred Specialty.
Your provider is required to get prior authorization bef ore you f ill
PA
PA Applies
your prescription, which ensures appropriate use of the selected
drug. Without prior approval, we may not cover this drug.
QPD
Quantity Per Day
Quantity Per Day.
HCG
High Cost Generic
High Cost Generic.
MVB
Minimal Value Brand
Minimal Value Brand.
MVG
Minimal Value Generic
Minimal Value Generic.
Non-FDA Approved
Non-FDA Approved.
BSP
Benef it Shif t Program
Benef it Shif t Program.
SBA
Select Brand Alternative
Select Brand Alternative
PS1
Pref erred 1st line
PS2
Pref erred 2nd line
NFD
PAGE 3
LAST UPDATED 01/2022
PRODUCT DESCRIPTION
TIER
LIMITS & RESTRICTIONS
ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)
NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS
CAFERGOT
DIBENZYLINE
3
SBA
Select Brand
Alternative
MVB
MINIMAL VALUE
BRAND
SELECT BRAND
ALTERNATIVE
3
SBA
PA
dihydroergotamine 1 mg/ml amp
dihydroergotamine 4 mg/ml spry
1
1
ergoloid mesylates
1
ERGOMAR
3
ergotamine-caffeine
1
MIGERGOT
3
BSP
BENEFIT SHIFT
PROGRAM
QL
8 / 30 days
PA
QPD
0.72 per day
MVB
MINIMAL VALUE
BRAND
QL
MIGRANAL
3
8 / 30 days
PA
MVB
MINIMAL VALUE
BRAND
HCG
phenoxybenzamine hcl
1
MVG
MINIMAL VALUE
GENERIC
SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT
alfuzosin hcl er
1
GL
QPD
GL
RAPAFLO
PAGE 4
3
Male
1 per day
Male
QPD
1 per day
SBA
Select Brand
Alternative
LAST UPDATED 01/2022
PRODUCT DESCRIPTION
silodosin
tamsulosin hcl
TIER
1
1
LIMITS & RESTRICTIONS
GL
QPD
1 per day
QPD
2 per day
GL
UROXATRAL
3
Male
Male
QPD
1 per day
SBA
Select Brand
Alternative
QPD
12 per day
MVB
Minimal Value
Brand
QPD
6 per day
QPD
6 per day
ANALGESICS AND ANTIPYRETICS
ANALGESICS AND ANTIPYRETICS, MISC.
ALLZITAL
BUPAP
butalbital-acetaminophn 50-300
3
1
1
HCG
MVG
MINIMAL VALUE
GENERIC
butalbital-acetaminophn 25-325
1
QPD
12 per day
butalbital-acetaminophn 50-325
1
QPD
6 per day
butalbital-acetaminophen-caffe
1
QPD
6 per day
CORICIDIN HBP COLD AND FLU
3
QPD
6 per day
ESGIC CAPSULE
ESGIC 50-325-40 MG TABLET
GRALISE 300-600 MG SAMPLE PACK
PAGE 5
1
3
3
HCG
MVG
MINIMAL VALUE
GENERIC
QPD
6 per day
SBA
Select Brand
Alternative
ST
LAST UPDATED 01/2022
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