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-Benazepril HCl Acamprosate Calcium Amlodipine Besylate-Olmesartan Medoxomil Acarbose Amlodipine Besylate-Valsartan Acebutolol HCl Amlodipine-Valsartan-Hydrochlorothiazide Acetazolamide Amoxapine Albuterol Sulfate Amphetamine-Dextroamphetamine Alendronate Sodium Anagrelide HCl Alendronate Sodium-Cholecalciferol Anastrozole Alfuzosin HCl Apixaban Aliskiren Fumarate Arformoterol Tartrate Allopurinol Aripiprazole Alogliptin Benzoate Armodafinil Alosetron HCl Asenapine Maleate Amantadine HCl Aspirin-Dipyridamole Amiloride & Hydrochlorothiazide Atenolol Amiloride HCl Atenolol & Chlorthalidone Amiodarone HCl Atomoxetine HCl Amitriptyline HCl Atorvastatin 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 Cimetidine Benazepril HCl Cimetidine HCl Benztropine Mesylate Citalopram Hydrobromide Betaxolol HCl Clobazam Betaxolol HCl (Ophth) Clomipramine HCl Betrixaban Maleate Clonidine Bimatoprost Clonidine HCl Bisoprolol & Hydrochlorothiazide Clonidine HCl (ADHD) Bisoprolol Fumarate Clopidogrel Bisulfate Brexpiprazole Colchicine w/ Probenecid Brimonidine Tartrate Colesevelam HCl Brimonidine Tartrate-Timolol Maleate Colestipol HCl Brinzolamide-Brimonidine Tartrate Conjugated Estrogens-Bazedoxifene Brivaracetam Conjugated Estrogens-Medroxyprogesterone Bromocriptine Mesylate Acetate Bromocriptine Mesylate (Diabetes) Cromolyn Sodium Budesonide (Inhalation) Cyclosporine Budesonide-Formoterol Fumarate Dihydrate Cyclosporine (Ophth) Bumetanide Cyclosporine Modified (For Microemulsion) Bupropion HCl Cysteamine Bitartrate Cysteamine HCl C Calcitonin (Salmon) D Calcitriol Dapagliflozin Propanediol Calcium Acetate (Phosphate Binder) Dapagliflozin-Metformin HCl Candesartan Cilexetil Dapsone Candesartan Cilexetil-Hydrochlorothiazide Darifenacin Hydrobromide Cannabidiol Deferiprone Captopril Desipramine HCl Carbamazepine Desmopressin Acetate Carbamazepine (Antipsychotic) Desmopressin Acetate Spray Carbidopa Desmopressin Acetate Spray Refrigerated Carbidopa-Levodopa Desogestrel & Ethinyl Estradiol Carbidopa-Levodopa-Entacapone Desogestrel-Ethinyl Estradiol (Biphasic) Carteolol HCl (Ophth) Desogestrel-Ethinyl Estradiol (Triphasic) Carvedilol Desvenlafaxine Succinate Celecoxib Dexlansoprazole Cevimeline HCl Dexmethylphenidate HCl Chloroquine Phosphate Dextroamphetamine Sulfate Chlorothiazide Dextromethorphan HBr-Quinidine Sulfate Chlorpromazine HCl Diazoxide Chlorpropamide 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 Estradiol Acetate Vaginal Diclofenac w/ Misoprostol Estradiol Vaginal Diflunisal Estradiol Valerate-Dienogest Digoxin Estradiol-Levonorgestrel Diltiazem HCl Estrogens, Conjugated Diltiazem HCl Coated Beads Estrogens, Conjugated Vaginal Diltiazem HCl Extended Release Beads Ethacrynic Acid Dipyridamole Ethosuximide Disopyramide Phosphate Ethotoin Disulfiram Ethynodiol Diacet & Eth Estrad Divalproex Sodium Etodolac Dofetilide Etonogestrel-Ethinyl Estradiol Donepezil Hydrochloride Ezetimibe Dorzolamide HCl Ezetimibe-Simvastatin Dorzolamide HCl-Timolol Maleate Doxazosin Mesylate F Doxepin HCl Famotidine Doxercalciferol Febuxostat Dronedarone HCl Felbamate Drospirenone Felodipine Drospirenone-Ethinyl Estradiol Fenofibrate Drospirenone-Ethinyl Estradiol-Levomefolate Fenofibrate Micronized Calcium Fenoprofen Calcium Dulaglutide Fesoterodine Fumarate Duloxetine HCl Finasteride Dutasteride Flavoxate HCl Flecainide Acetate E Fludrocortisone Acetate Echothiophate Iodide Fluoxetine HCl Empagliflozin Fluoxetine HCl (PMDD) Empagliflozin-Metformin HCl Fluphenazine HCl Enalapril Maleate Flurbiprofen Enalapril Maleate & Hydrochlorothiazide Fluticasone Furoate (Inhalation) Entacapone Fluticasone Furoate-Vilanterol Eplerenone Fluticasone Propionate (Inhalation) Eprosartan Mesylate Fluticasone Propionate HFA Erenumab-aooe Fluticasone-Salmeterol Ergocalciferol Fluticasone-Umeclidinium-Vilanterol Ergoloid Mesylates Fluvastatin Sodium Ertugliflozin L-Pyroglutamic Acid Fluvoxamine Maleate Ertugliflozin-Metformin HCl Folic Acid Escitalopram Oxalate Fosinopril Sodium Eslicarbazepine Acetate Fosinopril Sodium & Hydrochlorothiazide Esomeprazole Magnesium Furosemide Esterified Estrogens 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 Gabapentin Ipratropium Bromide HFA Gabapentin Enacarbil Ipratropium-Albuterol Galantamine Hydrobromide Irbesartan Galcanezumab-gnlm Irbesartan-Hydrochlorothiazide Gemfibrozil Isocarboxazid Glatiramer Acetate Isoniazid Glimepiride Isosorbide Dinitrate Glipizide Isosorbide Dinitrate-Hydralazine HCl Glipizide-Metformin HCl Isosorbide Mononitrate Glyburide Isradipine Glyburide Micronized Ivabradine HCl Glyburide-Metformin Glycopyrrolate-Formoterol Fumarate K Guanfacine HCl Ketoprofen Guanfacine HCl (ADHD) L H Labetalol HCl Haloperidol Lacosamide Haloperidol Lactate Lactulose Hydralazine HCl Lactulose (Encephalopathy) Hydrochlorothiazide Lamivudine (HBV) Hydroxychloroquine Sulfate Lamotrigine Hydroxyurea (Sickle Cell Anemia) Lansoprazole Lanthanum Carbonate I Latanoprost Ibandronate Sodium Leflunomide Ibuprofen Lesinurad Icosapent Ethyl Lesinurad-Allopurinol Imipramine HCl Letrozole Imipramine Pamoate Levalbuterol HCl Indacaterol Maleate Levalbuterol Tartrate Indacaterol Maleate-Glycopyrrolate Levetiracetam Indapamide Levobunolol HCl Indomethacin Levomilnacipran HCl Insulin Aspart Levonorgestrel & Eth Estradiol Insulin Aspart (with Niacinamide) Levonorgestrel-Eth Estradiol (Triphasic) Insulin Aspart Protamine & Aspart (Human) Levonorgestrel-Ethinyl Estradiol & Folic Acid Insulin Degludec Levonorgestrel-Ethinyl Estradiol (91-Day) Insulin Degludec-Liraglutide Levonorgestrel-Ethinyl Estradiol (Continuous) Insulin Detemir Levonorgestrel-Ethinyl Estradiol-Ferrous Insulin Glargine Bisglycinate Insulin NPH (Human) (Isophane) Levothyroxine Sodium Insulin NPH Isophane & Reg (Human) Linaclotide Insulin Regular (Human) Liothyronine Sodium Ipratropium Bromide 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 Montelukast Sodium Lisinopril & Hydrochlorothiazide Mycophenolate Mofetil Lithium Mycophenolate Sodium Lithium Carbonate Losartan Potassium N Losartan Potassium & Hydrochlorothiazide Nabumetone Lovastatin Nadolol Loxapine Succinate Naproxen Lubiprostone Naproxen Sodium Lurasidone HCl Nateglinide Nebivolol HCl M Nefazodone HCl Maprotiline HCl Niacin (Antihyperlipidemic) Mecamylamine HCl Niacin-Lovastatin Meclofenamate Sodium Niacin-Simvastatin Medroxyprogesterone Acetate Nicardipine HCl Mefenamic Acid Nifedipine Mefloquine HCl Nisoldipine Megestrol Acetate (Appetite) Nitroglycerin Meloxicam Nizatidine Memantine HCl Norelgestromin-Ethinyl Estradiol Mesalamine Norethin Acet & Estrad-Fe Metaproterenol Sulfate Norethindrone & Eth Estradiol Metformin HCl Norethindrone & Ethinyl Estradiol-Fe Methamphetamine 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 Methylphenidate (Biphasic) Methylphenidate HCl Norethindrone-Eth Estradiol (Triphasic) Methyltestosterone Norgestimate-Ethinyl Estradiol Metolazone Norgestimate-Ethinyl Estradiol (Triphasic) Metoprolol & Hydrochlorothiazide Norgestrel & Ethinyl Estradiol Metoprolol Succinate Nortriptyline HCl Metoprolol Tartrate Mexiletine HCl