title 19/21 smi integrated drug list · 1/1/2019 · does not work for you, we will then c over...
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Title 19/21 SMI Integrated Drug List Updated January 1, 2019
Updated January 1, 2019 Page 1 of 48
Formulary | Preferred Drug List
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 A uthorization: Mercy Care may require prior authorization for certain drugs on the Preferred Drug List. This means that your doctor will need t o 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 t ry Drug A first. If Drug A does not work for you, we will then c over 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.
Updated January 1, 2019 2
Formulary | Preferred Drug List
Key:
Abbreviations:
Cap = CapsuleChew = ChewableConc = Concentrate DR = Delayed Release Elix = Elixir ER = Extended Release IM = Intermuscular INJ = InjectableIR = Immediate Release LA = Long Acting ODT = Oral Disintegrating Tablet
PA – Prior Authorization required QLL – Quantity Limit Levels apply SL = Sublingual SOLN = Solution SR = Sustained Release Susp = Suspension Syr = Syrup STEP = Step Therapy Tab = Tablet TD = Transdermal 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 in formation about your Mercy Care prescription drug coverage, please review your Member Handbook. If you have questions about Mercy Ca re, please call Member Services at 1-800-564-5465. Or visit www.MercyCareAZ.org.
Updated January 1, 2019 3
Formulary | Preferred Drug List
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
Updated January 1, 2019 4
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 5
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
Butenafine cream
Ciclopirox cream, suspension, solution
Loprox/Penlac
Clotrimazole cream, solution 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
Updated January 1, 2019 6
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 7
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
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
Updated January 1, 2019 8
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
rifabutin Mycobutin
rifampin Rifadin
AMEBICIDES
YODOXIN
ANTHELMINTICS
albendazole 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
Updated January 1, 2019 9
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 10
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 11
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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;
Updated January 1, 2019 12
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 13
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 14
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 15
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 16
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 17
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 18
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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;
Updated January 1, 2019 19
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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 PA
donepezil ODT Aricept ODT PA
rivastigmine patch Exelon Patch PA
galantamine, -ER Razadyne, Razadyne ER PA
memantine Tabs Namenda PA
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
Updated January 1, 2019 20
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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.
2. O09.92- Supervision of high risk
pregnancy, 2nd Trimester.
3. O09.93- Supervision of high risk
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
Updated January 1, 2019 21
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 22
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 23
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 24
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 25
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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 >26 years of age
KERATOLYTIC DRUGS
Updated January 1, 2019 26
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 27
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
process with PA if there are prior fills of metformin
JARDIANCE STEP, QLL = 30/30 days
Updated January 1, 2019 28
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
process with PA if there are prior fills of metformin
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
Updated January 1, 2019 29
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 30
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 31
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 32
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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 QLL= 120ml/ 30 days
NULYTELY WITH FLAVOR PACKS
PANCRELIPASE AHCCCS Preferred Drug
Updated January 1, 2019 33
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
QLL=500/30 days
PEG 3350 ELECTROLYTE SOLUTION
PENTASA QLL =270/30 days
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 QLL =240/30 days
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 QLL = 50mg, 100mg, 200mg: 60/30 days
400mg: 30/30 days
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
Updated January 1, 2019 34
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 35
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 36
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 37
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 38
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 39
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 40
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 41
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 42
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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, Hycodan,Hydromet Syrup QLL= 900ml/ 30 days
Updated January 1, 2019 43
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
tablet
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
dutasteride Avodart
ELMIRON PA
finasteride Proscar
K-PHOS
potassium citrate
tamsulosin Flomax
MEDICAL (MISCELLANEOUS) SUPPLIES
DIABETIC SUPPLIES
Updated January 1, 2019 44
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 45
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 46
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 47
Formulary | Preferred Drug List
COVERED DRUG REFERENCE DRUG NAME REQUIREMENTS/LIMITS
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
Updated January 1, 2019 48