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Magellan Rx Precision Formulary

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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 – 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) dedicates 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 drugs’ 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. The request may be initiated by the member or the prescriber. If the request is initiated by the member using the online tool or via a telephone request to our offices, Magellan will contact your physician for the necessary clinical information to support this exception. If the request is initiated by your 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 magellanrx.com. TIER DESCRIPTION 1 Generics 2 Preferred Brands 3 Non-Preferred Brands 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. Your provider is required to get prior authorization before you fill your prescription, which ensures appropriate use of the PA Prior Authorization selected drug. Without prior approval, we may not cover this drug. In some cases, you may be required to first try certain drugs to ST Step Therapy treat your medical condition before you move up a “step” to other drug options. GL Gender Limit This prescription drug is restricted for a single gender. This prescription drug may only be covered if you meet the AL Age Limit minimum or maximum age limit. C Custom This drug has unique restrictions. 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. PS Preferred Specialty Preferred Specialty. PAGE 2 LAST UPDATED 09/2019 PRODUCT DESCRIPTION TIER LIMITS & ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH) NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS CAFERGOT 3 QL 10 / 30 days D.H.E.45 3 PA DIBENZYLINE 3 dihydroergotamine mesylate 1 mg/ml ampul 1 PA dihydroergotamine mesylate 0.5mg/spry QL 8 / 30 days 1 spray/pump PA ergoloid mesylates 1 ERGOMAR 3 ergotamine tartrate/caffeine 1 MIGERGOT 3 QL 8 / 30 days MIGRANAL 3 PA phenoxybenzamine hcl 1 phentolamine mesylate 1 phentolamine mesylate/alprostadil in bacteriostatic 1 water SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT QL 1 / day alfuzosin hcl 1 GL Male FLOMAX 3 QL 2 / day QL 1 / day RAPAFLO 2 GL Male PAGE 3 LAST UPDATED 09/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 1 / day silodosin 1 GL Male tamsulosin hcl 1 QL 2 / day QL 1 / day UROXATRAL 3 GL Male ANALGESICS AND ANTIPYRETICS ANALGESICS AND ANTIPYRETICS, MISC. ALLZITAL 3 QL 12 / day BUPAP 1 QL 6 / day butalbital/acetaminophen (butalbital/acetaminophen capsule, 1 QL 6 / day butalbital/acetaminophen tablet) butalbital/acetaminophen 50mg-325mg tablet 1 QL 6 / day butalbital/acetaminophen/caffeine (butalb/acetaminophen/caffeine 50-300-40 capsule, 1 QL 6 / day butalb/acetaminophen/caffeine 50-325-40 capsule, butalb/acetaminophen/caffeine 50-325-40 tablet) clonidine hcl/pf 1 CORICIDIN HBP COLD AND FLU 3 DURACLON 3 ESGIC CAPSULE 1 QL 6 / day ESGIC 50-325-40 MG TABLET 3 QL 6 / day FIORICET 3 QL 6 / day GRALISE 30-DAY STARTER PACK 3 ST QL 1 / day GRALISE ER 300 MG TABLET 3 ST PAGE 4 LAST UPDATED 09/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 3 / day GRALISE ER 600 MG TABLET 3 ST isometheptene mucate/caffeine/acetaminophen 1 isometheptene 1 mucate/dichloralphenazone/acetaminophen QL 3 / day LYRICA CR (CR 82.5 MG TABLET, CR 165 MG TABLET) 3 PA QL 2 / day LYRICA CR 330 MG TABLET 3 PA MARTEN-TAB 1 QL 6 / day NODOLOR 1 PHRENILIN FORTE 1 QL 6 / day PRIALT 3 S PRODRIN 3 TENCON 1 QL 6 / day VANATOL LQ 3 ZEBUTAL 1 QL 6 / day OPIATE AGONISTS QL 140 / day acetaminophen with codeine 120-12mg/5 solution 1 AL At least 12 yrs old QL 139 / day acetaminophen with codeine 300mg/12.5 solution 1 AL At least 12 yrs old QL 22 / day acetaminophen with codeine 300mg-15mg tablet 1 AL At least 12 yrs old QL 12 / day acetaminophen with codeine 300mg-30mg tablet 1 AL At least 12 yrs old PAGE 5 LAST UPDATED 09/2019 PRODUCT DESCRIPTION TIER LIMITS & QL 6 / day acetaminophen with codeine 300mg-60mg tablet 1 AL At least 12 yrs old acetaminophen/caffeine/dihydrocodeine bitartrate (acetaminophen/caff/dihydrocod 320.5-30mg QL 10 / day 1 capsule, acetaminophen/caff/dihydrocod 325-30-16 AL At least 18 yrs old tablet) QL 4 / day ACTIQ 3 PA AL At least 18 yrs old QL 12 / day APADAZ 3 AL At least 18 yrs old QL 6 / day ASCOMP WITH CODEINE 1 AL At least 18 yrs old QL 10 / day aspirin/caffeine/dihydrocodeine bitartrate 1 AL At least 18 yrs old QL 12 / day benzhydrocodone hcl/acetaminophen 1 AL At least 18 yrs old butalbital/acetaminophen/caffeine/codeine phosphate (butalbit/acetamin/caff/codeine 50-300- 1 QL 6 / day 30 capsule, butalbit/acetamin/caff/codeine 50-325- 30 capsule) QL 125 / day CAPITAL W-CODEINE 3 AL At least 12 yrs old QL 6 / day codeine phosphate/butalbital/aspirin/caffeine 1 AL At least 18 yrs old QL 6 / day codeine sulfate 1 AL At least 18 yrs old QL 1 / day CONZIP (100 MG CAPSULE, 200 MG CAPSULE, 300 3 PA MG CAPSULE) AL At least 18 yrs old PAGE 6 LAST UPDATED 09/2019 PRODUCT DESCRIPTION TIER LIMITS & DEMEROL (25 MG/0.5 ML AMPUL, 50 MG/ML QL 10 / day AMPUL, 50 MG/ML CARPUJECT, 50 MG/ML VIAL, 75 3 MG/1.5 ML AMPUL, 100 MG/2 ML AMPUL) AL At least 18 yrs old QL 20 / day DEMEROL 25 MG/ML CARPUJECT 3 AL At least 18 yrs old QL 7 / day DEMEROL 75 MG/ML CARPUJECT 3 AL At least 18 yrs old QL 5 / day DEMEROL 100 MG TABLET 3 AL At least 18 yrs old DEMEROL (100 MG/ML AMPUL, 100 MG/ML QL 5 / day 3 CARPUJECT, 100 MG/ML VIAL) AL At least 18 yrs old QL 13 / day DILAUDID 5 MG/5 ML ORAL LIQUID 3 AL At least 18 yrs old DILAUDID (0.5 MG/0.5 ML SYRINGE, 1 MG/ML 3 AL At least 18 yrs old SYRINGE, 2 MG/ML SYRINGE, 4 MG/ML SYRINGE) DILAUDID (2 MG TABLET, 4 MG TABLET, 8 MG QL 6 / day 3 TABLET) AL At least 18 yrs old QL 3 / day DOLOPHINE HCL 3 PA DSUVIA 3 QL 0.5 / day DURAGESIC 3 PA DURAMORPH 10 MG/10 ML AMPUL 1 QL 5 / day DURAMORPH 5 MG/10 ML AMPUL 1 QL 10 / day QL 10 / day DVORAH 3 AL At least 18 yrs old QL 2 / day EMBEDA 2 PA PAGE 7 LAST UPDATED 09/2019 PRODUCT DESCRIPTION TIER LIMITS & ENDOCET (5-325 TABLET, 7.5-325 MG TABLET, 10- QL 12 / day 1 325 MG TABLET) AL At least 18 yrs old QL 12 / day ENDOCET 2.5-325 MG TABLET 1 AL At least 18 yrs old QL 2 / day EXALGO 3 PA fentanyl (12 mcg/hr patch td72, 25 mcg/hr patch QL 0.5 / day td72, 50mcg/hr patch td72, 75mcg/hr patch td72, 1 87.5mcg/hr patch td72, 100 mcg/hr patch td72) PA fentanyl (37.5mcg/hr patch td72, 62.5mcg/hr patch QL 0.5 / day 1 td72) PA fentanyl citrate (200 mcg lozenge hd, 400 mcg QL 4 / day lozenge hd, 600 mcg lozenge hd, 1200 mcg lozenge 1 PA hd, 1600 mcg lozenge hd) AL At least 18 yrs old QL 4 / day fentanyl citrate 800 mcg lozenge hd 1 PA AL At least 18 yrs old fentanyl citrate-0.9 % nacl/pf 1375mcg/55 pca 1 QL 15 / day syring fentanyl citrate in 0.9 % sodium chloride/pf (% nacl/pf 600mcg/30 pca syring, % nacl/pf 600mcg/30 1 QL 19 / day pca vial) PAGE 8 LAST UPDATED 09/2019 PRODUCT DESCRIPTION TIER LIMITS & fentanyl citrate in 0.9 % sodium chloride/pf (% nacl/pf 5 mcg/ml plast.
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