sign in sign up
<<
Home , Nateglinide, Nisoldipine, Phenytoin, Tolazamide, Trospium chloride, Umeclidinium bromide

Ambetter 90-Day-Maintenance 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 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 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 Besylate-Benazepril HCl Acamprosate Calcium Amlodipine Besylate-Olmesartan Medoxomil Amlodipine Besylate-Valsartan HCl Amlodipine-Valsartan-Hydrochlorothiazide Albuterol Sulfate Amphetamine-Dextroamphetamine Alendronate Sodium Anagrelide HCl Alendronate Sodium-Cholecalciferol Anastrozole Alfuzosin HCl Apixaban Aliskiren Fumarate Tartrate Aripiprazole Benzoate Armodafinil Alosetron HCl Asenapine Maleate HCl -Dipyridamole & Hydrochlorothiazide Amiloride HCl Atenolol & Chlorthalidone HCl HCl HCl Calcium Amlodipine Besylate Auranofin Amlodipine Besylate-Atorvastatin Calcium Azathioprine

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Ambetter of Peach State Inc. All rights reserved 1-877-687-1180 (TTY/TDD 1-877-941-9231) 1100 Circle 75 Parkway, Suite 1100 Atlanta, GA 30339 Ambetter.pshpgeorgia.com Azilsartan Medoxomil Chlorthalidone Cholestyramine B Cholestyramine Light Beclomethasone Dipropionate HFA Cilostazol Benazepril & Hydrochlorothiazide Benazepril HCl Cimetidine HCl Benztropine Mesylate Hydrobromide Betaxolol HCl Betaxolol HCl (Ophth) HCl Betrixaban Maleate Clonidine Bimatoprost Clonidine HCl Bisoprolol & Hydrochlorothiazide Clonidine HCl (ADHD) Bisoprolol Fumarate Bisulfate Brexpiprazole Colchicine w/ Probenecid Brimonidine Tartrate Colesevelam HCl Brimonidine Tartrate-Timolol Maleate Colestipol HCl Brinzolamide-Brimonidine Tartrate Conjugated - -Medroxyprogesterone Mesylate Acetate Bromocriptine Mesylate (Diabetes) Cromolyn Sodium (Inhalation) Cyclosporine Budesonide- Fumarate Dihydrate Cyclosporine (Ophth) Cyclosporine Modified (For Microemulsion) HCl Cysteamine Bitartrate Cysteamine HCl C Calcitonin (Salmon) D Calcitriol Propanediol Calcium Acetate (Phosphate Binder) Dapagliflozin- HCl Candesartan Cilexetil Dapsone Candesartan Cilexetil-Hydrochlorothiazide Hydrobromide Deferiprone Captopril HCl Desmopressin Acetate Carbamazepine (Antipsychotic) Desmopressin Acetate Spray Carbidopa Desmopressin Acetate Spray Refrigerated Carbidopa-Levodopa & Ethinyl Carbidopa-Levodopa-Entacapone Desogestrel-Ethinyl Estradiol (Biphasic) Carteolol HCl (Ophth) Desogestrel-Ethinyl Estradiol (Triphasic) Desvenlafaxine Succinate Celecoxib Dexlansoprazole HCl HCl Chloroquine Phosphate Dextroamphetamine Sulfate Chlorothiazide HBr- Sulfate HCl Diclofenac Potassium

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Ambetter of Peach State Inc. All rights reserved 1-877-687-1180 (TTY/TDD 1-877-941-9231) 1100 Circle 75 Parkway, Suite 1100 Atlanta, GA 30339 Ambetter.pshpgeorgia.com Diclofenac Sodium Vaginal Diclofenac w/ Misoprostol Estradiol Vaginal Diflunisal -Dienogest Estradiol-Levonorgestrel HCl Estrogens, Conjugated Diltiazem HCl Coated Beads Estrogens, Conjugated Vaginal Diltiazem HCl Extended Release Beads Ethacrynic Acid Dipyridamole Phosphate Disulfiram Ethynodiol Diacet & Eth Estrad Divalproex Sodium Etodolac Etonogestrel-Ethinyl Estradiol Hydrochloride Ezetimibe Dorzolamide HCl Ezetimibe- Dorzolamide HCl-Timolol Maleate Doxazosin Mesylate F HCl Famotidine Doxercalciferol Febuxostat HCl Drospirenone Drospirenone-Ethinyl Estradiol Fenofibrate Drospirenone-Ethinyl Estradiol-Levomefolate Fenofibrate Micronized Calcium Fenoprofen Calcium Fumarate Duloxetine HCl Finasteride Dutasteride HCl Acetate E Fludrocortisone Acetate Echothiophate Iodide HCl Fluoxetine HCl (PMDD) Empagliflozin-Metformin HCl HCl Enalapril Maleate Flurbiprofen Enalapril Maleate & Hydrochlorothiazide Furoate (Inhalation) Entacapone Fluticasone Furoate- Eplerenone (Inhalation) Eprosartan Mesylate Fluticasone Propionate HFA Erenumab-aooe Fluticasone- Ergocalciferol Fluticasone-Umeclidinium-Vilanterol Mesylates Fluvastatin Sodium L-Pyroglutamic Acid Maleate Ertugliflozin-Metformin HCl Folic Acid Oxalate Fosinopril Sodium Fosinopril Sodium & Hydrochlorothiazide Esomeprazole Estradiol G

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Ambetter of Peach State Inc. All rights reserved 1-877-687-1180 (TTY/TDD 1-877-941-9231) 1100 Circle 75 Parkway, Suite 1100 Atlanta, GA 30339 Ambetter.pshpgeorgia.com Ipratropium HFA Ipratropium-Albuterol Galantamine Hydrobromide Irbesartan Galcanezumab-gnlm Irbesartan-Hydrochlorothiazide Gemfibrozil Isocarboxazid Glatiramer Acetate Isoniazid Isosorbide Dinitrate Isosorbide Dinitrate-Hydralazine HCl Glipizide-Metformin HCl Isosorbide Mononitrate Glyburide Glyburide Micronized Ivabradine HCl Glyburide-Metformin Glycopyrrolate-Formoterol Fumarate K Guanfacine HCl Ketoprofen Guanfacine HCl (ADHD) L H Labetalol HCl Haloperidol Lactate Lactulose Hydralazine HCl Lactulose (Encephalopathy) Hydrochlorothiazide Lamivudine (HBV) Hydroxychloroquine Sulfate Hydroxyurea (Sickle Cell Anemia) Lansoprazole Carbonate I Latanoprost Ibandronate Sodium Leflunomide Lesinurad Icosapent Ethyl Lesinurad-Allopurinol HCl Letrozole Imipramine Pamoate Levalbuterol HCl Maleate Levalbuterol Tartrate Indacaterol Maleate-Glycopyrrolate Indapamide Levobunolol HCl Indomethacin Levomilnacipran HCl Aspart Levonorgestrel & Eth Estradiol (with Niacinamide) Levonorgestrel-Eth Estradiol (Triphasic) Insulin Aspart Protamine & Aspart (Human) Levonorgestrel-Ethinyl Estradiol & Folic Acid Levonorgestrel-Ethinyl Estradiol (91-Day) Insulin Degludec- Levonorgestrel-Ethinyl Estradiol (Continuous) Levonorgestrel-Ethinyl Estradiol-Ferrous Bisglycinate Insulin NPH (Human) (Isophane) Sodium Insulin NPH Isophane & Reg (Human) Linaclotide Insulin Regular (Human) Liothyronine Sodium Liraglutide Ipratropium Bromide (Nasal) Lisdexamfetamine Dimesylate

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Ambetter of Peach State Inc. All rights reserved 1-877-687-1180 (TTY/TDD 1-877-941-9231) 1100 Circle 75 Parkway, Suite 1100 Atlanta, GA 30339 Ambetter.pshpgeorgia.com Lisinopril Sodium Lisinopril & Hydrochlorothiazide Mycophenolate Mofetil Lithium Mycophenolate Sodium Lithium Carbonate Losartan Potassium N Losartan Potassium & Hydrochlorothiazide Nabumetone Succinate Naproxen Lubiprostone Naproxen Sodium HCl Nebivolol HCl M HCl HCl (Antihyperlipidemic) Mecamylamine HCl Niacin-Lovastatin Meclofenamate Sodium Niacin-Simvastatin Medroxyprogesterone Acetate HCl HCl Megestrol Acetate (Appetite) Nitroglycerin Meloxicam Nizatidine HCl -Ethinyl Estradiol Mesalamine Norethin Acet & Estrad-Fe Metaproterenol Sulfate Norethindrone & Eth Estradiol Metformin HCl Norethindrone & Ethinyl Estradiol-Fe HCl Norethindrone (Contraceptive) Methazolamide Norethindrone Acet & Eth Estra Methimazole Norethindrone Acetate Methsuximide Norethindrone Acetate-Ethinyl Estradiol Methyclothiazide Norethindrone Acetate-Ethinyl Estradiol-Fe Methyldopa Norethindrone Acetate-Ethinyl Estradiol-Fe Fum (Biphasic) Methylphenidate HCl Norethindrone-Eth Estradiol (Triphasic) Norgestimate-Ethinyl Estradiol Metolazone Norgestimate-Ethinyl Estradiol (Triphasic) & Hydrochlorothiazide Norgestrel & Ethinyl Estradiol Metoprolol Succinate HCl Metoprolol Tartrate HCl O Milnacipran HCl Olmesartan Medoxomil Olmesartan Medoxomil-Amlodipine- Hydrochlorothiazide Olmesartan Medoxomil-Hydrochlorothiazide Misoprostol HCl Modafinil Olsalazine Sodium Moexipril HCl Omega-3-acid Ethyl Esters

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Ambetter of Peach State Inc. All rights reserved 1-877-687-1180 (TTY/TDD 1-877-941-9231) 1100 Circle 75 Parkway, Suite 1100 Atlanta, GA 30339 Ambetter.pshpgeorgia.com Probenecid Omeprazole-Sodium Bicarbonate Prochlorperazine Maleate Micronized Oxaprozin HCl HCl Chloride Propylthiouracil HCl P Paliperidone Q Pancrelipase (Lipase-Protease-Amylase) Fumarate Pantoprazole Sodium Quinapril HCl Paricalcitol Quinapril-Hydrochlorothiazide HCl Quinidine Sulfate Pentoxifylline R Perindopril Erbumine Sodium HCl Perphenazine-Amitriptyline Ramipril Phenelzine Sulfate Ranitidine HCl Rasagiline Mesylate Phenytoin Sodium Extended HCl Repaglinide-Metformin HCl Pilocarpine HCl (Oral) Risedronate Sodium HCl Risperidone Pioglitazone HCl-Glimepiride Rivaroxaban Pioglitazone HCl-Metformin HCl Rivastigmine Tartrate Piroxicam Pitavastatin Calcium Ropinirole Hydrochloride Posaconazole Maleate Potassium Bicarb & Chloride Rosuvastatin Calcium Potassium Bicarbonate Rotigotine Potassium Chloride Potassium Chloride Microencapsulated Crystals ER S Dihydrochloride Sacrosidase Acetate Sacubitril-Valsartan Vaginal Salmeterol Xinafoate Prasugrel HCl Salsalate Pravastatin Sodium Segesterone Acetate-Ethinyl Estradiol Prazosin HCl Selegiline HCl Pregabalin (Once-Daily) HCl

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Ambetter of Peach State Inc. All rights reserved 1-877-687-1180 (TTY/TDD 1-877-941-9231) 1100 Circle 75 Parkway, Suite 1100 Atlanta, GA 30339 Ambetter.pshpgeorgia.com Sevelamer Carbonate Tartrate Silodosin Simvastatin Citrate Torsemide Phosphate Trandolapril Sitagliptin-Metformin HCl Trandolapril- HCl Sodium Phenylbutyrate Tranylcypromine Sulfate Succinate Travoprost HCl HCl HCl Treprostinil Diolamine Sotalol HCl (AFIB/AFL) Triamterene & Hydrochlorothiazide Spironolactone & Hydrochlorothiazide HCl Stannous Fluoride HCl Sucralfate Maleate Sucroferric Oxyhydroxide Sulfasalazine Sulindac U T Umeclidinium-Vilanterol Tadalafil Ursodiol Tafluprost Citrate V Tamsulosin HCl Valganciclovir HCl Tasimelteon Sodium Valproic Acid Telmisartan-Amlodipine Valsartan Telmisartan-Hydrochlorothiazide Valsartan-Hydrochlorothiazide Terazosin HCl HCl Sulfate Verapamil HCl Vilazodone HCl Vorapaxar Sulfate HCl Vortioxetine HBr Thiothixene Thyroid W HCl Sodium Ticagrelor Timolol Maleate Z Timolol Maleate (Ophth) Timothy Grass Pollen Allergen Extract Monohydrate Ziprasidone HCl Tolcapone Tolmetin Sodium

Inclusion of drugs on this list does not guarantee coverage. Please consult your benefit materials for further information. © 2020 Ambetter of Peach State Inc. All rights reserved 1-877-687-1180 (TTY/TDD 1-877-941-9231) 1100 Circle 75 Parkway, Suite 1100 Atlanta, GA 30339 Ambetter.pshpgeorgia.com