Ambetter 90-Day-Maintenance Drug List- 2020 -Texas

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

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Celtic Insurance Company. All rights reserved. 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) 5900 E. Ben White Blvd. Austin, TX 78741 Ambetter.SuperiorHealthPlan.com Atomoxetine HCl Celecoxib Atorvastatin Calcium Cevimeline HCl Auranofin Chloroquine Phosphate Azathioprine Chlorothiazide Azilsartan Medoxomil Chlorpromazine HCl Chlorpropamide B Chlorthalidone Beclomethasone Dipropionate HFA Cholestyramine Benazepril & Hydrochlorothiazide Cholestyramine Light Benazepril HCl Cilostazol Benztropine Mesylate Cimetidine Betaxolol HCl Cimetidine HCl Betaxolol HCl (Ophth) Citalopram Hydrobromide Betrixaban Maleate Clobazam Bimatoprost Clomipramine HCl Bisoprolol & Hydrochlorothiazide Clonidine Bisoprolol Fumarate Clonidine HCl Brexpiprazole Clonidine HCl (ADHD) Brimonidine Tartrate Clopidogrel Bisulfate Brimonidine Tartrate-Timolol Maleate Colchicine w/ Probenecid Brinzolamide-Brimonidine Tartrate Colesevelam HCl Brivaracetam Colestipol HCl Bromocriptine Mesylate Conjugated Estrogens-Bazedoxifene Bromocriptine Mesylate (Diabetes) Conjugated Estrogens-Medroxyprogesterone Budesonide (Inhalation) Acetate Budesonide-Formoterol Fumarate Dihydrate Cromolyn Sodium Bumetanide Cyclosporine Bupropion HCl Cyclosporine (Ophth) Cyclosporine Modified (For Microemulsion) C Cysteamine Bitartrate Calcitonin (Salmon) Cysteamine HCl Calcitriol Calcium Acetate (Phosphate Binder) D Candesartan Cilexetil Dapagliflozin Propanediol Candesartan Cilexetil-Hydrochlorothiazide Dapagliflozin-Metformin HCl Cannabidiol Dapsone Captopril Darifenacin Hydrobromide Carbamazepine Deferiprone Carbamazepine (Antipsychotic) Desipramine HCl Carbidopa Desmopressin Acetate Carbidopa-Levodopa Desmopressin Acetate Spray Carbidopa-Levodopa-Entacapone Desmopressin Acetate Spray Refrigerated Carteolol HCl (Ophth) Desogestrel & Ethinyl Estradiol Carvedilol Desogestrel-Ethinyl Estradiol (Biphasic)

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Celtic Insurance Company. All rights reserved. 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) 5900 E. Ben White Blvd. Austin, TX 78741 Ambetter.SuperiorHealthPlan.com Desogestrel-Ethinyl Estradiol (Triphasic) Erenumab-aooe Desvenlafaxine Succinate Ergocalciferol Dexlansoprazole Ergoloid Mesylates Dexmethylphenidate HCl Ertugliflozin L-Pyroglutamic Acid Dextroamphetamine Sulfate Ertugliflozin-Metformin HCl Dextromethorphan HBr-Quinidine Sulfate Escitalopram Oxalate Diazoxide Eslicarbazepine Acetate Diclofenac Potassium Esomeprazole Magnesium Diclofenac Sodium Esterified Estrogens Diclofenac w/ Misoprostol Estradiol Diflunisal Estradiol Acetate Vaginal Digoxin Estradiol Vaginal Diltiazem HCl Estradiol Valerate-Dienogest Diltiazem HCl Coated Beads Estradiol-Levonorgestrel Diltiazem HCl Extended Release Beads Estrogens, Conjugated Dipyridamole Estrogens, Conjugated Vaginal Disopyramide Phosphate Ethacrynic Acid Disulfiram Ethosuximide Divalproex Sodium Ethotoin Dofetilide Ethynodiol Diacet & Eth Estrad Donepezil Hydrochloride Etodolac Dorzolamide HCl Etonogestrel-Ethinyl Estradiol Dorzolamide HCl-Timolol Maleate Ezetimibe Doxazosin Mesylate Ezetimibe-Simvastatin Doxepin HCl Doxercalciferol F Dronedarone HCl Famotidine Drospirenone Febuxostat Drospirenone-Ethinyl Estradiol Felbamate Drospirenone-Ethinyl Estradiol-Levomefolate Felodipine Calcium Fenofibrate Dulaglutide Fenofibrate Micronized Duloxetine HCl Fenoprofen Calcium Dutasteride Fesoterodine Fumarate Finasteride E Flavoxate HCl Echothiophate Iodide Flecainide Acetate Empagliflozin Fludrocortisone Acetate Empagliflozin-Metformin HCl Fluoxetine HCl Enalapril Maleate Fluoxetine HCl (PMDD) Enalapril Maleate & Hydrochlorothiazide Fluphenazine HCl Entacapone Flurbiprofen Eplerenone Fluticasone Furoate (Inhalation) Eprosartan Mesylate Fluticasone Furoate-Vilanterol

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Celtic Insurance Company. All rights reserved. 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) 5900 E. Ben White Blvd. Austin, TX 78741 Ambetter.SuperiorHealthPlan.com Fluticasone Propionate (Inhalation) Indapamide Fluticasone Propionate HFA Indomethacin Fluticasone-Salmeterol Insulin Aspart Fluticasone-Umeclidinium-Vilanterol Insulin Aspart (with Niacinamide) Fluvastatin Sodium Insulin Aspart Protamine & Aspart (Human) Fluvoxamine Maleate Insulin Degludec Folic Acid Insulin Degludec-Liraglutide Fosinopril Sodium Insulin Detemir Fosinopril Sodium & Hydrochlorothiazide Insulin Glargine Furosemide Insulin NPH (Human) (Isophane) Insulin NPH Isophane & Reg (Human) G Insulin Regular (Human) Gabapentin Ipratropium Bromide Gabapentin Enacarbil Ipratropium Bromide (Nasal) Galantamine Hydrobromide Ipratropium Bromide HFA Galcanezumab-gnlm Ipratropium-Albuterol Gemfibrozil Irbesartan Glatiramer Acetate Irbesartan-Hydrochlorothiazide Glimepiride Isocarboxazid Glipizide Isoniazid Glipizide-Metformin HCl Isosorbide Dinitrate Glyburide Isosorbide Dinitrate-Hydralazine HCl Glyburide Micronized Isosorbide Mononitrate Glyburide-Metformin Isradipine Glycopyrrolate-Formoterol Fumarate Ivabradine HCl Guanfacine HCl Guanfacine HCl (ADHD) K Ketoprofen H Haloperidol L Haloperidol Lactate Labetalol HCl Hydralazine HCl Lacosamide Hydrochlorothiazide Lactulose Hydroxychloroquine Sulfate Lactulose (Encephalopathy) Hydroxyurea (Sickle Cell Anemia) Lamivudine (HBV) Lamotrigine I Lansoprazole Ibandronate Sodium Lanthanum Carbonate Ibuprofen Latanoprost Icosapent Ethyl Leflunomide Imipramine HCl Lesinurad Imipramine Pamoate Lesinurad-Allopurinol Indacaterol Maleate Letrozole Indacaterol Maleate-Glycopyrrolate Levalbuterol HCl

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Celtic Insurance Company. All rights reserved. 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) 5900 E. Ben White Blvd. Austin, TX 78741 Ambetter.SuperiorHealthPlan.com Levalbuterol Tartrate Methyclothiazide Levetiracetam Methyldopa Levobunolol HCl Methylphenidate Levomilnacipran HCl Methylphenidate HCl Levonorgestrel & Eth Estradiol Methyltestosterone Levonorgestrel-Eth Estradiol (Triphasic) Metolazone Levonorgestrel-Ethinyl Estradiol & Folic Acid Metoprolol & Hydrochlorothiazide Levonorgestrel-Ethinyl Estradiol (91-Day) Metoprolol Succinate Levonorgestrel-Ethinyl Estradiol (Continuous) Metoprolol Tartrate Levonorgestrel-Ethinyl Estradiol-Ferrous Mexiletine HCl Bisglycinate Miglitol Levothyroxine Sodium Milnacipran HCl Linaclotide Minoxidil Liothyronine Sodium Mirabegron Liraglutide Mirtazapine Lisdexamfetamine Dimesylate Misoprostol Lisinopril Modafinil Lisinopril & Hydrochlorothiazide Moexipril HCl Lithium Montelukast Sodium Lithium Carbonate Mycophenolate Mofetil Losartan Potassium Mycophenolate Sodium Losartan Potassium & Hydrochlorothiazide Lovastatin N Loxapine Succinate Nabumetone Lubiprostone Nadolol Lurasidone HCl Naproxen Naproxen Sodium M Nateglinide Maprotiline HCl Nebivolol HCl Mecamylamine HCl Nefazodone HCl Meclofenamate Sodium Niacin (Antihyperlipidemic) Medroxyprogesterone Acetate Niacin-Lovastatin Mefenamic Acid Niacin-Simvastatin Mefloquine HCl Nicardipine HCl Megestrol Acetate (Appetite) Nifedipine Meloxicam Nisoldipine Memantine HCl Nitroglycerin Mesalamine Nizatidine Metaproterenol Sulfate Norelgestromin-Ethinyl Estradiol Metformin HCl Norethin Acet & Estrad-Fe Methamphetamine HCl Norethindrone & Eth Estradiol Methazolamide Norethindrone & Ethinyl Estradiol-Fe Methimazole Norethindrone (Contraceptive) Methsuximide Norethindrone Acet & Eth Estra

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Celtic Insurance Company. All rights reserved. 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) 5900 E. Ben White Blvd. Austin, TX 78741 Ambetter.SuperiorHealthPlan.com Norethindrone Acetate Pimozide Norethindrone Acetate-Ethinyl Estradiol Pindolol Norethindrone Acetate-Ethinyl Estradiol-Fe Pioglitazone HCl Norethindrone Acetate-Ethinyl Estradiol-Fe Fum Pioglitazone HCl-Glimepiride (Biphasic) Pioglitazone HCl-Metformin HCl Norethindrone-Eth Estradiol (Triphasic) Piroxicam Norgestimate-Ethinyl Estradiol Pitavastatin Calcium Norgestimate-Ethinyl Estradiol (Triphasic) Posaconazole Norgestrel & Ethinyl Estradiol Potassium Bicarb & Chloride Nortriptyline HCl Potassium Bicarbonate Potassium Chloride O Potassium Chloride Microencapsulated Crystals Olanzapine ER Olmesartan Medoxomil Pramipexole Dihydrochloride Olmesartan Medoxomil-Amlodipine- Pramlintide Acetate Hydrochlorothiazide Prasterone Vaginal Olmesartan Medoxomil-Hydrochlorothiazide Prasugrel HCl Olodaterol HCl Pravastatin Sodium Olsalazine Sodium Prazosin HCl Omega-3-acid Ethyl Esters Pregabalin Omeprazole Pregabalin (Once-Daily) Omeprazole-Sodium Bicarbonate Primidone Ospemifene Probenecid Oxaprozin Prochlorperazine Maleate Oxcarbazepine Progesterone Micronized Oxybutynin Chloride Propafenone HCl Propranolol HCl P Propylthiouracil Paliperidone Protriptyline HCl Pancrelipase (Lipase-Protease-Amylase) Pantoprazole Sodium Q Paricalcitol Quetiapine Fumarate Paroxetine HCl Quinapril HCl Pentoxifylline Quinapril-Hydrochlorothiazide Perampanel Quinidine Sulfate Perindopril Erbumine Perphenazine R Perphenazine-Amitriptyline Rabeprazole Sodium Phenelzine Sulfate Raloxifene HCl Phenobarbital Ramipril Phenytoin Ranitidine HCl Phenytoin Sodium Extended Ranolazine Pilocarpine HCl Rasagiline Mesylate Pilocarpine HCl (Oral) Repaglinide

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Celtic Insurance Company. All rights reserved. 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) 5900 E. Ben White Blvd. Austin, TX 78741 Ambetter.SuperiorHealthPlan.com Repaglinide-Metformin HCl Tacrolimus Rifaximin Tadalafil Riluzole Tafluprost Risedronate Sodium Tamoxifen Citrate Risperidone Tamsulosin HCl Rivaroxaban Tasimelteon Rivastigmine Tartrate Telmisartan Roflumilast Telmisartan-Amlodipine Ropinirole Hydrochloride Telmisartan-Hydrochlorothiazide Rosiglitazone Maleate Terazosin HCl Rosuvastatin Calcium Terbutaline Sulfate Rotigotine Testosterone Rufinamide Theophylline Thioridazine HCl S Thiothixene Sacrosidase Thyroid Sacubitril-Valsartan Tiagabine HCl Salmeterol Xinafoate Ticagrelor Salsalate Timolol Maleate Segesterone Acetate-Ethinyl Estradiol Timolol Maleate (Ophth) Selegiline Timothy Grass Pollen Allergen Extract Selegiline HCl Tiotropium Bromide Monohydrate Semaglutide Tolazamide Sertraline HCl Tolbutamide Sevelamer Carbonate Tolcapone Silodosin Tolmetin Sodium Simvastatin Tolterodine Tartrate Sirolimus Topiramate Sitagliptin Phosphate Toremifene Citrate Sitagliptin-Metformin HCl Torsemide Sodium Phenylbutyrate Trandolapril Solifenacin Succinate Trandolapril-Verapamil HCl Solriamfetol HCl Tranylcypromine Sulfate Sotalol HCl Travoprost Sotalol HCl (AFIB/AFL) Trazodone HCl Spironolactone Treprostinil Diolamine Spironolactone & Hydrochlorothiazide Triamterene Stannous Fluoride Triamterene & Hydrochlorothiazide Sucralfate Trifluoperazine HCl Sucroferric Oxyhydroxide Trihexyphenidyl HCl Sulfasalazine Trimipramine Maleate Sulindac Tropicamide Trospium Chloride T

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