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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