Ambetter 90-Day-Maintenance Drug List- 2020

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Ambetter 90-Day-Maintenance Drug List

Guide to this list:

What is Ambetter 90‐Day‐Maintenance Drug List?

Ambetter 90‐Day‐Supply Maintenance Drug List is a list of maintenance medications that are available for 90 day supply through mail order or through our Extended Day Supply Network.

How do I find a pharmacy that is participating in Extended Day Supply Network?

To find a retail pharmacy that is participating in our Extended Day Supply Network please consult information available under Pharmacy Resources tab on our webpage. Alternatively, you can utilize our mail order pharmacy. Information on mail order pharmacy is available in Pharmacy Resources tab on our webpage.

Are all formulary drugs covered for 90 day supply?

No, certain specialty and non‐specialty drugs are excluded from 90 day supply. Please consult 90‐Day‐ Supply Maintenance Drug List for information if your drug is included.

A Amitriptyline HCl Acamprosate Calcium Amlodipine Besylate Acarbose Amlodipine Besylate-Atorvastatin Calcium Acebutolol HCl Amlodipine Besylate-Benazepril HCl Acetazolamide Amlodipine Besylate-Olmesartan Medoxomil Albuterol Sulfate Amlodipine Besylate-Valsartan Alendronate Sodium Amlodipine-Valsartan-Hydrochlorothiazide Alendronate Sodium-Cholecalciferol Amoxapine Alfuzosin HCl Amphetamine-Dextroamphetamine Aliskiren Fumarate Anagrelide HCl Allopurinol Anastrozole Alogliptin Benzoate Apixaban Alosetron HCl Arformoterol Tartrate Amantadine HCl Aripiprazole Amiloride & Hydrochlorothiazide Armodafinil Amiloride HCl Asenapine Maleate Amiodarone HCl Aspirin-Dipyridamole

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. Ambetter from Meridian is underwritten by Meridian Health Plan of Michigan, Inc. © 2020 Meridian Health Plan of Michigan, Inc. All rights reserved. 1-833-993-2426 (TTY/TDD Relay 711) 1 Campus Martius, Suite 700 Detroit, MI 48226 AmbetterMeridian.com Atenolol Carbidopa-Levodopa-Entacapone Atenolol & Chlorthalidone Carteolol HCl (Ophth) Atomoxetine HCl Carvedilol Atorvastatin Calcium Celecoxib Auranofin Cevimeline HCl Azathioprine Chloroquine Phosphate Azilsartan Medoxomil Chlorothiazide Chlorpromazine HCl B Chlorpropamide Beclomethasone Dipropionate HFA Chlorthalidone Benazepril & Hydrochlorothiazide Cholestyramine Benazepril HCl Cholestyramine Light Benztropine Mesylate Cilostazol Betaxolol HCl Cimetidine Betaxolol HCl (Ophth) Cimetidine HCl Betrixaban Maleate Citalopram Hydrobromide Bimatoprost Clobazam Bisoprolol & Hydrochlorothiazide Clomipramine HCl Bisoprolol Fumarate Clonidine Brexpiprazole Clonidine HCl Brimonidine Tartrate Clonidine HCl (ADHD) Brimonidine Tartrate-Timolol Maleate Clopidogrel Bisulfate Brinzolamide-Brimonidine Tartrate Colchicine w/ Probenecid Brivaracetam Colesevelam HCl Bromocriptine Mesylate Colestipol HCl Bromocriptine Mesylate (Diabetes) Conjugated Estrogens-Bazedoxifene Budesonide (Inhalation) Conjugated Estrogens-Medroxyprogesterone Budesonide-Formoterol Fumarate Dihydrate Acetate Bumetanide Cromolyn Sodium Bupropion HCl Cyclosporine Cyclosporine (Ophth) C Cyclosporine Modified (For Microemulsion) Calcitonin (Salmon) Cysteamine Bitartrate Calcitriol Cysteamine HCl Calcium Acetate (Phosphate Binder) Candesartan Cilexetil D Candesartan Cilexetil-Hydrochlorothiazide Dapagliflozin Propanediol Cannabidiol Dapagliflozin-Metformin HCl Captopril Dapsone Carbamazepine Darifenacin Hydrobromide Carbamazepine (Antipsychotic) Deferiprone Carbidopa Desipramine HCl Carbidopa-Levodopa Desmopressin Acetate

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. Ambetter from Meridian is underwritten by Meridian Health Plan of Michigan, Inc. © 2020 Meridian Health Plan of Michigan, Inc. All rights reserved. 1-833-993-2426 (TTY/TDD Relay 711) 1 Campus Martius, Suite 700 Detroit, MI 48226 AmbetterMeridian.com Desmopressin Acetate Spray Enalapril Maleate Desmopressin Acetate Spray Refrigerated Enalapril Maleate & Hydrochlorothiazide Desogestrel & Ethinyl Estradiol Entacapone Desogestrel-Ethinyl Estradiol (Biphasic) Eplerenone Desogestrel-Ethinyl Estradiol (Triphasic) Eprosartan Mesylate Desvenlafaxine Succinate Erenumab-aooe Dexlansoprazole Ergocalciferol Dexmethylphenidate HCl Ergoloid Mesylates Dextroamphetamine Sulfate Ertugliflozin L-Pyroglutamic Acid Dextromethorphan HBr-Quinidine Sulfate Ertugliflozin-Metformin HCl Diazoxide Escitalopram Oxalate Diclofenac Potassium Eslicarbazepine Acetate Diclofenac Sodium Esomeprazole Magnesium Diclofenac w/ Misoprostol Esterified Estrogens Diflunisal Estradiol Digoxin Estradiol Acetate Vaginal Diltiazem HCl Estradiol Vaginal Diltiazem HCl Coated Beads Estradiol Valerate-Dienogest Diltiazem HCl Extended Release Beads Estradiol-Levonorgestrel Dipyridamole Estrogens, Conjugated Disopyramide Phosphate Estrogens, Conjugated Vaginal Disulfiram Ethacrynic Acid Divalproex Sodium Ethosuximide Dofetilide Ethotoin Donepezil Hydrochloride Ethynodiol Diacet & Eth Estrad Dorzolamide HCl Etodolac Dorzolamide HCl-Timolol Maleate Etonogestrel-Ethinyl Estradiol Doxazosin Mesylate Ezetimibe Doxepin HCl Ezetimibe-Simvastatin Doxercalciferol Dronedarone HCl F Drospirenone Famotidine Drospirenone-Ethinyl Estradiol Febuxostat Drospirenone-Ethinyl Estradiol-Levomefolate Felbamate Calcium Felodipine Dulaglutide Fenofibrate Duloxetine HCl Fenofibrate Micronized Dutasteride Fenoprofen Calcium Fesoterodine Fumarate E Finasteride Echothiophate Iodide Flavoxate HCl Empagliflozin Flecainide Acetate Empagliflozin-Metformin HCl Fludrocortisone Acetate

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. Ambetter from Meridian is underwritten by Meridian Health Plan of Michigan, Inc. © 2020 Meridian Health Plan of Michigan, Inc. All rights reserved. 1-833-993-2426 (TTY/TDD Relay 711) 1 Campus Martius, Suite 700 Detroit, MI 48226 AmbetterMeridian.com Fluoxetine HCl Ibandronate Sodium Fluoxetine HCl (PMDD) Ibuprofen Fluphenazine HCl Icosapent Ethyl Flurbiprofen Imipramine HCl Fluticasone Furoate (Inhalation) Imipramine Pamoate Fluticasone Furoate-Vilanterol Indacaterol Maleate Fluticasone Propionate (Inhalation) Indacaterol Maleate-Glycopyrrolate Fluticasone Propionate HFA Indapamide Fluticasone-Salmeterol Indomethacin Fluticasone-Umeclidinium-Vilanterol Insulin Aspart Fluvastatin Sodium Insulin Aspart (with Niacinamide) Fluvoxamine Maleate Insulin Aspart Protamine & Aspart (Human) Folic Acid Insulin Degludec Fosinopril Sodium Insulin Degludec-Liraglutide Fosinopril Sodium & Hydrochlorothiazide Insulin Detemir Furosemide Insulin Glargine Insulin NPH (Human) (Isophane) G Insulin NPH Isophane & Reg (Human) Gabapentin Insulin Regular (Human) Gabapentin Enacarbil Ipratropium Bromide Galantamine Hydrobromide Ipratropium Bromide (Nasal) Galcanezumab-gnlm Ipratropium Bromide HFA Gemfibrozil Ipratropium-Albuterol Glatiramer Acetate Irbesartan Glimepiride Irbesartan-Hydrochlorothiazide Glipizide Isocarboxazid Glipizide-Metformin HCl Isoniazid Glyburide Isosorbide Dinitrate Glyburide Micronized Isosorbide Dinitrate-Hydralazine HCl Glyburide-Metformin Isosorbide Mononitrate Glycopyrrolate-Formoterol Fumarate Isradipine Guanfacine HCl Ivabradine HCl Guanfacine HCl (ADHD) K H Ketoprofen Haloperidol Haloperidol Lactate L Hydralazine HCl Labetalol HCl Hydrochlorothiazide Lacosamide Hydroxychloroquine Sulfate Lactulose Hydroxyurea (Sickle Cell Anemia) Lactulose (Encephalopathy) Lamivudine (HBV) I Lamotrigine

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. Ambetter from Meridian is underwritten by Meridian Health Plan of Michigan, Inc. © 2020 Meridian Health Plan of Michigan, Inc. All rights reserved. 1-833-993-2426 (TTY/TDD Relay 711) 1 Campus Martius, Suite 700 Detroit, MI 48226 AmbetterMeridian.com Lansoprazole Meloxicam Lanthanum Carbonate Memantine HCl Latanoprost Mesalamine Leflunomide Metaproterenol Sulfate Lesinurad Metformin HCl Lesinurad-Allopurinol Methamphetamine HCl Letrozole Methazolamide Levalbuterol HCl Methimazole Levalbuterol Tartrate Methsuximide Levetiracetam Methyclothiazide Levobunolol HCl Methyldopa Levomilnacipran HCl Methylphenidate Levonorgestrel & Eth Estradiol Methylphenidate HCl Levonorgestrel-Eth Estradiol (Triphasic) Methyltestosterone Levonorgestrel-Ethinyl Estradiol & Folic Acid Metolazone Levonorgestrel-Ethinyl Estradiol (91-Day) Metoprolol & Hydrochlorothiazide Levonorgestrel-Ethinyl Estradiol (Continuous) Metoprolol Succinate Levonorgestrel-Ethinyl Estradiol-Ferrous Metoprolol Tartrate Bisglycinate Mexiletine HCl Levothyroxine Sodium Miglitol Linaclotide Milnacipran HCl Liothyronine Sodium Minoxidil Liraglutide Mirabegron Lisdexamfetamine Dimesylate Mirtazapine Lisinopril Misoprostol Lisinopril & Hydrochlorothiazide Modafinil Lithium Moexipril HCl Lithium Carbonate Montelukast Sodium Losartan Potassium Mycophenolate Mofetil Losartan Potassium & Hydrochlorothiazide Mycophenolate Sodium Lovastatin Loxapine Succinate N Lubiprostone Nabumetone Lurasidone HCl Nadolol Naproxen M Naproxen Sodium Maprotiline HCl Nateglinide Mecamylamine HCl Nebivolol HCl Meclofenamate Sodium Nefazodone HCl Medroxyprogesterone Acetate Niacin (Antihyperlipidemic) Mefenamic Acid Niacin-Lovastatin Mefloquine HCl Niacin-Simvastatin Megestrol Acetate (Appetite) Nicardipine HCl

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. Ambetter from Meridian is underwritten by Meridian Health Plan of Michigan, Inc. © 2020 Meridian Health Plan of Michigan, Inc. All rights reserved. 1-833-993-2426 (TTY/TDD Relay 711) 1 Campus Martius, Suite 700 Detroit, MI 48226 AmbetterMeridian.com Nifedipine Pentoxifylline Nisoldipine Perampanel Nitroglycerin Perindopril Erbumine Nizatidine Perphenazine Norelgestromin-Ethinyl Estradiol Perphenazine-Amitriptyline Norethin Acet & Estrad-Fe Phenelzine Sulfate Norethindrone & Eth Estradiol Phenobarbital Norethindrone & Ethinyl Estradiol-Fe Phenytoin Norethindrone (Contraceptive) Phenytoin Sodium Extended Norethindrone Acet & Eth Estra Pilocarpine HCl Norethindrone Acetate Pilocarpine HCl (Oral) Norethindrone Acetate-Ethinyl Estradiol Pimozide Norethindrone Acetate-Ethinyl Estradiol-Fe Pindolol Norethindrone Acetate-Ethinyl Estradiol-Fe Fum Pioglitazone HCl (Biphasic) Pioglitazone HCl-Glimepiride Norethindrone-Eth Estradiol (Triphasic) Pioglitazone HCl-Metformin HCl Norgestimate-Ethinyl Estradiol Piroxicam Norgestimate-Ethinyl Estradiol (Triphasic) Pitavastatin Calcium Norgestrel & Ethinyl Estradiol Posaconazole Nortriptyline HCl Potassium Bicarb & Chloride Potassium Bicarbonate O Potassium Chloride Olanzapine Potassium Chloride Microencapsulated Crystals Olmesartan Medoxomil ER Olmesartan Medoxomil-Amlodipine- Pramipexole Dihydrochloride Hydrochlorothiazide Pramlintide Acetate Olmesartan Medoxomil-Hydrochlorothiazide Prasterone Vaginal Olodaterol HCl Prasugrel HCl Olsalazine Sodium Pravastatin Sodium Omega-3-acid Ethyl Esters Prazosin HCl Omeprazole Pregabalin Omeprazole-Sodium Bicarbonate Pregabalin (Once-Daily) Ospemifene Primidone Oxaprozin Probenecid Oxcarbazepine Prochlorperazine Maleate Oxybutynin Chloride Progesterone Micronized Propafenone HCl P Propranolol HCl Paliperidone Propylthiouracil Pancrelipase (Lipase-Protease-Amylase) Protriptyline HCl Pantoprazole Sodium Paricalcitol Q Paroxetine HCl Quetiapine Fumarate

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. Ambetter from Meridian is underwritten by Meridian Health Plan of Michigan, Inc. © 2020 Meridian Health Plan of Michigan, Inc. All rights reserved. 1-833-993-2426 (TTY/TDD Relay 711) 1 Campus Martius, Suite 700 Detroit, MI 48226 AmbetterMeridian.com Quinapril HCl Solifenacin Succinate Quinapril-Hydrochlorothiazide Solriamfetol HCl Quinidine Sulfate Sotalol HCl Sotalol HCl (AFIB/AFL) R Spironolactone Rabeprazole Sodium Spironolactone & Hydrochlorothiazide Raloxifene HCl Stannous Fluoride Ramipril Sucralfate Ranitidine HCl Sucroferric Oxyhydroxide Ranolazine Sulfasalazine Rasagiline Mesylate Sulindac Repaglinide Repaglinide-Metformin HCl T Rifaximin Tacrolimus Riluzole Tadalafil Risedronate Sodium Tafluprost Risperidone Tamoxifen Citrate Rivaroxaban Tamsulosin HCl Rivastigmine Tartrate Tasimelteon Roflumilast Telmisartan Ropinirole Hydrochloride Telmisartan-Amlodipine Rosiglitazone Maleate Telmisartan-Hydrochlorothiazide Rosuvastatin Calcium Terazosin HCl Rotigotine Terbutaline Sulfate Rufinamide Testosterone Theophylline S Thioridazine HCl Sacrosidase Thiothixene Sacubitril-Valsartan Thyroid Salmeterol Xinafoate Tiagabine HCl Salsalate Ticagrelor Segesterone Acetate-Ethinyl Estradiol Timolol Maleate Selegiline Timolol Maleate (Ophth) Selegiline HCl Timothy Grass Pollen Allergen Extract Semaglutide Tiotropium Bromide Monohydrate Sertraline HCl Tolazamide Sevelamer Carbonate Tolbutamide Silodosin Tolcapone Simvastatin Tolmetin Sodium Sirolimus Tolterodine Tartrate Sitagliptin Phosphate Topiramate Sitagliptin-Metformin HCl Toremifene Citrate Sodium Phenylbutyrate Torsemide

U Umeclidinium Bromide Umeclidinium-Vilanterol Ursodiol

V Valganciclovir HCl Valproate Sodium Valproic Acid Valsartan Valsartan-Hydrochlorothiazide Venlafaxine HCl Verapamil HCl Vilazodone HCl Vorapaxar Sulfate Vortioxetine HBr

W Warfarin Sodium

Z Zafirlukast Zileuton Ziprasidone HCl Zonisamide