Dual Eligible Preferred Drug List
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Dual EligiblePreferred Drug List
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PH-ANR-31Rev120920
Dual Eligible Preferred Drug List
This is a supplemental preferred drug list and only applies to members who have dual eligibility.
Effective December 10, 2020
This Preferred Drug List is a list of medicines that are covered by your pharmacy benefit. The list includes prescription and non-prescription medicines. In addition to this list, you can use our online search tool. You’ll also find the Preferred Drug List Quick Reference on our website at mibluecrosscomplete.com. This is an easy-to-use summary of the medicines we cover.
If you have questions, please contact Blue Cross Complete of Michigan Pharmacy Services at 1-888-288-3231. You can call this number from 8:30 a.m. until 6 p.m., Monday through Friday.
Encl: Nondiscrimination Notice and Language Services
Blue Cross Complete participates in the Michigan Common Formulary
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
1
Drug Tier Status Notes Alternative Therapy
Alternative Therapy - Antioxidant EYE HEALTH PLUS LUTEIN F
Analgesic, Anti-Inflammatory Or Antipyretic
Analgesic Or Antipyretic Non-Opioid ACEPHEN F OTC
ACETAMINOPHEN EXTRA STRENGTH F OTC
acetaminophen oral drops,suspension F OTC
acetaminophen oral elixir F OTC
acetaminophen oral liquid 160 mg/5 ml F OTC
acetaminophen oral solution 160 mg/5 ml (5 ml) F OTC
acetaminophen oral suspension 160 mg/5 ml F OTC
acetaminophen oral tablet F OTC
acetaminophen oral tablet extended release F OTC
acetaminophen oral tablet,disintegrating F OTC
acetaminophen rectal F OTC
ATHENOL F OTC
BETATEMP F OTC
CHILD FEVER REDUCER-PAIN RELVR F OTC
CHILD PAIN REL-FEVER REDUCER F OTC
CHILDREN'S ACETAMINOPHEN ORAL SUSPENSION 160 MG/5 ML, 160 MG/5 ML (5 ML)
F OTC
CHILDREN'S ACETAMINOPHEN ORAL TABLET,CHEWABLE 80 MG
F OTC
CHILDREN'S FEVER REDUCING F OTC
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 2
Drug Tier Status Notes CHILDREN'S MAPAP ORAL TABLET,CHEWABLE 80 MG
F OTC
CHILDREN'S NON-ASPIRIN ORAL SUSPENSION
F OTC
CHILDREN'S NON-ASPIRIN ORAL TABLET,CHEWABLE
F OTC
CHILDREN'S NON-ASPIRIN PAIN F OTC
CHILDREN'S PAIN RELIEF ORAL LIQUID F OTC
CHILDREN'S PAIN RELIEF ORAL SUSPENSION
F OTC
CHILDREN'S PAIN RELIEVER ORAL SUSPENSION
F OTC
CHILDREN'S PAIN-FEVER RELIEF ORAL LIQUID
F OTC
CHILDREN'S PAIN-FEVER RELIEF ORAL SUSPENSION
F OTC
CHILDREN'S PAIN-FEVER RELIEF ORAL TABLET,CHEWABLE 80 MG
F OTC
CHILDREN'S Q-PAP F OTC
CHILDREN'S TACTINAL F OTC
CHILDREN'S TYLENOL ORAL SUSPENSION F OTC
FEVER REDUCER F OTC
FEVERALL RECTAL SUPPOSITORY 120 MG, 325 MG, 650 MG
F OTC
INFANT FEVER REDUCER-PAIN RELF F OTC
INFANT PAIN RELIEVER F OTC
INFANT'S NON-ASPIRIN ORAL DROPS F OTC
INFANTS' PAIN AND FEVER F OTC
INFANTS' PAIN RELIEF F OTC
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
3
Drug Tier Status Notes INFANT'S PAIN RELIEF ORAL SUSPENSION F OTC
JR. ACETAMINOPHEN F OTC
LITTLE REMEDIES FEVER AND PAIN F OTC
MAPAP (ACETAMINOPHEN) ORAL CAPSULE
F OTC
MAPAP (ACETAMINOPHEN) ORAL SUSPENSION
F OTC
MAPAP (ACETAMINOPHEN) ORAL TABLET F OTC
MAPAP EXTRA STRENGTH F OTC
NON-ASPIRIN CHILDREN'S F OTC
NON-ASPIRIN EXTRA STRENGTH ORAL CAPSULE
F OTC
NON-ASPIRIN EXTRA STRENGTH ORAL TABLET
F OTC
NON-ASPIRIN ORAL SUSPENSION F OTC
NON-ASPIRIN ORAL TABLET F OTC
NON-ASPIRIN ORAL TABLET,CHEWABLE 80 MG
F OTC
NON-ASPIRIN PAIN RELIEF ORAL TABLET 500 MG
F OTC
NORTEMP ORAL SUSPENSION F OTC
PAIN AND FEVER ORAL TABLET F OTC
PAIN RELIEF (ACETAMINOPHEN) ORAL CAPSULE
F OTC
PAIN RELIEF (ACETAMINOPHEN) ORAL LIQUID
F OTC
PAIN RELIEF (ACETAMINOPHEN) ORAL TABLET
F OTC
PAIN RELIEF EXTRA STRENGTH F OTC
PAIN RELIEF REGULAR STRENGTH F OTC
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 4
Drug Tier Status Notes PAIN RELIEVER (ACETAMINOPHEN) F OTC
PAIN RELIEVER EXTRA STRENGTH F OTC
PEDIACARE FEVER REDUCER F OTC
PHARBETOL F OTC
Q-PAP EXTRA STRENGTH F OTC
Q-PAP ORAL DROPS F OTC
Q-PAP ORAL TABLET 325 MG F OTC
TACTINAL F OTC
TACTINAL EXTRA STRENGTH F OTC
TYLENOL EXTRA STRENGTH ORAL TABLET
F OTC
TYLENOL ORAL TABLET F OTC
Nsaid Analgesics (Cox Non-Specific) - Propionic Acid Derivatives ALL DAY PAIN RELIEF P OTC
ALL DAY RELIEF P OTC
CHILDREN'S IBUPROFEN P OTC
IBU-200 P OTC
IBUPROFEN IB P OTC
IBUPROFEN JR STRENGTH P OTC
ibuprofen oral capsule P OTC
ibuprofen oral suspension P OTC
ibuprofen oral tablet 100 mg, 200 mg P OTC
INFANT'S IBUPROFEN P OTC
naproxen sodium oral capsule P OTC
naproxen sodium oral tablet 220 mg P OTC
PROVIL P OTC
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
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Drug Tier Status Notes Salicylate Analgesics ASPIR-81 F OTC; QL
ASPIRIN CHILDRENS F OTC; QL
ASPIRIN LOW DOSE F OTC; QL
ASPIRIN LOW-STRENGTH F OTC; QL
aspirin oral tablet F OTC; QL; AL
aspirin oral tablet,chewable F OTC; QL
aspirin oral tablet,delayed release (dr/ec) 325 mg F OTC; QL; AL
aspirin oral tablet,delayed release (dr/ec) 81 mg F OTC; QL
aspirin rectal F OTC
ASPIR-LOW F OTC; QL
BAYER ASPIRIN F OTC; QL; AL
BAYER CHEWABLE ASPIRIN F OTC; QL
CHILD ASPIRIN F OTC; QL
CHILDREN'S ASPIRIN F OTC; QL
ECOTRIN LOW STRENGTH F OTC; QL
LITE COAT ASPIRIN F OTC; QL; AL
LO-DOSE ASPIRIN F OTC; QL
Salicylate Analgesics, Buffered aspirin,buffd-calcium carb-mag F OTC; AL
BUFFERIN F OTC; AL
TRI-BUFFERED ASPIRIN F OTC; AL
Anti-Infective Agents
Anthelmintic Agents Other PIN-X F OTC
REESE'S PINWORM MEDICINE F OTC
Antiseptics And Disinfectants
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 6
Drug Tier Status Notes Antiseptic - Alcohols CURITY ALCOHOL PREPS 2 PLY,MEDIUM F OTC; QL
Cardiovascular Therapy Agents
Antihyperlipidemic - Nicotinic Acid Derivatives niacin oral tablet 500 mg NP PA; OTC
Antihyperlipidemic Agents - Dietary Source ALGAL OMEGA-3 DHA F
FISH OIL CONCENTRATE F
omega-3 fatty acids oral capsule F
PRENATAL DHA ORAL CAPSULE 200 MG F
SUPER OMEGA-3 ORAL CAPSULE 1,000 MG F
Antihyperlipidemic Agents - Dietary Source Combinations FISH OIL ORAL CAPSULE 100-160-1,000 MG, 300-1,000 MG, 300-500 MG, 340-1,000 MG, 360-1,200 MG, 60-90-500 MG
F
FISH OIL ORAL CAPSULE,DELAYED RELEASE(DR/EC) 300-1,000 MG, 360-1,200 MG
F
omega 3-dha-epa-fish oil oral capsule 1,000 mg (120 mg-180 mg), 1,200 (144-216) mg, 300-1,000 mg
F
omega 3-dha-epa-fish oil oral capsule,delayed release(dr/ec) 300 mg (120 mg- 180mg)-1,000 mg
F
omega-3 fatty acids-fish oil oral capsule 300-1,000 mg, 340-1,000 mg, 360-1,200 mg
F
SEA-OMEGA 30 F
vitamin e oral capsule 100 unit, 400 unit F
Central Nervous System Agents
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
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Drug Tier Status Notes Sedative-Hypnotic - Antihistamines diphenhydramine hcl oral capsule F OTC; AL
diphenhydramine hcl oral tablet 25 mg F OTC; AL
Chemical Dependency, Agents To Treat
Smoking Deterrents - Nicotine-Type nicotine (polacrilex) F OTC; QL
nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr
F OTC; QL
nicotine transdermal patch, td daily, sequential F OTC; QL
NTS STEP 1 F OTC; QL
Contraceptives
Emergency Contraceptives AFTERA F OTC
ECONTRA EZ F OTC
FALLBACK SOLO F OTC
MY WAY F OTC
NEXT CHOICE ONE DOSE F OTC
OPCICON ONE-STEP F OTC
TAKE ACTION F OTC
Emergency Contraceptives - Progestin Type AFTERA F OTC
ECONTRA EZ F OTC
FALLBACK SOLO F OTC
MY WAY F OTC
NEXT CHOICE ONE DOSE F OTC
OPCICON ONE-STEP F OTC
TAKE ACTION F OTC
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 8
Drug Tier Status Notes Spermicides GYNOL II F OTC
TODAY CONTRACEPTIVE SPONGE F OTC
VAGINAL CONTRACEPTIVE FOAM F OTC
Dermatological
Acne Therapy Topical - Keratolytic benzoyl peroxide topical cleanser 10 %, 5 % F OTC
benzoyl peroxide topical gel 10 % F OTC; QL
benzoyl peroxide topical gel 5 % F OTC
CREAMY ACNE FACE F OTC
PANOXYL-4 F OTC
Acne Therapy Topical - Retinoids And Derivatives DIFFERIN TOPICAL GEL 0.1 % F OTC; QL
Dermatological - Antibacterial Mixtures TRIPLE ANTIBIOTIC TOPICAL OINTMENT F OTC
TRIPLE ANTIBIOTIC TOPICAL OINTMENT IN PACKET
F OTC
Dermatological - Antibacterial Polymyxins And Derivatives bacitracin topical F OTC
bacitracin zinc F OTC
Dermatological - Antifungal Allylamines terbinafine hcl topical F OTC
Dermatological - Antifungal Benzylamines butenafine NP PA; OTC
Dermatological - Antifungal Imidazole And Related Agents ANTIFUNGAL (CLOTRIMAZOLE) P OTC
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
9
Drug Tier Status Notes ANTIFUNGAL CREAM (MICONAZOLE) P OTC
ATHLETE'S FOOT (CLOTRIMAZOLE) P OTC
clotrimazole topical P OTC
LOTRIMIN AF (CLOTRIMAZOLE) TOPICAL CREAM
NP PA; OTC
miconazole nitrate topical cream P OTC
Dermatological - Antifungal Thiocarbamate ANTIFUNGAL (TOLNAFTATE) TOPICAL CREAM
P OTC
ANTIFUNGAL (TOLNAFTATE) TOPICAL POWDER
P OTC
FUNGOID-D NP PA; OTC
tolnaftate topical cream P OTC
tolnaftate topical powder P OTC
Dermatological - Antiviral, Herpes ABREVA F OTC
Dermatological - Emollients ammonium lactate F OTC; QL
Dermatological - Glucocorticoid ANTI-ITCH (HC) TOPICAL CREAM P OTC
hydrocortisone acetate topical cream P OTC
hydrocortisone acetate topical ointment P OTC
hydrocortisone topical cream 0.5 %, 1 % P OTC
hydrocortisone topical ointment 0.5 %, 1 % P OTC
SCALPICIN ANTI-ITCH NP PA; OTC
Dermatological - Glucocorticoid-Emollient Combinations hydrocortisone-aloe vera topical cream 1 % NP PA; OTC
Dermatological - Topical Local Anesthetic Amides
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 10
Drug Tier Status Notes ASPERCREME (LIDOCAINE HCL) TOPICAL CREAM
F OTC; QL
ASPERCREME (LIDOCAINE) F OTC; QL
Dermatological Irritants-Counter-Irritant Single Agents capsaicin topical cream 0.025 % F OTC
Scabicide And Pediculicide Combinations LICE KILLING F OTC; QL
LICE PYRINYL SHAMPOO F OTC; QL
LICE TREATMENT TOPICAL SHAMPOO F OTC; QL
RID LICE KILLING F OTC; QL
Scabicide And Pediculicide Single Agents LICE CREAM RINSE F OTC; QL
LICE KILLING (PERMETHRIN) F OTC; QL
LICE TREATMENT (PERMETHRIN) F OTC; QL
LICE TREATMENT TOPICAL LIQUID 1 % F OTC; QL
NIX CREME RINSE F OTC; QL
permethrin topical liquid F OTC; QL
Electrolyte Balance-Nutritional Products
B-Complex Vitamin Combinations ALBA-LYBE F
APETEX F
APETIGEN F
B COMPLEX 1 (WITH FOLIC ACID) F
B COMPLEX 100 ORAL F
B COMPLEX PLUS VITAMIN C F
b complex-vitamin c-folic acid F
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
11
Drug Tier Status Notes B-100 COMPLEX ORAL TABLET EXTENDED RELEASE
F
BALANCE B-100 (FOLIC ACID) F
BALANCE B-50 (WITH FOLIC ACID) F
BALANCED B COMPLEX-VIT C F OTC
BALANCED B-100 COMPLEX ORAL TABLET EXTENDED RELEASE 100 MG
F
BALANCED B-100 ORAL TABLET 0.4 MG, 100 MG
F
b-complex with vitamin c oral tablet F
B-COMPLEX WITH VITAMIN C ORAL TABLET 400-500 MCG-MG
F
BIOPETIT F
CARDIOTEK-RX (BIOPERINE) F
COMPLEX B-100 ORAL TABLET EXTENDED RELEASE 400 MCG
F
COMPLEX B-50 F
DIALYVITE 3000 F
DIALYVITE 800 ORAL TABLET F
DIALYVITE 800 PLUS D F
DIALYVITE 800 WITH ZINC 15 F
DIALYVITE 800 WITH ZINC 50 F
DIALYVITE 800-ULTRA D F
DIALYVITE ORAL TABLET 100-1 MG F
DIALYVITE SUPREME D F
FOLBEE AR F
FOLBEE PLUS F
FULL SPECTRUM B-VITAMIN C F
KOBEE F
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 12
Drug Tier Status Notes MEDTYCHOLL-B COMPLEX-LIVER F
MYNEPHROCAPS F
NATURAL B-100 COMPLEX F
NEPHROCAPS F
NEPHROCAPS QT F
NEPHRONEX F
NEPHRONEX-SL F
NEPHRO-VITE F
PRORENAL F
QUIN B STRONG F
RENAL CAPS F
RENA-VITE F
RENO CAPS F
STRESS 500 PLUS ZINC F OTC
STRESS B PLUS ZINC F
STRESS FORMULA F
STRESS FORMULA ENERGY F OTC
STRESS FORMULA WITH IRON F
STRESS FORMULA WITH IRON(SULF) F
SUPER B COMPLEX + C F
SUPER QUINTS F
SUPERVITE F
TRIPHROCAPS F
VIRT-CAPS F
vitamin b complex-folic acid F
VITAMINS B COMPLEX ORAL TABLET 500 MG-400 MCG- 18 MG IRON
F
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
13
Drug Tier Status Notes B-Complex Vitamins B COMPLETE F OTC
B COMPLEX ORAL F OTC
B COMPLEX SUBLINGUAL F
B COMPLEX-VITAMIN B12 F
B-100 COMPLEX ORAL TABLET F OTC
B-50 COMPLEX F OTC
BAL B-100 F
BAL B-50 F
BALANCED B-100 COMPLEX ORAL TABLET EXTENDED RELEASE
F OTC
BALANCED B-100 ORAL TABLET F
BALANCED B-150 F OTC
BALANCED B-50 F
COMPLEX B-100 ORAL TABLET EXTENDED RELEASE
F
FOLGARD F
HI-B COMPLEX F
NATURAL B-100 F
STRESS B-BIOTIN F
STRESS FORMULA F
SUPER B-50 COMPLEX F
SUPER B-50 COMPLEX PLUS F
SUPER QUINTS B-50 F
ULTRA B-100 COMPLEX F
vitamin b complex F
VITAMIN B-100 COMPLEX F OTC
VITAMINS B COMPLEX ORAL CAPSULE F
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 14
Drug Tier Status Notes VITAMINS B COMPLEX ORAL TABLET F
B-Complex Vitamins And Combinations APETIGEN PLUS ORAL LIQUID F
DIALYVITE ORAL TABLET 1-100-300-50 MG-MG-MCG-MG
F
NEPHPLEX RX F
RABANO YODADO F
RENA-VITE RX F
Brewers Yeast BREWER'S YEAST ORAL TABLET 500 MG (7.5 GR)
F OTC
BREWER'S YEAST ORAL TABLET 680 MG F
yeast F OTC
Dietary Product - Dietary Supplements PROSTAMEN F OTC
SEA-OMEGA F
Geriatric Vitamins CENTRAL-VITE SELECT F OTC
multivitamin with minerals oral tablet F
Minerals And Electrolytes - Calcium Replacement CALCIUM 600 F
calcium carbonate oral suspension F OTC
calcium carbonate oral tablet 500 mg calcium (1,250 mg), 600 mg calcium (1,500 mg)
F
calcium carbonate oral tablet,chewable 260 mg calcium (650 mg)
F
calcium citrate oral tablet 200 mg (950 mg) F
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
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Drug Tier Status Notes OYSTER SHELL CALCIUM 500 F
Minerals And Electrolytes - Calcium Replacement Combinations BIOCAL F
PRO-CAL ORAL TABLET F
Minerals And Electrolytes - Calcium Replacement/Vitamin D Combinations CALCITRATE-VITAMIN D F
CALCIUM 500 + D (D3) F
CALCIUM 500 + D ORAL TABLET F
CALCIUM 500 WITH D F
CALCIUM 600 + D(3) ORAL TABLET F
calcium carbonate-vitamin d3 oral tablet 250-125 mg-unit, 500 mg(1,250mg) -125 unit, 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit
F
calcium carbonate-vitamin d3 oral tablet,chewable 500-100 mg-unit
F
CALCIUM CITRATE + D F
calcium citrate-vitamin d3 oral tablet 315 mg-5 mcg (200 unit), 315 mg-6.25 mcg (250 unit)
F
CALCIUM WITH VITAMIN D F
CALCIUM+D ORAL TABLET 500 MG(1,250MG) -200 UNIT
F OTC
CALTRATE WITH VITAMIN D3 F
CITRACAL + D MAXIMUM F
CITRUS CALCIUM-VITAMIN D3 ORAL TABLET 315 MG-6.25 MCG (250 UNIT)
F
OS-CAL 500 + D3 F
OYSCO D F OTC
OYSTER SHELL + D3 F
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 16
Drug Tier Status Notes OYSTER SHELL CALCIUM-VIT D2 F OTC
OYSTER SHELL CALCIUM-VIT D3 ORAL TABLET
F
OYSTERCAL-D F
Minerals And Electrolytes - Iron FEOSOL ORAL TABLET 325 MG (65 MG IRON)
F
FERATE ORAL TABLET 240 MG (27 MG IRON)
F
FERGON ORAL TABLET 240 MG (27 MG IRON)
F
FEROSUL ORAL ELIXIR F AL
FEROSUL ORAL TABLET F
FERRO-TIME F
ferrous gluconate oral tablet 236 mg (27 mg iron), 240 mg (27 mg iron), 324 mg (37.5 mg iron), 324 mg (38 mg iron)
F
ferrous sulfate oral drops F AL
ferrous sulfate oral liquid F AL
ferrous sulfate oral solution F AL
ferrous sulfate oral tablet 325 mg (65 mg iron) F
ferrous sulfate oral tablet,delayed release (dr/ec) F
FERROUSUL F
IRON (DRIED) F
IRON (FERROUS SULFATE) F
IRON 100 PLUS F AL
IRON HIGH POTENCY F
IRON ORAL TABLET 325 MG (65 MG IRON) F
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AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
17
Drug Tier Status Notes IRON ORAL TABLET EXTENDED RELEASE 159 MG (45 MG IRON)
F
SLOW RELEASE IRON ORAL TABLET EXTENDED RELEASE 142 MG (45 MG IRON), 159 MG (45 MG IRON), 160 MG (50 MG IRON), 250 MG (50 MG IRON)
F
SLOW RELEASE IRON ORAL TABLET EXTENDED RELEASE 47.5 MG IRON
F OTC
Minerals And Electrolytes - Iron Combinations COMPLETE ORAL TABLET 27-0.4 MG F OTC
PARVLEX F
SIDEROL ORAL TABLET F
STRESS FORMULA F
Minerals And Electrolytes - Magnesium LAXATIVE DIETARY SUPPLEMENT F
MAG GLYCINATE F
MAGBID ER F
MAG-G F
MAGINEX F
magnesium F
MAGNESIUM (OXIDE/AA CHELATE) F
magnesium amino acid chelate F
magnesium chloride oral tablet,delayed release (dr/ec) 70 mg
F
magnesium citrate oral tablet F
magnesium gluconate F
magnesium oxide oral capsule F
magnesium oxide oral tablet 250 mg magnesium, 400 mg magnesium, 420 mg, 500 mg
F
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 18
Drug Tier Status Notes magnesium oxide oral tablet 400 mg (241.3 mg magnesium)
F OTC
MAGONATE (MAGNESIUM CARB) F
MAGOX F
MAGTAB F
PHILLIPS F
SLOW-MAG F
URO-MAG F
Minerals And Electrolytes - Magnesium Combinations BEELITH F
Minerals And Electrolytes - Oral Electrolytes CERALYTE-70 ORAL SOLUTION F
CERASPORT ORAL LIQUID 115 MG-40 MG -40 KCAL/240 ML
F OTC
electrolytes-dextrose F
ENFAMIL ENFALYTE F
ORALYTE F
PEDIALYTE ADVANCED CARE F
PEDIALYTE ORAL SOLUTION F
PEDIALYTE SINGLES F
PEDIATRIC ELECTROLYTE ORAL SOLUTION
F
PEDIATRIC FREEZER POPS F
PEDIAVANCE F
Minerals And Electrolytes - Phosphate PHOS-NAK F
PHOSPHOROUS SUPPLEMENT F
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
19
Drug Tier Status Notes Multivitamin And Mineral Combinations A THRU Z F
A THRU Z MEN'S ULTIMATE F
A THRU Z SELECT 50PLUS FORMULA F
A THRU Z SELECT ORAL TABLET 300-600-300 MCG, 500-300-250 MCG
F
A THRU Z SELECT WOMEN'S F
ABC PLUS F
ACTICAL F
ADULT MULTIVITAMIN GUMMIES F
ADULT ONE DAILY GUMMIES F
AQUADEKS F
BACMIN F
BIO-35, GLUTEN FREE F
BIOCEL (WITH LUTEIN) F
BIOTIN PLUS-CALCIUM AND VIT D3 F
BODY, HAIR, SKIN AND NAILS F
CENTRAL VITE WITH LUTEIN F OTC
CENTRAL-VITE ENERGY F OTC
CENTRAL-VITE MEN'S UNDER 50 F OTC
CENTRAL-VITE PERFORMANCE ORAL TABLET
F OTC
CENTRAL-VITE SELECT F OTC
CENTRAL-VITE SENIOR F
CENTRAL-VITE WITH LYCOPENE F OTC
CENTRAL-VITE WOMEN'S MATURE F
CENTRAVITES F
CENTRUM CHEWABLES F
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 20
Drug Tier Status Notes CENTRUM MEN F
CENTRUM ORAL TABLET,CHEWABLE F OTC
CENTRUM SILVER ORAL TABLET F
CENTRUM SILVER ULTRA MEN'S F
CENTRUM SILVER WOMEN F
CENTRUM SPECIALIST HEART F
CENTRUM ULTRA MEN'S F
CENTURY ADULTS 50 PLUS F
CENTURY CARDIO F
CENTURY CARDIO HEALTH FORMULA F OTC
CENTURY ENERGY METABOLISM F OTC
CENTURY MATURE ORAL TABLET 0.4-300-250 MG-MCG-MCG, 400-30 MCG
F
CENTURY ORAL TABLET 18-0.4 MG F OTC
CENTURY ULTIMATE MEN'S F
CENTURY ULTIMATE WOMEN'S ORAL TABLET 8 MG IRON-400 MCG-300 MCG
F
CERTA PLUS F
CERTAVITE SENIOR-ANTIOXIDANT F
COMPETE F OTC
COMPLETE 50 PLUS F
COMPLETE MEN 50 PLUS F
COMPLETE MULTI F
COMPLETE MULTI 50+ F
COMPLETE MULTIVITAMIN ORAL TABLET F
COMPLETE MV ADULT 50 PLUS F
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
21
Drug Tier Status Notes COMPLETE ORAL TABLET 18-500-300-250 MG-MCG-MCG-MCG
F
COMPLETE PREMIUM VITAMIN F
COMPLETE SENIOR ORAL TABLET 0.4-300-250 MG-MCG-MCG
F
CORVITE FREE F
DAILY ENERGY F OTC
DAILY GUMMIES F
DAILY MULTIPLE FOR WOMEN 50+ F
DAILY MULTIPLE ORAL TABLET , 400-120 MCG-MG
F
DAILY MULTIPLE WEIGHT LOSS F OTC
DAILY MULTIVITAMIN F
DAILY VITAMIN FORMULA-MINERALS F
DAILY VITAMIN WITH IRON F
DAILY VITAMIN WITH IRON AND CA F
DAILY VITES/IRON F
DAILY-VITE F
DIABETES HEALTH FORMULA F
DIALYVITE 5000 F
ECEE PLUS F OTC
ESSENTIAL BALANCE WITH LUTEIN F
ESSENTIAL DAILY F
ESSENTIAL MAN F
ESSENTIAL MAN 50+ F
ESSENTIAL WOMAN 50+ F
EYE HEALTH PLUS LUTEIN F
FOSFREE F
FREEDAVITE F
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 22
Drug Tier Status Notes HAIR, SKIN AND NAILS-ARGAN OIL F
HAIR,SKIN AND NAILS F
HAIR,SKIN AND NAILS(FA-BIOTIN) ORAL TABLET 66.7-1,000 MCG
F
ICAPS MV F
ICAPS PLUS F OTC
K-PAX IMMUNE SUPPORT F
K-PAX ORAL CAPSULE F OTC
MAXIMUM DAILY MULTIVITAMIN F
MEGA MULTI FOR WOMEN F
MEGA MULTIVITAMIN FOR MEN F
MEGA MULTIVITAMIN WITH MINERAL ORAL TABLET 13.5-200-250 MG-MCG-MCG
F
MEN'S DAILY F
MEN'S DAILY MULTIVIT-MINERAL F
MEN'S MULTIVITAMIN GUMMIES F
MEN'S ONE DAILY F
MONOCAPS F
MULTI FOR HER ORAL TABLET F
MULTI-DELYN WITH IRON F
MULTILEX F
MULTILEX-T AND M F
MULTIPLE VITAMIN, WOMENS F
MULTIPLE VITAMIN-MINERALS F
MULTIVITAL F OTC
MULTIVITAL PERFORMANCE F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
23
Drug Tier Status Notes MULTIVITAL PLATINUM ORAL TABLET 500-300-250 MCG
F OTC
multivitamin with iron F
multivitamin with minerals oral tablet F
M-VIT F OTC; QL; AL
mv-min-folic acid-lutein F
MY-VITALIFE F
NUTRICAP F
O-CAL F.A. F QL; AL
OCUTABS F
OMNICAP F
ONE DAILY CALCIUM/IRON F
ONE DAILY COMPLETE F
ONE DAILY DIET SUPPORT F OTC
ONE DAILY DIETER'S SUPPORT F OTC
ONE DAILY ENERGY ORAL TABLET F
ONE DAILY ESSENTIAL ORAL TABLET 0.4 MG
F
ONE DAILY FOR MEN F
ONE DAILY FOR WOMEN F
ONE DAILY GUMMY VITES F
ONE DAILY HEALTHY WEIGHT F
ONE DAILY MAXIMUM F
ONE DAILY MAXIMUM (WITH CA) F OTC
ONE DAILY MENS 50 PLUS(GINKGO) F OTC
ONE DAILY MULTI-VIT W-MINERAL ORAL TABLET
F
ONE DAILY ORAL TABLET 0.4-600 MG-MCG F
ONE DAILY PLUS IRON ORAL TABLET F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 24
Drug Tier Status Notes ONE DAILY PLUS MINERALS F
ONE DAILY WITH IRON F
ONE DAILY WOMEN 50 PLUS F
ONE DAILY WOMENS 50 PLUS F
ONE DAILY WOMEN'S ORAL TABLET 27-0.4 MG
F
ONE-A-DAY MAXIMUM FORMULA F
ONE-A-DAY MEN VITACRAVES F
ONE-A-DAY MENOPAUSE FORMULA F
ONE-A-DAY MEN'S 50 PLUS F
ONE-A-DAY MEN'S MULTIVITAMIN F
ONE-A-DAY TEEN ADVANTAGE ORAL TABLET 9 MG IRON-400 MCG
F
ONE-A-DAY VITACRAVES F
ONE-A-DAY VITACRAVES IMMUNITY F
ONE-A-DAY VITACRAVES OMEGA-3 F
ONE-A-DAY WEIGHTSMART F
ONE-A-DAY WOMEN VITACRAVES F
ONE-A-DAY WOMEN'S 50 PLUS ORAL TABLET 400 MCG-500 MG CALCIUM-20 MCG
F OTC
ONE-A-DAY WOMEN'S ACTIVE F
ONE-A-DAY WOMEN'S HEALTHY SKIN F
OPTISOURCE F
OPURITY MULTIVITAMIN F
PROCERV HP F
PRORENAL QD F
PROTECT CARDIO AF F
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
25
Drug Tier Status Notes PROTECT PLUS SO F
QUINTABS-M F
QUINTABS-M IRON FREE F
SENTRY (WITH LUTEIN) F
SENTRY SENIOR F
SOFTGELS MULTIVIT-A,B,D,E,K,ZN F
SOLO F
SPECTRAVITE ADULT F
SPECTRAVITE ADULT 50 PLUS F
SPECTRAVITE ADVANCED FORMULA ORAL TABLET 0.4-300-250 MG-MCG-MCG
F OTC
SPECTRAVITE MEN'S F
SPECTRAVITE PERFORMANCE F OTC
SPECTRAVITE SENIOR ORAL TABLET 500-300-250 MCG
F
SPECTRAVITE ULTRA MEN 50+ F
SPECTRAVITE ULTRA MEN'S SR F
SPECTRAVITE ULTRA WOMEN'S SR F
STRESS FORMULA ADVANCED F OTC
SUNVITE F
SUPER GINSENG MULTIVITAMIN F
SUPER MULTIPLE - LOW IRON F
SUPER MULTIPLE ORAL CAPSULE F
SUPER THERA VITE M F
TAB-A-VITE/IRON F
TAB-A-VITE-MINERALS F
THERA M PLUS (FERROUS FUMARAT) F
THERAGRAN-M PREMIER 50 PLUS F
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 26
Drug Tier Status Notes THERALOGIX COMPANION F
THERA-M F
THERAPEUTIC M + BETA-CAROTENE F OTC
THERAPEUTIC-M ORAL TABLET 9 MG IRON-400 MCG
F
THERA-TABS M F
THERATRUM COMPLETE WITH LUTEIN F
THEREMS F
THEREMS-H F
THEREMS-M F
TRUEPLUS DIABETIC MULTIVITAMIN F
ULTIMATE MEN'S COMPLETE 50+ F
ULTIMATE WOMEN'S COMPLETE 50+ F
ULTRA FREEDA F
UNICOMPLEX-M F
V-C FORTE F
VIC-FORTE F
VITACEL (WITH LUTEIN) F
VITAL-D RX F
VITALEE F
VITAMINS A-D-E SELENIUM F
VITAMINS AND MINERALS F
VITATRUM F
VITRUM SENIOR ORAL TABLET 500-300-250 MCG
F
VOL-NATE F QL; AL
VOL-PLUS F QL; AL
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
27
Drug Tier Status Notes VOL-TAB RX F QL; AL
WHOLE SOURCE MULTI-VITAMINS F OTC
WOMEN'S ACTIVE F
WOMEN'S BIOMULTIPLE F OTC
WOMEN'S COMPLEX F
WOMEN'S DAILY CAPLET F
WOMEN'S DAILY FORMULA ORAL TABLET 27-0.4 MG
F
WOMEN'S DAILY MULTIVITAMIN F OTC
WOMEN'S MULTIVITAMIN GUMMIES F
Multivitamins A THRU Z ADVANCED FORMULA F
CENTRAL-VITE ORAL TABLET 18-400 MG-MCG
F
CENTRAL-VITE WOMEN'S UNDER 50 F OTC
CENTRUM COMPLETE F
CENTURY ORAL TABLET 18-400 MG-MCG F
CENTURY ULTIMATE WOMEN'S ORAL TABLET 18-400 MG-MCG
F
CEROVITE ADVANCED FORMULA F
CERTAVITE-ANTIOXIDANT F
CHEWABLE-VITE F
COMPLETE MULTIVITAMIN-MINERAL ORAL TABLET
F
DAILY MULTIPLE FOR MEN 50+ F
DAILY MULTIPLE FOR WOMEN F
DAILY MULTIPLE ORAL TABLET , 18-400 MG-MCG
F
DAILY MULTI-VITAMIN F
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 28
Drug Tier Status Notes DAILY MULTIVITAMIN WITH IRON F
DAILY VALUE F
DAILY VITAMIN FORMULA F
DAILY VITAMIN FORMULA-IRON F
DAILY-VITE F
DECUBI VITE F
ESSENTIA F
ESSENTIAL BALANCE WITH LUTEIN F
FORTAVIT F
L-METHYL-MC F
MEN'S MULTI-VITAMIN F
METAFOLBIC F
MULTI COMPLETE WITH IRON F
MULTI-DAY WITH IRON F
MULTIPLE VITAMINS F
multivitamin oral tablet F
MULTI-VITE (WITH FOLIC ACID) F OTC
ONCE DAILY F
ONCOVITE F
ONE DAILY ESSENTIAL ORAL TABLET , 400 MCG
F
ONE DAILY FOR MEN 50+ ADVANCED F
ONE DAILY MEN'S 50 PLUS MEMORY F
ONE DAILY MULTIVITAMIN ORAL TABLET F
ONE DAILY MULTIVIT-IRON(FOLIC) F
ONE DAILY ORAL TABLET F
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
29
Drug Tier Status Notes ONE DAILY PLUS IRON ORAL TABLET 18-400 MG-MCG
F
ONE DAILY WOMEN'S ORAL TABLET 18 MG IRON-400 MCG-450 MG CA
F
ONE-A-DAY ENERGY F
ONE-A-DAY ESSENTIAL F
ONE-A-DAY MAXIMUM FORMULA F
ONE-A-DAY MEN'S 50PLUS(GINKGO) F
ONE-A-DAY TEEN ADVANTAGE ORAL TABLET 18-400 MG-MCG
F
ONE-A-DAY WOMEN'S PETITES F
PRENATAL-U F QL; AL
QUINTABS F
SENTRY F
SPECTRAVITE ADVANCED FORMULA ORAL TABLET 18-400 MG-MCG
F
SPECTRAVITE ULTRA WOMEN F
TAB-A-VITE ORAL TABLET F
THERA F
THERA-TABS F
THEREMS F
vitamin e acetate-selenium F OTC
WOMEN'S ONE DAILY F
YELETS F
Pediatric Vitamins CHEWABLE MULTIVIT-A,B,D,E,K,ZN F
CHEWABLE-VITE F
POLY-VITAMIN F
TRI-VI-SOL F
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 30
Drug Tier Status Notes TRI-VITAMIN F QL
Pediatric Vitamins And Mineral Combinations AQUADEKS PEDIATRIC F
Pediatric Vitamins With Fluoride And Minerals Combinations MULTI-VIT WITH FLUORIDE-IRON F QL; AL
TRI-VIT WITH FLUORIDE AND IRON F QL; AL
Pediatric Vitamins With Fluoride Combinations MULTI-VIT WITH FLUORIDE-IRON F QL; AL
MULTI-VITAMIN WITH FLUORIDE ORAL DROPS
F QL; AL
MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG, 1 MG
F QL; AL
MULTIVITAMINS WITH FLUORIDE F QL; AL
MULTIVIT-FLUOR (VIT E ACETATE) F QL; AL
MVC-FLUORIDE F QL; AL
TRIPLE VITAMIN WITH FLUORIDE F OTC; QL; AL
TRI-VITAMIN WITH FLUORIDE F QL; AL
VITAMINS A,C,D AND FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML
F QL; AL
Prenatal Vitamins And Minerals CLASSIC PRENATAL F QL; AL
COMPLETENATE F QL; AL
HEMENATAL OB F QL; AL
M-VIT F OTC; QL; AL
MYNATAL PLUS F QL; AL
MYNATAL-Z F QL; AL
NESTABS F QL; AL
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
31
Drug Tier Status Notes NESTABS DHA F QL; AL
NEWGEN F QL; AL
PNV 29-1 F QL; AL
PREFERA-OB F QL; AL
PRENATABS FA F QL; AL
PRENATABS RX F QL; AL
PRENATAL 19 F QL; AL
PRENATAL COMPLETE F QL; AL
PRENATAL FORMULA ORAL TABLET 28 MG IRON- 800 MCG
F QL; AL
PRENATAL GUMMY F QL; AL
PRENATAL LOW IRON F QL; AL
PRENATAL MULTI-DHA(WITH VIT K) F QL; AL
PRENATAL MULTIVITAMINS F QL; AL
PRENATAL ORAL TABLET 28 MG IRON- 800 MCG
F QL; AL
PRENATAL PLUS F QL; AL
PRENATAL PLUS (CALCIUM CARB) F QL; AL
PRENATAL TABLET F QL; AL
PRENATAL VITAMIN ORAL TABLET , 27 MG IRON- 0.8 MG
F QL; AL
PRENATAL VITAMIN PLUS LOW IRON F QL; AL
PRENATAL VITAMIN WITH MINERALS F QL; AL
PRENATAL-U F QL; AL
PREPLUS F QL; AL
PRETAB F QL; AL
TARON-BC F QL; AL
THERANATAL ORAL TABLET F QL; AL
TRICARE F QL; AL
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 32
Drug Tier Status Notes TRINATAL RX 1 F QL; AL
TRINATE F QL; AL
TRI-TABS DHA F QL; AL
VINATE II F QL; AL
VINATE M F QL; AL
VINATE ONE F QL; AL
VIRT NATE F QL; AL
VOL-NATE F QL; AL
VOL-PLUS F QL; AL
VOL-TAB RX F QL; AL
VP-HEME OB F QL; AL
Vitamins - B Preparation Combinations B COMPLEX W-VIT C F
B-COMPLEX WITH B-12 F
FABB F
FOLBEE F
FOLBIC F
FOLBIC RF F
FOLINIC-PLUS F
FOLPLEX 2.2 F
FOLTABS 800 F
FOLTANX F
FOLTX F
HOMOCYSTEINE FORMULA F
L-METHYL-B6-B12 F
LMTHF-PYRIDOXINE-CYANOCOBALAMN F
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
33
Drug Tier Status Notes TL GARD RX F
VIRT-VITE F
VIRT-VITE FORTE F
VITA-RESPA F
Vitamins - B-1, Thiamine And Derivatives ARKALIOX F
Vitamins - B-3, Niacin And Derivatives ENDUR-ACIN ORAL TABLET EXTENDED RELEASE 250 MG
F
niacin (inositol niacinate) oral capsule 400 mg niacin (500 mg), 500 mg
F
niacin (inositol niacinate) oral tablet F
NIACIN FLUSH FREE F
NIACIN NO FLUSH F
niacin oral capsule, extended release 500 mg NP PA
niacin oral tablet 100 mg NP PA
niacin oral tablet 250 mg, 50 mg F
niacin oral tablet 500 mg NP PA; OTC
niacin oral tablet extended release 1,000 mg, 250 mg, 750 mg
F
niacin oral tablet extended release 500 mg NP PA
niacinamide F
SLO-NIACIN ORAL TABLET EXTENDED RELEASE 250 MG, 750 MG
F
Vitamins - Biotin biotin oral capsule 1 mg, 2,500 mcg, 5 mg F
biotin oral tablet F
CYTO B7 F
HARD NAILS F
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 34
Drug Tier Status Notes MEGA BIOTIN F
MERIBIN F
Vitamins - D Derivatives cholecalciferol (vitamin d3) oral capsule 1,250 mcg (50,000 unit), 10 mcg (400 unit), 125 mcg (5,000 unit), 25 mcg (1,000 unit), 50 mcg (2,000 unit)
F
cholecalciferol (vitamin d3) oral drops 10 mcg/ml (400 unit/ml)
F
cholecalciferol (vitamin d3) oral tablet 125 mcg (5,000 unit)
F
cholecalciferol (vitamin d3) oral tablet,chewable 10 mcg (400 unit)
F
DIALYVITE VITAMIN D3 MAX F
VITAL-D RX F
VITAMIN D3 ORAL CAPSULE 10 MCG (400 UNIT), 25 MCG (1,000 UNIT), 50 MCG (2,000 UNIT)
F
VITAMIN D3 ORAL TABLET 10 MCG (400 UNIT), 125 MCG (5,000 UNIT)
F
Vitamins - E AQUA-E F
AQUASOL E (D-ALPHA TOCOPHEROL) F AL
LIQUI-E F OTC
vitamin e (dl, acetate) oral capsule 200 unit, 400 unit, 450 mg (1,000 unit)
F
vitamin e (dl, acetate) oral drops 100 unit/0.25 ml F
vitamin e (dl, acetate) oral drops 22.5 mg (50 unit)/ml
F AL
vitamin e acetate F
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
35
Drug Tier Status Notes vitamin e mixed F
vitamin e oral F
vitamin e succinate F
wheat germ oil oral capsule F OTC
wheat germ oil oral oil F
Vitamins - Folic Acid And Derivatives folic acid oral tablet 1 mg F OTC
folic acid oral tablet 400 mcg F QL
folic acid oral tablet 800 mcg F
Vitamins - Folic Acid Combinations FABB F
FOLBEE F
FOLBIC F
FOLPLEX 2.2 F
TL GARD RX F
VIRT-VITE F
VIRT-VITE FORTE F
VITA-RESPA F
Endocrine
Agents To Treat Hypoglycemia (Hyperglycemics) DEX4 GLUCOSE ORAL TABLET,CHEWABLE F QL
DEX4 GLUCOSE POUCH PACK F QL
DEX4 GLUCOSE QUICK DISSOLVE F QL
glucose oral tablet,chewable 4 gram F QL
TRUEPLUS GLUCOSE ORAL TABLET,CHEWABLE
F QL
Gastrointestinal Therapy Agents
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 36
Drug Tier Status Notes Antacid - Aluminum aluminum hydroxide gel oral suspension 320 mg/5 ml
F OTC
Antacid - Antacid Combinations ACID GONE ANTACID F OTC
FOAMING ANTACID ORAL SUSPENSION F OTC
GAVISCON ORAL SUSPENSION F OTC
Antacid - Bicarbonate sodium bicarbonate oral F OTC
Antacid - Calcium ANTACID (CALCIUM CARBONATE) ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG)
F OTC
ANTACID CALCIUM ORAL TABLET,CHEWABLE 215 MG CALCIUM (500 MG)
F OTC
ANTACID EXT STR (CALCIUM CARB) F OTC
ANTACID EXTRA-STRENGTH ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG), 300 MG (750 MG)
F OTC
ANTACID ULTRA STRENGTH ORAL TABLET,CHEWABLE 400 MG CALCIUM (1,000 MG)
F OTC
CALCIUM ANTACID ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG), 300 MG (750 MG), 320 MG CALCIUM (750 MG), 400 MG CALCIUM (1,000 MG)
F OTC
CALCIUM ANTACID TROPICAL F OTC
CALCIUM ANTACID ULTRA MAX ST F OTC
calcium carbonate oral suspension F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
37
Drug Tier Status Notes calcium carbonate oral tablet,chewable 200 mg calcium (500 mg), 400 mg calcium (1,000 mg)
F OTC
CAL-GEST ANTACID F OTC
FLAVOR CHEWS ANTACID F OTC
SMOOTH ANTACID F OTC
TUMS F OTC
TUMS E-X F OTC
TUMS EXTRA STRENGTH SMOOTHIES F OTC
TUMS FRESHERS F OTC
TUMS ULTRA ORAL TABLET,CHEWABLE 400 MG CALCIUM (1,000 MG)
F OTC
ULTRA STRENGTH ANTACID F OTC
ULTRA STRENGTH CALCIUM ANTACID F OTC
Antacid - Magnesium magnesium oxide oral tablet 400 mg (241.3 mg magnesium)
F OTC
Antacid - Simethicone Combinations ADVANCED ANTACID-ANTIGAS F OTC
ALMACONE ORAL SUSPENSION F OTC
ALMACONE-2 F OTC
ANTACID F OTC
ANTACID ANTI-GAS F OTC
ANTACID ANTI-GAS DOUBLE STR F OTC
ANTACID EXTRA-STRENGTH ORAL SUSPENSION
F OTC
ANTACID LIQUID F OTC
ANTACID M F OTC
ANTACID MAXIMUM STRENGTH F OTC
ANTACID PLUS ANTI-GAS F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 38
Drug Tier Status Notes ANTACID REGULAR STRENGTH F OTC
ANTACID WITH SIMETHICONE F OTC
ANTACID-ANTIGAS F OTC
ANTACID-SIMETHICONE F OTC
COMFORT GEL F OTC
COMFORT GEL EXTRA STRENGTH F OTC
FLANAX ANTACID F OTC
GERI-LANTA ORAL SUSPENSION 200-200-20 MG/5 ML
F OTC
GERI-MOX ANTACID-ANTIGAS F OTC
LIQUID ANTACID ORAL SUSPENSION 200-200-20 MG/5 ML
F OTC
MAALOX ADVANCED ORAL SUSPENSION F OTC
MAALOX MAXIMUM STRENGTH F OTC
MAG-AL PLUS F OTC
MAG-AL PLUS EXTRA STRENGTH F OTC
MASANTI DOUBLE STRENGTH F OTC
MI-ACID F OTC
MINTOX F OTC
MINTOX MAXIMUM STRENGTH F OTC
RI-MOX F OTC
RULOX F OTC
Antidiarrheal - Antiperistaltic Agents ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/7.5 ML
P OTC
ANTI-DIARRHEAL (LOPERAMIDE) ORAL TABLET
P OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
39
Drug Tier Status Notes loperamide oral capsule P OTC
Antidiarrheal - Bismuth Agents ANTI-DIARRHEAL F OTC
BISMATROL F OTC
BISMUTH F OTC
BISMUTH MAXIMUM STRENGTH F OTC
DIARRHEA RELIEF (BISMUTH SUBS) F OTC
DIOTAME F OTC
KAOPECTATE (BISMUTH SUBSALICY) ORAL SUSPENSION
F OTC
KAOPECTATE EX STR (BISMUTH SS) F OTC
KAO-TIN (BISMUTH SUBSALICYLAT) F OTC
K-PEC ANTIDIARRHEAL (BISM SUB) F OTC
MEDI-BISMUTH F OTC
PEPTIC RELIEF F OTC
PEPTO-BISMOL F OTC
PEPTO-BISMOL MAX ST F OTC
PEPTO-BISMOL TO-GO F OTC
PINK BISMUTH F OTC
PINK BISMUTH MAXIMUM STRENGTH F OTC
SOOTHE (BISMUTH SUBSALICYLATE) F OTC
SOOTHE REGULAR STRENGTH F OTC
STOMACH RELIEF F OTC
STOMACH RELIEF MAX STRENGTH F OTC
STOMACH RELIEF ORIGINAL F OTC
Antiemetic - Antihistamines dimenhydrinate oral F OTC
meclizine oral tablet 12.5 mg, 25 mg F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 40
Drug Tier Status Notes meclizine oral tablet,chewable F OTC
Gastric Acid Secretion Reducers - Histamine H2-Receptor Antagonists cimetidine oral tablet 200 mg F OTC
famotidine oral tablet 10 mg, 20 mg F OTC
Gastric Acid Secretion Reducing Agents - Proton Pump Inhibitors (Ppis) ACID REDUCER (OMEPRAZOLE) NP PA; OTC
esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg
NP PA; OTC
HEARTBURN TREATMENT NP PA; OTC
HEARTBURN TREATMENT 24 HOUR NP PA; OTC
lansoprazole oral capsule,delayed release(dr/ec) 15 mg
NP PA; OTC
omeprazole magnesium oral capsule,delayed release(dr/ec)
NP PA; OTC
omeprazole oral tablet,delayed release (dr/ec) NP PA; OTC
PREVACID 24HR NP PA; OTC
Gastrointestinal Antiflatulents GAS RELIEF (SIMETHICONE) ORAL DROPS,SUSPENSION
F OTC
GAS RELIEF (SIMETHICONE) ORAL TABLET,CHEWABLE
F OTC
GAS RELIEF 80 (SIMETHICONE) F OTC
GAS RELIEF EXTRA STRENGTH ORAL TABLET,CHEWABLE
F OTC
GAS-X EXTRA STRENGTH ORAL TABLET,CHEWABLE
F OTC
GAS-X ORAL TABLET,CHEWABLE F OTC
INFANTS GAS RELIEF F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
41
Drug Tier Status Notes MI-ACID GAS RELIEF(SIMETHICON) F OTC
MYTAB GAS (SIMETHICONE) F OTC
MYTAB GAS MAXIMUM STRENGTH F OTC
simethicone oral drops,suspension F OTC
simethicone oral tablet,chewable F OTC
Laxative - Bulk Forming DAILY FIBER (PSYLLIUM-SUCROSE) ORAL POWDER 3.4 GRAM/7 GRAM
F OTC
FIBER (PSYLLIUM HUSK/SUGAR) F OTC
FIBER (WITH ASPARTAME) ORAL POWDER 3.4 GRAM/5.8 GRAM
F OTC
FIBER LAXATIVE (HUSK/SUGAR) F OTC
FIBER LAXATIVE (PS.SEED/SUGAR) F OTC
FIBER LAXATIVE (PSYLLIUM) S/F F OTC
FIBER ORAL POWDER F OTC
FIBER SMOOTH F OTC
FIBER SMOOTH (SUCROSE) F OTC
FIBER THERAPY (PSYLLIUM SEED) F OTC
GERI-MUCIL (ASPARTAME) F OTC
HYDROCIL F OTC
KONSYL (SUGAR) ORAL POWDER F OTC
METAMUCIL (SUGAR) F OTC
METAMUCIL (WITH SUGAR) ORAL POWDER 3.4 GRAM/12 GRAM, 3.4 GRAM/7 GRAM
F OTC
METAMUCIL MULTIHEALTH FIBER F OTC
METAMUCIL SUGAR FREE F OTC
METAMUCIL SUGAR-FREE (ASPART) ORAL POWDER 3.4 GRAM/5.8 GRAM
F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 42
Drug Tier Status Notes NATURAL DAILY FIBER F OTC
NATURAL FIBER LAXATIVE (SUGAR) F OTC
NATURAL FIBER LAXATIVE SMOOTH F OTC
NATURAL FIBER LAXATIVE THERAPY F OTC
NATURAL FIBER LAXATIVE(ASPART) ORAL POWDER
F OTC
NATURAL PSYLLIUM FIBER F OTC
NATURAL VEGETABLE F OTC
NATURAL VEGETABLE (PSYLLIUM) F OTC
NATURAL VEGETABLE POWDER F OTC
REGULOID (PSYLLIUM HUSK-SUCRO) ORAL POWDER 3.4 GRAM/12 GRAM, 3.4 GRAM/7 GRAM
F OTC
REGULOID, SUGAR FREE F OTC
WAL-MUCIL FIBER (ASPARTAME) F OTC
WAL-MUCIL FIBER (SUGAR) F OTC
WAL-MUCIL NATURAL FIBER LAX F OTC
Laxative - Lubricant ENEMA RECTAL ENEMA F OTC
FLEET MINERAL OIL F OTC
mineral oil rectal F OTC
READY-TO-USE ENEMA (MIN OIL) F OTC
Laxative - Saline And Osmotic CITRATE OF MAGNESIA F OTC
CITROMA F OTC
LAXATIVE PEG 3350 ORAL POWDER F OTC
magnesium citrate oral solution F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
43
Drug Tier Status Notes MILK OF MAGNESIA F OTC
PHILLIPS MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5 ML
F OTC
polyethylene glycol 3350 oral powder F OTC
Laxative - Saline/Osmotic Mixtures ENEMA DISPOSABLE F OTC
ENEMA RECTAL ENEMA 19-7 GRAM/118 ML F OTC
FLEET ENEMA F OTC
PEDIATRIC ENEMA F OTC
READY-TO-USE ENEMA F OTC
Laxative - Stimulant ALOPHEN (BISACODYL) F OTC
BISAC-EVAC F OTC
bisacodyl F OTC
BISA-LAX (BISACODYL) F OTC
BISCOLAX F OTC
CORRECTOL F OTC
DUCODYL (BISACODYL) F OTC
DULCOLAX (BISACODYL) ORAL F OTC
EX-LAX (SENNOSIDES) ORAL TABLET F OTC
EX-LAX MAXIMUM STRENGTH F OTC
FLEET LAXATIVE (BISACODYL) F OTC
GENTLE LAXATIVE (BISACODYL) ORAL F OTC
GERI-KOT F OTC
LAXATIVE (BISACODYL) ORAL F OTC
LAXATIVE (SENNOSIDES) ORAL TABLET F OTC
LAXATIVE FEMININE F OTC
LAXATIVE MAXIMUM STRENGTH F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 44
Drug Tier Status Notes LAXATIVE PILLS F OTC
LAXATIVE PILLS REGULAR F OTC
NATURAL LAXATIVE F OTC
NATURAL SENNA LAXATIVE F OTC
NATURAL VEG LAXATIVE(SENNOSID) F OTC
PERDIEM OVERNIGHT RELIEF F OTC
SENEXON F OTC
SENNA LAX F OTC
SENNA LAXATIVE F OTC
SENNA ORAL CAPSULE F OTC
SENNA ORAL SYRUP 8.8 MG/5 ML F OTC
SENNA ORAL TABLET F OTC
SENNA-EXTRA F OTC
SENNO F OTC
SENOKOT F OTC
SENOKOTXTRA F OTC
SEN-O-TAB F OTC
WOMAN'S LAXATIVE (BISACODYL) F OTC
WOMEN'S GENTLE LAXATIVE(BISAC) F OTC
WOMEN'S LAXATIVE (BISACODYL) F OTC
Laxative - Stimulant And Surfactant Combinations DOC-Q-LAX F OTC
DOK PLUS F OTC
LAXATIVE PLUS STOOL SOFTENER F OTC
MEDI-LAXX F OTC
P-COL RITE F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
45
Drug Tier Status Notes PERI-COLACE F OTC
SENEXON-S F OTC
SENNA LAXATIVE-STOOL SOFTENER F OTC
SENNA PLUS ORAL TABLET F OTC
SENNA WITH DOCUSATE SODIUM F OTC
SENNALAX-S F OTC
SENNA-S F OTC
SENNA-TIME S F OTC
sennosides-docusate sodium F OTC
SENOKOT-S F OTC
STIMULANT LAXATIVE PLUS F OTC
STOOL SOFTENER-LAXATIVE F OTC
STOOL SOFTENER-STIMULANT LAXAT ORAL TABLET
F OTC
Laxative - Surfactant COLACE CLEAR F OTC
COL-RITE ORAL CAPSULE 50 MG F OTC
DOCU F OTC
DOCUPRENE F OTC
docusate calcium F OTC
docusate sodium oral capsule F OTC
docusate sodium oral liquid F OTC
docusate sodium oral tablet F OTC
DOK ORAL TABLET F OTC
ENEMEEZ F OTC
ENEMEEZ PLUS F OTC
PROMOLAXIN F OTC
STOOL SOFTENER ORAL CAPSULE 50 MG F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 46
Drug Tier Status Notes STOOL SOFTENER ORAL TABLET F OTC
Genitourinary Therapy
Urinary Alkalinizer - Citrates potassium citrate-citric acid oral solution F
sodium citrate-citric acid F
Urinary Antispasmodic - Smooth Muscle Relaxants OXYTROL FOR WOMEN F OTC
Hematological Agents
Platelet Aggregation Inhibitors - Salicylates ASPIR-81 F OTC; QL
ASPIRIN CHILDRENS F OTC; QL
ASPIRIN LOW DOSE F OTC; QL
ASPIRIN LOW-STRENGTH F OTC; QL
aspirin oral tablet F OTC; QL; AL
aspirin oral tablet,chewable F OTC; QL
aspirin oral tablet,delayed release (dr/ec) 325 mg F OTC; QL; AL
aspirin oral tablet,delayed release (dr/ec) 81 mg F OTC; QL
ASPIR-LOW F OTC; QL
BAYER ASPIRIN F OTC; QL; AL
BAYER CHEWABLE ASPIRIN F OTC; QL
CHILD ASPIRIN F OTC; QL
CHILDREN'S ASPIRIN F OTC; QL
ECOTRIN LOW STRENGTH F OTC; QL
LITE COAT ASPIRIN F OTC; QL; AL
LO-DOSE ASPIRIN F OTC; QL
Medical Supplies And Durable Medical Equipment (Dme)
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
47
Drug Tier Status Notes Medical Supplies And Dme - Female Condoms FC2 FEMALE CONDOM F OTC; QL
Medical Supplies And Dme - Glucose Monitoring Test Supplies ACCU-CHEK AVIVA CONTROL SOLN F OTC
ACCU-CHEK FASTCLIX LANCET DRUM F OTC; QL
ACCU-CHEK GUIDE GLUCOSE METER F OTC; QL
ACCU-CHEK GUIDE L1-L2 CTRL SOL F OTC
ACCU-CHEK GUIDE ME GLUCOSE MTR F OTC; QL
ACCU-CHEK SMARTVIEW CONTRL SOL F OTC
ACCU-CHEK SOFT DEV LANCETS F OTC
ACCU-CHEK SOFTCLIX LANCETS F OTC; QL
SOFT TOUCH LANCETS F OTC; QL
Medical Supplies And Dme - Insulin Needles-Syringes And Admin Supplies BD INSULIN SYRINGE U-500 F QL
BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 31 GAUGE X 5/16
F OTC; QL
BD ULTRA-FINE MICRO PEN NEEDLE F OTC; QL
BD ULTRA-FINE MINI PEN NEEDLE F OTC; QL
BD ULTRA-FINE ORIG PEN NEEDLE F OTC; QL
BD ULTRA-FINE SHORT PEN NEEDLE F OTC; QL
BD VEO INSULIN SYR HALF UNIT F OTC; QL
BD VEO INSULIN SYRINGE UF F OTC; QL
Medical Supplies And Dme - Male Condoms AIMSCO LATEX CONDOM F OTC; QL
CONDOMS-PREM LUBRICATED F OTC; QL
FANTASY CONDOM F OTC; QL
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 48
Drug Tier Status Notes KIMONO CONDOMS(NON-LUBRICATED) F OTC; QL
KIMONO MAXX CONDOMS F OTC; QL
KIMONO MICROTHIN AQUA LUBE CON F OTC; QL
KIMONO MICROTHIN CONDOMS F OTC; QL
KIMONO MICROTHIN LARGE CONDOMS F OTC; QL
KIMONO TEXTURED CONDOMS F OTC; QL
TRUSTEX LATEX CONDOM F OTC; QL
TRUSTEX LUBRICATED CONDOMS F OTC; QL
TRUSTEX NON-LUB CONDOMS F OTC; QL
TRUSTEX-RIA LUB/SPERMICIDE F OTC; QL
TRUSTEX-RIA NON-LUB CONDOMS F OTC; QL
Medical Supplies And Dme - Peak Flow Meters AIRZONE PEAK FLOW METER F OTC; QL
ASSESS FULL RANGE PEAK METER F OTC; QL
ASTHMA CHECK METER F OTC; QL
ASTHMAMENTOR PEAK FLOW METER F OTC; QL
IN-CHECK NASAL WITH MASK F OTC; QL
IN-CHECK ORAL FLOW METER F OTC; QL
MICROLIFE PEAK FLOW METER F OTC; QL
PEAK AIR PEAK FLOW METER F OTC; QL
PERSONAL BEST FULL RANGE F OTC; QL
PIKO 1 F OTC; QL
POCKET PEAK FLOW METER F OTC; QL
Medical Supplies And Dme - Respiratory Therapy Supplies MOUTHPIECE F OTC; QL
ONE WAY VALVED MOUTHPIECE F OTC; QL
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
49
Drug Tier Status Notes PANDA MASK F OTC; QL
PEDIATRIC MEDIUM MASK F OTC; QL
PEDIATRIC PANDA MASK F OTC; QL
PEDIATRIC SMALL MASK F OTC; QL
SIDESTREAM PEDIATRIC FACE MASK F OTC; QL
SILICONE MASK - PEDIATRIC F OTC; QL
VORTEX ADULT MASK F OTC; QL
VORTEX FROG MASK-CHILD F OTC; QL
VORTEX LADYBUG MASK-TODDLER F OTC; QL
Medical Supply, Fdb Superset
Medical Supply, Fdb Superset ACCU-CHEK AVIVA CONTROL SOLN F OTC
ACCU-CHEK FASTCLIX LANCET DRUM F OTC; QL
ACCU-CHEK GUIDE GLUCOSE METER F OTC; QL
ACCU-CHEK GUIDE L1-L2 CTRL SOL F OTC
ACCU-CHEK GUIDE ME GLUCOSE MTR F OTC; QL
ACCU-CHEK SMARTVIEW CONTRL SOL F OTC
ACCU-CHEK SOFT DEV LANCETS F OTC
ACCU-CHEK SOFTCLIX LANCETS F OTC; QL
AIMSCO LATEX CONDOM F OTC; QL
AIRZONE PEAK FLOW METER F OTC; QL
ASSESS FULL RANGE PEAK METER F OTC; QL
ASTHMA CHECK METER F OTC; QL
ASTHMAMENTOR PEAK FLOW METER F OTC; QL
BD INSULIN SYRINGE U-500 F QL
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 50
Drug Tier Status Notes BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML 31 GAUGE X 5/16
F OTC; QL
BD ULTRA-FINE MICRO PEN NEEDLE F OTC; QL
BD ULTRA-FINE MINI PEN NEEDLE F OTC; QL
BD ULTRA-FINE ORIG PEN NEEDLE F OTC; QL
BD ULTRA-FINE SHORT PEN NEEDLE F OTC; QL
BD VEO INSULIN SYR HALF UNIT F OTC; QL
BD VEO INSULIN SYRINGE UF F OTC; QL
CONDOMS-PREM LUBRICATED F OTC; QL
FANTASY CONDOM F OTC; QL
FC2 FEMALE CONDOM F OTC; QL
IN-CHECK NASAL WITH MASK F OTC; QL
IN-CHECK ORAL FLOW METER F OTC; QL
KIMONO CONDOMS(NON-LUBRICATED) F OTC; QL
KIMONO MAXX CONDOMS F OTC; QL
KIMONO MICROTHIN AQUA LUBE CON F OTC; QL
KIMONO MICROTHIN CONDOMS F OTC; QL
KIMONO MICROTHIN LARGE CONDOMS F OTC; QL
KIMONO TEXTURED CONDOMS F OTC; QL
MICROLIFE PEAK FLOW METER F OTC; QL
MOUTHPIECE F OTC; QL
ONE WAY VALVED MOUTHPIECE F OTC; QL
PANDA MASK F OTC; QL
PEAK AIR PEAK FLOW METER F OTC; QL
PEDIATRIC MEDIUM MASK F OTC; QL
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
51
Drug Tier Status Notes PEDIATRIC PANDA MASK F OTC; QL
PEDIATRIC SMALL MASK F OTC; QL
PERSONAL BEST FULL RANGE F OTC; QL
PIKO 1 F OTC; QL
POCKET PEAK FLOW METER F OTC; QL
SIDESTREAM PEDIATRIC FACE MASK F OTC; QL
SILICONE MASK - PEDIATRIC F OTC; QL
SOFT TOUCH LANCETS F OTC; QL
TRUSTEX LATEX CONDOM F OTC; QL
TRUSTEX LUBRICATED CONDOMS F OTC; QL
TRUSTEX NON-LUB CONDOMS F OTC; QL
TRUSTEX-RIA LUB/SPERMICIDE F OTC; QL
TRUSTEX-RIA NON-LUB CONDOMS F OTC; QL
VORTEX ADULT MASK F OTC; QL
VORTEX FROG MASK-CHILD F OTC; QL
VORTEX LADYBUG MASK-TODDLER F OTC; QL
Mouth-Throat-Dental - Preparations
Dental Product - Fluoride Preparations fluoride (sodium) oral drops F QL; AL
fluoride (sodium) oral tablet,chewable F QL; AL
LUDENT FLUORIDE F QL; AL
Ophthalmic Agents
Artificial Tears And Lubricant Combinations ARTIFICIAL TEARS (PF) F OTC
ARTIFICIAL TEARS(DEXT70-HYPRO) F OTC
ARTIFICIAL TEARS(GLYCERIN-PEG) F OTC
ARTIFICIAL TEARS(PVALCH-POVID) F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 52
Drug Tier Status Notes BION TEARS (PF) F OTC
LUBRICANT (P-GLYCOL-GLYCERIN) F OTC
LUBRICANT EYE (PG-PEG 400) F OTC
LUBRICANT EYE(DEXTRAN70-HYPML) F OTC
NATURAL TEARS (PF) F OTC
REFRESH LACRI-LUBE F OTC
REFRESH P.M. F OTC
SYSTANE (PROPYLENE GLYCOL) F OTC
SYSTANE GEL OPHTHALMIC (EYE) DROPS,GEL
F OTC
SYSTANE ULTRA F OTC
TEARS NATURALE FREE (PF) F OTC
TEARS NATURALE II F OTC
TEARS PURE F OTC
Artificial Tears And Lubricant Single Agents ARTIFICIAL TEARS (POLYVIN ALC) F OTC
artificial tears(hypromellose) F OTC
LIQUITEARS F OTC
LUBRICANT EYE DROPS OPHTHALMIC (EYE) DROPS 0.5 %
F OTC
LUBRICATING PLUS F OTC
NATURAL BALANCE F OTC
NATURE'S TEARS (HYPROMELLOSE) F OTC
polyvinyl alcohol F OTC
REFRESH CELLUVISC F OTC
REFRESH LIQUIGEL F OTC
REFRESH TEARS F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
53
Drug Tier Status Notes Ophthalmic - Antihistamine-Decongestant Combinations ALLERGY EYE (NAPHAZOLINE-PHEN) F OTC
EYE ALLERGY RELIEF F OTC
NAPHCON-A F OTC
OPCON-A F OTC
VISINE-A F OTC
Ophthalmic - Antihistamines ALAWAY P OTC
CHILDREN'S ALAWAY P OTC
EYE ITCH RELIEF P OTC
ketotifen fumarate P OTC
PATADAY OPHTHALMIC (EYE) DROPS 0.1 % NP PA; OTC
ZADITOR P OTC
Ophthalmic - Hyperosmolar Agents ARTIFICIAL TEARS(DEXT70-HYPRO) OPHTHALMIC (EYE) DROPS
F OTC
sodium chloride ophthalmic (eye) F OTC
Respiratory Therapy Agents
Antihistamine - 1St Generation - Alkylamines ALLER-CHLOR ORAL TABLET F OTC
ALLERGY (CHLORPHENIRAMINE) F OTC
ALLERGY 4-HOUR F OTC
ALLERGY RELIEF(CHLORPHENIRAMN) ORAL TABLET
F OTC
ALLERGY-TIME F OTC
chlorpheniramine maleate oral tablet F OTC
chlorpheniramine maleate oral tablet extended release
F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 54
Drug Tier Status Notes CHLORTABS F OTC
CHLOR-TRIMETON F OTC
ED-CHLORTAN F OTC
PHARBECHLOR F OTC
WAL-FINATE F OTC
Antihistamine - 1St Generation - Ethanolamines clemastine oral tablet 1.34 mg F
diphenhydramine hcl oral capsule F OTC; AL
diphenhydramine hcl oral liquid F OTC
diphenhydramine hcl oral syrup F OTC
diphenhydramine hcl oral tablet 25 mg F OTC; AL
Antihistamines - 1St Generation ALLER-CHLOR ORAL TABLET F OTC
ALLERGY (CHLORPHENIRAMINE) F OTC
ALLERGY 4-HOUR F OTC
ALLERGY RELIEF(CHLORPHENIRAMN) ORAL TABLET
F OTC
ALLERGY-TIME F OTC
chlorpheniramine maleate oral tablet F OTC
chlorpheniramine maleate oral tablet extended release
F OTC
CHLORTABS F OTC
CHLOR-TRIMETON F OTC
clemastine oral tablet 1.34 mg F
diphenhydramine hcl oral capsule F OTC; AL
diphenhydramine hcl oral liquid F OTC
diphenhydramine hcl oral syrup F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
55
Drug Tier Status Notes diphenhydramine hcl oral tablet 25 mg F OTC; AL
ED-CHLORTAN F OTC
PHARBECHLOR F OTC
WAL-FINATE F OTC
Antihistamines - 2Nd Generation 24HR ALLERGY RELIEF P OTC
ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET
P OTC
ALLER-EASE ORAL TABLET NP PA; OTC
ALLERGY RELIEF (CETIRIZINE) ORAL CAPSULE
NP PA; OTC
ALLERGY RELIEF (CETIRIZINE) ORAL TABLET
P OTC
ALLERGY RELIEF (FEXOFENADINE) ORAL TABLET 180 MG
NP PA; OTC
ALLERGY RELIEF (LORATADINE) P OTC
cetirizine oral solution 5 mg/5 ml NP PA; OTC
cetirizine oral tablet P OTC
cetirizine oral tablet,chewable NP PA; OTC
CHILD ALLERGY RELF(CETIRIZINE) ORAL SOLUTION
P OTC
CHILDREN'S ALLERGY RELIEF(LOR) ORAL SOLUTION
P OTC
CHILDREN'S ALLERGY(CETIRIZINE) P OTC
CHILDREN'S CETIRIZINE ORAL SOLUTION P OTC
CHILDREN'S CETIRIZINE ORAL TABLET,CHEWABLE
NP PA; OTC
CHILDREN'S LORATADINE P OTC
CHILD'S ALL DAY ALLERGY(CETIR) P OTC
fexofenadine oral suspension NP PA; OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 56
Drug Tier Status Notes fexofenadine oral tablet 180 mg, 60 mg NP PA; OTC
loratadine oral capsule P OTC
loratadine oral solution P OTC
loratadine oral tablet P OTC
NON-DROWSY ALLERGY P OTC
Antihistamines - 2Nd Generation - Piperazines 24HR ALLERGY RELIEF P OTC
ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET
P OTC
ALLERGY RELIEF (CETIRIZINE) ORAL CAPSULE
NP PA; OTC
ALLERGY RELIEF (CETIRIZINE) ORAL TABLET
P OTC
cetirizine oral solution 5 mg/5 ml NP PA; OTC
cetirizine oral tablet P OTC
cetirizine oral tablet,chewable NP PA; OTC
CHILD ALLERGY RELF(CETIRIZINE) ORAL SOLUTION
P OTC
CHILDREN'S ALLERGY(CETIRIZINE) P OTC
CHILDREN'S CETIRIZINE ORAL SOLUTION P OTC
CHILDREN'S CETIRIZINE ORAL TABLET,CHEWABLE
NP PA; OTC
CHILD'S ALL DAY ALLERGY(CETIR) P OTC
Antihistamines - 2Nd Generation - Piperidines ALLER-EASE ORAL TABLET NP PA; OTC
ALLERGY RELIEF (FEXOFENADINE) ORAL TABLET 180 MG
NP PA; OTC
ALLERGY RELIEF (LORATADINE) P OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
57
Drug Tier Status Notes CHILDREN'S ALLERGY RELIEF(LOR) ORAL SOLUTION
P OTC
CHILDREN'S LORATADINE P OTC
fexofenadine oral suspension NP PA; OTC
fexofenadine oral tablet 180 mg, 60 mg NP PA; OTC
loratadine oral capsule P OTC
loratadine oral solution P OTC
loratadine oral tablet P OTC
NON-DROWSY ALLERGY P OTC
Nasal Corticosteroids 24 HOUR NASAL ALLERGY NP PA; OTC
ALLERGY RELIEF (FLUTICASONE) NP PA; OTC
budesonide nasal NP PA; OTC
CHILDREN'S FLONASE ALLERGY RLF NP PA; OTC
CHILDREN'S FLONASE SENSIMIST NP PA; OTC
FLONASE ALLERGY RELIEF NP PA; OTC
FLONASE SENSIMIST NP PA; OTC
fluticasone propionate nasal P OTC
NASAL ALLERGY NP PA; OTC
triamcinolone acetonide nasal NP PA; OTC
Nasal Mast Cell Stabilizers cromolyn nasal F OTC
NASALCROM F OTC
Nasal Moisturizers ALTAMIST F OTC
AYR SALINE NASAL AEROSOL,SPRAY F OTC
BABY AYR SALINE F OTC
DEEP SEA NASAL F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014. 58
Drug Tier Status Notes LITTLE REMEDIES F OTC
NASAL MOISTURIZING F OTC
NASAL SPRAY (SODIUM CHLORIDE) F OTC
OCEAN FOR KIDS F OTC
OCEAN NASAL F OTC
SALINE MIST F OTC
SALINE NASAL F OTC
SALINE NASAL MIST NASAL AEROSOL,SPRAY
F OTC
SALINE NOSE F OTC
SEA SOFT NASAL MIST F OTC
Vaginal Products
Vaginal Antifungal - Imidazoles 3-DAY VAGINAL F OTC
CLOTRIMAZOLE 3 DAY F OTC
clotrimazole vaginal cream F OTC
CLOTRIMAZOLE-3 F OTC
CLOTRIMAZOLE-7 F OTC
GYNE-LOTRIMIN F OTC
MICONAZOLE 7 F OTC
miconazole nitrate vaginal comb pack,prefill appl, cream
F OTC
miconazole nitrate vaginal cream F OTC
miconazole nitrate vaginal suppository F OTC
MICONAZOLE-3 PREFIL,CREAM,WIPE F OTC
MICONAZOLE-3 VAGINAL KIT F OTC
-
AL = Age Limit F = Formulary product NP = Formulary; PDL Non-Preferred; PA required P = Formulary; PDL Preferred P-PA = Formulary; PDL Preferred; PA required PA = Prior Authorization QL = Quantity Limit ST = Step Therapy State Carve Out = Carve-out medications must be billed to Medicaid Fee For Service. For billing assistance call the Magellan Clinical Call Center at 877-864-9014.
59
Drug Tier Status Notes MONISTAT 3 VAGINAL COMB PACK,PREFILL APPL, CREAM
F OTC
MONISTAT 3 VAGINAL KIT F OTC
MONISTAT 7 F OTC
VAGISTAT-3 F OTC
-
60
Index
2 24 HOUR NASAL ALLERGY
.......................................... 57 24HR ALLERGY RELIEF . 55,
56 3 3-DAY VAGINAL ............... 58 A A THRU Z ............................ 19 A THRU Z ADVANCED
FORMULA ...................... 27 A THRU Z MEN'S
ULTIMATE ..................... 19 A THRU Z SELECT ............ 19 A THRU Z SELECT 50PLUS
FORMULA ...................... 19 A THRU Z SELECT
WOMEN'S ....................... 19 ABC PLUS ........................... 19 ABREVA ............................... 9 ACCU-CHEK AVIVA
CONTROL SOLN...... 47, 49 ACCU-CHEK FASTCLIX
LANCET DRUM ....... 47, 49 ACCU-CHEK GUIDE
GLUCOSE METER ... 47, 49 ACCU-CHEK GUIDE L1-L2
CTRL SOL ................. 47, 49 ACCU-CHEK GUIDE ME
GLUCOSE MTR ........ 47, 49 ACCU-CHEK SMARTVIEW
CONTRL SOL ........... 47, 49 ACCU-CHEK SOFT DEV
LANCETS .................. 47, 49 ACCU-CHEK SOFTCLIX
LANCETS .................. 47, 49 ACEPHEN ............................. 1 acetaminophen ........................ 1 ACETAMINOPHEN EXTRA
STRENGTH ....................... 1 ACID GONE ANTACID ..... 36 ACID REDUCER
(OMEPRAZOLE) ............ 40 ACTICAL............................. 19 ADULT MULTIVITAMIN
GUMMIES ....................... 19 ADULT ONE DAILY
GUMMIES ....................... 19
ADVANCED ANTACID-ANTIGAS ........................ 37
AFTERA ................................ 7 AIMSCO LATEX CONDOM
.................................... 47, 49 AIRZONE PEAK FLOW
METER ...................... 48, 49 ALAWAY ............................ 53 ALBA-LYBE ....................... 10 ALGAL OMEGA-3 DHA ...... 6 ALL DAY ALLERGY
(CETIRIZINE) ........... 55, 56 ALL DAY PAIN RELIEF ...... 4 ALL DAY RELIEF ................ 4 ALLER-CHLOR ............ 53, 54 ALLER-EASE ................ 55, 56 ALLERGY
(CHLORPHENIRAMINE) .................................... 53, 54
ALLERGY 4-HOUR ...... 53, 54 ALLERGY EYE
(NAPHAZOLINE-PHEN) 53 ALLERGY RELIEF
(CETIRIZINE) ........... 55, 56 ALLERGY RELIEF
(FEXOFENADINE) ... 55, 56 ALLERGY RELIEF
(FLUTICASONE) ............ 57 ALLERGY RELIEF
(LORATADINE)........ 55, 56 ALLERGY
RELIEF(CHLORPHENIRAMN) ............................ 53, 54
ALLERGY-TIME .......... 53, 54 ALMACONE ....................... 37 ALMACONE-2 .................... 37 ALOPHEN (BISACODYL) . 43 ALTAMIST .......................... 57 aluminum hydroxide gel ....... 36 ammonium lactate .................. 9 ANTACID ............................ 37 ANTACID (CALCIUM
CARBONATE) ................ 36 ANTACID ANTI-GAS ........ 37 ANTACID ANTI-GAS
DOUBLE STR ................. 37 ANTACID CALCIUM......... 36
ANTACID EXT STR (CALCIUM CARB) ......... 36
ANTACID EXTRA-STRENGTH ............... 36, 37
ANTACID LIQUID ............. 37 ANTACID M ........................ 37 ANTACID MAXIMUM
STRENGTH ..................... 37 ANTACID PLUS ANTI-GAS
.......................................... 37 ANTACID REGULAR
STRENGTH ..................... 38 ANTACID ULTRA
STRENGTH ..................... 36 ANTACID WITH
SIMETHICONE ............... 38 ANTACID-ANTIGAS ......... 38 ANTACID-SIMETHICONE 38 ANTI-DIARRHEAL ............ 39 ANTI-DIARRHEAL
(LOPERAMIDE) .............. 38 ANTIFUNGAL
(CLOTRIMAZOLE) .......... 8 ANTIFUNGAL
(TOLNAFTATE) ............... 9 ANTIFUNGAL CREAM
(MICONAZOLE) ............... 9 ANTI-ITCH (HC) ................... 9 APETEX ............................... 10 APETIGEN ........................... 10 APETIGEN PLUS ................ 14 AQUADEKS ........................ 19 AQUADEKS PEDIATRIC .. 30 AQUA-E ............................... 34 AQUASOL E (D-ALPHA
TOCOPHEROL) .............. 34 ARKALIOX ......................... 33 ARTIFICIAL TEARS (PF) .. 51 ARTIFICIAL TEARS
(POLYVIN ALC) ............. 52 ARTIFICIAL
TEARS(DEXT70-HYPRO) .................................... 51, 53
ARTIFICIAL TEARS(GLYCERIN-PEG) .......................................... 51
artificial tears(hypromellose) 52
-
61
ARTIFICIAL TEARS(PVALCH-POVID) .......................................... 51
ASPERCREME (LIDOCAINE HCL)................................. 10
ASPERCREME (LIDOCAINE) ................. 10
ASPIR-81 ......................... 5, 46 aspirin ............................... 5, 46 ASPIRIN CHILDRENS ... 5, 46 ASPIRIN LOW DOSE ..... 5, 46 ASPIRIN LOW-STRENGTH
...................................... 5, 46 aspirin,buffd-calcium carb-mag
............................................ 5 ASPIR-LOW .................... 5, 46 ASSESS FULL RANGE
PEAK METER ........... 48, 49 ASTHMA CHECK METER
.................................... 48, 49 ASTHMAMENTOR PEAK
FLOW METER .......... 48, 49 ATHENOL ............................. 1 ATHLETE'S FOOT
(CLOTRIMAZOLE) .......... 9 AYR SALINE ...................... 57 B B COMPLETE ..................... 13 B COMPLEX ....................... 13 B COMPLEX 1 (WITH
FOLIC ACID) .................. 10 B COMPLEX 100 ................ 10 B COMPLEX PLUS
VITAMIN C ..................... 10 B COMPLEX W-VIT C ....... 32 B COMPLEX-VITAMIN B12
.......................................... 13 b complex-vitamin c-folic acid
.......................................... 10 B-100 COMPLEX .......... 11, 13 B-50 COMPLEX .................. 13 BABY AYR SALINE .......... 57 bacitracin ................................ 8 bacitracin zinc ........................ 8 BACMIN .............................. 19 BAL B-100 ........................... 13 BAL B-50 ............................. 13 BALANCE B-100 (FOLIC
ACID) ............................... 11 BALANCE B-50 (WITH
FOLIC ACID) .................. 11
BALANCED B COMPLEX-VIT C ................................ 11
BALANCED B-100 ....... 11, 13 BALANCED B-100
COMPLEX ................. 11, 13 BALANCED B-150 ............. 13 BALANCED B-50 ............... 13 BAYER ASPIRIN ............ 5, 46 BAYER CHEWABLE
ASPIRIN ...................... 5, 46 B-COMPLEX WITH B-12 .. 32 b-complex with vitamin c ..... 11 B-COMPLEX WITH
VITAMIN C ..................... 11 BD INSULIN SYRINGE U-
500 .............................. 47, 49 BD INSULIN SYRINGE
ULTRA-FINE ............ 47, 50 BD ULTRA-FINE MICRO
PEN NEEDLE ............ 47, 50 BD ULTRA-FINE MINI PEN
NEEDLE .................... 47, 50 BD ULTRA-FINE ORIG PEN
NEEDLE .................... 47, 50 BD ULTRA-FINE SHORT
PEN NEEDLE ............ 47, 50 BD VEO INSULIN SYR
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