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Magellan Complete Care of Virginia- MCC VA Magellan Complete Care of Virginia – MCC VA We cover both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. What is a Preferred Drug List? A Preferred Drug List is a list of covered drugs which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our Preferred Drug List as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. How to Search For Drugs Use the alphabetical list to search by the first letter of your medication. Search by typing part of the generic (chemical) and brand (trade) names. How to Request an Exception You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make: You can ask us to cover your drug even if it is not on our Preferred Drug List. You can ask us to waive coverage restrictions or limits on your drug. You should contact us to ask us for an initial coverage decision for a Preferred Drug List or utilization restriction exception. When you are requesting a Preferred Drug List or utilization restriction exception you should submit a statement from your physician supporting your request. TIER DESCRIPTION T0 Covered OTC T1 Preferred Drugs T2 Non-Preferred Drugs TYPE DESCRIPTION There is a limit on the amount of this drug that is covered per QL Quantity Limit prescription, or within a specific time frame. This prescription drug may only be covered if you meet the AL Age Limit minimum or maximum age limit. Specialty drugs are high-cost drugs used to treat complex or rare conditions. Some examples of the diseases include; S Specialty Drug multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. DC Drug Class Drug Class. PS Preferred Specialty Preferred Specialty. Your provider is required to get prior authorization before you fill your prescription, which ensures appropriate use of the PA PA Applies selected drug. Without prior approval, we may not cover this drug. QPD Quantity Per Day Quantity Per Day. IPC IPC - SPECIALTY PROGRAM IPC- Specialty Program. PAGE 2 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ANALGESICS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS ADDED STRENGTH HEADACHE T1 ADULT LOW DOSE ASPIRIN EC T0 ADVIL JUNIOR STRENGTH T0 ALL DAY PAIN RELIEF (CVS PAIN RLF 220 MG TB, GNP PAIN RLF 220 MG TB, PAIN RELIEF 220 MG TAB, PAIN RLF 220 T1 MG CAPLET, SM RELIEF 220 MG CAPLT, SM RELIEF 220 MG TAB) ALL DAY RELIEF T1 ANAPROX DS T2 PA ARTHROTEC 50 T2 PA ARTHROTEC 75 T2 PA ASPIR 81 T1 ASPIR-LOW T1 ASPIR-TRIN T1 aspirin (300 mg supp.rect, 600 mg supp.rect) T1 aspirin (81 mg tab chew, 81 mg tablet dr, 325 mg tablet, T1 325 mg tablet dr) aspirin (bayer 325 mg caplet, bayer 325 mg tablet, 500 mg tablet dr, bayer 500 mg caplet, bayer 500 mg tablet, T0 650 mg tablet dr) aspirin/calcium carbonate/magnesium T1 BAYER ADVANCED T0 BAYER CHEWABLE ASPIRIN T0 BAYER MIGRAINE T1 PAGE 3 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS CALDOLOR 800 MG/8 ML VIAL T2 PA QL 1 / day CAMBIA T2 PA QL 2 / day CELEBREX (50 MG CAPSULE, 200 MG CAPSULE) T2 PA QL 3 / day CELEBREX 100 MG CAPSULE T2 PA QL 1 / day CELEBREX 400 MG CAPSULE T2 PA celecoxib 100 mg capsule T1 QL 3 / day celecoxib 200 mg capsule T1 QL 2 / day QL 1 / day celecoxib 400 mg capsule T2 PA QL 2 / day celecoxib 50 mg capsule T2 PA CHILDREN'S MOTRIN T1 CHILDREN'S PROFEN IB T1 CHILDREN'S PROFENIB T1 choline salicyl/mag salicylate 500 mg/5ml liquid T2 PA DAYPRO T2 PA diclofenac potassium T2 PA diclofenac sodium 100 mg tab er 24h T2 PA diclofenac sodium (50 mg tablet dr, 75 mg tablet dr) T1 diclofenac sodium 25 mg tablet dr T1 diclofenac sodium/misoprostol (sodium/misoprostol 50 T2 PA tab ir dr, sodium/misoprostol 75 tab ir dr) PAGE 4 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS diflunisal 500 mg tablet T1 QL 3 / day DUEXIS T2 PA EC-NAPROSYN T2 PA ECOTRIN T0 ECPIRIN T1 etodolac (400 mg tab er 24h, 500 mg tab er 24h, 600 mg T2 PA tab er 24h) etodolac (200 mg capsule, 300 mg capsule, 400 mg tablet, T1 500 mg tablet) EXTRA PAIN RELIEF T1 EXTRAPRIN T1 FELDENE T2 PA fenoprofen calcium (200 mg capsule, 400 mg capsule, 600 T2 PA mg tablet) FENORTHO T2 PA FLANAX 220 MG TABLET T1 flurbiprofen (50 mg tablet, 100 mg tablet) T1 GOODY'S EXTRA STRENGTH T2 PA HEADACHE RELIEF T1 I-PRIN T1 IBU T1 IBU-200 T1 IBUPAK T2 PA PAGE 5 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ibuprofen (50 mg/1.25 drops susp, 100 mg tablet, 100 mg/5ml oral susp, 200 mg capsule, 200 mg tablet, 400 mg T1 tablet, 600 mg tablet, 800 mg tablet) ibuprofen 100 mg tab chew T1 ibuprofen lysine/pf T2 PA QL 6 / day INDOCIN 25 MG/5 ML SUSPENSION T2 PA QL 4 / day INDOCIN 50 MG SUPPOSITORY T2 PA indomethacin (25 mg capsule, 50 mg capsule) T1 indomethacin 75 mg capsule er T2 PA indomethacin sodium T2 PA indomethacin, submicronized T2 PA INFANT'S MOTRIN T1 INFANTS PROFENIB T1 INFANTS' ADVIL T1 INFANTS' MOTRIN T1 ketoprofen (50 mg capsule, 75 mg capsule, 200 mg T2 PA cap24h pel) ketorolac tromethamine 15.75 mg spray T2 PA ketorolac tromethamine 10 mg tablet T1 QL 21 / fill ketorolac tromethamine (15 mg/ml cartridge, 15 mg/ml QL 40 / 23 days T2 vial) PA ketorolac tromethamine (30 mg/ml cartridge, 30 mg/ml QL 0.667 / DAY vial, 60 mg/2 ml cartridge, 60 mg/2 ml syringe, 60 mg/2 T2 ml vial) PA PAGE 6 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS ketorolac tromethamine (30 mg/ml syringe, 30mg/ml(1) QL 0.87 / DAY T2 vial) PA LODINE T2 PA meclofenamate sodium (50 mg capsule, 100 mg capsule) T2 PA MEDIPROXEN T1 QL 5 / day mefenamic acid 250 mg capsule T2 PA meloxicam (7.5 mg tablet, 15 mg tablet) T1 QL 1 / day MIDOL 220 MG CAPLET T1 MIGRAINE FORMULA T1 MIGRAINE RELIEF T1 QL 1 / day MOBIC T2 PA MOTRIN IB 200 MG CAPLET T1 nabumetone (500 mg tablet, 750 mg tablet) T2 PA NALFON (400 MG CAPSULE, 600 MG TABLET) T2 PA NAPRELAN (CR 375 MG TABLET, CR 500 MG TABLET) T2 PA QL 1 / day NAPRELAN CR 750 MG TABLET T2 PA NAPROSYN (125 MG/5 ML SUSPEN, 500 MG TABLET) T2 PA naproxen 125 mg/5ml oral susp T2 PA naproxen (250 mg tablet, 375 mg tablet, 375 mg tablet T1 dr, 500 mg tablet, 500 mg tablet dr) naproxen sodium (220 mg capsule, 220 mg tablet) T1 naproxen sodium (275 mg tablet, 375 mg tbmp 24hr, 500 T2 PA mg tbmp 24hr, 550 mg tablet) PAGE 7 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 2 / day naproxen/esomeprazole magnesium T2 PA NEOPROFEN T2 PA oxaprozin 600 mg tablet T2 PA PAIN RELIEVER (RA RELIEVER TABLET, RELIEVER TABLET, T1 RELIEVR 250-250-65MG CPLT) PAIN RELIEVER PLUS T1 PAIN-OFF T1 AL Up to 75 yrs old piroxicam (10 mg capsule, 20 mg capsule) T2 PA PROFENO T2 PA PROVIL T1 AL At least 17 yrs old salsalate (500 mg tablet, 750 mg tablet) T2 PA SPRIX T2 PA ST. JOSEPH ASPIRIN T0 ST. JOSEPH ASPIRIN EC T0 sulindac (150 mg tablet, 200 mg tablet) T1 TIVORBEX T2 PA tolmetin sodium (200 mg tablet, 400 mg capsule, 600 mg T2 PA tablet) TRI-BUFFERED ASPIRIN 325 MG T1 QL 2 / day VIMOVO T2 PA QL 1 / day VIVLODEX T2 AL At least 18 yrs old PA PAGE 8 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS VOLTAREN-XR T2 PA WAL-PROFEN (200 MG CAPLET, 200 MG CAPSULE, 200 T1 MG SOFTGEL, 200 MG TABLET) WAL-PROXEN T1 QL 4 / day ZIPSOR T2 PA QL 3 / day ZORVOLEX T2 PA OPIOID ANALGESICS, LONG-ACTING QL 1 / day CONZIP (100 MG CAPSULE, 200 MG CAPSULE, 300 MG T2 DC LONG ACTING CAPSULE) OPIOIDS PA QL 6 / day DOLOPHINE HCL T2 DC LONG ACTING OPIOIDS PA QL 0.334 / day DURAGESIC T2 DC LONG ACTING OPIOIDS PA QL 0.334 / day fentanyl (12 mcg/hr patch td72, 25 mcg/hr patch td72, 50mcg/hr patch td72, 75mcg/hr patch td72, 100 mcg/hr T1 DC LONG ACTING OPIOIDS patch td72) PA hydrocodone bitartrate (10 mg cap er 12h, 15 mg cap er DC LONG ACTING 12h, 20 mg cap er 12h, 30 mg cap er 12h, 40 mg cap er T2 OPIOIDS 12h, 50 mg cap er 12h) PA QL 2 / day KADIAN (ER 10 MG CAPSULE, ER 20 MG CAPSULE, ER 50 T2 DC LONG ACTING MG CAPSULE, ER 100 MG CAPSULE) OPIOIDS PA PAGE 9 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 1 / day KADIAN (ER 30 MG CAPSULE, ER 40 MG CAPSULE, ER 60 T2 DC LONG ACTING MG CAPSULE, ER 80 MG CAPSULE, ER 200 MG CAPSULE) OPIOIDS PA QL 6 / day methadone hcl (5 mg tablet, 10 mg tablet) T2 DC LONG ACTING OPIOIDS PA QL 2 / day morphine sulfate (10 mg cap er pel, 20 mg cap er pel, 50 T2 DC LONG ACTING mg cap er pel, 100 mg cap er pel) OPIOIDS PA QL 1 / day morphine sulfate (30 mg cap er pel, 60 mg cap er pel, 80 T2 DC LONG ACTING mg cap er pel) OPIOIDS PA morphine sulfate (30 mg cpmp 24hr, 40 mg cap er pel, 45 DC LONG ACTING mg cpmp 24hr, 60 mg cpmp 24hr, 75 mg cpmp 24hr, 90 T2 OPIOIDS mg cpmp 24hr, 120 mg cpmp 24hr) PA QL 4 / day morphine sulfate 15 mg tablet er T1 DC LONG ACTING OPIOIDS PA QL 3 / day morphine sulfate 30 mg tablet er T1 DC LONG ACTING OPIOIDS PA QL 2 / day morphine sulfate 60 mg tablet er T1 DC LONG ACTING OPIOIDS PA PAGE 10 LAST UPDATED 01/2021 PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS QL 4 / day MS CONTIN ER 15 MG TABLET T2 DC LONG ACTING OPIOIDS PA QL 3 / day MS CONTIN ER 30 MG TABLET T2 DC LONG ACTING OPIOIDS PA QL 2 / day MS CONTIN ER 60 MG TABLET T2 DC LONG ACTING OPIOIDS PA tramadol hcl (100 mg cpbp 25-75, 100 mg tab er 24h, 100 QL
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