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Updated October 1, 2018 of 48

Title 19/21 SMI Integrated Drug List Updated October 1, 2018

Formulary | Preferred Drug List

Updated October 1, 2018 2

What is the Mercy Care Preferred Drug List? A Preferred Drug List is a list of drugs chosen by Mercy Care and a team of doctors and pharmacists. Mercy Care will generally cover drugs listed in our Preferred Drug List as long as they are medically necessary. Prescriptions must also be filled at a Mercy Care network pharmacy, and other plan rules must be followed. The Preferred Drug List begins on page 4. It gives you information about the drugs covered by Mercy Care. The first column of the chart lists the drug that is covered by the plan. Brand name drugs are capitalized (e.g., AMOXIL). Generic drugs are listed in lower case (e.g., amoxicillin). The second column serves as a reference for providing the brand or generic name of the covered drug. The third column lists any requirements for the drug such as prior authorization (PA), quantity limits (QLL), step therapy (ST), Age restrictions (AGE), and other information. Injectable medications require prior authorization unless otherwise noted on the Preferred Drug List.

Can the Preferred Drug List change? Yes, Mercy Care may add or take off drugs during the year. To get the latest information about covered drugs, visit our website, www.MercyCareAZ.org, or call Member Services at 1-800-564-5465 or TTY 711.

How do I use the Preferred Drug List? The Preferred Drug List begins on page 4. Drugs are grouped depending on the type of medical conditions they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Medications.” If you know what your drug is used for, look for the category name in the list that begins on page 18. Then look under the category name for your drug.

Are there any other restrictions on coverage? Some drugs may have additional requirements or limits on coverage. These may include:

Prior Authorization: Mercy Care may require prior authorization for certain drugs on the Preferred Drug List. This means that your doctor will need to get approval from us before you can fill some of your prescriptions. If approval isn’t given, Mercy Maricopa Integrated Care will not cover the drug.

Quantity Limits: For certain drugs, Mercy Care limits the amount of the drug it will cover. For example, we provide 60 pills in 30 days per prescription for Lisinopril 40 mg. Please refer to the quantity limit levels list at the end of this document.

Step Therapy: In some cases, Mercy Care requires you to try certain drugs first to treat your medical condition before we will cover another drug for that same condition. For example, if Drug A and Drug B both treat your medical condition, Mercy Care may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the third column of the list. All brand-named drugs are subject to non-formulary status when generics are available.

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Key:

Abbreviations: Cap = Capsule PA – Prior Authorization required Chew = Chewable QLL – Quantity Limit Levels apply Conc = Concentrate SL = Sublingual DR = Delayed Release SOLN = Solution Elix = Elixir SR = Sustained Release ER = Extended Release Susp = Suspension IM = Intermuscular Syr = Syrup INJ = Injectable STEP = Step Therapy IR = Immediate Release Tab = Tablet LA = Long Acting TD = Transdermal ODT = Oral Disintegrating Tablet XL = Extended Release

What if my drug is not on the Preferred Drug List? If your drug is not on this Preferred Drug List, you should first call your doctor and ask if your drug is covered. If we do not cover it, you have two options: Ask your doctor to prescribe a similar drug that is covered. Your doctor can ask Mercy Care to make an exception and cover your drug through the prior authorization

process.

What are generic drugs? Mercy Care covers both brand name and generic drugs. Generic drugs usually cost less and are approved by the Food and Drug Administration (FDA). Generic drugs are listed in lower-case (e.g., amoxicillin). Brand name drugs are capitalized (e.g., AMOXIL).

Mail order pharmacy service You can use our network mail order pharmacy service, CVS Caremark, to fill prescriptions for what are called “maintenance” drugs. These are drugs that you take on a regular basis for a chronic or long-term medical condition. These are the only drugs available through our mail order service. For more information on mail order pharmacy services, call Member Services.

For more information For more detailed information about your Mercy Care prescription drug coverage, please review your Member Handbook. If you have questions about Mercy Care, please call Member Services at 1-800-564-5465. Or visit www.MercyCareAZ.org.

http://www.mercycareaz.org/



COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS

ANESTHETICS

TOPICAL ANESTHETICS

Aspercreme with lidocaine 4%

lidocaine hcl topical cream 4% ST

Lidocaine gel 2%

lidocaine ointment 5% PA, QLL=90 grams/ 30 days

Lidocaine solution 4%

lidocaine hcl viscous 2% Xylocaine

lidocaine-prilocaine topical Emla

lidocaine 5% Topical Patch Lidoderm PA, QLL=90 patches/30 days

ANTIINFECTIVES

CEPHALOSPORINS

Cefaclor Ceclor

Cefadroxil Duricef

cefdinir Omnicef

cefpodoxime proxetil Vantin

cefprozil Cefzil

cefuroxime Ceftin

cephalexin 250mg, 500mg Keflex

ceftriaxone Rocephin

cefuroxime axetil Ceftin

cefixime 100mg/ 5ml and 200mg/ 5ml Suprax

SUPRAX 400mg QLL= 1/ 30 days

CLINDAMYCINS

clindamycin Cleocin

ERYTHROMYCINS

erythromycin w/sulfisoxazole Pediazole

OTHER MACROLIDES

azithromycin Zithromax

clarithromycin, er Biaxin, Biaxin XL

PENICILLINS

amox tr-potassium clavulanate Augmentin

amoxicillin Amoxil

ampicillin Principen

dicloxacillin

penicillin v potassium Veetids

SULFONAMIDES

sulfamethoxazole/trimethoprim Septra

Sulfadiazine




TETRACYCLINES

demeclocycline

doxycycline hyclate tablets 20mg and 100mg capsules

doxycycline hyclate capsules 50mg and 100mg

doxycycline monohydrate capsules 50mg and 100mg

minocycline hcl capsules Minocin

URINARY ANTIINFECTIVES

nitrofurantoin (25mg only) Macrodantin (25mg only)

methenamine hippurate

nitrofurantoin macrocrystal Macrodantin

nitrofurantoin suspension 25mg/ml Furadantin

Trimethoprim

QUINOLONES

ciprofloxacin oral suspension Cipro Oral Suspension QLL=250mg/5ml:1bottle/fill

ciprofloxacin hcl Cipro

ofloxacin Floxin

Levofloxacin Levaquin

TOPICAL ANTIBACTERIAL DRUGS

bacitracin ointment

bacitracin/polymyxin B Polysporin

erythromycin Eryderm

gentamicin sulfate Genoptic

mupirocin ointment, cream Bactroban

neomycin/bacitracin/polymyxin B Neosporin

silver sulfadiazine Silvadene

sulfacetamide sodium Ovace

ORAL ANTIFUNGAL DRUGS

clotrimazole troche Mycelex

Fluconazole suspension, tab Diflucan

griseofulvin microsize Grifulvin V

Nystatin tab, suspension Mycostatin

terbinafine Lamisil QLL= 90/ 365 days

VAGINAL ANTIFUNGALS

clotrimazole Mycelex

nystatin ointment, cream Mycostatin

terconazole Terazol

OTHER TOPICAL ANTIFUNGALS




Butenafine cream

Ciclopirox cream, suspension, solution

Loprox/Penlac

clotrimazole Lotrimin

Ketoconazole cream, shampoo Nizoral

miconazole

Nystatin ointment, cream, powder Mycostatin

terbinafine Lamisil

tolnaftate

TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB.

clotrimazole/betamethasone lotion Lotrisone

ANTIRETROVIRALS & PROTEASE INHIBITORS

abacavir tablet, solution Ziagen

abacavir Sulfate-lamivudine-zidovudine 300mg-150mg-300mg

Trizivir

abacavir sulfate-lamivudine tablets EPZICOM

APTIVUS

atazanavir tabs REYATAZ

ATRIPLA

BIKTARVY

COMPLERA

CRIXIVAN

DESCOVY

didanosine Videx EC

EDURANT

efavirenz SUSTIVA

EMTRIVA

EVOTAZ

Fosamprenavir LEXIVA

FUZEON COVERED FOR ID SPECIALISTS; ALL OTHERS REQUIRE PA

GENVOYA

INTELENCE

INVIRASE

ISENTRESS tabs, chew tabs, suspension

ISENTRESS HD tabs

JULUCA QLL=30/30days

KALETRA tabs

lopinavir/ritonavir 80mg/20mg Kaletra solution




solution

lamivudine 100mg, 150mg, 300mg Epivir, HBV

lamivudine oral solution Epivir

lamivudine-zidovudine 150mg-300mg Combivir

nevirapine tablets, oral suspension Viramune

ODEFSEY

NORVIR capsules, solution, powder

PREZISTA tablets, oral suspension

PREZCOBIX

RESCRIPTOR

REYATAZ powder suspension

ritonavir 100mg tablet NORVIR

SELZENTRY

stavudine Zerit

STRIBILD

SYMFI QLL = 30/30 days

SYMFI LO QLL = 30/30 days

SYMTUZA QLL = 30/30 days

tenofovir tab VIREAD

TIVICAY

TRIUMEQ

TRUVADA QLL= 30/ 30 days

TYBOST QLL:30/30 days

VIDEX ORAL SOLUTION

VIRACEPT

VIRAMUNE XR

VITEKTA

Zidovudine

OTHER ANTIINFECTIVE DRUGS

atovaquone suspension Mepron PA

CLEOCIN (100 MG VAGINAL OVULE)

Dapsone

vancomycin capsules Vancocin pulvules PA

First vancomycin oral solution compound kit 25mg, 50mg

FIRVANQ solution 25mg/50ml,50mg/ml

Vancomycin solution

linezolid Zyvox PA

OTHER ANTIVIRAL DRUGS




acyclovir Zovirax

acyclovir 5% ointment Zovirax ointment ST, QLL= 15gm/ 30 days

adefovir dipivoxil Hepsera PA

amantadine hcl Symmetrel

BARACLUDE solution Entecavir QLL = 600ml/30days

Entecavir tab Baraclude QLL = 30/ 30 days

EPIVIR HBV 100mg tab, oral solution

famciclovir Famvir

foscarnet injection Foscavir PA

ganciclovir Cytovene PA

INFERGEN PA

INTRON A PA

MAVYRET AHCCCS Preferred Drug PA

PEG-INTRON (SUBCUTANE) PA

PEGASYS PA

PEGASYS PROCLICK (SUB Q) PA

PEGASYS SYRINGE (SUB Q) PA

PEGASYS VIAL (SUBCUTANE) PA

rimantadine Flumadine

RELENZA QLL/Rx=20 inhalation diskus/Rx

Ribavirin tablet, capsule PA

oseltamivir

Tamiflu

QLL/Rx=75mg: 10 capsules /Rx 45mg: 10 capsules /Rx 30mg: 20 capsules/Rx

6mg/ml oral suspension 3 bottles/Rx

TYZEKA COVERED FOR GASTROENTEROLOGISTS OR ID SPECIALISTS; ALL OTHERS

REQUIRE PA

valacyclovir

Valtrex QLL=500 mg: 60/30 days; 1 gram:30/30 days

VEMLIDY QLL = 30/30days

valganciclovir Valcyte PA, QLL = 60/30 days

cidofovir injection Vistide Injection PA

ANTITUBERCULOSIS DRUGS

ethambutol Myambutol

iIsoniazid Nydrazid

isoniazid-rifampin Isonarif, Rifamate

PRIFTIN




Pyrazinamide

rifabutin Mycobutin

rifampin Rifadin

AMEBICIDES

YODOXIN

ANTHELMINTICS

Albenza STEP

Mebendazole

ivermectin Stromectol

pyrantel pamoate Reese’s Pinworm Medicine

Praziquantel Biltricide

PLASMODICIDES

atovaquone-proguanil Malarone

chloroquine phosphate Aralen

COARTEM

DARAPRIM PA

hydroxychloroquine sulfate Plaquenil

mefloquine Lariam

primaquine

quinine sulfate Qualaquin

TRICHOMONOCIDES

metronidazole Flagyl

AMINOGLYCOSIDES

neomycin

paromomycin

tobramycin Tobi PA

ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS MEDICATIONS WITHIN THIS CLASS ARE COVERED FOR FDA APPROVED INDICATIONS AND MAY REQUIRE PRIOR AUTHORIZATION. ALL

INJECTABLE MEDICATIONS WITHIN THIS CLASS REQUIRE PRIOR AUTHORIZATION.

ACTIMMUNE PA

AFINITOR PA

AFINITOR DISPERZ PA

ALFERON N PA

melphalan ALKERAN TABS

anastrozole Arimidex

azathioprine Imuran

BEXAROTENE PA

bicalutamide Casodex

CABOMETYX PA, QLL= 30/ 30 days

capecitabine Xeloda PA, QLL = 150mg:140/21days;




500mg:154/ 21 days

CAPRELSA PA

CELLCEPT INJECTION PA

cyclophosphamide Cytoxan PA (INJECTABLE ONLY)

cyclosporine Neoral PA (INJECTABLE ONLY)

DEPO-PROVERA 400mg/ml (INJ) PA

ELIGARD (INJ) PA

ENBREL AHCCCS Preferred Drug, PA

ETOPOSIDE CAPSULES PA

exemestane Aromasin

fluorouracil Adrucil PA (INJECTABLE ONLY)

FARESTON PA

flutamide

Imatinib Gleevec PA

HUMIRA AHCCCS Preferred Drug, PA

hydroxyurea Hydrea

IMBRUVICA PA

INCLUSIG PA

INLYTA PA

IRESSA PA

JAKAFI PA

leflunomide Arava

letrozole Femara

leucovorin tablets

LEUPROLIDE PA

LUPRON Depot PA

MATULANE PA

megestrol acetate Megace

mercaptopurine Purinethol

MESNEX TABLETS ONLY

methotrexate 2.5mg Tab Trexall

methotrexate INJ QLL= 4 vials/ 30 days

mycophenolate mofetil Cellcept

mycophenolic Acid 180mg & 360mg Delayed-Release

Myfortic

mitoxantrone [INJ] Novantrone PA

NEXAVAR PA

octreotide Sandostatin PA

REVLIMID PA

Sandostatin LAR PA




sirolimus Rapamune

SPRYCEL PA, QLL=30/30days

STIVARGA PA

SUTENT PA

SYLATRON PA

TABLOID

tacrolimus Prograf

tamoxifen citrate Nolvadex

TARCEVA PA

TASIGNA PA, QLL = 50mg:120/30

THALOMID PA

tretinoin Vesinoid

TYKERB PA

VELCADE PA

VERZENIO PA, QLL = 60/30days

VOTRIENT PA

XALKORI PA

ZELBORAF PA

ZOLADEX [INJ] PA

ZOLINZA COVERED FOR ONCOLOGISTS; ALL OTHERS REQUIRE PA

AUTONOMIC AND CNS MEDICATIONS

ANALGESICS

acetaminophen Tylenol OTC

aspirin, enteric-coated aspirin

buffered aspirin Bufferin, Ascriptin

BUTRANS patch AHCCCS Preferred Drug, PA

enteric-coated aspirin Ecotrin

tramadol hcl Ultram Age <16 requires PA

tramadol hcl-acetaminophen Ultracet QLL= 4 grams APAP/day

VICOSUPPLEMENTS

HYALGAN PA

GEL-ONE PA

CLASS II NARCOTICS (Short Acting Opioids limited to 5 day supply for children < 18 and opioid naïve adults)

EMBEDA AHCCCS Preferred Drug, PA

fentanyl patches (12.5mcg, 25mcg, 50mcg, 75mcg, & 100mcg)

Duragesic AHCCCS Preferred Drug, PA

fentanyl lozenges Actiq PA

hydrocodone-acetaminophen Vicodin, Lortab




hydrocodone bit-ibuprofen Vicoprofen

hydromorphone hcl tab Dilaudid

meperidine Demerol

morphine sulfate IR tabs, suppositories

Various

morphine sulfate ER tablets MS Contin AHCCCS Preferred Drug, PA

oxycodone-acetaminophen Percocet

oxycodone-aspirin

oxycodone hcl Oxyir

Tramadol ER tablet AHCCCS Preferred Drug, PA

XTAMPZA ER AHCCCS Preferred Drug, PA

CLASS III NARCOTICS

acetaminophen-codeine Tylenol #3 QLL= 4 grams APAP/ day

butalbital/aspirin/caffeine with codeine

Fiorinal with Codeine QLL= 240/30 days

DRUGS TO PREVENT AND TREAT HEADACHES

butalbital/acetaminophen/caffeine Esgic/Fioricet/Triad

butalbital/aspirin/caffeine Fiorinal, Fortabs QLL= 180/30 days

CAFERGOT

dihyrdoergotamine nasal spray Migranal QLL=8 units/ 30 days

ergoloid mesylates Hydergine

ERGOMAR

MIGERGOT Suppository QLL = 12/30days

naratriptan AMERGE QLL= 9/30 days

rizatriptan tablets, ODT Maxalt QLL= 9/30 days

sumatriptan Imitrex QLL= 6 nasal sprays/ 30 days; 9 tabs/ 30 days

sumatriptan INJ, cartridge Imitrex QLL=2/ 30 days

Zolmitriptan tabs, ODT ZOMIG QLL= 9/30 days

ANXIOLYTICS

alprazolam IR Xanax QLL= 0.25mg, 0.5mg and 1mg:120/30days; 2mg: 60/30 days

alprazolam intensol solution QLL= 120 ml/30 days

alprazolam ODT QLL= 0.25mg, 0.5mg and 1mg:120/30days;2mg: 60/30 days

alprazolam XR XanaxXR QLL= 0.5mg, 1mg, 2mg and 3mg:30/30 days

buspirone hcl Buspar QLL = 5mg, 7.5mg, 10mg, 15mg:120/30days; 30mg:60/30days

chlordiazepoxide hcl Librium QLL = 60/ 30days




clorazepate dipotassium Tranxene T-Tab QLL= 3.75mg and 7.5mg:120/30 days; 15mg: 60/30days

diazepam 2.5 mg, 10 mg, 20 mg rectal gel

Diastat QLL = 2 applicators (1box) /fill

diazepam Valium QLL= 120/ 30days

diazepam intensol Diazepam Intensol QLL= 240ml/ 30 days

lorazepam Ativan QLL= 0.5mg and 1mg: 120/30days; 2mg:60/30days

lorazepam intensol Lorazepam Intensol QLL=60ml/30 days

oxazepam Serax QLL= 60/30days

SEDATIVE/HYPNOTIC DRUGS

Temazepam 15mg and 30mg Restoril QLL= 30/30 days

ROZEREM ramelteon ST, QLL=30/30

zolpidem tabs

Ambien

QLL=5mg:60/30 days; 10mg:30/30 days

ANTIMANIA DRUGS

lithium carbonate Eskalith/CR

lithium carbonate ER Tab Lithobid

lithium oral solution

CARBAMAZEPINES

carbamazepine, ER Tab Epitol, Tegretol Tegretol XR

carbamazepine ER Cap Carbatrol, Equetro

oxcarbazepine tablets, suspension Trileptal

carbamazepine XR TEGRETOL XR

ANTICONVULSANT/BENZODIAZEPINES

clonazepam tab Klonopin QLL= 0.5mg and 1mg: 120/30 days; 2mg: 60/30 days

clonazepam ODT Klonopin ODT QLL=0.25mg,0.5mg,1mg:120/30 days; 2mg: 60/30 days

HYDANTOINS

phenytoin sodium, ER Dilantin, ER, infatabs

DILANTIN 30 MG EXTENDED RELEASE

phenytoin extended release capsules Phenytek

VALPROIC ACID AND DERIVATIVES

divalproex Depakote

divalproex sodium ER, delayed-release

Depakote ER, Delayed-Release

valproic acid Depakene

ANTICONVULSANT BARBITURATES




Phenobarbital

primidone Mysoline

OTHER ANTICONVULSANTS

BANZEL PA

CELONTIN

Ethosuximide

felbamate Felbatol

gabapentin Tab, Cap, Soln Neurontin Cumulative maximum daily dose = 3600mg/day

HORIZANT gabapentin ER Tab PA Cumulative maximum daily dose =

3600mg/day

GRALISE gabapentin Tab PA Cumulative maximum daily dose =

3600mg/day

GABITRIL 12 mg, 16 mg QLL= 60/30 days

lamotrigine Lamictal

lamotrigine ER Tab Lamictal XR

levetiracetam, -ER Keppra, Keppra XR

LYRICA PA

gabapentin solution Neurontin Solution

ONFI PA

tiagabine 2 mg, 4 mg Gabitril QLL= 60/30 days

topiramate Topamax

VIMPAT PA

zonisamide Zonegran

ANTIDEPRESSANTS

ALPHA-2 RECEPTOR ANTAGONISTS

Mirtazapine, - ODT Remeron Remeron SolTab

QLL =30/30 days

MONOAMINE OXIDASE INHIBITORS (MAOIs)

EMSAM seligilene COVERED FOR NEUROLOGIST; ALL

OTHERS REQUIRE PA

Isocarboxazid Marplan

phenelzine sulfate Nardil

tranylcypromine sulfate Parnate

NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIBITORS (NDRIs)

bupropion SR Wellbutrin SR QLL= 60/30days

bupropion IR Wellbutrin,

QLL= 120/30 days




bupropion XL Wellbutrin XL QLL= 30/30 days

TRICYCLIC ANTIDEPRESSANTS & RELATED NON-SELECTIVE REUPTAKE INHIBITORS

amitriptyline hcl tab Elavil

amoxapine

Clomipramine Anafranil

desipramine hcl tab Norpramin

doxepin hcl cap, Conc Sinequan Capsule QLL= 90/30 days; Soln=180ml/30days

imipramine hcl Tab, Cap Tofranil

maprotiline hcl Various

nortriptyline hcl Cap, Soln Pamelor

protriptyline hcl Vivactil

trimipramine Surmontil

SELECTIVE SEROTONIN REUPTAKE INHIBITORS

citalopram Tab, Soln Celexa QLL= 60/30 days Solution QLL= 600 ml/ 30 days

escitalopram Tab, Soln Lexapro QLL= 10mg,20mg: 30/30days; 5mg= 60/30 days

Solution QLL= 600 ml/ 30 days

fluoxetine hcl Cap, Soln Prozac QLL= 10mg:60/30days; 20 mg = 120/30 days;

40 mg= 60/30 days Soln=600ml/30 days

fluoxetine hcl DR Cap Prozac Weekly PA, QLL= 1 pkg/ 28days

fluvoxamine maleate Luvox QLL=100mg: 90/30 days; 50mg:180/30 days; 25mg:60/30 days

fluvoxamine maleate ER Cap Luvox CR QLL= 100mg:90/30 days; 150mg:60/30days

paroxetine hcl Tab

Paxil

QLL= 30/30 days except for 40mg:45/30 days

paroxetine ER Paxil CR QLL=90/30 days

PAXIL Suspension paroxetine QLL = 900ml/30days

PEXEVA

PA QLL= 10 mg:180/ 30days

20 mg:90/ 30days 30 mg: 60/ 30days




40 mg:45/ 30days

sertraline hcl Soln, Tab

Zoloft

QLL= 25mg:90/30 days; 50mg:120/30days;

100 mg= 60/30days; Soln:300ml/30days

VIIBRYD, VIIBRYD starter pack PA

SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIs)

nefazodone QLL=50mg, 100mg, 250mg:60/30days; 150mg:120/30days; 200mg:90/30days

trazodone hcl Desyrel QLL= 50mg:90/30days; 100mg:120/30days; 150mg:60/30days 300mg:30/30days

SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)

desvenlafaxine Pristiq QLL= 120/ 30days

duloxetine 20mg, 30mg and 60mg only

Cymbalta QLL= 20mg,30mg: 120/30 days; 60mg:60/30days

SAVELLA ST

venlafaxine hcl Tab venlafaxine hcl QLL= 25mg:120/30days; 37.5mg, 50mg, 100mg:90/30days;

75mg:150/30days

venlafaxine hcl ER , Cap Effexor ER QLL= 37.5mg, 75mg: 90/30days; 150mg:30/30days

ANTIPSYCHOTICS Covered for RBHA Providers, All others require PA, PA Required for child < 6

FIRST GENERATION ANTIPYSYCHOTICS

haloperidol tab, Susp Haldol

haloperidol decanoate Haldol Suspension for Injection

loxapine succinate Loxitane

pimozide Orap

thiothixene Navane

SECOND GENERATION ANTIPSYCHOTICS

Aripiprazole tablets, ODT tablet Abilify AHCCCS Preferred Drug QLL = 30/30 days

Aripiprazole solution AHCCCS Preferred Drug QLL = 150ml/30days




ABILIFY MAINTENA AHCCCS Preferred Drug PA for <18 years of age

QLL = 1/28 days

ARISTADA AHCCCS Preferred Drug PA for <18 years of age

QLL = 1/28 days; 1064mg = 1/56 days

ARISTADA INITIO AHCCCS Preferred Drug PA for <18 years of age

QLL = 2/365 days

clozapine Tab Clozaril AHCCCS Preferred Drug PA for <18 years of age

QLL= 150/30 days

clozapine ODT Tab FazaClo AHCCCS Preferred Drug PA for <18 years of age

QLL= 150/ 30 days

INVEGA SUSTENNA AHCCCS Preferred Drug PA for <18 years of age

QLL = 1/28 days

INVEGA TRINZA AHCCCS Preferred Drug PA for <18 years of age

QLL = 1/84 days

LATUDA AHCCCS Preferred Drug QLL = 30/30days

olanzapine Zyprexa AHCCCS Preferred Drug QLL= 5mg, 10mg: 60/30 days;

15mg, 20mg: 30/30days

olanzapine ODT Zyprexa Zydis AHCCCS Preferred Drug QLL= 5mg, 10mg: 60/30 days;

15mg, 20mg: 30/30days

quetiapine Tab Seroquel AHCCCS Preferred Drug QLL = 60/30 days

risperidone

Risperdal

AHCCCS Preferred Drug QLL = 60/30days

Solution QLL= 240ml/ 30days

RISPERDAL CONSTA AHCCCS Preferred Drug QLL= 2 inj/30 days

risperidone ODT Risperdal M-TAB AHCCCS Preferred Drug QLL= 60/30

SAPHRIS AHCCCS Preferred Drug QLL= 60/ 30 days

ziprasidone hcl Geodon AHCCCS Preferred Drug




QLL= 60/ 30 days

PHENOTHIAZINE ANTIPSYCHOTICS

chlorpromazine hcl Various

fluphenazine decanoate Inj Prolixin

fluphenazine hcl Tab, Susp, Elix Prolixin

perphenazine Tab Trilafon

thioridazine hcl Tab Mellaril

trifluoperazine hcl Tab Stelazine

ANTIVERTIGO AND ANTIEMETIC DRUGS

aprepitant QLL= 6/21 days

ANZEMET PA

Doxylamine succinate 25mg

granisetron Kytril COVERED FOR ONCOLOGISTS; ALL OTHERS REQUIRE PA

meclizine

ondansetron, -ODT 4mg, 8mg, Zofran, -ODT QLL= 90/30days

ondansetron 24mg Zofran PA

prochlorperazine maleate Compazine

promethazine hcl Phenergan

trimethobenzamide 250 mg, 300 mg capsules, 200 mg suppositories

Tigan

ANTIPARKINSON ANTICHOLINERGIC DRUGS

benztropine mesylate Cogentin

trihexyphenidyl Artane

OTHER ANTIPARKINSON DRUGS

bromocriptine mesylate Parlodel

carbidopa/levodopa Sinemet

carbidopa/levodopa/entacapone Stalevo COVERED FOR NEUROLOGIST; ALL OTHERS REQUIRE PA

QLL= 270/ 30 days

EMSAM

seligilene

COVERED FOR NEUROLOGIST; ALL

OTHERS REQUIRE PA

entacapone Comtan

pramipexole Mirapex

ropinirole Requip

selegiline

DRUGS FOR MULTIPLE SCLEROSIS

AUBAGIO PA, QLL= 30/ 30 days




AVONEX PA

BETASERON PA

COPAXONE 20MG PA

EXTAVIA PA

GILENYA PA

GLATOPA 40MG COPAXONE 40MG PA

REBIF PA

TECFIDERA PA; QLL= 60/30 days

CNS STIMULANT DRUGS PA

ADDERALL AHCCCS Preferred Drug QLL=60/ 30 days

ADDERALL XR AHCCCS Preferred Drug QLL=30/ 30 days

APTENSIO XR AHCCCS Preferred Drug QLL=30/ 30 days

Armodafinil NUVIGIL PA, QLL= 50mg: 60/30days; 150mg,200mg.250mg:30/30days

atomoxetine STRATERRA AHCCCS Preferred Drug; QLL= 30/ 30 days

DAYTRANA Methylphenidate AHCCCS Preferred Drug QLL= 30/30days

dextroamphetamine, IR tab, ER Cap Dexedrine, Dexedrine Spansule AHCCCS Preferred Drug QLL = 60/ 30days

FOCALIN (Brand) AHCCCS Preferred Drug QLL= 60/30 days

FOCALIN XR (Brand) AHCCCS Preferred Drug QLL= 60/ 30 days

Methylphenidate CD METADATE CD AHCCCS Preferred Drug QLL= 30/ 30days

methylphenidate er, sr

Concerta, Ritalin-LA, Ritalin-SR AHCCCS Preferred Drug QLL= 60/30 days

METHYLIN SOLUTION (Brand) AHCCCS Preferred Drug QLL= 300ml/30days

methylphenidate hcl Ritalin AHCCCS Preferred Drug; QLL= 90/30 days

QUILLIVANT XR Methylphenidate susp AHCCCS Preferred Drug; QLL= 150ml/ 30days

QUILLICHEW ER AHCCCS Preferred Drug QLL = 30/ 30 days

RITALIN LA 10mg AHCCCS Preferred Drug;




QLL= 30/ 30 days

VYVANSE lisdexamfetamine dimesylate AHCCCS Preferred Drug QLL=30/ 30 days

VYVANSE chewable tablet AHCCCS Preferred Drug; QLL= 30/ 30 days

ANTIDEMENTIA DRUGS

donepezil 5MG, 10 MG (23 MG IS NON-FORMULARY)

Aricept

donepezil ODT Aricept ODT

rivastigmine patch Exelon Patch PA

galantamine, -ER

Razadyne, Razadyne ER

PA

memantine Tabs Namenda

memantine Solution Namenda Solution PA

rivastigmine capsules Exelon PA

SMOKING CESSATION DRUGS

bupropion SR buproban

Zyban MONTHLY QLL= 60/30 days; COVERED FOR 90 DAYS/ 6 MONTH

PERIOD

CHANTIX MONTHLY COMBINED QLL=0.5 mg,1 mg=60 tabs/30 days; QLL=1 starter

pack/month; COVERED FOR 90 DAYS/ 6 MONTH PERIOD

nicotine gum OTC MONTHLY QLL 2 MG=660 pieces/30 days; MONTHLY QLL 4 MG=330

pieces/30 days; COVERED FOR 90 DAYS/ 6 MONTH PERIOD

nicotine lozenge OTC MONTHLY QLL=324 lozenges/30 days; COVERED FOR 90 DAYS/ 6 MONTH

PERIOD

nicotine patch OTC

MONTHLY QLL=30 patches/30 days; COVERED FOR 90 DAYS/ 6 MONTH

PERIOD

NICOTROL CARTRIDGE MONTHLY QLL=3 boxes/30 days; COVERED FOR 90 DAYS/ 6 MONTH

PERIOD

NICOTROL NASAL SPRAY MONTHLY QLL=15 bottle/30 days; COVERED FOR 90 DAYS/ 6 MONTH

PERIOD

SUBSTANCE ABUSE




OPIATE AGONISTS/PARTIAL AGONISTS

buprenorphine PA Required unless the member is

pregnant- the prescriber must note one

of the following ICD-10 codes on the

prescription:

1. O09.91- Supervision of high risk

pregnancy, 1st Trimester.


pregnancy, 2nd Trimester.


pregnancy, 3rd Trimester.

4. O09.91- Supervision of high risk pregnancy- use for Post-Partum Nursing

Mothers.

SUBOXONE FILM buprenorphine hcl /

naloxone AHCCCS Preferred Drug

methadone Dolophine Covered for Opioid Treatment Program (OTP) Providers only

OPIATE ANTAGONISTS

NARCAN Nasal Spray naloxone AHCCCS Preferred Drug

naloxone syringe (injection) AHCCCS Preferred Drug

naloxone vial (injection) AHCCCS Preferred Drug

Naltrexone Revia AHCCCS Preferred Drug

VIVITROL naltrexone INJ AHCCCS Preferred Drug

MISCELLANEOUS AGENTS

acamprosate DR Tab Campral

disulfiram Antabuse

OTHER CNS DRUGS

caffeine citrate oral solution

pyridostigmine

ANORETIC AGENTS

BELVIQ PA; QLL= 60/ 30 days

benzphetamine PA; QLL= 90/ 30 days

CONTRAVE PA; QLL- 120/ 30 days

diethylpropion 25mg PA; QLL= 90/ 30 days

diethylpropion ER 75mg PA; QLL= 30/ 30 days




ORLISTAT 60mg PA; QLL= 180/ 30 days

phendimetrazine 35mg PA; QLL= 90/ 30 days

Phendimetrazine ER 105mg PA; QLL= 30/ 30 days

phentermine Adipex PA; QLL 15mg= 60/ 30days QLL 30mg= 30/ 30 days

QLL 37.5mg= 30/ 30 days

QSYMIA PA; QLL 30/ 30 days

CARDIOVASCULAR MEDICATIONS

CARDIAC GLYCOSIDES

digoxin Lanoxin

LANOXIN

CALCIUM ANTAGONISTS

amlodipine Norvasc QLL=2.5mg,5mg: 60/ 30 days; 10mg:30/30days

diltiazem hcl extended release beads cap SR 24hr, cap SR 12hr

diltiazem hcl tablets

felodipine er Plendil

nifediac cc QLL= 90/ 30days

nifedical xl QLL= 90/ 30 days

nifedipine, er Procardia Procardia XL

Extended Release QLL= 90/ 30 days

verapamil, er Verelan/Calan/Calan SR QLL: Extended Release= 60/30 days

CARBONIC ANHYDRASE INHIBITORS

acetazolamide, -ER Diamox

LOOP DIURETICS

bumetanide Bumex

furosemide Lasix

torsemide Demadex

THIAZIDE AND RELATED DRUGS

chlorthalidone

chlorothiazide

hydrochlorothiazide capsules (12.5mg)

hydrochlorothiazide tablets (25, 50mg)

Microzide

indapamide Lozol

metolazone Zaroxolyn

methyclothiazide Aquatensen, Enduron




POTASSIUM SPARING DIURETICS

amiloride

amiloride hcl w/hctz Midamor

eplerenone Inspra PA

spironolactone Aldactone

spironolactone w/hctz Aldactazide

triamterene w/hctz Maxzide/Diazide

BETA-ADRENERGIC ANTAGONIST DRUGS

atenolol Tenormin

bisoprolol fumarate Zebeta

carvedilol Coreg

labetalol hcl Normodyne/Trandate

metoprolol succinate Toprol XL

metoprolol tartrate Lopressor

nadolol Corgard

propranolol, er Inderal/LA

VASODILATOR ANTIHYPERTENSIVES

doxazosin mesylate Cardura QLL= 30/30 days

hydralazine hcl Apresoline

minoxidil

prazosin hcl Minipress

terazosin hcl Hytrin

CENTRALLY ACTING ANTIHYPERTENSIVES

clonidine patches Catapres TTS QLL= 4/28days

clonidine tablets Catapres

guanfacine hcl Tenex

guanfacine ER Intuniv AHCCCS Preferred Drug QLL= 30/ 30 days

KAPVAY ER QLL= 120/ 30 days

ANGIOTENSIN CONVERTING ENZYME INHIBITORS

benazepril hcl Lotensin

captopril Capoten

enalapril maleate Vasotec

fosinopril sodium Monopril

lisinopril Prinivil/Zestril

moexipril hcl Univasc

perindopril Aceon

quinapril hcl Accupril

ramipril Altace




trandolapril Mavik

ANGIOTENSIN II RECEPTOR ANTAGONISTS

candesartan Atacand

Cadesartan HCTZ Atacand HCT

Telmisartan Micardis QLL = 30/30days

valsartan Diovan

valsartan HCTZ Diovan HCT

irbesartan Avapro

losartan Cozaar

losartan HCT Hyzaar

OTHER ANTIHYPERTENSIVES

amlodipine/benazepril Lotrel

amlodipine/valsartan Exforge QLL= 30/30 days

atenolol w/chlorthalidone Tenoretic

bisoprolol fumarate w/hctz Ziac

captopril w/hctz Capozide

CORLANOR PA, QLL= 60/30 days

enalapril maleate w/hctz Vaseretic

ENTRESTO PA

fosinopril w/hctz Monopril HCT

lisinopril w/hctz Prinzide/Zestoretic

methyldopa w/hctz

metoprolol w/hctz Lopressor HCT

moexipril w/hctz Uniretic

nadolol-bendroflumethiazide Corzide

propranolol hcl w/hctz Inderide

quinapril w/hctz Quinaretic

NITRATES

isosorbide dinitrate Isochron/Isordil

isosorbide mononitrate Imdur/Ismo/Monoket

nitro-bid ointment

nitroglycerin (patch, sublingual tablet,)

Nitro-Dur/Nitrostat

OTHER VASODILATING DRUGS

epoprostenol Flolan PA

LETAIRIS PA

OPSUMIT PA

REMODULIN PA

sildenafil Revatio COVERED WHEN PRESCRIBED BY CARDIOLOGISTS AND




PULMONOLOGISTS; ALL OTHERS REQUIRE PA

tadalafil Adcirca STEP

TRACLEER PA

TYVASO PA

VENTAVIS PA

CLASS 1A ANTIARRHYTHMICS

disopyramide Norpace

quinidine gluconate

quinidine sulfate

CLASS 1B ANTIARRHYTHMICS

mexiletine Mexitil

CLASS 1C ANTIARRHYTHMICS

flecainide acetate Tambocor

propafenone hcl, SR 12hr Rythmol, Rythmol SR

OTHER ANTIARRHYTHMICS

Amiodarone 200mg Pacerone

MULTAQ PA, QLL= 60/30

RANEXA PA

sotalol Betapace

dofetilide Tikosyn PA

HYPOLIPOPROTEINEMICS

cholestyramine, -light Questran, Questran Light

colestipol hcl Colestid

fenofibrate 54mg, 67mg, 134mg, 160mg, 200mg

Lofibra

fenofibrate 48 mg, 145 mg Tricor

gemfibrozil Lopid

OTC niacin

Niacin tab CR Slo Niacin OTC

ezetimibe Zetia STEP

HMG-COA REDUCTASE INHIBITORS

atorvastatin Lipitor QLL= 30/30 days

rosuvastatin Crestor STEP

fluvastatin Lescol QLL= 30/30 days

lovastatin Mevacor QLL= 30/30 days; 40 mg= 60/30 days

pravastatin Pravachol QLL= 30/30 days

simvastatin Zocor QLL= 30/30 days

fluvastatin XL Lescol XL QLL= 30/30 days




OTHER CARDIOVASCULAR DRUGS

midodrine ProAmatine

pentoxifylline Trental

DERMATOLOGICAL MEDICATIONS

TOPICAL CORTICOSTEROID DRUGS

betamethasone dipropionate lotion, aug cream

Diprolene

betamethasone valerate cream, lotion, ointment

Beta-Val

clobetasol propionate cream, ointment, gel, solution

Cream, ointment QLL= 60gm/30 days

fluocinolone body oil, scalp oil

fluocinonide 0.05% gel, ointment, cream, solution

fluticasone propionate cream, ointment

Halobetasol cream, ointment Ultravate QLL = 50gm/30days

Hydrocortisone cream, lotion, ointment

Ala-Cort/Cetacort/Hytone

mometasone furoate cream, ointment, solution

Elocon

triamcinolone acetonide cream, lotion, ointment

Kenalog

ANTIPRURITIC DRUGS

hydroxyzine hcl tablets, syrup QLL:240/30days; Syrup: 300ml/30days

hydroxyzine pamoate QLL: 120/30days

ANTIACNE DRUGS

adapalene cream, gel Differin PA for >35 years of age; QLL= 45gram/

30 days

amnesteem Accutane

benzoyl peroxide

clindamycin phosphate Cleocin T/Clindamax

erythromycin A/T/S / Emgel/Erycette

metronidazole gel, lotion Metrogel, Metrolotion

salicylic acid cream, gel, lotion,

Zenatane, Mysorium Accutane QLL= 60/30 days; :Lifetime limit of 10

months

tretinoin cream and gel Avita/Retin-A STEP for >35 years of age

KERATOLYTIC DRUGS




CONDYLOX GEL

podofilox solution Condylox

ANTIPSORIASIS AND ANTIECZEMA DRUGS

calcipotriene cream, ointment, scalp solution

Dovonex

coal tar shampoo

DRITHO-SCALP

selenium sulfide Selseb

sulfacetamide sodium Carmol Scalp

tazarotene QLL = 90gm/30 days

ORAL DERMATOLOGICAL DRUGS

METHOXSALEN RAPID CAP 10 MG Oxsoralen Ultra

TOPICAL DERMATOLOGICAL DRUGS

ammonium lactate OTC lotion, cream Lac-Hydrin

FLUOROPLEX

fluorouracil Efudex

capsaicin OTC

CARAC

DRYSOL 20%

ELIDEL STEP;QLL= 30gm/30 days

HYPERCARE 20% aluminum chloride

imiquimod 5% cream Aldara

SANTYL

tacrolimus Protopic STEP;QLL= 30gm/30days

wart remover (salicylic acid 17%) Occlusal-HP

SCABICIDES/PEDICULICIDES

EURAX

malathion 0.5% lotion Ovide STEP

spinosad 0.9% TOPICAL SUSPENSION Natroba STEP, QLL = 1 pkg/ 180 days

permethrin 5% cream Elimite

Permethrin Lotion 1%

piperonyl butoxide/pyrethrins OTC shampoo and gel

Rid

SKLICE STEP, QLL= 1 pkg/ 180 days

EAR-NOSE-THROAT MEDICATIONS

DRUGS AFFECTING THE EAR

antipyrine/benzocaine otic Benzotic/Otogesic

acetic acid, -HC otic

carbamide peroxide Debrox

ciprofloxacin 0.2% otic solution




CIPRODEX OTIC

neomycin/polymixin/hydrocortisone

ofloxacin

DRUGS AFFECTING THE NOSE

azelastine Astelin

flunisolide Nasarel

FLONASE OTC, FLONASE OTC Childrens

Flonase

fluticasone OTC

ipratropium bromide Atrovent

mometasone furoate Nasonex STEP, QLL= 2 bottles/ 30 days

olopatadine 0.1% and 0.2% STEP

OTC Nasacort Allergy 24 hour spray

OTC RHINOCORT

OTC oxymetazoline nasal spray

triamcinolone acetonide nasal Nasacort AQ PA

DRUGS AFFECTING THE THROAT AND MOUTH

ABREVA OTC

APHTHASOL

chlorhexidine gluconate 0.12% rinse Peridex

pilocarpine hcl Salagen

Saliva substitute Salivart Spray

triamcinolone acetonide Kenalog in Orabase

ENDOCRINE MEDICATIONS

ORAL HYPOGLYCEMIC DRUGS

acarbose Precose

glimepiride Amaryl

glipizide, er Glucotrol, XL

glipizide-metformin Metaglip

glyburide, -micro Diabeta/Micronase

glyburide-metformin Glucovance

INVOKAMET STEP, QLL= 60/30 days

INVOKANA STEP, QLL= 30/30 days

JANUMET, JANUMET XR AHCCCS Preferred Drug, PA, will

process with PA if there are prior fills of metformin

JANUVIA AHCCCS Preferred Drug, PA, will


JARDIANCE STEP, QLL = 30/30 days




metformin metformin ER 500mg, 750mg (generics for Glucophage XR only)

Glucophage Glucophage XR

JENTADUETO AHCCCS Preferred Drug, PA, will process

with PA if there are prior fills of metformin

KOMBIGLYZE XR

AHCCCS Preferred Drug, PA, will process

with PA if there are prior fills of

metformin

ONGLYZA AHCCCS Preferred Drug, PA, will process

with PA if there are prior fills of metformin

nateglinide Starlix

Repaglinide-metformin Prandimet

repaglinide Prandin

SYNJARDY STEP, QLL = 60/30 days

SYNJARDY XR 5-1000mg, 12.5-1000mg

STEP

QLL = 60/30days

SYNJARDY XR 10-1000mg, 25-1000mg STEP

QLL = 30/30days

TRADJENTA AHCCCS Preferred Drug, PA, will


INSULIN SENSITIZERS

AVANDIA STEP, QLL= 30/ 30 days

pioglitazone Actos

pioglitazone-metformin Actoplus Met

GLUCOSE ELEVATING DRUGS

GLUCAGON

glucose chewable tablets OTC

INSULIN

HUMALOG KWIK PEN 100unit/ ml AHCCCS Preferred Drug

HUMALOG VIAL AHCCCS Preferred Drug

HUMALOG MIX PEN AHCCCS Preferred Drug

HUMALOG MIX VIAL AHCCCS Preferred Drug

HUMULIN R (500 U/ML VIAL) AHCCCS Preferred Drug,PA

HUMULIN R (500 U/ML PEN) AHCCCS Preferred Drug, PA

HUMULIN 70/30 VIAL AHCCCS Preferred Drug

HUMULIN VIAL AHCCCS Preferred Drug




LANTUS AHCCCS Preferred Drug

LANTUS SOLOSTAR PEN AHCCCS Preferred Drug

LEVEMIR AHCCCS Preferred Drug

LEVEMIR PEN AHCCCS Preferred Drug

NOVOLOG MIX 70/30 FLEXPEN AHCCCS Preferred Drug

NOVOLOG MIX 70/30 VIAL AHCCCS Preferred Drug

NOVOLOG 100UNIT/ML VIAL AHCCCS Preferred Drug

NOVOLOG 100UNIT/ML FLEXPEN AHCCCS Preferred Drug

NOVOLOG 100UNIT/ML CATRIDGE AHCCCS Preferred Drug

OTHER GLUCOSE-LOWERING DRUGS

BYDUREON PEN, VIAL AHCCCS Preferred Drug, PA; will process with PA if there are prior fills of

metformin

BYETTA AHCCCS Preferred Drug, PA; will process without PA if there are fills of

metformin

GLYXAMBI AHCCCS Preferred Drug, PA, will process without PA if there are prior

fills of metformin

SYMLIN PENS AHCCCS Preferred Drug, PA

VICTOZA AHCCCS Preferred Drug, PA, will process without PA if there are prior fills of

metformin

GLUCOCORTICOID DRUGS

cortisone

dexamethasone

hydrocortisone Cortef

hydrocortisone injection Solu-Cortef PA

methylprednisolone Medrol

methylprednisolone injection Solu-Medrol PA

prednisolone Prelone

prednisone Sterapred

prednisolone sodium phosphate, - ODT

ORAPRED, -ODT

triamcinolone INJ Kenalog PA

GROWTH HORMONES AND RELATED AGENTS

GENOTROPIN AHCCCS Preferred Drug

PA

NORDITROPIN AHCCCS Preferred Drug

PA




MINERALOCORTICOID DRUGS

fludrocortisone acetate Florinef

THYROID SUPPLEMENTS

ARMOUR THYROID

levothroid

levothyroxine sodium Levothyroid / Synthroid

Levoxyl levothyroid

liothyronine Cytomel

thyroid, dessicated Armour Thyroid

unithroid Synthroid

ANTITHYROID DRUGS

methimazole Tapazole

propylthiouracil

ANDROGEN DRUGS

ANDRODERM PATCH PA

ANDROXY

danazol

testosterone cypionate injection PA

testosterone enanthate injection PA

Testosterone gel 1% Androgel PA

Testosterone gel (50mg/5gm) 1% Testim PA

Testosterone topical solution Axiron PA

OTHER ENDOCRINE DRUGS

alendronate sodium Fosamax

cabergoline Dostinex COVERED FOR ENDO; ALL OTHERS REQUIRE PA

calcitonin nasal spray Miacalcin

desmopressin acetate DDAVP/Minirin Tablet QLL= 90/30 days

etidronate Didronel

fortical nasal spray

Ibandronate (INJ) Boniva

KUVAN PA

MAKENA 1,250mg/5ml, 250mg/ml vial, 275mg/1.1ML Autoinject

PA, AHCCCS Preferred Drug

MIACALCIN (INJ) PA

Pamidronate (INJ) Aredia

zoledronic solution(INJ) Reclast (INJ) PA

SENSIPAR PA

TYMLOS PA, QLL= 1/30 days

GASTROINTESTINAL MEDICATIONS




ANTIDIARRHEAL DRUGS

bismuth subsalicylate Kaopectate

diphenoxylate w/atropine Lomotil QLL= 240/ 30 days; 1200ml/ 30 days

loperamide hcl Imodium

ANTISPASMODICS/DRUGS AFFECT GI MOTILITY

dicyclomine hcl Bentyl

glycopyrrolate tablets Robinul

hyoscyamine Nulev/Levbrel

metoclopramide hcl Reglan

ANTIULCER DRUGS

cimetidine tablets Tagamet

famotidine tablets Pepcid

nizatidine tablets Axid

ranitidine tablets, syrup, solution Zantac

OTHER ANTIULCER DRUGS

misoprostol Cytotec

sucralfate Carafate

CARAFATE SUSPENSION

PROTON PUMP INHIBITORS

esomeprazole OTC Nexium OTC QLL= 60/ 30days

First-lansoprazole 3mg/ml oral suspension

First-omeprazole 2mg/ml oral suspension

lansoprazole ODT Prevacid ODT PA, QLL = 30/30

lansoprazole OTC Prevacid OTC QLL= 60/ 30days

lansoprazole Prevacid

omeprazole Prilosec

omeprazole OTC Prilosec OTC QLL= 60/ 30 days

omeprazole/ Bicarb OTC Zegrid OTC

pantoprazole Protonix

rabeprazole Aciphex QLL= 30/ 30 days

LAXATIVES AND CATHARTICS

bisacodyl

cascara sagrada cap

constulose

DOCUSOL ENEMA

docusate Colace

ENEMEEZ ENEMA

Fiber tablet, cap, powder




OTC FLEET BISACODYL ENEMA

KONSYL D OTC

Magnesium citrate solution

Magnesium oxide tab

Methylcellulose powder, tab

MIRALAX OTC QLL= 510 gm/ 30 days

MOVANTIK PA, QLL= 30/ 30 days

polyethylene glycol 3350 powder for solution (bottles/ packets)

psyllium OTC Metamucil

Senna tab, syrup, liquid

SENOKOT OTC (brand and generic OTC dosage forms covered)

SORBITOL OTC 70% ORAL SOLN

OTHER GI DRUGS

OTC aluminum hydroxide gel Alternagel

AMITIZA QLL= 60/ 30 days

antacids Mylanta, Maalox

APRISO

mesalamine 800mg delayed-release tablet

Asacol HD

mesalamine 1.2gm Lialda QLL= 120/30

balsalazide Colazal QLL= 270/ 30 days

belladonna alkaloids-opium

budesonide Entocort EC

CANASA

CORTIFOAM

CREON AHCCCS Preferred Drug QLL=500/30 days

Delzicol

DIPENTUM

hydrocortisone 1%, 2.5% rectal cream Proctocort 1%, Proctosol-HC 2.5%

hydrocortisone rectal enema suspension

Colocort/ Cortenema

IPECAC SYRUP

LINZESS STEP, QLL= 30/ 30 days

mesalamine enema Rowasa

NULYTELY WITH FLAVOR PACKS

PANCRELIPASE AHCCCS Preferred Drug




QLL=500/30 days

PEG 3350 ELECTROLYTE SOLUTION

PENTASA

PramCort 1%-1% Topical Cream

Proctocort 1%, Procto Pak

Proctocream- HC, PROCTOFOAM-HC

Proctosol-HC, Proctozone-HC

propantheline

RECTIV PA, QLL= 30gm/ 30 days

sulfasalazine Azulfidine

ursodiol Actigall

ZENPEP AHCCCS Preferred Drug QLL=500/30 days

IMMUNOLOGICALS AND VACCINES

RHOGAM

WINRHO

MUSCULOSKELETAL MEDICATIONS

SALICYLATES AND RELATED DRUGS

aspirin

choline magnesium trisalicylate

diflunisal Dolobid

salsalate Disalcid

NON-STEROIDAL ANTIINFLAMMATORY AGENTS

celecoxib Celebrex STEP

diclofenac sodium tab Voltaren

diclofenac sodium 1% gel QLL = 200gm/30days

diclofenac potassium Cataflam

diclofenac ER Voltaren XR

etodolac Lodine/Lodine XL

fenoprofen

flurbiprofen Anasaid

ibuprofen Motrin, Advil

indomethacin Indocin SR

ketoprofen Orudis/Oruvail

ketorolac Toradol QLL= 20/30days

Meloxicam tablets Mobic

nabumetone Relafen

naproxen Naprosyn, Aleve

oxaprozin Daypro

piroxicam Feldene




sulindac Clinoril

tolmetin

OTHER DRUGS FOR ARTHRITIS

RIDAURA COVERED FOR RHEUMATOLOGIST; ALL OTHERS REQUIRE PA

DRUGS TO PREVENT AND TREAT GOUT

allopurinol Zyloprim

colchicine / probenecid

colchicine 0.6mg tablets Colcrys

colchicine 0.6mg capsules

probenecid

ULORIC PA

DIRECT MUSCLE RELAXANTS

baclofen

tizanidine hcl tablets Zanaflex tablets

CNS MUSCLE RELAXANTS

Carisoprodol 350mg only Soma QLL= 120/ 30 days

chlorzoxazone

cyclobenzaprine hcl 5mg and 10mg Flexeril

dantrolene capsule Dantrium

methocarbamol Robaxin

orphenadine

OTHER MUSCULOSKELETAL MEDICATIONS

riluzole Rilutek COVERED FOR NEUROLOGIST; ALL OTHERS REQUIRE PA

NUTRITION, BLOOD MODIFIERS, ELECTROLYTES, ENZYME REPLACEMENT

THERAPEUTIC VITAMINS & MINERALS

alpha-tocopherol Vitamin E – Various

CALCIFEROL Drisdol

calcitriol Calcijex/Rocaltrol

calcium acetate capsules, tablets Phoslo

calcium carbonate, - with vitamin D Tums/Maalox, Calcitrate +D, Caltrate +D

calcium citrate Citracal

cholecalciferol (OTC) Vitamin D3

cyanocobalamin [inj]

ERGOCAL Cap QLL= 30/30 days

ergocalciferol Vitamin D2

ferrous gluconate

ferrous sulfate




folic acid

Iron up liquid

Omega 3 Fatty Acid (1gram) cap Lovaza ST; QLL = 120/30days

OTC Fish Oil (omega-3 fatty acids)

levocarnitine COVERED FOR NEUROLOGIST; ALL OTHERS REQUIRE PA

magnesium oxide tablets

multivitamin with fluoride

poly-vitamin drops, -w iron drops QLL= 1 bottle/ 30 days

NEPHROCAPS

paricalcitol ZEMPLAR STEP, QLL= 30/ 30 days

K-PHOS NEUTRAL TABLETS

phosphorous 250mg powder for solution

PHOS-NAK

pyridoxine Vitamin B6 - Various

sodium bicarbonate

sodium fluoride drops, chewable tablets, tablets

thiamine Vitamin B1 - Various

Vitamin B12 tab, SL tabs Vitamin B12

Vitamin E Chew Tab, capsule

POTASSIUM SUPPLEMENTS

citric acid/sodium citrate oral soln Bicitra

klor con, klor con m, klor con effervescent

potassium citrate ER

potassium chloride caps and tabs K-Dur/Klotrix

SHOHL’S MODIFIED

POTASSIUM REMOVING RESINS

sodium polystyrene sulfonate Kayexalate

ORAL ANTICOAGULANTS

PRADAXA AHCCCS Preferred Drug QLL=60/30 days

ELIQUIS AHCCCS Preferred Drug QLL=60/30 days

ELIQUIS STARTER PACK AHCCCS Preferred Drug QLL=74/30 days

JANTOVEN AHCCCS Preferred Drug

warfarin sodium Coumadin AHCCCS Preferred Drug

XARELTO Tabs AHCCCS Preferred Drug




QLL=60/30 days

XARELTO starter pack AHCCCS Preferred Drug, QLL=51/30

HEPARINS

heparin sodium [inj] (heparin lock flush solution not covered)

LOW-MOLECULAR WEIGHT HEPARINS (LMWH)

enoxaparin [inj] LOVENOX AHCCCS Preferred Drug QLL=60syringes/30 days

ANTIPLATELET DRUGS

BRILINTA PA

cilostazol Pletal

clopidogrel Plavix

dipyridamole Persantine

prasugrel Effient QLL= 30/30 days

ticlopidine hcl Ticlid

HEMOSTATICS

AMICAR

phytonadione tab MEPHYTON

HEMATOPOIETIC AGENTS

EPOGEN PA

PROCRIT PA

PROMACTA PA

NEUPOGEN PA

NEULASTA PA

BLOOD DETOXICANTS

enulose

generlac

lactulose

RENAGEL PA

RENVELA sevelamer PA

OTHER BLOOD MODIFIERS

anagrelide Agrylin

ARCALYST PA

SOLIRIS COVERED FOR HEMATOLOGIST; ALL OTHERS REQUIRE PA

ENZYME REPLACEMENTS

CEREZYME PA

ELAPRASE PA

SUCRAID PA

OBSTETRICAL & GYNECOLOGICAL MEDICATIONS




PRENATAL VITAMINS

complete natal DHA

CONCEPT DHA

fe plus tablet

prenatal advantage (prenatal AD)

prenatal low iron

SELECT-OB, SELECT-OB + DHA

trinate

vinatal forte

vinate II

vinate az

vinate calcium

vinate gt

vinate one

vinate m

vinate ultra

vitafol-ob

vitafol-pn

OB/GYN TOPICAL ANTIINFECTIVES

AVC vaginal cream

CLEOCIN OVULE

clindamycin 2% vaginal cream Clindamax

metronidazole 0.75% vaginal gel MetroGel

miconazole vaginal suppositories, cream

MONISTAT 3 and 7 OTC VAGINAL CREAM AND COMBINATION PACK

ESTROGEN DRUGS

CENESTIN

estradiol tablets Estrace

estradiol transdermal patch Climara

estropipate Ogen/Ortho-Est

estradiol 0.01% vaginal cream ESTRACE

ESTRING

FEMRING

MENEST

PREMARIN

PREMARIN CREAM PA

Yuvafem VAGIFEM

Estradiol Dis (twice weekly) patch VIVELLE DOT QLL= 8 patches/ 30 days




ESTROGEN/PROGESTIN COMBINATIONS

CLIMARA PRO

COMBIPATCH

estradiol/norethindrone acetate 0.5mg-0.1mg, 1 mg-0.5 mg

Activella 0.5mg-0.1mg Activella1 mg-0.5mg

Norethindrone acetate/ ethinyl estradiol 0.5mg/2.5mcg

Femhrt

PREFEST

PREMPRO

SELECTIVE ESTROGEN RECEPTOR MODULATOR

raloxifene Evista

PROGESTIN DRUGS

medroxyprogesterone acetate Provera QLL = 1 inj/ 90 days

norethindrone acetate Aygestin

progesterone capsule Prometrium

OTHER OB/GYN DRUGS

Methylergonovine maleate tablets Methergine Tablets

METHERGINE

OPHTHALMIC MEDICATIONS

OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS

bacitracin ophth ointment QLL= 3.5gm/ 7 days

bacitracin/polymixin ophth ointment AK-Poly Bac

ciprofloxacin hcl (ophth drops) Ciloxan

CILOXAN OPTHALMIC OINTMENT

erythromycin

gentamicin sulfate Garamycin/Gentak

levofloxacin 0.5% ophth soln Quixin

neomycin/polymyxin/bacitracin Neosporin

neomycin/polymyxin/gramicidin

ofloxacin Ocuflox

polymyxin/trimethoprim Polytrim

sulfacetamide sodium Bleph-10

tobramycin sulfate Tobrex

TOBREX OINTMENT moxifloxacin 0.5% ophthalmic Vigamox

OPHTHALMIC CORTICOSTEROID DRUGS

dexamethasone

PRED MILD

prednisolone Omnipred/Pred Forte

fluorometholone




OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS

bacitracin/neomycin/polymixinB/ hydrocortisone

BLEPHAMIDE DROPS, OINT.

neomycin/polymyxin/dexamethasone Methadex/Maxitrol

Neomycin/bacitracin/polymixin B/hydrocortisone

prednisolone/sulfacetamide

prednisolone/gentamicin sulfate Pred G

TOBRADEX OINTMENT

tobramycin/dexamethasone susp Tobradex

ANTIGLAUCOMA DRUGS

AZOPT STEP

acetazolamide, -ER

betaxolol hcl 0.5%

brimonidine tartrate 0.2% Alphagan QLL=10ml/30days

carteolol hcl

COMBIGAN STEP

dorzolamide Trusopt

dorzolamide/timolol Cosopt

ISOPTO CARBACHOL

latanoprost Xalatan QLL= 5mL (2 bottles)/ 30 days

levobunolol hcl Betagan

methazolamide

metipranolol Optipranolol

PHOSPHOLINE IODIDE

pilocarpine hcl Isopto Carpine

timolol maleate Timoptic

timolol gel Timoptic-XE STEP

travoprost Travatan

TRAVATAN Z

ZIOPTAN PA

OTHER OPHTHALMIC DRUGS

artificial tears drops, ointment

atropine sulfate Isopto Atropine

cromolyn sodium Crolom

Azelastine Optivar STEP

cyclopentolate Cyclogyl

diclofenac sodium Voltaren

Epinasitne Elestat STEP




flurbiprofen sodium Ocufen

ISOPTO HOMATROPINE

ISOPTO HYOSCINE

ketorolac tromethamine Acular, Acular LS

ketotifen

MUROCOLL-2

naphazoline 0.1% eye drops AK-Con, Naphcon-Forte

naphazoline/pheniramine Naphcon A, Opcon A

NATACYN

phenylephrine

REFRESH TEARS, LIQUIGEL

RESTASIS PA

SYSTANE

trifluridine

carboxymethylcellulose sodium ophth solun 0.25%

THERATEARS

tropicamide Tropicacyl

ketotifen fumarate ophthalmic solution

Zaditor OTC

RESPIRATORY MEDICATIONS

BETA-2 ADRENERGIC DRUGS

albuterol sulfate (syrup)

Albuterol nebulizer solution 0.083%, 0.5%

Albuterol nebulizer solution 0.63mg/3ml and 1.25mg/3ml

STEP required for >18 years of age

ARCAPTA NEOHALER QLL = 30 capsules for inhalation/30days

levalbuterol solution XOPENEX PA required for age > 4

SEREVENT DISKUS PA

STRIVERDI RESPIMAT QLL= 1/ 30 days

VENTOLIN HFA

INHALED CORTICOSTEROIDS

ADVAIR DISKUS AHCCCS Preferred Drug, STEP

ADVAIR HFA Covered for ages 4-12; all others require STEP

ASMANEX Twisthaler AHCCCS Preferred Drug

DULERA AHCCCS Preferred Drug, STEP

FLOVENT HFA AHCCCS Preferred Drug

PULMICORT FLEXHALER AHCCCS Preferred Drug

PULMICORT RESPULES (Brand) AHCCCS Preferred Drug, PA




SYMBICORT AHCCCS Preferred Drug, STEP

LEUKOTRIENE MODIFIERS

montelukast 4mg, 5mg 10mg tablets, chewable tabs

SINGULAIR QLL= 30/30 days

montelukast 4mg granules PA required for age > 4 QLL=30/30 days

METHYL XANTHINE DRUGS

theophylline, er

OTHER DRUGS FOR ASTHMA

ATROVENT (INHALER) HFA AHCCCS Preferred Drug

COMBIVENT RESPIMAT AHCCCS Preferred Drug

cromolyn sodium nebulizer soln

Epinephrine 0.3mg/0.3ml and 0.15mg/0.15ml Pens (Mylan)

EPIPEN, EPIPEN JR AHCCCS Preferred Drug, PA Required for >2 twin packs per month

ipratropium bromide AHCCCS Preferred Drug

ipratropium bromide/albuterol inhalation soln

DUONEB AHCCCS Preferred Drug

sodium chloride 0.9% nebulizer solution OTC

OTHER RESPIRATORY DRUGS

ARALAST NP, PROLASTIN PA

BEVESPI Aerosphere AHCCCS Preferred Drug, PA

ESBRIET PA

PULMOZYME PA, QLL= 60 ampules/ 30 days

sodium chloride 3%, 7% for inhalation Hypersal

SPIRIVA AHCCCS Preferred Drug

STIOLTO RESPIMAT AHCCCS Preferred Drug, PA

INHALED ANTIBIOTICS

BETHKIS AHCCCS Preferred Drug, PA

KITABIS AHCCCS Preferred Drug, PA

ANTIHISTAMINES AND DECONGESTANTS

fexofenadine 30mg/5ml Suspension ALLEGRA 30mg/5ml Suspension

brompheniramine

Bromax ER tablets brompheniramine maleate

carbinoxamine

cetirizine, cetirizine-D OTC OTC Zyrtec cetirizine-D QLL= 60/30 days cetirizine syrup QLL= 300ml/ 30Days

chlorpheniramine maleate

clemastine fumarate Tavist




cyproheptadine hcl Periactin

diphenhydramine hcl Benadryl

fexofenadine tablets, fexofenadine-D Allegra QLL= 30/ 30 days

hydroxyzine hcl Atarax

hydroxyzine pamoate cap Vistaril

Loratadine tab, chew tab, syrup loratadine-D OTC

OTC Claritin,Claritin D Loratadine tab, loratadine-D QLL= 30 /30 days

Chew tab QLL= 60/30 Syrup = 300ml/30days

pseudoephedrine Sudafed

Vazol oral solution brompheniramine maleate

ANTIHISTAMINE/DECONGESTANT COMBINATIONS

brompheniramine/phenylephrine

promethazine vc plain syrup (promethazine-phenylephrine)

Phenergan VC

Sildec syrup (brompheniramine/pseudoephedrine)

Rondec, Cardec syrup

Virdec drops (chlorpheniramine/phenylephrine)

Rondec drops

ANTITUSSIVE AND EXPECTORANT DRUGS

benzonatate Tessalon

brompheniramine-dm-phenylephrine Alahist-DM

brompheniramine-dm-pseudoephedrine

Sildec DM

CHERATUSSIN AC OTC (guaifensin-codeine)

CHERATUSSIN DAC OTC (guaifensin-pseudoephed-codeine)

DELSYM SUSPENSION

guaifenesin plain syrup, MUCINEX ER Robitussin

guaifenesin w/codeine syrup Tussi-Organidin NR

guaifenesin-dm syrup, MUCINEX DM ER

Robitussin DM

guaifenesin-dm-pseudoephedrine Robitussin CF QLL= 480ml/ 30 days

guaifenesin / dextromethorphan / phenylephrine

Robitussin PE

guaifenesin-phenylephrine Despec

hydrocodone-homatropine syrup, tablet

Hycodan,Hydromet Syrup QLL= 900ml/ 30 days

MUCINEX D ER




(guaifenesin-pseudoephedrine)

NoHist-DM syrup (chlorpheniramine-dm-phenylephrine)

Rondec DM

promethazine-codeine Phenergan w/Codeine

promethazine vc w/codeine syrup (promethazine-phenylephrine-codeine)

Phenergan VC w/Codeine

promethazine-dm Phenergan DM

Virdec-DM drops (chlorpheniramine-dm-phenylephrine)

Rondec-DM drops

TOXICOLOGY MEDICATIONS

acetylcysteine

CUPRIMINE

UROLOGICAL MEDICATIONS

ANTICHOLINERGIC ANTISPASMODICS DRUGS

flavoxate Urispas

oxybutynin chloride Ditropan

oxybutynin chloride er Ditropan XL

tolterodine Detrol STEP

Tolterodine ER Detrol LA STEP

trospium Sanctura

trospium ER Sanctura XR STEP, QLL= 30/ 30 days

CHOLINERGIC STIMULANTS

bethanechol chloride Urecholine

URINARY ANESTHETICS

phenazopyridine hcl Pyridium/Urodol

OTHER GENITOURINARY PRODUCTS

alfuzosin Uroxatral

CYTRA, K

dutasteride Avodart

ELMIRON PA

finasteride Proscar

K-PHOS

potassium citrate

tamsulosin Flomax

MEDICAL (MISCELLANEOUS) SUPPLIES

DIABETIC SUPPLIES TEST STRIPS COMBINED QLL=150 TEST STRIPS/30 DAYS




MICROLET LANCING DEVICE/LANCETS

AUTOJECT 2 INJECTION DEVICE

Insulin Syringes

BD Pen Needles

ONE TOUCH DELICA LANCETS

ONE TOUCH SURESOFT LANCETS

ONE TOUCH TEST STRIPS, CONTROL SOLUTION

Combined QLL for test strips= 150 strips/30 days

ONE TOUCH ULTRA2, ULTRALINK, ULTRAMINI, ULTRASMART, VERIO, VERIO HIGH GLUCOMETERS/TEST STRIPS

Combined QLL for test strips= 150 strips/30 days

ONE TOUCH ULTRASOFT LANCETS

CHEMSTRIP

KETOSTIX

OTHER SUPPLIES

AEROCHAMBER, MICROCHAMBER, OPTICHAMBER, and others available on the market

QLL= 2/ year

PEAK FLOW METER QLL= 1/ 365 days

ALCOHOL PREP PADS

REPRODUCTIVE HEALTH* *Family planning services are administered by Aetna Medicaid Administrators, LLC.

COVERED CONTRACEPTIVES

ALTAVERA NORDETTE-28

AMETHYST TAB 90-20MCG

AMETHIA, DAYSEE, CAMRESE SEASONIQUE QLL= Amethia 91/ 91 days; QLL= Camrese 84/ 91 days

APRI DESOGEN

ARANELLE TRI-NORINYL

AVIANE ALESSE-28

AZURETTE MIRCETTE

BALZIVA OVCON-35

CAMILA NOR-Q-D

CAZIANT CYCLESSA

CESIA CYCLESSA

CRYSELLE LO/OVRAL-28

CYCLAFEM 1-35 ORTHO-NOVUM 1/35




CYCLAFEM 7/7/7 ORTHO-NOVUM 7/7/7

ELLA

EMOQUETTE DESOGEN

ENPRESSE TRI-LEVLEN 28

ERRIN NOR-Q-D

ethynodiol diacetate and ethinyl estradiol ZOVIA 1/50E

GIANVI TAB 3-0.02MG YAZ-28

GILDESS FE1-20 LOESTRIN FE 1/20

GILDESS FE 1.5-30 LOESTRIN FE 1.5/30

INTROVALE- 91 tablet pack SEASONALE

JOLESSA - 91 tablet pack SEASONALE

JOLIVETTE NOR-Q-D

JUNEL 1/20 LOESTRIN 1/20

JUNEL 1.5/30 LOESTRIN 1.5/30

JUNEL FE 1/20 LOESTRIN FE 1/20

JUNEL FE 1.5/30 LOESTRIN FE

JUNEL FE 24 1/20, LARIN 24, GILDESS 24, LOMEDIA 24 LOESTRIN FE 24

KARIVA MIRCETTE

KELNOR 1/35 DEMULEN 1/35-28

LAYOLIS FE CHEW

LEENA TRI-NORINYL

LESSINA ALESSE-28

Levonorgestrel/Ethinyl Estradiol 0.15mg-0.03mg Tablet SEASONALE

LEVONORGESTREL 0.75MG PLAN B

LEVORA-28 NORDETTE-28

LO LOESTRIN, CAMRESE LO, AMETHIA LO LO SEASONIQUE

LORYNA TAB 3-0.02MG YAZ-28

LOW-OGESTREL LO/OVRAL-28

LUTERA ALESSE-28

MARLISSA-28 NORDETTE-28

MICROGESTIN 1/20 LOESTRIN

MICROGESTIN 1.5/30 LOESTRIN

MICROGESTIN FE 1/20 LOESTRIN FE 1/20

MICROGESTIN FE 1.5/30 LOESTRIN FE

MONONESSA ORTHO-CYCLEN

MYZILRA-28 TRI-LEVLEN 28




NECON MODICON

NECON NECON

NECON 1/35 ORTHO-NOVUM 1/35

NECON NORINYL 1+50

NECON 7/7/7 ORTHO-NOVUM 7/7/7

NEXT CHOICE PLAN B

NEXT CHOICE ONE DOSE PLAN B ONE STEP

NORA-BE NOR-Q-D

NORTREL MODICON

NORTREL 1/35 ORTHO-NOVUM 1/35

Norgestimate/ Ethinyl Estradiol 28-day ORTHO-TRI CYCLEN LO

NORTREL ORTHO-NOVUM

OGESTREL OVRAL-28

OCELLA 28 YASMIN 28

PLAN B ONE STEP

PORTIA NORDETTE-28

PREVIFEM ORTHO-CYCLEN

QUASENSE 91 tablet pack SEASONALE

RECLIPSEN DESOGEN

SOLIA DESOGEN

SPRINTEC ORTHO-CYCLEN

SRONYX ALESSE-28

TILIA FE ESTROSTEP FE

TRINESSA ORTHO TRI-CYCLEN

TRINESSA LO ORTHO TRI-CYCLEN LO

TRI-LO-SPRINTEC ORTHO TRI-CYCLEN LO

TRINESSA LO ORTHO TRI-CYCLEN LO

TRI-PREVIFEM ORTHO TRI-CYCLEN

TRI-SPRINTEC ORTHO TRI-CYCLEN

TRIVORA-28 TRI-LEVLEN 28

VELIVET CYCLESSA

VESTURA TAB 3-0.02MG YAZ-28

VIORELE MIRCETTE

WYMZYA CHW

XULANE PATCH Ortho Evra QLL= 3 patches/ month

ZENCHENT OVCON-35

ZENCHENT FE CHW

ZOVIA 1/35E DEMULEN 1/35-28

ZOVIA 1/50E DEMULEN 1/50-21




IMPLANTS AND IUDS

MIRENA IUD QLL= 1/999 days

IMPLANON IMPLANT QLL= 1/999 days

NEXPLANON IMPLANT QLL= 1/999 days

PARAGARD QLL= 1/999 days

LILETTA QLL= 1/999 days

KYLEENA QLL= 1/999 days

SKYLA QLL= 1/999 days

INTRAVAGINAL CONTRACEPTION

NUVARING

INJECTABLE CONTRACEPTION

Medroxyprogesterone acetate 150mg DEPO-PROVERA MPA

OTHER PRODUCTS- MISC.

DIAPHRAGMS Various

OTC CONDOMS Various

Spermacidal Foam / Jelly Various

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