Amerigroup Medication Formulary
Applies to Medicaid markets in Florida, Georgia, Louisiana, Maryland, Nevada and New Jersey
The medications included in the Amerigroup formulary are reviewed and approved by the Amerigroup Pharmacy and Therapeutics Committee,
which includes practitioners and pharmacists from the Amerigroup provider community. Medications not listed in the formulary are considered
to be non-formulary and are subject to prior authorization. Some medications listed may have additional requirements or limitations of coverage.
These requirements and limits may include prior authorization, quantity limits, age limits or step therapy. Additionally, if a medication is available
as a generic formulation, this will be Amerigroup's preferred agent, unless otherwise noted. If a brand name medication is requested when a
generic exists, a prior authorization request will need to be submitted. If you have any questions about coverage of a certain product, please
contact us at 800-454-3730. In order to request prior authorization, the provider or member must contact the Amerigroup pharmacy department
at 800-454-3730. Providers should be prepared to provide relevant clinical information that supports medical necessity of the requested medication.
Formulary Legend:
PA - Prior Authorization required
ST - Step Therapy required
QL - Quantity Limits apply
GL - Gender restrictions apply
AL - Age Limits apply
Version Date: February 1, 2013
RX - Prescription medication
OTC - Over The Counter medication
X - Medication provided by specialty pharmacy network
MD - Maryland carve-out (Amerigroup edits do NOT apply)
FL - medication is covered as brand in Florida
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
Brand Name Reference
Notes
acetaminophen
butalbital/apap/caffeine
tramadol
tramadol/apap
Tylenol
Fioricet
Ultram
Ultracet
OTC
QL
QL
QL
narcotic analgesics
butalbital/apap/caffeine/cod.
butalbital/asa/caffeine/codeine
butalbital/asa/caffeine
codeine sulfate
codeine/apap
fentanyl
fentanyl transdermal
hydrocodone/apap
hydrocodone/apap soln
hydrocodone/ibuprofen
hydromorphone
meperidine
methadone
morphine sulfate ER
morphine sulfate ER
morphine tabs, soln, supp
oxycodone
oxycodone ER
oxycodone/apap
Fioricet w/codeine
Fiorinal w/codeine
Fiorinal
codeine sulfate
Tylenol-2, T-3, T-4
Actiq
Duragesic
Lorcet, Lortab, Vicodin
Hycet solution
Vicoprofen
Dilaudid
Demerol
Dolophine
Avinza
MS Contin
morphine
Roxicodone
OxyContin
Tylox, Percocet, etc
QL
QL
QL
QL
QL
QL PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL PA
QL
NSAIDs
celecoxib
etodolac tabs, ER tabs
diclofenac delayed-release tabs
diclofenac extended release
flurbiprofen
ibuprofen
indomethacin
ketoprofen
meloxicam
nabumetone
naproxen
naproxen sodium
oxaprozin
piroxicam
salsalate
sulindac
tolmetin
Celebrex
Lodine/ER
diclofenac delayed-release
Voltaren XR
Ansaid
Motrin
Indocin
Actron
Mobic
Relafen
Naprosyn, EC-Naprosyn
Anaprox
Daypro
Feldene
Disalcid
Clinoril
Tolectin
QL ST
Analgesics
non-narcotic analgesics
Version Date: February 1, 2013
2
Amerigroup Medication Formulary
Therapeutic Class
Anticonvulsants
Generic Name
carbamazepine
carbamazepine ext-release
clonazepam
diazepam rectal gel
divalproex sodium
divalproex sodium delayed release
divalproex sodium ext-rel
ethosuximide
ethotoin
felbamate
gabapentin
lacosamide
lamotrigine
levetiracetam
methsuximide
oxcarbazepine
phenobarbital
phenytoin
phenytoin sodium ext-release
pregabalin
primidone
rufinamide
tiagabine
topiramate
valproic acid
zonisamide
Brand Name Reference
Tegretol
Carbatrol
Klonopin
Diastat
Depakote Sprinkle
Depakote
Depakote ER
Zarontin
Peganone
Felbatol
Neurontin
Vimpat
Lamictal
Keppra
Celontin
Trileptal
Luminal
Dilantin Infatabs
Dilantin
Lyrica
Mysoline
Banzel
Gabitril
Topamax
Depakene (all dosage forms)
Zonegran
Notes
QL MD FL
QL MD
QL MD
QL MD, Brand Preferred
QL MD
QL MD
QL
QL
QL
QL MD
QL MD
QL MD ST
QL MD
QL MD
QL
QL MD
QL
QL
QL FL
QL MD ST
QL
QL MD PA
QL MD
QL MD
QL MD
QL MD
clotrimazole troches
fluconazole
griseofulvin suspension
griseofulvin microsize
griseofulvin ultramicrosize
ketoconazole
nystatin
terbinafine
voriconazole
Mycelex
Diflucan
griseofulvin suspension
Grifulvin V
Gris-Peg
Nizoral
Mycostatin
Lamisil
Vfend
QL
QL
QL
QL
QL
QL
QL
QL
QL
antivirals-CMV
ganciclovir
valganciclovir
Cytovene
Valcyte
antivirals-hepatitis B
adefovir
entecavir
lamivudine
Hepsera
Baraclude
Epivir-HBV
Anti-infectives
antifungals
QL AL
QL AL
QL AL MD
Version Date: February 1, 2013
3
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
telbivudine
tenofovir
Brand Name Reference
Tyzeka
Viread
Notes
QL AL
QL AL MD
antivirals-hepatitis C
interferon alfa
boceprevir
peginterferon alfa
ribavirin tab, cap
ribavirin solution
telaprevir
Intron A
Victrelis
Pegasys
Copegus
Rebetol
Incivek
PA X
PA X
PA X
X
X
PA X
antivirals-herpes agents
acyclovir
famciclovir
valacyclovir
Zovirax
Famvir
Valtrex
QL
antivirals-HIV and related
abacavir
atazanavir
darunavir
delavirdine
didanosine suspension
didanosine delayed release
efavirenz
emtricitabine
enfuvirtide
etravirine
fosamprenavir
indinavir
lamivudine
maraviroc
megestrol
nelfinavir
nevirapine
nevirapine extended release
raltegravir
rilpivirine
ritonavir
saquinavir mesylate
stavudine
tenofovir
tipranavir
zidovudine
Ziagen
Reyataz
Prezista
Rescriptor
Videx suspension
Videx EC
Sustiva
Emtriva
Fuzeon
Intelence
Lexiva
Crixivan
Epivir
Selzentry
Megace
Viracept
Viramune
Viramune XR
Isentress
Edurant
Norvir
Invirase
Zerit
Viread
Aptivus
Retrovir
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD PA
QL MD ST
QL MD
QL MD
QL MD
QL MD
QL
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
antivirals-HIV combination
efavirenz/emtricitabine/tenofovir
lamivudine/zidovudine
rilpivirine/emtricitabine/tenofovir
abacavir/lamivudine
Atripla
Combivir
Complera
Epzicom
QL MD
QL MD
QL MD
QL MD
Version Date: February 1, 2013
4
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
lopinavir/ritonavir
elvitegravir/cobicistat/emtricitabine/tenofovir
abacavir/lamivudine/zidovudine
emtricitabine/tenofovir
Brand Name Reference
Kaletra
Stribild
Trizivir
Truvada
Notes
QL MD
PA MD
QL MD
QL MD
oseltamivir
rimantadine
zanamivir
Tamiflu
Flumadine
Relenza
QL
cephalosporins 1st generation
cefadroxil
cephalexin
Duricef
Keflex
QL
QL
cephalosporins 2nd generation
cefaclor
cefprozil
cefuroxime
Ceclor
Cefzil
Ceftin
QL
QL
QL
cephalosporins 3rd generation
cefdinir
cefditoren
cefixime
cefpodoxime
Omnicef
Spectracef
Suprax
Vantin
QL
QL
QL PA
QL
fluoroquinolones
ciprofloxacin
levofloxacin
moxifloxacin
ofloxacin
Cipro
Levaquin
Avelox
Floxin
QL AL <2 req PA
QL
QL AL <2 req PA
QL AL <2 req PA
macrolides
azithromycin
clarithromycin, clarithromycin ER
erythromycin base
erythromycin delayed-release
erythromycin ethylsuccinate
erythromycin stearate
erythromycin/sulfisoxazole
Zithromax
Biaxin, Biaxin XL
erythromycin
Eryc
EES
Erythrocin Stearate
Pediazole
QL
QL
QL
QL
QL
QL
QL
miscellaneous
atovaquone
chloroquine phosphate
clindamycin
dapsone
ethambutol
hydroxychloroquine
isoniazid
linezolid
mebendazole
mefloquine
metronidazole
Mepron
Aralen
Cleocin
dapsone
Myambutol
Plaquenil
isoniazid
Zyvox
Vermox
Larium
Flagyl
antivirals-influenza
QL
QL
QL
Version Date: February 1, 2013
5
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
neomycin
nitrofurantoin
pentamidine
pyrazinamide
pyrimethamine
rifampin
rifaximin
tinidazole
trimethoprim
vancomycin
Brand Name Reference
Mycifradin
Macrobid
Pentam 300
pyrazinamide
Daraprim
Rifadin
Xifaxan
Tindamax
Primsol
Vancocin
Notes
penicillins
amoxicillin
amoxicillin/clavulanate
amoxicillin/clavulanate ext-rel
ampicillin
dicloxacillin
penicillin VK
Amoxil
Augmentin tab, susp, ES-600
Augmentin XR
ampicillin
Dicloxacillin
penicillin VK
QL
QL
QL
QL
QL
QL
sulfonamides
sulfadiazine
sulfamethoxazole/trimethoprim
Sulfadiazine
Bactrim
QL
QL
tetracyclines
doxycycline hyclate (50mg tab, 100mg tab/cap)
minocycline
tetracycline
doxycycline hyclate
minocycline
tetracycline
QL
QL
QL
sumatriptan
naratriptan
Imitrex tabs, spray, injection
Amerge
QL
QL
ergotamine/caffeine tabs
dihydroergotamine
Cafergot tabs
Migranal
QL
Antimigraine Agents
5-HT agonists
miscellaneous agents
Antineoplastic Agents
(Only oral oncology agents that require precertification are listed)
abiraterone
Zytiga
axitinib
Inlyta
Targretin
bexarotene
Xeloda
capecitabine
Xalkori
crizotinib
Sprycel
dasatinib
Tarceva
erlotinib
Afinitor
everolimus
Oforta
fludarabine
Gleevec
imatinib
Tykerb
lapatinib
Revlimid
lenalidomide
QL
PA
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
Version Date: February 1, 2013
6
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
nilotinib
pazopanib
sorafenib
sunitinib
temozolomide
thalidomide
topotecan
vandetanib
vemurafenib
vismodegib
vorinostat
Brand Name Reference
Tasigna
Votrient
Nexavar
Sutent
Temodar
Thalomid
Hycamtin
Caprelsa
Zelboraf
Erivedge
Zolinza
benazepril
captopril
enalapril
fosinopril
lisinopril
moexipril
perindopril
quinapril
ramipril
trandolapril
Lotensin
Capoten
Vasotec
Monopril
Prinivil, Zestril
Univasc
Aceon
Accupril
Altace
Mavik
ACE inhibitor combinations
benazepril/amlodipine
benazepril/HCTZ
captopril/HCTZ
enalapril/HCTZ
fosinopril/HCTZ
lisinopril/HCTZ
moexipril/HCTZ
quinapril/HCTZ
Lotrel
Lotensin HCT
captopril/HCTZ
Vaseretic
Monopril/HCTZ
Zestoretic, Prinzide
Uniretic
quinipril/HCTZ
ARBs
losartan
Cozaar
QL ST
ARB combinations
losartan/HCTZ
Hyzaar
QL ST
alpha blockers
doxazosin
prazosin
terazosin
Cardura
Minipress
terazosin
antiarrhythmics
amiodarone
amiodarone
digoxin
disopyramide
Cordarone, Pacerone
Pacerone (100mg only)
Lanoxin
Norpace
Cardiovascular
ACE inhibitors
Notes
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
FL
Version Date: February 1, 2013
7
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
mexiletine
procainamide
propafenone
quinidine gluconate ER
quinidine sulfate
Brand Name Reference
Mexitil
Procanabid
Rythmol
quinidine gluconate ER
quinidine sulfate
antihypertensives-miscellaneous
clonidine tabs
guanfacine
hydralazine
methyldopa
midodrine
minoxidil
Catapres
Tenex
Apresoline
Aldomet
midodrine
Loniten
beta blockers
acebutolol
atenolol
betaxolol
bisoprolol
carvedilol
labetalol
metoprolol
metoprolol ER
nadolol
pindolol
propranolol
propranolol ER
sotalol
timolol
Sectral
Tenormin
Kerlone
Zebeta
Coreg
labetalol
Lopressor
Toprol XL
Corgard
Visken
Inderal
Inderal LA
Betapace, Betapace AF
Blocadren
beta blocker combinations
atenolol/ chlorthalidone
bisoprolol/HCTZ
metoprolol/HCTZ
nadolol/bendroflumethiazide
propranolol/HCTZ
Tenoretic
Ziac
Lopressor HCT
Corzide
Inderide
calcium channel blockers
amlodipine
diltiazem
diltiazem ER
felodipine ER
nicardipine
nicardipine ext-rel
nifedipine
nifedipine ER
verapamil
verapamil ER
Norvasc
Cardizem
Dilacor XR
Plendil
Cardene
Cardene SR
Procardia
Adalat CC, Procardia XL
Calan
Calan SR
Notes
Version Date: February 1, 2013
8
Amerigroup Medication Formulary
Therapeutic Class
calcium channel blocker combinations
Generic Name
amlodipine/benazepril
Brand Name Reference
Lotrel
Notes
diuretics
amiloride/ HCTZ
bumetanide
chlorthalidone
chlorothiazide susp
furosemide
hydrochlorothiazide
indapamide
metolazone
spironolactone
spironolactone/ HCTZ
torsemide
triamterene
triamterene/ HCTZ
Moduretic
Bumex
Hygroton
Diuril
Lasix
hydrochlorothiazide
Lozol
Zaroxolyn
Aldactone
Aldactazide
Demadex
Dyrenium
Maxzide, Dyazide
hereditary angioedema
complement C1 esterase inhibitor
ecallantide
icatibant
Berinert, Cinryze
Kalbitor
Firazyr
hypolipidemics - bile acid sequestrants
cholestyramine
Questran
hypolipidemics - fibrates
fenofibrate
gemfibrozil
Lofibra
Lopid
QL
QL
hypolipidemics - miscellaneous
ezetimibe/simvastatin
ezetimibe
niacin
omega-3 fatty acids
Vytorin
Zetia
Niacin CR, SLO-Niacin
omega-3 fatty acids
QL ST
QL PA
QL OTC
QL OTC
hypolipidemics - statins
atorvastatin
lovastatin
pravastatin
simvastatin
Lipitor
Mevacor
Pravachol
Zocor
QL
QL
QL
QL
nitrates
isosorbide dinitrate SL, ER
isosorbide mononitrate ER
nitroglycerin sublingual
nitroglycerin topical
nitroglycerin transdermal
Isordil
Imdur
Nitrostat
Nitro-Bid
Nitro-Dur
pulmonary arterial hypertension
ambrisentan
bosentan
epoprostenol
iloprost
Letairis
Tracleer
Flolan
Ventavis
PA X
PA X
QL PA X
QL PA X
PA X
PA
PA
Version Date: February 1, 2013
9
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
sildenafil
tadalafil
treprostinil injection
treprostinil
Brand Name Reference
Revatio
Adcirca
Remodulin
Tyvaso
Notes
QL PA X
PA
PA X
PA
donepezil
galantamine
memantine
memantine ext-rel
Aricept, Aricept ODT
Razadyne, Razadyne ER
Namenda
Namenda XR
QL
QL
multiple sclerosis
fingolimod hcl
glatiramer
interferon beta-1a
interferon beta-1a
interferon beta-1b
natalizumab
Gilenya
Copaxone
Avonex
Rebif
Extavia
Tysabri
QL PA X
QL PA X
QL X
QL X
OL PA X
QL PA X
myasthenia gravis
pyridostigmine ext-rel
pyridostigmine
Mestinon Timespan
Mestinon
Parkinson’s disease
amantadine (except tab)
benztropine
bromocriptine
carbidopa/levodopa
carbidopa/levodopa ext-rel
carbidopa/levodopa/entacapone
diphenhydramine
entacapone
pramipexole
ropinirole
selegiline
tolcapone
trihexyphenidyl
Symmetrel
Cogentin
Parlodel
Sinemet
Sinemet CR
Stalevo
Benadryl
Comtan
Mirapex
Requip
Eldepryl
Tasmar
Artane
chloral hydrate
ramelteon
temazepam
triazolam
zaleplon
zolpidem
chloral hydrate
Rozerem
Restoril
Halcion
Sonata
Ambien
QL MD
QL MD ST
QL MD
QL MD PA
QL MD
QL MD
dextromethorphan syrup
diphenhydramine caps, liq
guaifenesin syrup
Delsym
Benadryl
Duratuss
AL QL ST ≥ 21
QL
AL QL ST ≥ 21
Central Nervous System
Alzheimer’s agents
sedative/hypnotics
Cough and Cold Products
QL
MD
ST
MD
Version Date: February 1, 2013
10
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
guaifenesin w/ codeine syrup
promethazine w/ codeine syrup
promethazine w/ DM syrup
pseudoephedrine tabs, syrup
saline drops, spray
Brand Name Reference
Robutissin-AC
promethazine w/ codeine
promethazine w/ DM
Sudafed
saline
Notes
AL QL ST ≥ 21
AL QL ST ≥ 21
AL QL ST ≥ 21
AL QL ST ≥ 21
AL QL ST ≥ 21
Dental/Oral Preparations
chlorhexidine gluconate
lidocaine viscous
pilocarpine
saliva substitute
sodium fluoride crm 1.1%
triamcinolone paste
Peridex
lidocaine viscous
Salagen
Salivart
SF 5000 PLUS
triamcinolone paste
QL
QL
doxycycline hyclate (50mg tab, 100mg tab/cap)
isotretinoin
minocycline
tetracycline
doxycycline hyclate
Accutane
Minocin
Sumycin
adapalene 0.1%
benzoyl peroxide crm, gel, liquid, lotion
clindamycin solution, gel, lotion
clindamycin/benzoyl peroxide
erythromycin 2% gel, solution
erythromycin/benzoyl peroxide
salicylic acid 17%
sodium sulfacetamide/sulfur cleanser, lotion
tazarotene
tretinoin gel, crm
Differin
benzoyl peroxide
Cleocin T
Benzaclin
Emgel
Benzamycin
salicylic acid 17%
Plexion cleanser, lotion
Tazorac
Retin A
PA
antibacterials
chlorhexidine gluconate
mupirocin
silver sulfadiazine
Hibiclens
Bactroban
Silvadene
OTC
antifungals
butenafine
ciclopirox 0.77% cream, suspension
ciclopirox 8% nail solution
clotrimazole crm, soln
clotrimazole/betamethasone crm, lot
econazole
ketoconazole crm, shampoo
miconazole 2% crm
miconazole 2%
nystatin
nystatin/triamcinolone
terbinafine crm
Lotrimin Ultra
Loprox
Penlac
Lotrimin
Lotrisone
Spectazole
Nizoral
Micatin 2%
Fungoid tincture
Mycostatin
Mycogen II
Lamisil
OTC
Dermatology
acne-oral
acne-topical
ST
AL
QL
OTC
QL
OTC
OTC
OTC
Version Date: February 1, 2013
11
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
Tolnaftate crm, powder
Brand Name Reference
Tinactin
Notes
OTC
antivirals
acyclovir
imiquimod
podofilox
Zovirax cream, ointment
Aldara
Condylox
QL
QL ST
miscellaneous dermatology
ammonium lactate 12%
becaplermin
emollient ointment
fluorouracil crm
fluorouracil solution
lidocaine crm, oint, lotion
lidocaine/prilocaine crm
lidocaine patch
lidocaine/hydrocortisone
pimecrolimus
selenium sulfide shampoo 2.5%
urea crm/gel 40%
Lac-Hydrin
Regranex
hydrolatum
Efudex crm
fluorouracil solution
lidocaine
Emla
Lidoderm
lidocaine/hydrocortisone
Elidel
Selsun
urea, various
QL
PA
pediculocides
malathion
permethrin rinse 1%
permethrin 5%
pyrethrins/piperonyl butoxide 4%
Ovide
Nix, various
permethrin 5%
RID
QL ST
QL OTC
QL
OTC
psoriasis agents
adalimumab
calcipotriene
etanercept
methotrexate tablets, injection
tazarotene cream, gel
Humira
Dovonex
Enbrel
Trexall
Tazorac
PA X
metronidazole 0.75% crm, lotion
metronidazole 1%
MetroCream, MetroLotion
MetroGel
steroids - low potency
alclometasone crm, oint 0.05%
desonide crm, lotion, oint 0.05%
fluocinolone oil, soln 0.01%
hydrocortisone crm, oint 1%
hydrocortisone crm, lot, oint 2.5%
Aclovate
DesOwen
DermaSmooth
hydrocortisone
hydrocortisone crm, lot, oint 2.5%
steroids - medium potency
betamethasone valerate crm, lotion, oint 0.1%
desoximetasone crm, 0.05%
fluocinolone crm, oint 0.025%
fluticasone crm 0.05%, oint 0.005%
hydrocortisone val crm, oint 0.2%
Beta-Val
Topicort crm, 0.05%
fluocinolone crm, oint 0.025%
Cutivate
Westcort
rosacea
QL
QL
QL
QL
QL ST
QL
QL ST AL
QL
QL
PA X
ST
ST
QL
QL
QL
QL
QL
Version Date: February 1, 2013
12
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
mometasone crm, oint, lotion
triamcinolone acetonide crm 0.025%, lotion, oint 0.1%
Brand Name Reference
Elocon
Kenalog crm, lotion 0.025%, oint 0.1%
steroids - high potency
amcinonide crm, oint, lot 0.1%
betamethasone dip. crm, oint, lot 0.05%
desoximetasone crm, oint 0.25% gel 0.05%
diflorasone diacetate crm 0.05%
fluocinonide crm, gel, oint 0.05%
triamcinolone acet. crm, oint 0.5%
Cyclocort
Diprolene
Topicort
Psorcon
fluocinonide crm, gel, oint 0.05%
triamcinolone acet. crm, oint 0.5%
steroids - very high potency
aug betamethasone dip oint 0.05%
clobetasol prop. crm, oint 0.05%
diflorasone diacetate oint 0.05%
halobetasol prop. crm, oint 0.05%
Diprolene
Temovate, misc
Psorcon
Ultravate
QL
QL
QL
QL
dexamethasone
fludrocortisone
hydrocortisone
methylprednisolone
prednisolone sod. Phosphate
prednisolone syrup
prednisone
DexPak
Florinef
Cortef
Medrol
Pediapred
prednisolone syrup
Deltasone
QL
QL
QL
QL
QL
QL
QL
androgens
testosterone transdermal
testosterone gel
Androderm
AndroGel
QL PA GL
QL PA GL
diabetes-glucose elevating agents
glucagon
glucose tablets
Glucagon Emergency Kit
glucose
QL
OTC
diabetes-insulin*
* AL applies to INSULIN PENS only, which are covered through age 18
human insulin
Humulin, Novolin
insulin glargine
Lantus
insulin glulisine
Apidra
insulin mix
Humalog Mix, Novolog Mix
insulin regular
Humulin R 500u/ml
QL AL*
QL AL*
QL AL*
QL AL*
QL AL*
diabetes-meters/strips/supplies
blood glucose test strips
lancets/syringes/needles
urine ketone test strips
TrueTest
various
Ketostix
Brand Preferred
QL
QL
diabetes- misc injectable agents
exenatide
liraglutide
pramlintide
Byetta
Victoza
Symlin Pen
QL PA
QL PA
QL PA
Endocrine
adrenocortical steroids
Notes
QL
QL
Version Date: February 1, 2013
13
Amerigroup Medication Formulary
Therapeutic Class
diabetes-oral agents
Generic Name
acarbose
glimepiride
glipizide, glipizide ER
glipizide/metformin
glyburide
glyburide micronized
glyburide/metformin
metformin, metformin ext-rel
nateglinide
pioglitazone
repaglinide
saxagliptin
saxagliptin/metformin
sitagliptin
sitagliptin/metformin
sitagliptan/simvastatin
Brand Name Reference
Precose
Amaryl
Glucotrol, Glucotrol XL
Metaglip
DiaBeta
Glynase
Glucovance
Glucophage, Glucophage XR
Starlix
Actos
Prandin
Onglyza
Kombiglyze XR
Januvia
Janumet/Janumet XR
Juvisync
Notes
growth hormone
somatropin
Tev-Tropin
PA X, Brand Preferred
hypercalcemia
cinacalcet
Sensipar
PA X
hyperphosphatemia
sevelamer
calcium acetate
lanthanum carbonate
Renagel, Renvela
PhosLo
Fosrenol
QL ST
miscellaneous
cabergoline
desmopressin
leuprolide
leuprolide
triptorelin
Dostinex
DDAVP tabs, spray, inj.
Lupron
Lupron Depot, Lupron Depot-PED
Trelstar Depot
QL
QL
PA X
PA X
PA
obesity agents
orlistat
Alli
PA OTC
osteoporosis/Paget’s
alendronate
calcitonin-salmon spray
etidronate
raloxifene
teriparatide
Fosamax
Fortical, Miacalcin
Didronel
Evista
Forteo
QL
QL
QL
QL
PA X
thyroid disease
levothyroxine
liothyronine
methimazole
propylthiouracil
thyroid
Synthroid, Levoxyl
Cytomel
Tapazole
various generics
Armour thyroid
QL
QL
QL
QL
QL
QL
QL ST
QL
QL ST
QL ST
QL ST
QL ST
QL ST
PA
Version Date: February 1, 2013
14
Amerigroup Medication Formulary
Therapeutic Class
Gastrointestinal
antidiarrheals
Generic Name
Brand Name Reference
Notes
diphenoxylate/atropine
loperamide
Lomotil
Imodium A-D
OTC
aprepitant
granisetron (tabs only)
meclizine
metoclopramide
ondansetron (ODT, injection)
prochlorperazine
promethazine
Emend
Kytril
Antivert
Reglan
Zofran
Compazine
Phenergan
antispasmodics/anticholinergics
dicyclomine
glycopyrrolate
hyoscyamine tabs, elix
hyoscyamine ER caps
propantheline
Bentyl
Robinul,Robinul Forte
Levsin
hyoscyamine ER caps
Pro-Banthine
H2 antagonists
famotidine
famotidine
nizatidine
ranitidine
Pepcid
Pepcid suspension
Axid suspension only
Zantac
OTC/RX
AL< 6
AL < 6
OTC/RX
inflammatory bowel disease
budesonide del rel cap
hydrocortisone acetate rectal foam
hydrocortisone enema
mesalamine delayed release
mesalamine ext-release
mesalamine rectal susp.
mesalamine suppositories
sulfasalazine
sulfasalazine delayed release
Entocort EC
Cortifoam
Colocort
Asacol/Asacol HD
Pentasa
Rowasa
Canasa
Azulfidine
Azulfidine EN-tabs
QL
QL
lactulose
PEG 3350/electrolytes
polyethylene glycol
sodium phosphate
Colyte
MiraLAX, GlycoLax
Visicol
QL
miscellaneous GI agents
lubiprostone
misoprostol
sucralfate
ursodiol
Amitiza
Cytotec
Carafate
Urso, Atigall, Urso Forte
PA, QL
QL
QL
QL
obesity
orlistat
Alli
PA OTC
antiemetics
laxative/bowel prep
QL
OTC
QL
MD
QL
QL
QL
Version Date: February 1, 2013
15
Amerigroup Medication Formulary
Therapeutic Class
pancreatic enzymes
Generic Name
pancreatic enzymes
pancreatic enzymes
pancreatic enzymes
Brand Name Reference
Zenpep
Pancreaze
Creon
Notes
QL ST
QL
QL
lansoprazole 15mg
omeprazole
pantoprazole
Prevacid 24HR 15mg
Prilosec
Protonix
QL, OTC only
RX QL
QL
warfarin
enoxaparin
heparin
Coumadin
Lovenox
heparin
FL
QL
QL
blood cell formation
darbepoetin alfa
epoetin alfa
filgrastim
pegfilgrastim
sargramostim
Aranesp
Procrit, Epogen
Neupogen
Neulasta
Leukine
PA X
PA X
PA X
PA X
PA X
miscellaneous
aminocaproic acid syrup, tabs
cilostazol
pentoxifylline ER
Amicar
Pletal
Trental
platelet aggregation inhibitors
dipyridamole
dipyridamole ext-rel/aspirin
clopidogrel
aspirin
Persantine
Aggrenox
Plavix
aspirin
QL
QL
QL
QL OTC
agalsidase
alglucerase
alglucosidase
alglucosidase
galsulfase
idursulfase
imiglucerase
laronidase
miglustat
taliglucerase
velaglucerase
Fabrazyme
Ceredase
Lumizyme
Myozyme
Naglazyme
Elaprase
Cerezyme
Aldurazyme
Zavesca
Elelyso
VPRIV
PA X
PA X
PA
PA X
PA X
PA X
PA X
PA X
PA X
PA X QL AL
PA X
allopurinol
colchicine
probenecid
Zyloprim
Colcrys
Benemid
ST
proton pump inhibitors
Hematology
anticoagulants
Lysosomal Storage Disorder
Musculoskeletal
gout
Version Date: February 1, 2013
16
Amerigroup Medication Formulary
Therapeutic Class
muscle relaxants/spasticity
Generic Name
baclofen
chlorzoxazone
cyclobenzaprine
dantrolene
diazepam
methocarbamol
tizanidine (tablets only)
Brand Name Reference
Lioresal
Parafon Forte DSC
Flexeril
Dantrium
Valium
Robaxin
Zanaflex
RA - DMARDs
auranofin
azathioprine
hydroxychloroquine
leflunomide
methotrexate tabs, inj
penicillamine
sulfasalazine
Ridaura
Imuran
Plaquenil
Arava
methotrexate tabs, inj
Cuprimine
Azulfidine EN-tab
RA - immunomodulators
etanercept
adalimumab
Enbrel
Humira
clindamycin
clindamycin
clotrimazole 1% & 2% crm
fluconazole
metronidazole-vaginal
miconazole
miconazole
nystatin vaginal tablet
terconazole
tioconazole
Cleocin vaginal crm
Cleocin suppositories
3 & 7 day cream
Diflucan
MetroGel - vaginal
Monistat-1 combination
Monistat 3 & 7 crm, supp, combo
nystatin vaginal tablet
Terazol 3, Terazol 7
Vagistat-1
antivirals
acyclovir
imiquimod
podofilox
Zovirax crm, oint
Aldara
Condylox
contraceptives - monophasic
levonorgestrel/EE 0.1/20
norethindrone/EE 1/20 and iron
norethindrone/EE 1/20
desogestrel/EE 0.15/30
drospirenone/EE 3/30
levonorgestrel/EE 0.15/30
norethindrone/EE 1.5/30 and iron
norethindrone/EE 1.5/30
norgestrel/EE 0.3/30
ethynodiol/EE 1/35
Aviane, Lutera
Loestrin Fe 1/20
Loestrin 1/20
Ortho-Cept
Yasmin
Levora
Loestrin Fe 1.5/30
Loestrin 1.5/30
Low-Ogestrel
Zovia 1/35
Ob-Gyn
anti infectives - vaginal
Notes
QL
QL
MD
QL
QL
PA X
PA X
OTC
OTC
OTC
OTC
GL
GL
GL
GL
GL
GL
GL
GL
GL
GL
Version Date: February 1, 2013
17
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
norethindrone/EE 0.5/35
norethindrone/EE 1/35
norgestimate/EE 0.25/35
ethynodiol/EE 1/50
norethindrone/ME 1/50
Brand Name Reference
Modicon
Ortho-Novum 1/35
Ortho-Cyclen
Zovia 1/50
Necon 1/50
Notes
GL
GL
GL
GL
GL
contraceptives - biphasic
desogestrel/EE
norethindrone/EE
Mircette
Necon 10/11
GL
GL
contraceptives - triphasic
desogestrel/EE
levonorgestrel/EE
norethindrone/EE
norethindrone/EE
norgestimate/EE
norgestimate/EE
Velivet
Trivora
Ortho-Novum 7/7/7
Tri-Norinyl
Ortho Tri-Cyclen
Ortho Tri-Cyclen Lo
GL
GL
GL
GL
GL
GL
contraceptives - miscellaneous
norelgestromin/ethinyl estradiol patch
etonogestrel/EE vaginal ring
norethindrone
medroxyprogesterone inj
Ortho Evra
NuvaRing
Micronor
Depo-Provera Injection
GL
GL
GL
GL
hormone replacement therapy
conjugated estrogens/medroxyprogesterone
estradiol
estradiol-transdermal
estrogens, conjugated
estrogens, conjugated crm
estrogens, conjugated synthetic
estropipate
ethinyl estradiol/norethindrone
medroxyprogesterone
norethindrone
Premphase, Prempro
Estrace
Climara
Premarin
Premarin Vaginal Crm
Cenestin
Ogen
Femhrt
Provera
Aygestin
GL
GL
GL
GL
GL
GL
GL
GL
GL
GL
miscellaneous
levonorgestrel
levonorgestrel
methylergonovine
Next-Choice
Plan B One-Step
Methergine
QL OTC GL
QL OTC GL
GL
cromolyn sodium
ketotifen
lodoxamide
Opticrom
Alaway
Alomide
QL
QL, OTC only
QL
bacitracin
bacitracin/polymyxin B
ciprofloxacin solution
erythromycin
bacitracin
bacitracin/polymyxin B
Ciloxan solution
Ilotycin
QL OTC
QL
QL
QL
Ophthalmics
allergy
anti-infectives
Version Date: February 1, 2013
18
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
ganciclovir
gatifloxacin 0.5%
gentamicin
moxifloxacin
neomycin/polymyxin B/dexamethasone
neomycin/polymyxin B/gramicidin
neomycin/polymyxin/ hydrocortisone
ofloxacin
polymyxin B/trimethoprim
sulfacetamide 10%
sulfacetamide/prednisolone phosphate
tobramycin ointment
tobramycin/dexamethasone drops
trifluridine
Brand Name Reference
Zirgan
Zymaxid
Gentak
Moxeza
Maxitrol
Neosporin
neomycin/polymyxin/ hydrocortisone
Ocuflox
Polytrim
Bleph-10
sulfacetamide/prednisolone phosphate
Tobrex
TobraDex
Viroptic
dexamethasone sodium phosphate
diclofenac 0.1%
fluorometholone
flurbiprofen
ketorolac 0.5%
loteprednol 0.5%
prednisolone acetate 0.12%
prednisolone acetate 1%
prednisolone phosphate 1%
rimexolone
dexamethasone sodium phosphate
Voltaren
FML
Ocufen
Acular
Lotemax
Pred Mild
Pred Forte
prednisolone phosphate 1%
Vexol
glaucoma agents
brimonidine 0.15%, 0.2%
dorzolamide
dorzolamide/timolol
latanoprost
levobunolol
pilocarpine
timolol hemihydrate
timolol maleate solution
Alphagan
Trusopt
Cosopt
Xalatan
Betagan
Isopto Carpine
Betimol
Timoptic solution
QL
QL
QL
QL
QL
QL
QL
QL
miscellaneous ophthalmics
cyclosporine emulsion
Restasis
PA
acetic acid/aluminum acetate
benzocaine/antipyrine
carbamide peroxide 6.5%
ofloxacin
neomycin/polymyxin B/HC
Domeboro
Aurodex, misc gen
Debrox
ofloxacin
Cortisporin Otic
QL
anti-inflammatory/steroids
Otic Agents
Notes
QL
PA
QL
ST
QL
QL
QL
QL
OTC
QL
Psychotherapeutic Agents
ADD/ADHD
Version Date: February 1, 2013
19
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
Brand Name Reference
For Maryland Plan Only (formulary rules apply):
Kapvay : For recipients 6 – 17 years old, Kapvay is part of the mental health formulary and billed fee-for-service.
For individuals not in this age range, Kapvay continues to be part of the MCO pharmacy benefit.
Intuniv: For recipients 6 – 17 years old, Intuniv is part of the mental health formulary and billed fee-for-service.
For individuals not in this age range, Intuniv continues to be part of the MCO pharmacy benefit.
atomoxetine
Strattera
amphetamine/dextroamphetamine/mixed salts
Adderall
amphetamine/dextroamphetamine/mixed salts
Adderall XR
dexmethylphenidate
Focalin
dexmethylphenidate ext –rel cap
Focalin XR
dextroamphetamine
Dexedrine tab
dextroamphetamine ext-rel
Dexedrine Spansules
guanfacine
Intuniv
lisdexamfetamine
Vyvanse
methylphenidate tab
Ritalin, Ritalin SR
methylphenidate ext-rel
Concerta
methylphenidate ext-rel
Metadate CD
Notes
QL MD AL <19
QL MD AL
QL MD AL <19
QL MD AL
QL MD AL <19
QL MD AL
QL MD AL <19
QL ST MD AL = 6 -17 YRS
QL PA MD AL <19
QL MD AL
QL MD AL <19
QL MD AL <19
alcohol deterrents
disulfiram
acamprosate
naltrexone
Antabuse
Campral
ReVia
QL
PA
QL
antidepressants-miscellaneous
bupropion
bupropion sust & ext release
doxepin
isocarboxazid
maprotiline
mirtazapine
phenelzine
tranylcypromine
trazodone
Wellbutrin
Wellbutrin SR & XL
Silenor
Marplan
Ludiomil
Remeron
Nardil
Parnate
Desyrel
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
antidepressants - SSRI and SNRI
citalopram
fluoxetine
fluvoxamine
paroxetine
sertraline
venlafaxine
venlafaxine XR
Celexa
Prozac
Luvox
Paxil
Zoloft
Effexor
Effexor XR
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD ST
QL MD ST
antidepressants-tricyclic
amitriptyline
amitriptyline/perphenazine
amoxapine
chlordiazepoxide/amitriptyline
Elavil
Etrafon
Asendin
Limbitrol
QL MD
QL MD
QL MD
QL MD
Version Date: February 1, 2013
20
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
desipramine
imipramine
nortriptyline
protriptyline
trimipramine
Brand Name Reference
Norpramin
Tofranil
Pamelor
Vivactil
Surmontil
Notes
QL MD
QL MD
QL MD
QL MD
QL MD
antipsychotics - atypical
clozapine
olanzapine
paliperidone
quetiapine
risperidone
risperidone
ziprasidone
Clozaril
Zyprexa
Invega Sustenna
Seroquel tab, XR tab
Risperdal
Risperdal Consta
Geodon
QL AL MD
QL AL MD
QL AL MD
QL AL ST MD
QL AL MD
QL AL MD
QL AL MD
antipsychotics - typical
chlorpromazine tabs, inj
fluphenazine
fluphenazine decanoate inj
haloperidol tabs, inj
lithium carbonate
lithium carbonate ext-rel tabs
loxapine
perphenazine
pimozide
thioridazine
thiothixene
trifluoperazine
Thorazine
Prolixin
fluphenazine decanoate inj
Haldol
Eskalith
Lithobid
Loxitane
Trilafon
Orap
Mellaril
Navane
Stelazine
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
anxiolytics
alprazolam
buspirone
chlordiazepoxide
clorazepate
clonazepam
diazepam
hydroxyzine hcl
hydroxyzine pamoate
lorazepam
midazolam
oxazepam
sertraline
venlafaxine ER
Xanax
buspirone
Librium
Tranxene T-Tab
Klonopin
Valium
hydroxyzine HCl
Vistaril
Ativan
midazolam
Serax
Zoloft
Effexor XR
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD PA
QL MD
QL MD
QL MD ST
opioid antagonists
buprenorphine/naloxone
buprenorphine
Suboxone
Subutex
QL PA
QL
Version Date: February 1, 2013
21
Amerigroup Medication Formulary
Therapeutic Class
smoking cessation
Generic Name
bupropion SR
nicotine transdermal patches
nicotine polacrilex gum, lozenges
varenicline
Brand Name Reference
Zyban
Nicoderm CQ
Nicorette
Chantix
Notes
QL
QL OTC
QL OTC
QL PA
cetirizine
cyproheptadine
diphenhydramine
fexofenadine
hydroxyzine hcl
hydroxyzine pamoate
loratadine
Zyrtec tabs, syrup, chewable
Periactin
Benadryl
Allegra tablets
Atarax
Vistaril
Claritin tabs, syrup, RediTabs
QL OTC
QL
QL OTC
QL OTC
QL MD
QL MD
QL OTC
beta agonists, inhaled
albuterol, CFC-free
albuterol, CFC-free
budesonide/formoterol
formoterol capsules
mometasone/fomoterol
salmeterol
salmeterol/fluticasone
salmeterol/fluticasone, CFC-free
Ventolin HFA
ProAir HFA
Symbicort
Foradil
Dulera
Serevent Diskus
Advair
Advair HFA
QL
QL
QL ST
QL
QL ST
QL
QL ST
QL
beta agonists, oral
albuterol
metaproterenol syrup
terbutaline
albuterol tabs, syrup
Alupent
terbutaline
QL
QL
QL
cystic fibrosis
dornase alfa
tobramycin for inhalation
Pulmozyme
Tobi
X
X
inhaled, misc
ipratropium, CFC-free aerosol
ipratropium/albuterol
tiotropium
Atrovent HFA
Combivent, Combivent Respimat
Spiriva
QL
QL AL
QL
inhalation delivery devices
AeroChamber
E-Z Spacer
EasiVent
InspirEase
MicroChamber
AeroChamber
E-Z Spacer
EasiVent
InspirEase
MicroChamber
QL
QL
QL
QL
QL
inhaled steroids
beclomethasone
fluticasone, CFC-free aerosol
fluticasone
QVAR
Flovent HFA
Flovent Diskus
QL
QL
QL
Respiratory
antihistamines
Version Date: February 1, 2013
22
Amerigroup Medication Formulary
Therapeutic Class
leukotriene receptor antagonists
Generic Name
montelukast
montelukast
zafirlukast
Brand Name Reference
Singulair
Singulair Granules
Accolate
Notes
QL ST
QL AL< 2 or PA
QL
miscellaneous
omalizumab
Xolair
PA X
nasal inhalers
azelastine
flunisolide
fluticasone
ipratropium spray
Astelin
Nasalide
Flonase
Atrovent nasal spray
QL
QL
QL
QL
nebulizer solutions
albuterol
budesonide
cromolyn soln
ipratropium soln
ipratropium/albuterol
sodium chloride 0.9%
AccuNeb
Pulmicort Respules
Intal
ipratropium soln
Duoneb
sodium chloride 0.9%
QL
QL AL < 5
QL
QL
QL
QL
theophylline
theophylline ext-rel tab
theophylline elixir
theophylline ext rel capsule
Theochron
Elixophyllin
Theo-24
FL QL
QL
AL
alfuzosin
doxazosin
finasteride
tamsulosin
terazosin
Uroxatral
Cardura
Proscar
Flomax
Hytrin
GL
miscellaneous
bethanechol
flavoxate
oxybutynin, oxybutynin ext-release
Urecholine
Urispas
Ditropan, Ditropan XL
QL
QL
QL
Vitamins/Supplements
pentosan polysulfate sodium
phenazopyridine
calcitriol
cyanocobalamin inj
ergocalciferol
ferrous sulfate
fluoride drops, tabs
folic acid
folic acid/vitamin B complex w/C
iron/B-12/vit C/intrinsic factor
iron/B-12/vit C/intrinsic factor/FA
levocarnitine cap
Elmiron
Pyridium
Rocaltrol
B-12
Calciferol
generic tabs, drops, elix
Luride
folic acid
Nephrocaps
iron/B-12/vit C/intrinsic factor
iron/B-12/vit C/intrinsic factor/FA
L-Carnitine
QL
QL
Urologicals
BPH
OTC
QL
QL
QL
QL
QL
Version Date: February 1, 2013
23
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
multivit./ferrous fumarate/FA
multivit./ferrous fumarate/FA
multivitamins
multivitamins w/iron
paricalcitol
potassium bicarb/citrate efferv tabs
potassium chloride ext-rel tabs, liquid, powder
potassium/sodium acid phosphate
prenatal vitamins
prenatal vitamins + DHA
prenatal vitamins (kosher)
vitamin A D C/fluoride/ w/ or w/o iron
vitamin D
vitamin K
Brand Name Reference
Vitafol tab
Vitafol liquid
various
various
Zemplar
potassium bicarb/citrate efferv tabs
various
K-Phos Neutral
various
various
Nestabs
vitamin A D C/fluoride/ w/ or w/o iron
various
Mephyton
Notes
QL
QL
QL OTC
QL OTC
QL ST
QL
QL
QL
G QL
QL
QL
QL
QL
QL
Miscellaneous Agents
epinephrine inj
milnacipran
EpiPen, EpiPen Jr
Savella
QL
PA
Version Date: February 1, 2013
24
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
Brand Name Reference
Notes
acetaminophen
butalbital/apap/caffeine
tramadol
tramadol/apap
Tylenol
Fioricet
Ultram
Ultracet
OTC
QL
QL
QL
narcotic analgesics
butalbital/apap/caffeine/cod.
butalbital/asa/caffeine/codeine
butalbital/asa/caffeine
codeine sulfate
codeine/apap
fentanyl
fentanyl transdermal
hydrocodone/apap
hydrocodone/apap soln
hydrocodone/ibuprofen
hydromorphone
meperidine
methadone
morphine sulfate ER
morphine sulfate ER
morphine tabs, soln, supp
oxycodone
oxycodone ER
oxycodone/apap
Fioricet w/codeine
Fiorinal w/codeine
Fiorinal
codeine sulfate
Tylenol-2, T-3, T-4
Actiq
Duragesic
Lorcet, Lortab, Vicodin
Hycet solution
Vicoprofen
Dilaudid
Demerol
Dolophine
Avinza
MS Contin
morphine
Roxicodone
OxyContin
Tylox, Percocet, etc
QL
QL
QL
QL
QL
QL PA
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL PA
QL
NSAIDs
celecoxib
etodolac tabs, ER tabs
diclofenac delayed-release tabs
diclofenac extended release
flurbiprofen
ibuprofen
indomethacin
ketoprofen
meloxicam
nabumetone
naproxen
naproxen sodium
oxaprozin
piroxicam
salsalate
sulindac
tolmetin
Celebrex
Lodine/ER
diclofenac delayed-release
Voltaren XR
Ansaid
Motrin
Indocin
Actron
Mobic
Relafen
Naprosyn, EC-Naprosyn
Anaprox
Daypro
Feldene
Disalcid
Clinoril
Tolectin
QL ST
Analgesics
non-narcotic analgesics
Version Date: February 1, 2013
1
Amerigroup Medication Formulary
Therapeutic Class
Anticonvulsants
Generic Name
carbamazepine
carbamazepine ext-release
clonazepam
diazepam rectal gel
divalproex sodium
divalproex sodium delayed release
divalproex sodium ext-rel
ethosuximide
ethotoin
felbamate
gabapentin
lacosamide
lamotrigine
levetiracetam
methsuximide
oxcarbazepine
phenobarbital
phenytoin
phenytoin sodium ext-release
pregabalin
primidone
rufinamide
tiagabine
topiramate
valproic acid
zonisamide
Brand Name Reference
Tegretol
Carbatrol
Klonopin
Diastat
Depakote Sprinkle
Depakote
Depakote ER
Zarontin
Peganone
Felbatol
Neurontin
Vimpat
Lamictal
Keppra
Celontin
Trileptal
Luminal
Dilantin Infatabs
Dilantin
Lyrica
Mysoline
Banzel
Gabitril
Topamax
Depakene (all dosage forms)
Zonegran
Notes
QL MD FL
QL MD
QL MD
QL MD, Brand Preferred
QL MD
QL MD
QL
QL
QL
QL MD
QL MD
QL MD ST
QL MD
QL MD
QL
QL MD
QL
QL
QL FL
QL MD ST
QL
QL MD PA
QL MD
QL MD
QL MD
QL MD
clotrimazole troches
fluconazole
griseofulvin suspension
griseofulvin microsize
griseofulvin ultramicrosize
ketoconazole
nystatin
terbinafine
voriconazole
Mycelex
Diflucan
griseofulvin suspension
Grifulvin V
Gris-Peg
Nizoral
Mycostatin
Lamisil
Vfend
QL
QL
QL
QL
QL
QL
QL
QL
QL
antivirals-CMV
ganciclovir
valganciclovir
Cytovene
Valcyte
antivirals-hepatitis B
adefovir
entecavir
lamivudine
Hepsera
Baraclude
Epivir-HBV
Anti-infectives
antifungals
QL AL
QL AL
QL AL MD
Version Date: February 1, 2013
2
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
telbivudine
tenofovir
Brand Name Reference
Tyzeka
Viread
Notes
QL AL
QL AL MD
antivirals-hepatitis C
interferon alfa
boceprevir
peginterferon alfa
ribavirin tab, cap
ribavirin solution
telaprevir
Intron A
Victrelis
Pegasys
Copegus
Rebetol
Incivek
PA X
PA X
PA X
X
X
PA X
antivirals-herpes agents
acyclovir
famciclovir
valacyclovir
Zovirax
Famvir
Valtrex
QL
antivirals-HIV and related
abacavir
atazanavir
darunavir
delavirdine
didanosine suspension
didanosine delayed release
efavirenz
emtricitabine
enfuvirtide
etravirine
fosamprenavir
indinavir
lamivudine
maraviroc
megestrol
nelfinavir
nevirapine
nevirapine extended release
raltegravir
rilpivirine
ritonavir
saquinavir mesylate
stavudine
tenofovir
tipranavir
zidovudine
Ziagen
Reyataz
Prezista
Rescriptor
Videx suspension
Videx EC
Sustiva
Emtriva
Fuzeon
Intelence
Lexiva
Crixivan
Epivir
Selzentry
Megace
Viracept
Viramune
Viramune XR
Isentress
Edurant
Norvir
Invirase
Zerit
Viread
Aptivus
Retrovir
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD PA
QL MD ST
QL MD
QL MD
QL MD
QL MD
QL
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
antivirals-HIV combination
efavirenz/emtricitabine/tenofovir
lamivudine/zidovudine
rilpivirine/emtricitabine/tenofovir
abacavir/lamivudine
Atripla
Combivir
Complera
Epzicom
QL MD
QL MD
QL MD
QL MD
Version Date: February 1, 2013
3
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
lopinavir/ritonavir
elvitegravir/cobicistat/emtricitabine/tenofovir
abacavir/lamivudine/zidovudine
emtricitabine/tenofovir
Brand Name Reference
Kaletra
Stribild
Trizivir
Truvada
Notes
QL MD
PA MD
QL MD
QL MD
oseltamivir
rimantadine
zanamivir
Tamiflu
Flumadine
Relenza
QL
cephalosporins 1st generation
cefadroxil
cephalexin
Duricef
Keflex
QL
QL
cephalosporins 2nd generation
cefaclor
cefprozil
cefuroxime
Ceclor
Cefzil
Ceftin
QL
QL
QL
cephalosporins 3rd generation
cefdinir
cefditoren
cefixime
cefpodoxime
Omnicef
Spectracef
Suprax
Vantin
QL
QL
QL PA
QL
fluoroquinolones
ciprofloxacin
levofloxacin
moxifloxacin
ofloxacin
Cipro
Levaquin
Avelox
Floxin
QL AL <2 req PA
QL
QL AL <2 req PA
QL AL <2 req PA
macrolides
azithromycin
clarithromycin, clarithromycin ER
erythromycin base
erythromycin delayed-release
erythromycin ethylsuccinate
erythromycin stearate
erythromycin/sulfisoxazole
Zithromax
Biaxin, Biaxin XL
erythromycin
Eryc
EES
Erythrocin Stearate
Pediazole
QL
QL
QL
QL
QL
QL
QL
miscellaneous
atovaquone
chloroquine phosphate
clindamycin
dapsone
ethambutol
hydroxychloroquine
isoniazid
linezolid
mebendazole
mefloquine
metronidazole
Mepron
Aralen
Cleocin
dapsone
Myambutol
Plaquenil
isoniazid
Zyvox
Vermox
Larium
Flagyl
antivirals-influenza
QL
QL
QL
Version Date: February 1, 2013
4
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
neomycin
nitrofurantoin
pentamidine
pyrazinamide
pyrimethamine
rifampin
rifaximin
tinidazole
trimethoprim
vancomycin
Brand Name Reference
Mycifradin
Macrobid
Pentam 300
pyrazinamide
Daraprim
Rifadin
Xifaxan
Tindamax
Primsol
Vancocin
Notes
penicillins
amoxicillin
amoxicillin/clavulanate
amoxicillin/clavulanate ext-rel
ampicillin
dicloxacillin
penicillin VK
Amoxil
Augmentin tab, susp, ES-600
Augmentin XR
ampicillin
Dicloxacillin
penicillin VK
QL
QL
QL
QL
QL
QL
sulfonamides
sulfadiazine
sulfamethoxazole/trimethoprim
Sulfadiazine
Bactrim
QL
QL
tetracyclines
doxycycline hyclate (50mg tab, 100mg tab/cap)
minocycline
tetracycline
doxycycline hyclate
minocycline
tetracycline
QL
QL
QL
sumatriptan
naratriptan
Imitrex tabs, spray, injection
Amerge
QL
QL
ergotamine/caffeine tabs
dihydroergotamine
Cafergot tabs
Migranal
QL
Antimigraine Agents
5-HT agonists
miscellaneous agents
Antineoplastic Agents
(Only oral oncology agents that require precertification are listed)
abiraterone
Zytiga
axitinib
Inlyta
Targretin
bexarotene
Xeloda
capecitabine
Xalkori
crizotinib
Sprycel
dasatinib
Tarceva
erlotinib
Afinitor
everolimus
Oforta
fludarabine
Gleevec
imatinib
Tykerb
lapatinib
Revlimid
lenalidomide
QL
PA
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
Version Date: February 1, 2013
5
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
nilotinib
pazopanib
sorafenib
sunitinib
temozolomide
thalidomide
topotecan
vandetanib
vemurafenib
vismodegib
vorinostat
Brand Name Reference
Tasigna
Votrient
Nexavar
Sutent
Temodar
Thalomid
Hycamtin
Caprelsa
Zelboraf
Erivedge
Zolinza
benazepril
captopril
enalapril
fosinopril
lisinopril
moexipril
perindopril
quinapril
ramipril
trandolapril
Lotensin
Capoten
Vasotec
Monopril
Prinivil, Zestril
Univasc
Aceon
Accupril
Altace
Mavik
ACE inhibitor combinations
benazepril/amlodipine
benazepril/HCTZ
captopril/HCTZ
enalapril/HCTZ
fosinopril/HCTZ
lisinopril/HCTZ
moexipril/HCTZ
quinapril/HCTZ
Lotrel
Lotensin HCT
captopril/HCTZ
Vaseretic
Monopril/HCTZ
Zestoretic, Prinzide
Uniretic
quinipril/HCTZ
ARBs
losartan
Cozaar
QL ST
ARB combinations
losartan/HCTZ
Hyzaar
QL ST
alpha blockers
doxazosin
prazosin
terazosin
Cardura
Minipress
terazosin
antiarrhythmics
amiodarone
amiodarone
digoxin
disopyramide
Cordarone, Pacerone
Pacerone (100mg only)
Lanoxin
Norpace
Cardiovascular
ACE inhibitors
Notes
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
QL PA X
FL
Version Date: February 1, 2013
6
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
mexiletine
procainamide
propafenone
quinidine gluconate ER
quinidine sulfate
Brand Name Reference
Mexitil
Procanabid
Rythmol
quinidine gluconate ER
quinidine sulfate
antihypertensives-miscellaneous
clonidine tabs
guanfacine
hydralazine
methyldopa
midodrine
minoxidil
Catapres
Tenex
Apresoline
Aldomet
midodrine
Loniten
beta blockers
acebutolol
atenolol
betaxolol
bisoprolol
carvedilol
labetalol
metoprolol
metoprolol ER
nadolol
pindolol
propranolol
propranolol ER
sotalol
timolol
Sectral
Tenormin
Kerlone
Zebeta
Coreg
labetalol
Lopressor
Toprol XL
Corgard
Visken
Inderal
Inderal LA
Betapace, Betapace AF
Blocadren
beta blocker combinations
atenolol/ chlorthalidone
bisoprolol/HCTZ
metoprolol/HCTZ
nadolol/bendroflumethiazide
propranolol/HCTZ
Tenoretic
Ziac
Lopressor HCT
Corzide
Inderide
calcium channel blockers
amlodipine
diltiazem
diltiazem ER
felodipine ER
nicardipine
nicardipine ext-rel
nifedipine
nifedipine ER
verapamil
verapamil ER
Norvasc
Cardizem
Dilacor XR
Plendil
Cardene
Cardene SR
Procardia
Adalat CC, Procardia XL
Calan
Calan SR
Notes
Version Date: February 1, 2013
7
Amerigroup Medication Formulary
Therapeutic Class
calcium channel blocker combinations
Generic Name
amlodipine/benazepril
Brand Name Reference
Lotrel
Notes
diuretics
amiloride/ HCTZ
bumetanide
chlorthalidone
chlorothiazide susp
furosemide
hydrochlorothiazide
indapamide
metolazone
spironolactone
spironolactone/ HCTZ
torsemide
triamterene
triamterene/ HCTZ
Moduretic
Bumex
Hygroton
Diuril
Lasix
hydrochlorothiazide
Lozol
Zaroxolyn
Aldactone
Aldactazide
Demadex
Dyrenium
Maxzide, Dyazide
hereditary angioedema
complement C1 esterase inhibitor
ecallantide
icatibant
Berinert, Cinryze
Kalbitor
Firazyr
hypolipidemics - bile acid sequestrants
cholestyramine
Questran
hypolipidemics - fibrates
fenofibrate
gemfibrozil
Lofibra
Lopid
QL
QL
hypolipidemics - miscellaneous
ezetimibe/simvastatin
ezetimibe
niacin
omega-3 fatty acids
Vytorin
Zetia
Niacin CR, SLO-Niacin
omega-3 fatty acids
QL ST
QL PA
QL OTC
QL OTC
hypolipidemics - statins
atorvastatin
lovastatin
pravastatin
simvastatin
Lipitor
Mevacor
Pravachol
Zocor
QL
QL
QL
QL
nitrates
isosorbide dinitrate SL, ER
isosorbide mononitrate ER
nitroglycerin sublingual
nitroglycerin topical
nitroglycerin transdermal
Isordil
Imdur
Nitrostat
Nitro-Bid
Nitro-Dur
pulmonary arterial hypertension
ambrisentan
bosentan
epoprostenol
iloprost
Letairis
Tracleer
Flolan
Ventavis
PA X
PA X
QL PA X
QL PA X
PA X
PA
PA
Version Date: February 1, 2013
8
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
sildenafil
tadalafil
treprostinil injection
treprostinil
Brand Name Reference
Revatio
Adcirca
Remodulin
Tyvaso
Notes
QL PA X
PA
PA X
PA
donepezil
galantamine
memantine
memantine ext-rel
Aricept, Aricept ODT
Razadyne, Razadyne ER
Namenda
Namenda XR
QL
QL
multiple sclerosis
fingolimod hcl
glatiramer
interferon beta-1a
interferon beta-1a
interferon beta-1b
natalizumab
Gilenya
Copaxone
Avonex
Rebif
Extavia
Tysabri
QL PA X
QL PA X
QL X
QL X
OL PA X
QL PA X
myasthenia gravis
pyridostigmine ext-rel
pyridostigmine
Mestinon Timespan
Mestinon
Parkinson’s disease
amantadine (except tab)
benztropine
bromocriptine
carbidopa/levodopa
carbidopa/levodopa ext-rel
carbidopa/levodopa/entacapone
diphenhydramine
entacapone
pramipexole
ropinirole
selegiline
tolcapone
trihexyphenidyl
Symmetrel
Cogentin
Parlodel
Sinemet
Sinemet CR
Stalevo
Benadryl
Comtan
Mirapex
Requip
Eldepryl
Tasmar
Artane
chloral hydrate
ramelteon
temazepam
triazolam
zaleplon
zolpidem
chloral hydrate
Rozerem
Restoril
Halcion
Sonata
Ambien
QL MD
QL MD ST
QL MD
QL MD PA
QL MD
QL MD
dextromethorphan syrup
diphenhydramine caps, liq
guaifenesin syrup
Delsym
Benadryl
Duratuss
AL QL ST ≥ 21
QL
AL QL ST ≥ 21
Central Nervous System
Alzheimer’s agents
sedative/hypnotics
Cough and Cold Products
QL
MD
ST
MD
Version Date: February 1, 2013
9
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
guaifenesin w/ codeine syrup
promethazine w/ codeine syrup
promethazine w/ DM syrup
pseudoephedrine tabs, syrup
saline drops, spray
Brand Name Reference
Robutissin-AC
promethazine w/ codeine
promethazine w/ DM
Sudafed
saline
Notes
AL QL ST ≥ 21
AL QL ST ≥ 21
AL QL ST ≥ 21
AL QL ST ≥ 21
AL QL ST ≥ 21
Dental/Oral Preparations
chlorhexidine gluconate
lidocaine viscous
pilocarpine
saliva substitute
sodium fluoride crm 1.1%
triamcinolone paste
Peridex
lidocaine viscous
Salagen
Salivart
SF 5000 PLUS
triamcinolone paste
QL
QL
doxycycline hyclate (50mg tab, 100mg tab/cap)
isotretinoin
minocycline
tetracycline
doxycycline hyclate
Accutane
Minocin
Sumycin
adapalene 0.1%
benzoyl peroxide crm, gel, liquid, lotion
clindamycin solution, gel, lotion
clindamycin/benzoyl peroxide
erythromycin 2% gel, solution
erythromycin/benzoyl peroxide
salicylic acid 17%
sodium sulfacetamide/sulfur cleanser, lotion
tazarotene
tretinoin gel, crm
Differin
benzoyl peroxide
Cleocin T
Benzaclin
Emgel
Benzamycin
salicylic acid 17%
Plexion cleanser, lotion
Tazorac
Retin A
PA
antibacterials
chlorhexidine gluconate
mupirocin
silver sulfadiazine
Hibiclens
Bactroban
Silvadene
OTC
antifungals
butenafine
ciclopirox 0.77% cream, suspension
ciclopirox 8% nail solution
clotrimazole crm, soln
clotrimazole/betamethasone crm, lot
econazole
ketoconazole crm, shampoo
miconazole 2% crm
miconazole 2%
nystatin
nystatin/triamcinolone
terbinafine crm
Lotrimin Ultra
Loprox
Penlac
Lotrimin
Lotrisone
Spectazole
Nizoral
Micatin 2%
Fungoid tincture
Mycostatin
Mycogen II
Lamisil
OTC
Dermatology
acne-oral
acne-topical
ST
AL
QL
OTC
QL
OTC
OTC
OTC
Version Date: February 1, 2013
10
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
Tolnaftate crm, powder
Brand Name Reference
Tinactin
Notes
OTC
antivirals
acyclovir
imiquimod
podofilox
Zovirax cream, ointment
Aldara
Condylox
QL
QL ST
miscellaneous dermatology
ammonium lactate 12%
becaplermin
emollient ointment
fluorouracil crm
fluorouracil solution
lidocaine crm, oint, lotion
lidocaine/prilocaine crm
lidocaine patch
lidocaine/hydrocortisone
pimecrolimus
selenium sulfide shampoo 2.5%
urea crm/gel 40%
Lac-Hydrin
Regranex
hydrolatum
Efudex crm
fluorouracil solution
lidocaine
Emla
Lidoderm
lidocaine/hydrocortisone
Elidel
Selsun
urea, various
QL
PA
pediculocides
malathion
permethrin rinse 1%
permethrin 5%
pyrethrins/piperonyl butoxide 4%
Ovide
Nix, various
permethrin 5%
RID
QL ST
QL OTC
QL
OTC
psoriasis agents
adalimumab
calcipotriene
etanercept
methotrexate tablets, injection
tazarotene cream, gel
Humira
Dovonex
Enbrel
Trexall
Tazorac
PA X
metronidazole 0.75% crm, lotion
metronidazole 1%
MetroCream, MetroLotion
MetroGel
steroids - low potency
alclometasone crm, oint 0.05%
desonide crm, lotion, oint 0.05%
fluocinolone oil, soln 0.01%
hydrocortisone crm, oint 1%
hydrocortisone crm, lot, oint 2.5%
Aclovate
DesOwen
DermaSmooth
hydrocortisone
hydrocortisone crm, lot, oint 2.5%
steroids - medium potency
betamethasone valerate crm, lotion, oint 0.1%
desoximetasone crm, 0.05%
fluocinolone crm, oint 0.025%
fluticasone crm 0.05%, oint 0.005%
hydrocortisone val crm, oint 0.2%
Beta-Val
Topicort crm, 0.05%
fluocinolone crm, oint 0.025%
Cutivate
Westcort
rosacea
QL
QL
QL
QL
QL ST
QL
QL ST AL
QL
QL
PA X
ST
ST
QL
QL
QL
QL
QL
Version Date: February 1, 2013
11
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
mometasone crm, oint, lotion
triamcinolone acetonide crm 0.025%, lotion, oint 0.1%
Brand Name Reference
Elocon
Kenalog crm, lotion 0.025%, oint 0.1%
steroids - high potency
amcinonide crm, oint, lot 0.1%
betamethasone dip. crm, oint, lot 0.05%
desoximetasone crm, oint 0.25% gel 0.05%
diflorasone diacetate crm 0.05%
fluocinonide crm, gel, oint 0.05%
triamcinolone acet. crm, oint 0.5%
Cyclocort
Diprolene
Topicort
Psorcon
fluocinonide crm, gel, oint 0.05%
triamcinolone acet. crm, oint 0.5%
steroids - very high potency
aug betamethasone dip oint 0.05%
clobetasol prop. crm, oint 0.05%
diflorasone diacetate oint 0.05%
halobetasol prop. crm, oint 0.05%
Diprolene
Temovate, misc
Psorcon
Ultravate
QL
QL
QL
QL
dexamethasone
fludrocortisone
hydrocortisone
methylprednisolone
prednisolone sod. Phosphate
prednisolone syrup
prednisone
DexPak
Florinef
Cortef
Medrol
Pediapred
prednisolone syrup
Deltasone
QL
QL
QL
QL
QL
QL
QL
androgens
testosterone transdermal
testosterone gel
Androderm
AndroGel
QL PA GL
QL PA GL
diabetes-glucose elevating agents
glucagon
glucose tablets
Glucagon Emergency Kit
glucose
QL
OTC
diabetes-insulin*
* AL applies to INSULIN PENS only, which are covered through age 18
human insulin
Humulin, Novolin
insulin glargine
Lantus
insulin glulisine
Apidra
insulin mix
Humalog Mix, Novolog Mix
insulin regular
Humulin R 500u/ml
QL AL*
QL AL*
QL AL*
QL AL*
QL AL*
diabetes-meters/strips/supplies
blood glucose test strips
lancets/syringes/needles
urine ketone test strips
TrueTest
various
Ketostix
Brand Preferred
QL
QL
diabetes- misc injectable agents
exenatide
liraglutide
pramlintide
Byetta
Victoza
Symlin Pen
QL PA
QL PA
QL PA
Endocrine
adrenocortical steroids
Notes
QL
QL
Version Date: February 1, 2013
12
Amerigroup Medication Formulary
Therapeutic Class
diabetes-oral agents
Generic Name
acarbose
glimepiride
glipizide, glipizide ER
glipizide/metformin
glyburide
glyburide micronized
glyburide/metformin
metformin, metformin ext-rel
nateglinide
pioglitazone
repaglinide
saxagliptin
saxagliptin/metformin
sitagliptin
sitagliptin/metformin
sitagliptan/simvastatin
Brand Name Reference
Precose
Amaryl
Glucotrol, Glucotrol XL
Metaglip
DiaBeta
Glynase
Glucovance
Glucophage, Glucophage XR
Starlix
Actos
Prandin
Onglyza
Kombiglyze XR
Januvia
Janumet/Janumet XR
Juvisync
Notes
growth hormone
somatropin
Tev-Tropin
PA X, Brand Preferred
hypercalcemia
cinacalcet
Sensipar
PA X
hyperphosphatemia
sevelamer
calcium acetate
lanthanum carbonate
Renagel, Renvela
PhosLo
Fosrenol
QL ST
miscellaneous
cabergoline
desmopressin
leuprolide
leuprolide
triptorelin
Dostinex
DDAVP tabs, spray, inj.
Lupron
Lupron Depot, Lupron Depot-PED
Trelstar Depot
QL
QL
PA X
PA X
PA
obesity agents
orlistat
Alli
PA OTC
osteoporosis/Paget’s
alendronate
calcitonin-salmon spray
etidronate
raloxifene
teriparatide
Fosamax
Fortical, Miacalcin
Didronel
Evista
Forteo
QL
QL
QL
QL
PA X
thyroid disease
levothyroxine
liothyronine
methimazole
propylthiouracil
thyroid
Synthroid, Levoxyl
Cytomel
Tapazole
various generics
Armour thyroid
QL
QL
QL
QL
QL
QL
QL ST
QL
QL ST
QL ST
QL ST
QL ST
QL ST
PA
Version Date: February 1, 2013
13
Amerigroup Medication Formulary
Therapeutic Class
Gastrointestinal
antidiarrheals
Generic Name
Brand Name Reference
Notes
diphenoxylate/atropine
loperamide
Lomotil
Imodium A-D
OTC
aprepitant
granisetron (tabs only)
meclizine
metoclopramide
ondansetron (ODT, injection)
prochlorperazine
promethazine
Emend
Kytril
Antivert
Reglan
Zofran
Compazine
Phenergan
antispasmodics/anticholinergics
dicyclomine
glycopyrrolate
hyoscyamine tabs, elix
hyoscyamine ER caps
propantheline
Bentyl
Robinul,Robinul Forte
Levsin
hyoscyamine ER caps
Pro-Banthine
H2 antagonists
famotidine
famotidine
nizatidine
ranitidine
Pepcid
Pepcid suspension
Axid suspension only
Zantac
OTC/RX
AL< 6
AL < 6
OTC/RX
inflammatory bowel disease
budesonide del rel cap
hydrocortisone acetate rectal foam
hydrocortisone enema
mesalamine delayed release
mesalamine ext-release
mesalamine rectal susp.
mesalamine suppositories
sulfasalazine
sulfasalazine delayed release
Entocort EC
Cortifoam
Colocort
Asacol/Asacol HD
Pentasa
Rowasa
Canasa
Azulfidine
Azulfidine EN-tabs
QL
QL
lactulose
PEG 3350/electrolytes
polyethylene glycol
sodium phosphate
Colyte
MiraLAX, GlycoLax
Visicol
QL
miscellaneous GI agents
lubiprostone
misoprostol
sucralfate
ursodiol
Amitiza
Cytotec
Carafate
Urso, Atigall, Urso Forte
PA, QL
QL
QL
QL
obesity
orlistat
Alli
PA OTC
antiemetics
laxative/bowel prep
QL
OTC
QL
MD
QL
QL
QL
Version Date: February 1, 2013
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Amerigroup Medication Formulary
Therapeutic Class
pancreatic enzymes
Generic Name
pancreatic enzymes
pancreatic enzymes
pancreatic enzymes
Brand Name Reference
Zenpep
Pancreaze
Creon
Notes
QL ST
QL
QL
lansoprazole 15mg
omeprazole
pantoprazole
Prevacid 24HR 15mg
Prilosec
Protonix
QL, OTC only
RX QL
QL
warfarin
enoxaparin
heparin
Coumadin
Lovenox
heparin
FL
QL
QL
blood cell formation
darbepoetin alfa
epoetin alfa
filgrastim
pegfilgrastim
sargramostim
Aranesp
Procrit, Epogen
Neupogen
Neulasta
Leukine
PA X
PA X
PA X
PA X
PA X
miscellaneous
aminocaproic acid syrup, tabs
cilostazol
pentoxifylline ER
Amicar
Pletal
Trental
platelet aggregation inhibitors
dipyridamole
dipyridamole ext-rel/aspirin
clopidogrel
aspirin
Persantine
Aggrenox
Plavix
aspirin
QL
QL
QL
QL OTC
agalsidase
alglucerase
alglucosidase
alglucosidase
galsulfase
idursulfase
imiglucerase
laronidase
miglustat
taliglucerase
velaglucerase
Fabrazyme
Ceredase
Lumizyme
Myozyme
Naglazyme
Elaprase
Cerezyme
Aldurazyme
Zavesca
Elelyso
VPRIV
PA X
PA X
PA
PA X
PA X
PA X
PA X
PA X
PA X
PA X QL AL
PA X
allopurinol
colchicine
probenecid
Zyloprim
Colcrys
Benemid
ST
proton pump inhibitors
Hematology
anticoagulants
Lysosomal Storage Disorder
Musculoskeletal
gout
Version Date: February 1, 2013
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Amerigroup Medication Formulary
Therapeutic Class
muscle relaxants/spasticity
Generic Name
baclofen
chlorzoxazone
cyclobenzaprine
dantrolene
diazepam
methocarbamol
tizanidine (tablets only)
Brand Name Reference
Lioresal
Parafon Forte DSC
Flexeril
Dantrium
Valium
Robaxin
Zanaflex
RA - DMARDs
auranofin
azathioprine
hydroxychloroquine
leflunomide
methotrexate tabs, inj
penicillamine
sulfasalazine
Ridaura
Imuran
Plaquenil
Arava
methotrexate tabs, inj
Cuprimine
Azulfidine EN-tab
RA - immunomodulators
etanercept
adalimumab
Enbrel
Humira
clindamycin
clindamycin
clotrimazole 1% & 2% crm
fluconazole
metronidazole-vaginal
miconazole
miconazole
nystatin vaginal tablet
terconazole
tioconazole
Cleocin vaginal crm
Cleocin suppositories
3 & 7 day cream
Diflucan
MetroGel - vaginal
Monistat-1 combination
Monistat 3 & 7 crm, supp, combo
nystatin vaginal tablet
Terazol 3, Terazol 7
Vagistat-1
antivirals
acyclovir
imiquimod
podofilox
Zovirax crm, oint
Aldara
Condylox
contraceptives - monophasic
levonorgestrel/EE 0.1/20
norethindrone/EE 1/20 and iron
norethindrone/EE 1/20
desogestrel/EE 0.15/30
drospirenone/EE 3/30
levonorgestrel/EE 0.15/30
norethindrone/EE 1.5/30 and iron
norethindrone/EE 1.5/30
norgestrel/EE 0.3/30
ethynodiol/EE 1/35
Aviane, Lutera
Loestrin Fe 1/20
Loestrin 1/20
Ortho-Cept
Yasmin
Levora
Loestrin Fe 1.5/30
Loestrin 1.5/30
Low-Ogestrel
Zovia 1/35
Ob-Gyn
anti infectives - vaginal
Notes
QL
QL
MD
QL
QL
PA X
PA X
OTC
OTC
OTC
OTC
GL
GL
GL
GL
GL
GL
GL
GL
GL
GL
Version Date: February 1, 2013
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Amerigroup Medication Formulary
Therapeutic Class
Generic Name
norethindrone/EE 0.5/35
norethindrone/EE 1/35
norgestimate/EE 0.25/35
ethynodiol/EE 1/50
norethindrone/ME 1/50
Brand Name Reference
Modicon
Ortho-Novum 1/35
Ortho-Cyclen
Zovia 1/50
Necon 1/50
Notes
GL
GL
GL
GL
GL
contraceptives - biphasic
desogestrel/EE
norethindrone/EE
Mircette
Necon 10/11
GL
GL
contraceptives - triphasic
desogestrel/EE
levonorgestrel/EE
norethindrone/EE
norethindrone/EE
norgestimate/EE
norgestimate/EE
Velivet
Trivora
Ortho-Novum 7/7/7
Tri-Norinyl
Ortho Tri-Cyclen
Ortho Tri-Cyclen Lo
GL
GL
GL
GL
GL
GL
contraceptives - miscellaneous
norelgestromin/ethinyl estradiol patch
etonogestrel/EE vaginal ring
norethindrone
medroxyprogesterone inj
Ortho Evra
NuvaRing
Micronor
Depo-Provera Injection
GL
GL
GL
GL
hormone replacement therapy
conjugated estrogens/medroxyprogesterone
estradiol
estradiol-transdermal
estrogens, conjugated
estrogens, conjugated crm
estrogens, conjugated synthetic
estropipate
ethinyl estradiol/norethindrone
medroxyprogesterone
norethindrone
Premphase, Prempro
Estrace
Climara
Premarin
Premarin Vaginal Crm
Cenestin
Ogen
Femhrt
Provera
Aygestin
GL
GL
GL
GL
GL
GL
GL
GL
GL
GL
miscellaneous
levonorgestrel
levonorgestrel
methylergonovine
Next-Choice
Plan B One-Step
Methergine
QL OTC GL
QL OTC GL
GL
cromolyn sodium
ketotifen
lodoxamide
Opticrom
Alaway
Alomide
QL
QL, OTC only
QL
bacitracin
bacitracin/polymyxin B
ciprofloxacin solution
erythromycin
bacitracin
bacitracin/polymyxin B
Ciloxan solution
Ilotycin
QL OTC
QL
QL
QL
Ophthalmics
allergy
anti-infectives
Version Date: February 1, 2013
17
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
ganciclovir
gatifloxacin 0.5%
gentamicin
moxifloxacin
neomycin/polymyxin B/dexamethasone
neomycin/polymyxin B/gramicidin
neomycin/polymyxin/ hydrocortisone
ofloxacin
polymyxin B/trimethoprim
sulfacetamide 10%
sulfacetamide/prednisolone phosphate
tobramycin ointment
tobramycin/dexamethasone drops
trifluridine
Brand Name Reference
Zirgan
Zymaxid
Gentak
Moxeza
Maxitrol
Neosporin
neomycin/polymyxin/ hydrocortisone
Ocuflox
Polytrim
Bleph-10
sulfacetamide/prednisolone phosphate
Tobrex
TobraDex
Viroptic
dexamethasone sodium phosphate
diclofenac 0.1%
fluorometholone
flurbiprofen
ketorolac 0.5%
loteprednol 0.5%
prednisolone acetate 0.12%
prednisolone acetate 1%
prednisolone phosphate 1%
rimexolone
dexamethasone sodium phosphate
Voltaren
FML
Ocufen
Acular
Lotemax
Pred Mild
Pred Forte
prednisolone phosphate 1%
Vexol
glaucoma agents
brimonidine 0.15%, 0.2%
dorzolamide
dorzolamide/timolol
latanoprost
levobunolol
pilocarpine
timolol hemihydrate
timolol maleate solution
Alphagan
Trusopt
Cosopt
Xalatan
Betagan
Isopto Carpine
Betimol
Timoptic solution
QL
QL
QL
QL
QL
QL
QL
QL
miscellaneous ophthalmics
cyclosporine emulsion
Restasis
PA
acetic acid/aluminum acetate
benzocaine/antipyrine
carbamide peroxide 6.5%
ofloxacin
neomycin/polymyxin B/HC
Domeboro
Aurodex, misc gen
Debrox
ofloxacin
Cortisporin Otic
QL
anti-inflammatory/steroids
Otic Agents
Notes
QL
PA
QL
ST
QL
QL
QL
QL
OTC
QL
Psychotherapeutic Agents
ADD/ADHD
Version Date: February 1, 2013
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Amerigroup Medication Formulary
Therapeutic Class
Generic Name
Brand Name Reference
For Maryland Plan Only (formulary rules apply):
Kapvay : For recipients 6 – 17 years old, Kapvay is part of the mental health formulary and billed fee-for-service.
For individuals not in this age range, Kapvay continues to be part of the MCO pharmacy benefit.
Intuniv: For recipients 6 – 17 years old, Intuniv is part of the mental health formulary and billed fee-for-service.
For individuals not in this age range, Intuniv continues to be part of the MCO pharmacy benefit.
atomoxetine
Strattera
amphetamine/dextroamphetamine/mixed salts
Adderall
amphetamine/dextroamphetamine/mixed salts
Adderall XR
dexmethylphenidate
Focalin
dexmethylphenidate ext –rel cap
Focalin XR
dextroamphetamine
Dexedrine tab
dextroamphetamine ext-rel
Dexedrine Spansules
guanfacine
Intuniv
lisdexamfetamine
Vyvanse
methylphenidate tab
Ritalin, Ritalin SR
methylphenidate ext-rel
Concerta
methylphenidate ext-rel
Metadate CD
Notes
QL MD AL <19
QL MD AL
QL MD AL <19
QL MD AL
QL MD AL <19
QL MD AL
QL MD AL <19
QL ST MD AL = 6 -17 YRS
QL PA MD AL <19
QL MD AL
QL MD AL <19
QL MD AL <19
alcohol deterrents
disulfiram
acamprosate
naltrexone
Antabuse
Campral
ReVia
QL
PA
QL
antidepressants-miscellaneous
bupropion
bupropion sust & ext release
doxepin
isocarboxazid
maprotiline
mirtazapine
phenelzine
tranylcypromine
trazodone
Wellbutrin
Wellbutrin SR & XL
Silenor
Marplan
Ludiomil
Remeron
Nardil
Parnate
Desyrel
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
antidepressants - SSRI and SNRI
citalopram
fluoxetine
fluvoxamine
paroxetine
sertraline
venlafaxine
venlafaxine XR
Celexa
Prozac
Luvox
Paxil
Zoloft
Effexor
Effexor XR
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD ST
QL MD ST
antidepressants-tricyclic
amitriptyline
amitriptyline/perphenazine
amoxapine
chlordiazepoxide/amitriptyline
Elavil
Etrafon
Asendin
Limbitrol
QL MD
QL MD
QL MD
QL MD
Version Date: February 1, 2013
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Amerigroup Medication Formulary
Therapeutic Class
Generic Name
desipramine
imipramine
nortriptyline
protriptyline
trimipramine
Brand Name Reference
Norpramin
Tofranil
Pamelor
Vivactil
Surmontil
Notes
QL MD
QL MD
QL MD
QL MD
QL MD
antipsychotics - atypical
clozapine
olanzapine
paliperidone
quetiapine
risperidone
risperidone
ziprasidone
Clozaril
Zyprexa
Invega Sustenna
Seroquel tab, XR tab
Risperdal
Risperdal Consta
Geodon
QL AL MD
QL AL MD
QL AL MD
QL AL ST MD
QL AL MD
QL AL MD
QL AL MD
antipsychotics - typical
chlorpromazine tabs, inj
fluphenazine
fluphenazine decanoate inj
haloperidol tabs, inj
lithium carbonate
lithium carbonate ext-rel tabs
loxapine
perphenazine
pimozide
thioridazine
thiothixene
trifluoperazine
Thorazine
Prolixin
fluphenazine decanoate inj
Haldol
Eskalith
Lithobid
Loxitane
Trilafon
Orap
Mellaril
Navane
Stelazine
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
anxiolytics
alprazolam
buspirone
chlordiazepoxide
clorazepate
clonazepam
diazepam
hydroxyzine hcl
hydroxyzine pamoate
lorazepam
midazolam
oxazepam
sertraline
venlafaxine ER
Xanax
buspirone
Librium
Tranxene T-Tab
Klonopin
Valium
hydroxyzine HCl
Vistaril
Ativan
midazolam
Serax
Zoloft
Effexor XR
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD
QL MD PA
QL MD
QL MD
QL MD ST
opioid antagonists
buprenorphine/naloxone
buprenorphine
Suboxone
Subutex
QL PA
QL
Version Date: February 1, 2013
20
Amerigroup Medication Formulary
Therapeutic Class
smoking cessation
Generic Name
bupropion SR
nicotine transdermal patches
nicotine polacrilex gum, lozenges
varenicline
Brand Name Reference
Zyban
Nicoderm CQ
Nicorette
Chantix
Notes
QL
QL OTC
QL OTC
QL PA
cetirizine
cyproheptadine
diphenhydramine
fexofenadine
hydroxyzine hcl
hydroxyzine pamoate
loratadine
Zyrtec tabs, syrup, chewable
Periactin
Benadryl
Allegra tablets
Atarax
Vistaril
Claritin tabs, syrup, RediTabs
QL OTC
QL
QL OTC
QL OTC
QL MD
QL MD
QL OTC
beta agonists, inhaled
albuterol, CFC-free
albuterol, CFC-free
budesonide/formoterol
formoterol capsules
mometasone/fomoterol
salmeterol
salmeterol/fluticasone
salmeterol/fluticasone, CFC-free
Ventolin HFA
ProAir HFA
Symbicort
Foradil
Dulera
Serevent Diskus
Advair
Advair HFA
QL
QL
QL ST
QL
QL ST
QL
QL ST
QL
beta agonists, oral
albuterol
metaproterenol syrup
terbutaline
albuterol tabs, syrup
Alupent
terbutaline
QL
QL
QL
cystic fibrosis
dornase alfa
tobramycin for inhalation
Pulmozyme
Tobi
X
X
inhaled, misc
ipratropium, CFC-free aerosol
ipratropium/albuterol
tiotropium
Atrovent HFA
Combivent, Combivent Respimat
Spiriva
QL
QL AL
QL
inhalation delivery devices
AeroChamber
E-Z Spacer
EasiVent
InspirEase
MicroChamber
AeroChamber
E-Z Spacer
EasiVent
InspirEase
MicroChamber
QL
QL
QL
QL
QL
inhaled steroids
beclomethasone
fluticasone, CFC-free aerosol
fluticasone
QVAR
Flovent HFA
Flovent Diskus
QL
QL
QL
Respiratory
antihistamines
Version Date: February 1, 2013
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Amerigroup Medication Formulary
Therapeutic Class
leukotriene receptor antagonists
Generic Name
montelukast
montelukast
zafirlukast
Brand Name Reference
Singulair
Singulair Granules
Accolate
Notes
QL ST
QL AL< 2 or PA
QL
miscellaneous
omalizumab
Xolair
PA X
nasal inhalers
azelastine
flunisolide
fluticasone
ipratropium spray
Astelin
Nasalide
Flonase
Atrovent nasal spray
QL
QL
QL
QL
nebulizer solutions
albuterol
budesonide
cromolyn soln
ipratropium soln
ipratropium/albuterol
sodium chloride 0.9%
AccuNeb
Pulmicort Respules
Intal
ipratropium soln
Duoneb
sodium chloride 0.9%
QL
QL AL < 5
QL
QL
QL
QL
theophylline
theophylline ext-rel tab
theophylline elixir
theophylline ext rel capsule
Theochron
Elixophyllin
Theo-24
FL QL
QL
AL
alfuzosin
doxazosin
finasteride
tamsulosin
terazosin
Uroxatral
Cardura
Proscar
Flomax
Hytrin
GL
miscellaneous
bethanechol
flavoxate
oxybutynin, oxybutynin ext-release
Urecholine
Urispas
Ditropan, Ditropan XL
QL
QL
QL
Vitamins/Supplements
pentosan polysulfate sodium
phenazopyridine
calcitriol
cyanocobalamin inj
ergocalciferol
ferrous sulfate
fluoride drops, tabs
folic acid
folic acid/vitamin B complex w/C
iron/B-12/vit C/intrinsic factor
iron/B-12/vit C/intrinsic factor/FA
levocarnitine cap
Elmiron
Pyridium
Rocaltrol
B-12
Calciferol
generic tabs, drops, elix
Luride
folic acid
Nephrocaps
iron/B-12/vit C/intrinsic factor
iron/B-12/vit C/intrinsic factor/FA
L-Carnitine
QL
QL
Urologicals
BPH
OTC
QL
QL
QL
QL
QL
Version Date: February 1, 2013
22
Amerigroup Medication Formulary
Therapeutic Class
Generic Name
multivit./ferrous fumarate/FA
multivit./ferrous fumarate/FA
multivitamins
multivitamins w/iron
paricalcitol
potassium bicarb/citrate efferv tabs
potassium chloride ext-rel tabs, liquid, powder
potassium/sodium acid phosphate
prenatal vitamins
prenatal vitamins + DHA
prenatal vitamins (kosher)
vitamin A D C/fluoride/ w/ or w/o iron
vitamin D
vitamin K
Brand Name Reference
Vitafol tab
Vitafol liquid
various
various
Zemplar
potassium bicarb/citrate efferv tabs
various
K-Phos Neutral
various
various
Nestabs
vitamin A D C/fluoride/ w/ or w/o iron
various
Mephyton
Notes
QL
QL
QL OTC
QL OTC
QL ST
QL
QL
QL
G QL
QL
QL
QL
QL
QL
Miscellaneous Agents
epinephrine inj
milnacipran
EpiPen, EpiPen Jr
Savella
QL
PA
Version Date: February 1, 2013
23