1. No category

Amerigroup Medication Formulary
Applies to the Nevada Medicaid market
Pharmacy services are included in the Managed Care Organization (MCO) benefit package. The MCO may design its own formulary based on clinical guidelines.
Medications not covered in the MCO's formulary must be available through a non-formulary request process based on physician certification
and justification of medical necessity. Medicaid Services Manual Chapter Section 3603.9 PHARMACY SERVICES.
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 1-800-454-3730. In order to request prior authorization, the provider or member must contact the Amerigroup pharmacy department
at 1-800-454-3730. 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: March 1, 2015
WEB-PEC-0269-15
RX - Prescription medication
OTC - Over The Counter medication
X - Medication provided by specialty pharmacy network
Amerigroup Medication Formulary
Nevada
Therapeutic Class
Generic Name
Brand Name Reference
Notes
lidocaine patch
Lidoderm
QL PA
lidocaine crm, oint, lotion
lidocaine
QL
lidocaine/prilocaine crm
Emla
QL
lidocaine/hydrocortisone
lidocaine/hydrocortisone
QL
acetaminophen
Tylenol
OTC
butalbital/apap 50-325
Marten-Tab
QL
butalbital/apap/caffeine
Fioricet
QL
tramadol
Ultram
QL
tramadol/apap
Ultracet
QL
butalbital/apap/caffeine/cod.
Fioricet w/codeine
QL
butalbital/asa/caffeine/codeine
Fiorinal w/codeine
QL
butalbital/asa/caffeine
Fiorinal
QL
codeine sulfate
codeine sulfate
QL
codeine/apap
Tylenol-2, T-3, T-4
QL
fentanyl
Actiq
QL PA
fentanyl transdermal
Duragesic
QL
hydrocodone/apap
Lorcet, Lortab, Vicodin
QL
hydrocodone/apap soln
Hycet solution
QL
hydrocodone/ibuprofen
Vicoprofen
QL
hydromorphone
Dilaudid
QL
meperidine
Demerol
QL
methadone
Dolophine
QL
morphine sulfate SR 24 HR
Generic Kadian (10mg, 20mg, 30mg, 50mg,
60mg, 80mg and 100mg only)
QL
morphine sulfate ER
MS Contin
QL
morphine tabs, soln, supp
morphine
QL
oxycodone
Roxicodone
QL
oxycodone ER
OxyContin
QL PA
oxycodone/apap
Tylox, Percocet, etc
QL
Analgesics
miscellaneous analgesics
non-narcotic analgesics
narcotic analgesics
Version Date: March 1, 2015
2
Amerigroup Medication Formulary
Nevada
NSAIDs
Anticonvulsants
pentazocine-acetaminophen 25-650
Talacen
pentazocine-naloxone 50-0.5
Talwin NX
QL
celecoxib
Celebrex
QL PA
etodolac tabs, ER tabs
Lodine/ER
diclofenac delayed-release tabs
diclofenac delayed-release
diclofenac extended release
Voltaren XR
fenoprofen calcium
fenoprofen calcium
flurbiprofen
Ansaid
ibuprofen
Motrin
indomethacin
Indocin
ketoprofen
Actron
ketorolac tromethamine tabs
Ketorolac
QL AL
meclofenamate sodium
Meclofen Sod
QL AL
meloxicam
Mobic
nabumetone
Relafen
naproxen
Naprosyn, EC-Naprosyn
naproxen sodium
Anaprox
oxaprozin
Daypro
piroxicam
Feldene
salsalate
Disalcid
sulindac
Clinoril
tolmetin
Tolectin
carbamazepine
Tegretol, Tegretol XR
QL (Brand and Generic)
carbamazepine ext-release
Carbatrol
QL
clonazepam
Klonopin
QL
diazepam rectal gel
Diastat (generic only)
QL
divalproex sodium
Depakote Sprinkle
QL
divalproex sodium delayed release
Depakote
QL
divalproex sodium ext-rel
Depakote ER
QL
ethosuximide
Zarontin
QL
ethotoin
Peganone
QL
felbamate
Felbatol
QL
QL AL
Version Date: March 1, 2015
3
Amerigroup Medication Formulary
Nevada
gabapentin
Neurontin
QL
lacosamide
Vimpat
QL PA
lamotrigine
Lamictal
QL
levetiracetam
Keppra
QL
methsuximide
Celontin
QL PA
oxcarbazepine
Trileptal
QL
phenobarbital
Luminal
QL
phenytoin
Dilantin Infatabs
QL
phenytoin sodium ext-release
Dilantin
QL (Brand and Generic)
phenytoin sodium ext-release
Phenytek
QL (Brand and Generic)
pregabalin
Lyrica
QL PA
primidone
Mysoline
QL
rufinamide
Banzel
QL PA
tiagabine
Gabitril
QL
topiramate
Topamax
QL
valproic acid
Depakene (all dosage forms)
QL
zonisamide
Zonegran
QL
clotrimazole troches
Mycelex
QL
fluconazole
Diflucan
QL
griseofulvin suspension
griseofulvin suspension
QL
griseofulvin microsize
Grifulvin V
QL
griseofulvin ultramicrosize
Gris-Peg
QL
ketoconazole
Nizoral
QL
nystatin
Mycostatin
QL
terbinafine
Lamisil
QL
voriconazole
Vfend
QL PA
ganciclovir
Cytovene
valganciclovir
Valcyte
adefovir
Hepsera
Anti-infectives
antifungals
antivirals-CMV
antivirals-hepatitis B
QL AL PA
Version Date: March 1, 2015
4
Amerigroup Medication Formulary
Nevada
antivirals-hepatitis C
antivirals-herpes agents
antivirals-HIV and related
entecavir
Baraclude
QL AL PA
lamivudine
Epivir-HBV
QL AL PA
telbivudine
Tyzeka
QL AL PA
tenofovir
Viread
QL AL
interferon alfa
Intron A
PA X
boceprevir
Victrelis
PA X
ledipasvir/sofosbuvir
Harvoni
PA X
peginterferon alfa
Pegasys
PA X
ribavirin tab, cap
Copegus
PA X
ribavirin solution
Rebetol
PA X
telaprevir
Incivek
PA X
famciclovir
Famvir
valacyclovir
Valtrex
QL
abacavir
Ziagen
QL
atazanavir
Reyataz
QL
darunavir
Prezista
QL
delavirdine
Rescriptor
QL
didanosine suspension
Videx suspension
QL
didanosine delayed release
Videx EC
QL
Dolutegravir
Tivicay
QL
efavirenz
Sustiva
QL
emtricitabine
Emtriva
QL
enfuvirtide
Fuzeon
QL PA
etravirine
Intelence
QL ST
fosamprenavir
Lexiva
QL
indinavir
Crixivan
QL
lamivudine
Epivir
QL
maraviroc
Selzentry
QL
megestrol
Megace
QL
nelfinavir
Viracept
QL
nevirapine
Viramune
QL
Version Date: March 1, 2015
5
Amerigroup Medication Formulary
Nevada
antivirals-HIV combination
antivirals-influenza
cephalosporins 1st generation
cephalosporins 2nd generation
cephalosporins 3rd generation
nevirapine extended release
Viramune XR
QL
raltegravir
Isentress
QL
rilpivirine
Edurant
QL
ritonavir
Norvir
QL
saquinavir mesylate
Invirase
QL
stavudine
Zerit
QL
tenofovir
Viread
QL PA
tipranavir
Aptivus
QL
zidovudine
Retrovir
QL
efavirenz/emtricitabine/tenofovir
Atripla
QL
lamivudine/zidovudine
Combivir
QL
rilpivirine/emtricitabine/tenofovir
Complera
QL
abacavir/lamivudine
Epzicom
QL
lopinavir/ritonavir
Kaletra
QL
elvitegravir/cobicistat/emtricitabine/tenofovir
Stribild
QL
abacavir/lamivudine/zidovudine
Trizivir
QL
emtricitabine/tenofovir
Truvada
QL
oseltamivir
Tamiflu
QL
rimantadine
Flumadine
zanamivir
Relenza
QL
cefadroxil
Duricef
QL
cephalexin
Keflex
QL
cefaclor
Ceclor
QL
cefprozil
Cefzil
QL
cefuroxime
Ceftin
QL
cefdinir
Omnicef
QL
cefditoren
Spectracef
cefixime
Suprax
QL
QL PA
cefpodoxime
Vantin
QL
Version Date: March 1, 2015
6
Amerigroup Medication Formulary
Nevada
fluoroquinolones
macrolides
miscellaneous
Ceftriaxone
Rocephin
QL
ciprofloxacin tabs
Cipro
AL <2 req PA QL
ciprofloxacin ER tabs
Cipro ER
AL
levofloxacin
Levaquin
AL QL
moxifloxacin
Avelox
AL QL PA
ofloxacin
Floxin
QL AL <2 req PA
azithromycin
Zithromax
QL
clarithromycin, clarithromycin ER
Biaxin, Biaxin XL
QL
erythromycin base
erythromycin
QL
erythromycin delayed-release
Eryc
erythromycin ethylsuccinate
EES
QL
QL PA
erythromycin stearate
Erythrocin Stearate
QL PA
erythromycin/sulfisoxazole
Pediazole
QL
atovaquone
Mepron
atovaquone- proguanil
Malarone
chloroquine phosphate
Aralen
clindamycin
Cleocin
dapsone
dapsone
ethambutol
Myambutol
hydroxychloroquine
Plaquenil
Iodoquinol
Yodoxin
isoniazid
isoniazid
linezolid
Zyvox
mebendazole
Vermox
mefloquine
Larium
metronidazole
Flagyl
neomycin
Mycifradin
nitrofurantoin
Macrobid
pentamidine
Pentam 300
pyrazinamide
pyrazinamide
pyrimethamine
Daraprim
QL PA
QL
QL
Version Date: March 1, 2015
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Amerigroup Medication Formulary
Nevada
penicillins
sulfonamides
rifampin
Rifadin
tinidazole
Tindamax
trimethoprim
Primsol
amoxicillin
Amoxil
QL
amoxicillin/clavulanate
Augmentin tab, susp, ES-600
QL
amoxicillin/clavulanate ext-rel
Augmentin XR
QL
ampicillin
ampicillin
QL
dicloxacillin
Dicloxacillin
QL
penicillin G benzathine intramusclular susp
Bicillin L-A-INJ 2400000
QL
penicillin G benzathine intramusclular susp
Bicillin L-A-INJ 1200000
QL
penicillin G benzathine intramusclular susp
Bicillin L-A-INJ 600000
QL
penicillin VK
penicillin VK
QL
sulfadiazine
Sulfadiazine
QL
sulfamethoxazole/trimethoprim
Bactrim
QL
doxycycline monohydrate (CAPS ONLY)
doxycycline monohydrate (CAPS ONLY)
QL
minocycline
minocycline
QL
tetracycline
tetracycline
QL
sumatriptan
Imitrex tabs, spray, injection
QL
naratriptan
Amerge
QL
ergotamine/caffeine tabs
Cafergot tabs
dihydroergotamine
Migranal
tetracyclines
Antimigraine Agents
5-HT agonists
miscellaneous agents
Antineoplastic Agents
QL PA
(Only oral oncology agents that require precertification are listed)
abiraterone
Zytiga
QL PA X
anastrozole
Arimidex
QL PA
axitinib
Inlyta
QL PA X
bexarotene
Targretin
QL PA X
Version Date: March 1, 2015
8
Amerigroup Medication Formulary
Nevada
bosutinib
Bosulif
QL PA X
cabozantinib S-Mal
Cometriq
QL PA X
capecitabine
Xeloda
QL PA X
crizotinib
Xalkori
QL PA X
cyclophosphamide
Cytoxan
dasatinib
Sprycel
QL PA X
enzalutamide
Xtandi
QL PA X
erlotinib
Tarceva
QL PA X
everolimus
Afinitor
QL PA X
exemestane
Aromasin
PA
fludarabine
Oforta
QL PA X
hydroxyurea
Hydrea
imatinib
Gleevec
QL PA X
lapatinib
Tykerb
QL PA X
lenalidomide
Revlimid
QL PA X
letrozole
Femara
QL PA
mercaptopurine
Mercaptopur
nilotinib
Tasigna
QL PA X
pazopanib
Votrient
QL PA X
pomalidomide
Pomalyst
QL PA X
ponatinib HCL
Iclusig
QL PA X
regorafenib
Stivarga
QL PA X
sorafenib
Nexavar
QL PA X
sunitinib
Sutent
QL PA X
tamoxifen
Nolvadex
temozolomide
Temodar
QL PA X
thalidomide
Thalomid
QL PA X
topotecan
Hycamtin
QL PA X
tretinoin capsule
Tretinoin
vandetanib
Caprelsa
QL PA X
vemurafenib
Zelboraf
QL PA X
vismodegib
Erivedge
QL PA X
vorinostat
Zolinza
QL PA X
Version Date: March 1, 2015
9
Amerigroup Medication Formulary
Nevada
antidotes
leucovorin
Leucovorin
QL
mesna
Mesnex
PA
deferoxamine
Desferal
sodium polystyrene sulfate suspension
Kionex
benazepril
Lotensin
captopril
Capoten
enalapril
Vasotec
fosinopril
Monopril
lisinopril
Prinivil, Zestril
moexipril
Univasc
perindopril
Aceon
quinapril
Accupril
ramipril
Altace
trandolapril
Mavik
benazepril/amlodipine
Lotrel
benazepril/HCTZ
Lotensin HCT
captopril/HCTZ
captopril/HCTZ
enalapril/HCTZ
Vaseretic
fosinopril/HCTZ
Monopril/HCTZ
lisinopril/HCTZ
Zestoretic, Prinzide
moexipril/HCTZ
Uniretic
quinapril/HCTZ
quinipril/HCTZ
candesartan cilexetil
Atacand
QL
irbesartan
Avapro
QL
losartan
Cozaar
QL
valsartan
Diovan
QL
candesartan /HCTZ
Atacand HCT
QL
irbesartan/HCTZ
Avalide
QL
losartan/HCTZ
Hyzaar
QL
Generic
Cardiovascular
ACE inhibitors
ACE inhibitor combinations
ARBs
ARB combinations
Version Date: March 1, 2015
10
Amerigroup Medication Formulary
Nevada
alpha blockers
antiarrhythmics
antihypertensives-miscellaneous
beta blockers
valsartan/HCTZ
Diovan HCT
doxazosin
Cardura
prazosin
Minipress
terazosin
terazosin
amiodarone
Cordarone, Pacerone (200 & 400mg only)
digoxin
Lanoxin
disopyramide
Norpace
mexiletine
Mexitil
propafenone
Rythmol
quinidine gluconate ER
quinidine gluconate ER
quinidine sulfate
quinidine sulfate
clonidine tabs
Catapres
clonidine patch
Catapres-TTS
guanfacine
Tenex
hydralazine
Apresoline
methyldopa
Aldomet
midodrine
midodrine
minoxidil
Loniten
acebutolol
Sectral
atenolol
Tenormin
betaxolol
Kerlone
bisoprolol
Zebeta
carvedilol
Coreg
labetalol
labetalol
metoprolol
Lopressor
metoprolol ER
Toprol XL
nadolol
Corgard
pindolol
Visken
propranolol
Inderal
propranolol ER
Inderal LA
QL
QL
QL PA
Version Date: March 1, 2015
11
Amerigroup Medication Formulary
Nevada
sotalol
Betapace, Betapace AF
timolol
Blocadren
atenolol/ chlorthalidone
Tenoretic
bisoprolol/HCTZ
Ziac
metoprolol/HCTZ
Lopressor HCT
nadolol/bendroflumethiazide
Corzide
propranolol/HCTZ
Inderide
amlodipine
Norvasc
diltiazem
Cardizem
diltiazem ER
Dilacor XR
felodipine ER
Plendil
isradipine
Isradipine
nicardipine
Cardene
nicardipine ext-rel
Cardene SR
nifedipine
Procardia
nifedipine ER
Adalat CC, Procardia XL
verapamil
Calan
verapamil ER
Calan SR
calcium channel blocker combinations
amlodipine/benazepril
Lotrel
diuretics
amiloride/ HCTZ
Moduretic
bumetanide
Bumex
chlorthalidone
Hygroton
chlorothiazide susp
Diuril
furosemide
Lasix
hydrochlorothiazide
hydrochlorothiazide
indapamide
Lozol
metolazone
Zaroxolyn
spironolactone
Aldactone
spironolactone/ HCTZ
Aldactazide (25/25mg only)
torsemide
Demadex
beta blocker combinations
calcium channel blockers
QL
PA
Version Date: March 1, 2015
12
Amerigroup Medication Formulary
Nevada
hereditary angioedema
hypolipidemics - bile acid sequestrants
hypolipidemics - fibrates
hypolipidemics - miscellaneous
hypolipidemics - statins
nitrates
pulmonary arterial hypertension
triamterene
Dyrenium
PA
triamterene/ HCTZ
Maxzide, Dyazide
complement C1 esterase inhibitor
Berinert, Cinryze
PA X
ecallantide
Kalbitor
PA X
icatibant
Firazyr
PA QL X
cholestyramine
Questran
QL
colestipol
Colestid
fenofibrate
Lofibra
fenofibrate acid
fenofibrate acid
gemfibrozil
Lopid
QL
ezetimibe/simvastatin
Vytorin
QL ST
ezetimibe
Zetia
QL ST
niacin
Niacin CR, SLO-Niacin
QL OTC
omega-3 fatty acids
omega-3 fatty acids
QL OTC
atorvastatin
Lipitor
QL
lovastatin
Mevacor
QL
pravastatin
Pravachol
QL
simvastatin
Zocor
QL
isosorbide dinitrate SL, ER
Isordil
isosorbide mononitrate ER
Imdur
nitroglycerin sublingual
Nitrostat
nitroglycerin topical
Nitro-Bid
nitroglycerin transdermal
Nitro-Dur
ambrisentan
Letairis
QL PA X
bosentan
Tracleer
PA X
epoprostenol
Flolan
PA
iloprost
Ventavis
PA
QL
Version Date: March 1, 2015
13
Amerigroup Medication Formulary
Nevada
sildenafil
Revatio
QL PA X
tadalafil
Adcirca
PA
treprostinil injection
Remodulin
PA X
treprostinil
Tyvaso
PA
donepezil
Aricept, Aricept ODT
QL
galantamine
Razadyne, Razadyne ER
QL
memantine
Namenda
QL AL
memantine ext-rel
Namenda XR
QL
dextromethorphan hbr-quinidine
Nuedexta
PA
milnacipran
Savella
PA
riluzole
Rilutek
dimethyl fumarate cap delayed release
Tecfidera
PA QL
fingolimod hcl
Gilenya
PA
glatiramer
Copaxone
PA QL
interferon beta-1a
Avonex
PA QL X
interferon beta-1a
Rebif
PA QL X
interferon beta-1a
Betaseron
PA QL X
interferon beta-1b
Extavia
PA QL X
natalizumab
Tysabri
PA X
teriflunomide
Aubagio
PA QL
pyridostigmine ext-rel
Mestinon Timespan
pyridostigmine
Mestinon
amantadine (except tab)
Symmetrel
benztropine
Cogentin
bromocriptine
Parlodel
carbidopa/levodopa
Sinemet
carbidopa/levodopa ext-rel
Sinemet CR
carbidopa/levodopa/entacapone
Stalevo
Central Nervous System
Alzheimer’s agents
miscellaneous
multiple sclerosis
myasthenia gravis
Parkinson’s disease
QL
Version Date: March 1, 2015
14
Amerigroup Medication Formulary
Nevada
sedative/hypnotics
Cough and Cold Products
Dental/Oral Preparations
entacapone
Comtan
pramipexole
Mirapex
ropinirole
Requip
selegiline
Eldepryl
tolcapone
Tasmar
trihexyphenidyl
Artane
estazolam
Prosom
ramelteon
Rozerem
QL PA
temazepam (15mg & 30mg only)
Restoril
QL
triazolam
Halcion
QL PA
zaleplon
Sonata
QL
zolpidem
Ambien
QL
benzonatate
Tessalon, Tessalon Perles
AL
dextromethorphan syrup
Delsym
AL QL ST
diphenhydramine caps, liq
Benadryl
QL
guaifenesin syrup
Duratuss
AL QL ST
guaifenesin w/ codeine syrup
Robutissin-AC
AL QL ST
promethazine w/ codeine syrup
promethazine w/ codeine
AL
promethazine/dextromethorphan syrup
Phenergran DM
AL
promethazine & phenylephrine
Promethazine VC Plain
AL
pseudoephedrine tabs, syrup
Sudafed
AL QL ST
saline drops, spray
saline
AL QL ST
chlorhexidine gluconate
Peridex
lidocaine viscous
lidocaine viscous
pilocarpine
Salagen
QL
saliva substitute
Salivart
QL
sodium fluoride crm 1.1%
SF 5000 PLUS
triamcinolone paste
triamcinolone paste
doxycycline monohydrate (CAPS ONLY)
doxycyline monohydrate (CAPS ONLY)
isotretinoin
Accutane
Dermatology
acne-oral
PA QL
Version Date: March 1, 2015
15
Amerigroup Medication Formulary
Nevada
acne-topical
- foam and wash products not covered
antibacterials
antifungals
antivirals
minocycline
Minocin
tetracycline
Sumycin
adapalene 0.1%
Differin
Benzoyl Peroxide
BENZAC GEL 10%
Benzoyl Peroxide
BENZAC AC LIQ 5%
clindamycin Phosphate Topical pledget
Cleocin-T
erythromycin 2% gel, solution
Emgel
erythromycin/benzoyl peroxide
Benzamycin
salicylic acid 17%
salicylic acid 17%
tazarotene
Tazorac
PA
tretinoin gel, crm
Retin A
AL
chlorhexidine gluconate
Hibiclens
OTC
mupirocin
Bactroban
silver sulfadiazine
Silvadene
butenafine
Lotrimin Ultra
ciclopirox 0.77% cream, suspension
Loprox
ciclopirox 8% nail solution
Penlac
QL PA
clotrimazole crm, soln
Lotrimin
OTC
clotrimazole/betamethasone crm, lot
Lotrisone
econazole
Spectazole
ketoconazole crm, shampoo
Nizoral
miconazole 2% crm
Micatin 2%
OTC
miconazole 2%
Fungoid tincture
OTC
nystatin
Mycostatin
nystatin/triamcinolone
Mycogen II
selenium sulfide lot, shampoo
selenium sulfide
terbinafine crm
Lamisil
OTC
Tolnaftate crm, powder
Tinactin
OTC
Undecylenic acid
Undecylenic acid
OTC
docosanol cream
Abreva cream
QL AL
PA
QL
OTC
QL
Version Date: March 1, 2015
16
Amerigroup Medication Formulary
Nevada
PA QL AL
imiquimod cream
Aldara
podofilox
Condylox
ammonium lactate 12%
Lac-Hydrin
QL
becaplermin
Regranex
PA
emollient ointment
hydrolatum
fluorouracil crm
Efudex crm
QL
fluorouracil solution
fluorouracil solution
QL
ingenol mebutate gel
Picato Gel
QL AL PA
pimecrolimus
Elidel
QL PA AL
selenium sulfide shampoo 2.5%
Selsun
QL
tacrolimus oint
Protopic oint
QL PA QL
urea crm/gel 40%
urea, various
QL
malathion
Ovide
QL ST
permethrin rinse 1%
Nix, various
QL OTC
permethrin 5%
permethrin 5%
QL
pyrethrins/piperonyl butoxide 4%
RID
OTC
adalimumab
Humira
PA
calcipotriene
Dovonex
QL PA
etanercept
Enbrel
PA
methotrexate tablets, injection
Trexall
tazarotene cream, gel
Tazorac
metronidazole 0.75% crm, lotion
MetroCream, MetroLotion
metronidazole 1%
MetroGel
steroids - low potency
hydrocortisone cream, oint, solution
Hydrocortisone
steroids - medium potency
betamethasone dipropionate lotion 0.05%
Del-Beta
betamethasone valerate crm 0.1%
Beta-Val
QL
fluticasone crm 0.05%, oint 0.005%
Cutivate
QL
mometasone crm, oint and topical lotion 0.1%
Elocon
QL
miscellaneous dermatology
pediculocides
psoriasis agents
rosacea
PA
ST
Version Date: March 1, 2015
17
Amerigroup Medication Formulary
Nevada
steroids - high potency
triamcinolone acetonide crm , 0.025%, 0.5%, 0.1%
Triamcinolone
triamcinolone acetonide oint , 0.025%, 0.5%, 0.1%
Triamcinolone
QL
amcinonide oint, lot 0.1%
Cyclocort
betamethasone dip (augmented) 0.5% cream
Diprolene A.F
betamethasone valerate ointment 0.1%
Beta-Val
fluocinonide E cream
Lidex E
dexamethasone
DexPak
QL
fludrocortisone
Florinef
QL
hydrocortisone
Cortef
QL
methylprednisolone
Medrol
QL
prednisolone sod. Phosphate
Pediapred
QL
prednisolone syrup
prednisolone syrup
QL
prednisone
Deltasone
QL
danazol
Danocrine
QL PA GL
testosterone transdermal
Androderm
QL PA GL
testosterone gel
AndroGel
QL PA GL
testosterone gel
Testim
QL PA GL
glucagon
Glucagon Emergency Kit
QL
glucose tablets
glucose
OTC
glucose gel
Insta- Glucose
human insulin
Humulin, Novolin
QL
insulin glargine
Lantus
QL
insulin glulisine
Apidra
QL
insulin mix
Humalog Mix, Novolog Mix
QL
insulin regular
Humulin R 500u/ml
QL
blood glucose test strips
TRUEtest Preferred Brand
QL
lancets/syringes/needles
various
QL
Endocrine
adrenocortical steroids
androgens
diabetes-glucose elevating agents
diabetes-insulin
diabetes-meters/strips/supplies
Version Date: March 1, 2015
18
Amerigroup Medication Formulary
Nevada
urine ketone test strips
Ketostix
QL
exenatide
Byetta
QL ST
liraglutide
Victoza
QL ST
pramlintide
Symlin Pen
QL PA
acarbose
Precose
QL
glimepiride
Amaryl
glipizide, glipizide ER
Glucotrol, Glucotrol XL
glipizide/metformin
Metaglip
glyburide
DiaBeta
QL
glyburide micronized
Glynase
QL
glyburide/metformin
Glucovance
QL
metformin, metformin ext-rel
Glucophage, Glucophage XR
QL
nateglinide
Starlix
QL
pioglitazone
Actos
QL ST
pioglitazone/glimepiride
Duetact
pioglitazone hcl-metformin
Actoplus Met
repaglinide
Prandin
QL
saxagliptin
Onglyza
QL ST
saxagliptin/metformin
Kombiglyze XR
QL ST
sitagliptin
Januvia
QL ST
sitagliptin/metformin
Janumet/Janumet XR
QL ST
somatropin
Tev-Tropin
PA X
somatropin
Norditropin
PA X
somatropin
Omnitrope
QL AL PA X
hypercalcemia
cinacalcet
Sensipar
PA QL X
hyperphosphatemia
sevelamer
Renagel, Renvela
QL PA
calcium acetate
PhosLo
lanthanum carbonate
Fosrenol
diabetes- misc injectable agents
diabetes-oral agents
growth hormone
PA
Version Date: March 1, 2015
19
Amerigroup Medication Formulary
Nevada
miscellaneous
obesity agents
osteoporosis/Paget’s
thyroid disease
cabergoline
Dostinex
QL
desmopressin
DDAVP tabs, spray, inj.
QL
leuprolide
Lupron
PA X
leuprolide
Lupron Depot, Lupron Depot-PED
PA X
triptorelin
Trelstar Depot
PA
orlistat
Alli
PA OTC QL
orlistat
Xenical
PA OTC QL
alendronate
Fosamax
QL
calcitonin-salmon spray
Fortical, Miacalcin
QL
etidronate
Didronel
QL
raloxifene
Evista
QL
teriparatide
Forteo
PA X
levothyroxine
Synthroid
QL ( Brand and Generic)
levothyroxine
Levoxyl
liothyronine
Cytomel
methimazole
Tapazole
propylthiouracil
various generics
thyroid
Armour thyroid
diphenoxylate/atropine
Lomotil
loperamide
Imodium A-D
OTC
aprepitant
Emend
QL
meclizine
Antivert
OTC
metoclopramide
Reglan
ondansetron
Zofran
prochlorperazine
Compazine
promethazine supp/syr/tab
Phenergan
dicyclomine
Bentyl
Gastrointestinal
antidiarrheals
antiemetics
antispasmodics/anticholinergics
QL
AL
Version Date: March 1, 2015
20
Amerigroup Medication Formulary
Nevada
H2 antagonists
inflammatory bowel disease
laxative/bowel prep
miscellaneous GI agents
glycopyrrolate
Robinul,Robinul Forte
hyoscyamine tabs, elix
Levsin
hyoscyamine ER caps
hyoscyamine ER caps
propantheline
Pro-Banthine
famotidine
famotiedine
OTC & RX
famotidine
Pepcid suspension
AL< 6
nizatidine
Axid suspension
AL < 6
ranitidine
Zantac
OTC & RX
budesonide del rel cap
Entocort EC
QL
hydrocortisone acetate rectal foam
Cortifoam
QL PA
hydrocortisone enema
Colocort
hydrocortisone rectal cream
Proctosol HC/ Proctozone HC
mesalamine delayed release
Asacol HD
QL
mesalamine delayed release
Asacol
PA
mesalamine delayed release
Delzicol
mesalamine kit
mesalamine kit
mesalamine ext-release
Pentasa
QL
mesalamine rectal susp.
Rowasa
QL
mesalamine suppositories
Canasa
PA
sulfasalazine
Azulfidine
sulfasalazine delayed release
Azulfidine EN-tabs
lactulose
PEG 3350/electrolytes
Colyte
polyethylene glycol
MiraLAX, GlycoLax
sodium phosphate
Visicol
lubiprostone
Amitiza
QL PA
misoprostol
Cytotec
QL
sucralfate
Carafate
QL
ursodiol
Urso, Atigall, Urso Forte
QL
QL
Version Date: March 1, 2015
21
Amerigroup Medication Formulary
Nevada
pancreatic enzymes
proton pump inhibitors
replacement preparations
pancrelipase 5,000
Pancrelipase
QL
pancreatic enzymes
Pancreaze
QL PA
pancreatic enzymes
Creon
QL
lansoprazole 15mg
Prevacid 24HR 15mg
QL OTC
esomeprazole
Nexium
QL OTC
omeprazole
omeprazole
QL OTC
pantoprazole
Protonix
QL
oral electrolyte solution
Pedialyte
warfarin
Coumadin
(Brand and Generic)
enoxaparin
Lovenox
QL
heparin
heparin
QL
dabigatran etexilate mesylate caps.
Pradaxa
QL PA
rivaroxaban tab
Xarelto
QL PA
darbepoetin alfa
Aranesp
PA QL X
epoetin alfa
Procrit, Epogen
PA X
filgrastim
Neupogen
PA X
pegfilgrastim
Neulasta
PA X
sargramostim
Leukine
PA X
aminocaproic acid syrup, tabs
Amicar
cilostazol
Pletal
pentoxifylline ER
Trental
dipyridamole
Persantine
QL
clopidogrel
Plavix
QL
aspirin
aspirin
QL OTC
agalsidase
Fabrazyme
PA X
Hematology
anticoagulants
blood cell formation
miscellaneous
platelet aggregation inhibitors
Lysosomal Storage Disorder
Version Date: March 1, 2015
22
Amerigroup Medication Formulary
Nevada
alglucerase
Ceredase
PA X
alglucosidase
Lumizyme
PA X
alglucosidase
Myozyme
PA X
galsulfase
Naglazyme
PA X
idursulfase
Elaprase
PA X
imiglucerase
Cerezyme
PA X
laronidase
Aldurazyme
PA X
miglustat
Zavesca
PA X
taliglucerase
Elelyso
PA X QL AL
velaglucerase
VPRIV
PA X
allopurinol
Zyloprim
colchicine
Colcrys
probenecid
Benemid
baclofen
Lioresal
carisoprodol
Soma
carisoprodol/ aspirin/ codeine
carisoprodol/aspirin/codeine
chlorzoxazone
Parafon Forte DSC
cyclobenzaprine
Flexeril
dantrolene
Dantrium
diazepam
Valium
methocarbamol
Robaxin
selegiline TD patch
Emsam
tizanidine (tablets only)
Zanaflex
auranofin
Ridaura
azathioprine
Imuran
hydroxychloroquine
Plaquenil
leflunomide
Arava
methotrexate tabs, inj
methotrexate tabs, inj
penicillamine
Cuprimine
sulfasalazine
Azulfidine EN-tab
Musculoskeletal
gout
muscle relaxants/spasticity
RA - DMARDs
PA QL
QL
QL
QL
QL
Version Date: March 1, 2015
23
Amerigroup Medication Formulary
Nevada
RA - immunomodulators
etanercept
Enbrel
PA
adalimumab
Humira
PA QL
clindamycin
Cleocin vaginal crm
clindamycin
Cleocin suppositories
clotrimazole 1% & 2% crm
3 & 7 day cream
fluconazole
Diflucan
metronidazole-vaginal
MetroGel - vaginal
miconazole
Monistat-1 combination
OTC
miconazole
Monistat 3 & 7 crm, supp, combo
OTC
nystatin vaginal tablet
nystatin vaginal tablet
terconazole
Terazol 3, Terazol 7
tioconazole
Vagistat-1
acyclovir
Zovirax ointment
imiquimod
Aldara
podofilox
Condylox
levonorgestrel/EE 0.1/20
Aviane, Lutera
GL
norethindrone/EE 1/20 and iron
Loestrin Fe 1/20
GL
norethindrone/EE 1/20
Loestrin 1/20
GL
desogestrel/EE 0.15/30
Ortho-Cept
GL
drospirenone/EE 3/30
Yasmin
GL
levonorgestrel/EE 0.15/30
Levora
GL
norethindrone/EE 1.5/30 and iron
Loestrin Fe 1.5/30
GL
norethindrone/EE 1.5/30
Loestrin 1.5/30
GL
norgestrel/EE 0.3/30
Low-Ogestrel
GL
ethynodiol/EE 1/35
Zovia 1/35
GL
norethindrone/EE 0.5/35
Modicon
GL
norethindrone/EE 1/35
Ortho-Novum 1/35
GL
norgestimate/EE 0.25/35
Ortho-Cyclen
GL
ethynodiol/EE 1/50
Zovia 1/50
GL
Ob-Gyn
anti infectives - vaginal
antivirals
contraceptives - monophasic
OTC
OTC
PA QL AL
Version Date: March 1, 2015
24
Amerigroup Medication Formulary
Nevada
norethindrone/ME 1/50
Necon 1/50
GL
desogestrel/EE
Mircette
GL
norethindrone/EE
Necon 10/11
GL
desogestrel/EE
Velivet
GL
levonorgestrel/EE
Trivora
GL
norethindrone/EE
Ortho-Novum 7/7/7
GL
norethindrone/EE
Tri-Norinyl
GL
norgestimate/EE
Ortho Tri-Cyclen
GL
norelgestromin/ethinyl estradiol patch
Ortho Evra
GL
etonogestrel/EE vaginal ring
NuvaRing
GL
norethindrone
Micronor
GL
medroxyprogesterone inj
Depo-Provera Injection
GL
contraceptive device
condoms
various
QL
hormone replacement therapy
conjugated estrogens/medroxyprogesterone
Premphase, Prempro
PA GL
estradiol
Estrace
GL
estradiol-transdermal
Climara
PA GL
estrogens, conjugated
Premarin
GL
estrogens, conjugated crm
Premarin Vaginal Crm
GL
estrogens, conjugated synthetic
Cenestin
PA GL
estrogens, esterifed
Menest
GL
estropipate
Ogen
GL
ethinyl estradiol/norethindrone
Femhrt
GL
medroxyprogesterone
Provera
GL
norethindrone
Aygestin
GL
Progesterone (cap)
Prometrium
GL
levonorgestrel
Next-Choice
QL OTC GL
levonorgestrel
Plan B One-Step
QL OTC GL
methylergonovine
Methergine
GL
contraceptives - biphasic
contraceptives - triphasic
contraceptives - miscellaneous
miscellaneous
Version Date: March 1, 2015
25
Amerigroup Medication Formulary
Nevada
Ophthalmics
allergy
anti-infectives
anti-inflammatory/steroids
cromolyn sodium
Opticrom
QL
ketotifen
Alaway
QL OTC only
olopatadine
Patanol
QL ST
bacitracin
bacitracin
QL OTC
bacitracin/polymyxin B
bacitracin/polymyxin B
QL
ciprofloxacin solution
Ciloxan solution
QL
erythromycin
Ilotycin
QL
ganciclovir
Zirgan
QL PA
gatifloxacin 0.5%
Zymaxid
PA
gentamicin
Gentak
QL
moxifloxacin
Moxeza
PA
neomycin/polymyxin B/dexamethasone
Maxitrol
QL
neomycin/polymyxin B/gramicidin
Neosporin
neomycin/polymyxin/ hydrocortisone
neomycin/polymyxin/ hydrocortisone
ofloxacin
Ocuflox
polymyxin B/trimethoprim
Polytrim
sulfacetamide 10%
Bleph-10
sulfacetamide/prednisolone phosphate
sulfacetamide/prednisolone phosphate
tobramycin solution
Tobrex
tobramycin/dexamethasone drops
TobraDex
trifluridine
Viroptic
dexamethasone sodium phosphate
dexamethasone sodium phosphate
diclofenac 0.1% gel
Voltaren
fluorometholone
FML
flurbiprofen
Ocufen
ketorolac 0.5%
Acular
QL
loteprednol 0.5%
Lotemax
PA
prednisolone acetate 0.12%
Pred Mild
PA
prednisolone acetate 1%
Pred Forte
prednisolone phosphate 1%
prednisolone phosphate 1%
rimexolone
Vexol
QL
QL PA
PA
Version Date: March 1, 2015
26
Amerigroup Medication Formulary
Nevada
glaucoma agents
miscellaneous ophthalmics
Otic Agents
apraclonidine
Iopidine
brimonidine 0.15%, 0.2%
Alphagan
QL
QL
carteolol
Carteolol HCL Ophth Soln 1%
QL
dorzolamide
Trusopt
QL
dorzolamide/timolol
Cosopt
QL
latanoprost
Xalatan
QL
levobunolol
Betagan
QL
metipranolol
Metipranolol Ophth Soln 0.3%
QL
pilocarpine
Isopto Carpine
QL
timolol hemihydrate
Betimol
QL PA
timolol maleate solution
Timoptic solution
QL
cyclosporine emulsion
Restasis
PA
artifical tears ointment
artifical tears ointment
Generic
acetic acid/aluminum acetate
Domeboro
QL
benzocaine/antipyrine
Aurodex, misc gen
carbamide peroxide 6.5%
Debrox
OTC
ofloxacin
ofloxacin
QL
neomycin/polymyxin B/HC
Cortisporin Otic
atomoxetine
Strattera
QL AL PA
amphetamine/dextroamphetamine/mixed salts
Adderall
QL AL
amphetamine/dextroamphetamine/mixed salts
Adderall XR
QL AL
dexmethylphenidate
Focalin
QL AL
dextroamphetamine
Dexedrine tab
QL AL
dextroamphetamine ext-rel
Dexedrine Spansules
QL AL
dextroamphetamine sulfate
Zenzedi
PA
lisdexamfetamine
Vyvanse
QL PA
methylphenidate tab
Ritalin, Ritalin SR
QL AL
methylphenidate ext-rel
Concerta
QL AL
Psychotherapeutic Agents
ADD/ADHD
Version Date: March 1, 2015
27
Amerigroup Medication Formulary
Nevada
alcohol deterrents
antidepressants-miscellaneous
antidepressants - SSRI and SNRI
antidepressants-tricyclic
methylphenidate ext-rel
Metadate CD
QL AL
disulfiram
Antabuse
QL
acamprosate
Campral
naltrexone
ReVia
QL
bupropion
Wellbutrin
QL
bupropion sust & ext release
Wellbutrin SR & XL
QL
doxepin
doxepin
QL
isocarboxazid
Marplan
QL
maprotiline
Ludiomil
QL
mirtazapine
Remeron
QL
phenelzine
Nardil
QL
tranylcypromine
Parnate
QL
trazodone
Desyrel
QL
citalopram
Celexa
QL
fluoxetine
Prozac
QL
fluvoxamine
Luvox
QL
paroxetine
Paxil
QL
sertraline
Zoloft
QL
venlafaxine
Effexor
QL
venlafaxine XR
Effexor XR
QL
amitriptyline
Elavil
QL
amitriptyline/perphenazine
Etrafon
QL
amoxapine
Asendin
QL
chlordiazepoxide/amitriptyline
Limbitrol
QL
desipramine
Norpramin
QL
imipramine
Tofranil
nortriptyline
Pamelor
protriptyline
Vivactil
trimipramine
Surmontil
QL
Version Date: March 1, 2015
28
Amerigroup Medication Formulary
Nevada
antipsychotics - atypical orals
antipsychotics - atypical injectables
antipsychotics - typical
anxiolytics
carbamazepine
Equetro
QL AL
clozapine (except 200mg)
Clozaril
QL AL
olanzapine
Zyprexa
QL AL
paliperidone
Invega Sustenna
QL AL
quetiapine
Seroquel
QL AL
quetiapine fumarate tab SR 24HR
Seroquel XR
QL AL ST
risperidone
Risperdal
QL AL
ziprasidone
Geodon
QL AL
olanzapine
Zyprexa Relprevv
QL AL
risperidone
Risperdal Consta
QL AL
chlorpromazine tabs, inj
Thorazine
QL
fluphenazine
Prolixin
QL
fluphenazine decanoate inj
fluphenazine decanoate inj
QL
haloperidol tabs, inj
Haldol
QL
lithium carbonate
Eskalith
QL
lithium carbonate ext-rel tabs
Lithobid
QL
loxapine
Loxitane
QL AL
perphenazine
Trilafon
QL AL
pimozide
Orap
QL AL PA
prochlorperazine inj
prochlorperazine inj
thioridazine
Mellaril
QL
thiothixene
Navane
QL
trifluoperazine
Stelazine
QL
alprazolam
Xanax
QL
buspirone
buspirone
QL
chlordiazepoxide
Librium
QL
clorazepate
Tranxene T-Tab
QL
clonazepam
Klonopin
QL
diazepam
Valium
QL
hydroxyzine hcl
hydroxyzine HCl
QL
Version Date: March 1, 2015
29
Amerigroup Medication Formulary
Nevada
opioid antagonists
smoking cessation
hydroxyzine pamoate
Vistaril
QL
lorazepam
Ativan
QL
midazolam
midazolam
QL PA
oxazepam
Serax
QL
sertraline
Zoloft
QL
venlafaxine ER
Effexor XR
QL
buprenorphine
Subutex
QL
buprenorphine hcl - naloxone hcl
Suboxone SL tab
QL PA
bupropion SR
Zyban
QL
nicotine transdermal patches
Nicoderm CQ
QL OTC
nicotine polacrilex gum, lozenges
Nicorette
QL OTC
varenicline
Chantix
QL PA
cyproheptadine
Periactin
QL
diphenhydramine
Benadryl
QL OTC
fexofenadine (except ODT)
Allegra tablets and solution 30mg/5ml
QL OTC AL
hydroxyzine hcl
Atarax
QL
hydroxyzine pamoate
Vistaril
QL
loratadine
Claritin tabs, syrup, RediTabs
QL OTC
albuterol, CFC-free
Ventolin HFA
QL
albuterol, CFC-free
ProAir HFA
QL
salmeterol
Serevent Diskus
QL
albuterol
albuterol tabs, syrup
QL
metaproterenol syrup
Alupent
QL
terbutaline
terbutaline
QL
dornase alfa
Pulmozyme
X
Respiratory
antihistamines
beta agonists, inhaled
beta agonists, oral
cystic fibrosis
Version Date: March 1, 2015
30
Amerigroup Medication Formulary
Nevada
tobramycin for inhalation
Tobi Nebule
X
ipratropium, CFC-free aerosol
Atrovent HFA
QL
ipratropium/albuterol
Combivent Respimat
QL AL
tiotropium
Spiriva
QL
AeroChamber
AeroChamber
QL
E-Z Spacer
E-Z Spacer
QL
EasiVent
EasiVent
QL
InspirEase
InspirEase
QL
MicroChamber
MicroChamber
QL
budesonide
Pulmicort Flexhaler
QL
beclomethasone
QVAR HFA
QL
fluticasone, CFC-free aerosol
Flovent HFA
QL
fluticasone
Flovent Diskus
QL
mometasone furoate
Asmanex Twisthaler
QL
salmeterol/fluticasone
Advair Diskus
QL ST
salmeterol/fluticasone, CFC-free
Advair HFA
QL ST
montelukast
Singulair
PA QL
montelukast
Singulair Granules
QL AL< 2 or PA
zafirlukast
Accolate
PA QL
miscellaneous
omalizumab
Xolair
PA X
nasal inhalers
azelastine
Astelin
PA QL
flunisolide
Nasalide
QL
fluticasone
Flonase
QL
ipratropium spray
Atrovent nasal spray
QL
triamcinolone
Nasacort Allergy 24 HR
OTC
inhaled, misc
inhalation delivery devices
inhaled steroids
inhaled steroid combination
leukotriene receptor antagonists
Version Date: March 1, 2015
31
Amerigroup Medication Formulary
Nevada
nebulizer solutions
theophylline
albuterol
AccuNeb
QL
budesonide
Pulmicort Respules
QL AL < 5
cromolyn soln
Intal
QL
ipratropium soln
ipratropium soln
QL
ipratropium/albuterol
Duoneb
QL
sodium chloride 0.9%
sodium chloride 0.9%
QL
theophylline ext-rel tab
Theochron
QL
theophylline elixir
Elixophyllin
QL
theophylline ext rel capsule
Theo-24
QL
alfuzosin
Uroxatral
doxazosin
Cardura
finasteride
Proscar
GL
tamsulosin
Flomax
GL
terazosin
Hytrin
bethanechol
Urecholine
QL
flavoxate
Urispas
QL
oxybutynin, oxybutynin ext-release
Ditropan, Ditropan XL
QL
oxybutynin transdermal patch
Oxytrol
OTC
calcitriol
Rocaltrol
calcium products (for osteoporosis)
calcium
QL
cyanocobalamin tab,lozenge, inj
B-12
OTC & RX
ergocalciferol
Calciferol
PA
ferrous sulfate
generic tabs, drops, elix
OTC & RX
fluoride drops, tabs
Luride
folic acid
folic acid
QL
folic acid/vitamin B complex w/C
Nephrocaps
QL
iron/B-12/vit C/intrinsic factor
iron/B-12/vit C/intrinsic factor
QL
iron/B-12/vit C/intrinsic factor/FA
iron/B-12/vit C/intrinsic factor/FA
QL
levocarnitine cap
L-Carnitine
QL
Urologicals
BPH
miscellaneous
Vitamins/Supplements
Version Date: March 1, 2015
32
Amerigroup Medication Formulary
Nevada
Miscellaneous Agents
multivit./ferrous fumarate/FA
Vitafol tab
QL
multivit./ferrous fumarate/FA
Vitafol liquid
QL
multivitamins (oral generic)
various
QL OTC & RX
multivitamins w/iron
various
QL OTC & RX
paricalcitol
Zemplar
QL ST
pentosan polysulfate sodium
Elmiron
QL PA
phenazopyridine
Pyridium
QL
potassium bicarb/citrate efferv tabs
potassium bicarb/citrate efferv tabs
QL
potassium chloride ext-rel tabs, liquid, powder
various
QL
potassium citrate ER
Urocit-K
potassium/sodium acid phosphate
K-Phos Neutral
QL
prenatal vitamins (generic )
various
GL QL OTC & RX
prenatal vitamins (kosher)
Nestabs
QL
vitamin A D C/fluoride/ w/ or w/o iron
vitamin A D C/fluoride/ w/ or w/o iron
QL
vitamin B
various
QL
vitamin C
various
vitamin D
various
QL
vitamin E
various
QL
vitamin K
Mephyton
QL
epinephrine inj
EpiPen, EpiPen Jr
QL
Version Date: March 1, 2015
33