AHCCCS DRUG LIST - azahcccs.gov · METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE METADATE CD PA...
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Drug Class/Drug Name Reference Brand Name Brand Only Preferred Drug Status PA Type Step Therapy Requirements Quantity Limit QL Days ADHD/ANTI-NARCOLEPSY AMPHETAMINES AMPHETAMINE-DEXTROAMPHETAMINE CAPSULE CONTROLLED RELEASE ADDERALL XR PA Required for ages < 6 years 30 30 AMPHETAMINE-DEXTROAMPHETAMINE TABLETS ADDERALL PA Required for ages < 6 years 60 30 DEXTROAMPHETAMINE SULFATE CAPSULE CONTROLLED RELEASE DEXEDRINE PA Required for ages < 6 years 60 30 DEXTROAMPHETAMINE SULFATE SOLUTION PROCENTRA PA Required for ages < 6 years 600 30 DEXTROAMPHETAMINE SULFATE TABLETS ZENZEDI PA Required for ages < 6 years 60 30 ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) ATOMOXETINE HCL CAPSULES STRATTERA PA Required 60 30 STIMULANTS - MISC. METHYLPHENIDATE HCL CHEWABLE TABLETS METHYLIN PA Required for ages < 6 years 90 30 METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE RITALIN LA PA Required for ages < 6 years 30 30 METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE METADATE CD PA Required for ages < 6 years 30 30 METHYLPHENIDATE HCL SOLUTION METHYLIN PA Required for ages < 6 years 300 30 METHYLPHENIDATE HCL SUSPENSION QUILLIVANT XR PA Required for ages < 6 years 150 30 METHYLPHENIDATE HCL TABLETS RITALIN PA Required for ages < 6 years 60 30 METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE METHYLPHENIDATE HCL ER PA Required for ages < 6 years 60 30 AMINOGLYCOSIDES AMINOGLYCOSIDES NEOMYCIN SULFATE TABLETS NEOMYCIN SULFATE INHALED ANTIBIOTICS TOBRAMYCIN NEBULIZED BETHKIS Preferred Drug PA Required TOBRAMYCIN NEBULIZED KITABIS Preferred Drug PA Required ANALGESICS - ANTI-INFLAMMATORY ANTIRHEUMATIC ANTIMETABOLITES METHOTREXATE SODIUM TABLETS RHEUMATREX NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) CELECOXIB CAPSULES CELEBREX PA Required DICLOFENAC SODIUM TABLET 24-HOUR VOLTAREN-XR DICLOFENAC SODIUM TABLET ENTERIC COATED VOLTAREN ETODOLAC CAPSULES VARIOUS ETODOLAC TABLETS VARIOUS FENOPROFEN CALCIUM CAPSULES NALFON FENOPROFEN CALCIUM TABLETS FENOPROFEN CALCIUM FLURBIPROFEN TABLETS FLURBIPROFEN IBUPROFEN CAPSULES ADVIL IBUPROFEN CHEWABLE TABLETS CHILDRENS MOTRIN IBUPROFEN SUSPENSION CHILDRENS MOTRIN IBUPROFEN TABLETS ADVIL INDOMETHACIN CAPSULES VARIOUS INDOMETHACIN CAPSULE CONTROLLED RELEASE INDOMETHACIN CR INDOMETHACIN SUPPOSITORY INDOCIN INDOMETHACIN SUSPENSION INDOCIN AHCCCS DRUG LIST • Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization 1
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Transcript of AHCCCS DRUG LIST - azahcccs.gov · METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE METADATE CD PA...
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days ADHD/ANTI-NARCOLEPSYAMPHETAMINESAMPHETAMINE-DEXTROAMPHETAMINE CAPSULE CONTROLLED RELEASE ADDERALL XR PA Required for ages < 6 years 30 30AMPHETAMINE-DEXTROAMPHETAMINE TABLETS ADDERALL PA Required for ages < 6 years 60 30DEXTROAMPHETAMINE SULFATE CAPSULE CONTROLLED RELEASE DEXEDRINE PA Required for ages < 6 years 60 30DEXTROAMPHETAMINE SULFATE SOLUTION PROCENTRA PA Required for ages < 6 years 600 30DEXTROAMPHETAMINE SULFATE TABLETS ZENZEDI PA Required for ages < 6 years 60 30ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) ATOMOXETINE HCL CAPSULES STRATTERA PA Required 60 30STIMULANTS - MISC.METHYLPHENIDATE HCL CHEWABLE TABLETS METHYLIN PA Required for ages < 6 years 90 30METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE RITALIN LA PA Required for ages < 6 years 30 30METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE METADATE CD PA Required for ages < 6 years 30 30METHYLPHENIDATE HCL SOLUTION METHYLIN PA Required for ages < 6 years 300 30METHYLPHENIDATE HCL SUSPENSION QUILLIVANT XR PA Required for ages < 6 years 150 30METHYLPHENIDATE HCL TABLETS RITALIN PA Required for ages < 6 years 60 30METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE METHYLPHENIDATE HCL ER PA Required for ages < 6 years 60 30AMINOGLYCOSIDESAMINOGLYCOSIDESNEOMYCIN SULFATE TABLETS NEOMYCIN SULFATEINHALED ANTIBIOTICSTOBRAMYCIN NEBULIZED BETHKIS Preferred Drug PA RequiredTOBRAMYCIN NEBULIZED KITABIS Preferred Drug PA RequiredANALGESICS - ANTI-INFLAMMATORYANTIRHEUMATIC ANTIMETABOLITESMETHOTREXATE SODIUM TABLETS RHEUMATREXNONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)CELECOXIB CAPSULES CELEBREX PA RequiredDICLOFENAC SODIUM TABLET 24-HOUR VOLTAREN-XRDICLOFENAC SODIUM TABLET ENTERIC COATED VOLTARENETODOLAC CAPSULES VARIOUSETODOLAC TABLETS VARIOUSFENOPROFEN CALCIUM CAPSULES NALFONFENOPROFEN CALCIUM TABLETS FENOPROFEN CALCIUMFLURBIPROFEN TABLETS FLURBIPROFENIBUPROFEN CAPSULES ADVILIBUPROFEN CHEWABLE TABLETS CHILDRENS MOTRINIBUPROFEN SUSPENSION CHILDRENS MOTRINIBUPROFEN TABLETS ADVIL INDOMETHACIN CAPSULES VARIOUSINDOMETHACIN CAPSULE CONTROLLED RELEASE INDOMETHACIN CRINDOMETHACIN SUPPOSITORY INDOCININDOMETHACIN SUSPENSION INDOCIN
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
1
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
KETOPROFEN CAPSULES ORUDISKETOROLAC TROMETHAMINE TABLETS KETOROLAC TROMETHAMINE 20 30MELOXICAM SUSPENSION MOBICMELOXICAM TABLETS MOBICNABUMETONE TABLETS NABUMETONENAPROXEN SODIUM TABLETS ALEVE. ANAPROXNAPROXEN SUSPENSION NAPROSYNNAPROXEN TABLETS NAPROSYNOXAPROZIN TABLETS DAYPROPIROXICAM CAPSULES FELDENESULINDAC TABLETS SULINDACPYRIMIDINE SYNTHESIS INHIBITORSLEFLUNOMIDE TABLETS ARAVACYTOKINE & CAM ANTAGONIST AGENTSADALIMUMAB HUMIRA Preferred Drug PA RequiredETANERCEPT ENBREL Preferred Drug PA RequiredANALGESICS - NONNARCOTICANALGESIC COMBINATIONSBUTALBITAL-ACETAMINOPHEN-CAFFEINE CAPSULES FIORICETBUTALBITAL-ACETAMINOPHEN-CAFFEINE TABLETS ESGICBUTALBITAL-ASPIRIN-CAFFEINE CAPSULES FIORINALBUTALBITAL-ASPIRIN-CAFFEINE TABLETS BUTAL/ASA/CAFFANALGESICS OTHERACETAMINOPHEN CAPSULES VARIOUSACETAMINOPHEN CHEWABLE TABLETS VARIOUSACETAMINOPHEN ELIXIR VARIOUSACETAMINOPHEN LIQUID VARIOUSACETAMINOPHEN SUPPOSITORY FEVERALL INFANTSACETAMINOPHEN SUSPENSION TYLENOL INFANTSSALICYLATESASPIRIN CHEWABLE TABLETS VARIOUSASPIRIN SUPPOSITORY VARIOUSASPIRIN TABLETS VARIOUSDIFLUNISAL TABLETS DIFLUNISALSALSALATE TABLETS DISALCIDANALGESICS - OPIOIDOPIOID AGONISTSFENTANYL PATCH DURAGESIC PA Required
HYDROMORPHONE HCL LIQUID DILAUDID
PA Required for > 2 Short Acting
Narcotics Fill 180 30
HYDROMORPHONE HCL SUPPOSITORY HYDROMORPHONE HCL
PA Required for > 2 Short Acting
Narcotics Fill 180 30
2
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
HYDROMORPHONE HCL TABLETS DILAUDID
PA Required for > 2 Short Acting
Narcotics Fill 180 30
MEPERIDINE HCL TABLETS DEMEROL
PA Required for > 2 Short Acting
Narcotics Fill 180 30
METHADONE HCL CONCENTRATE METHADONE HCL INTENSOL
PA Required for > 1 Long Acting
Narcotics Fill 180 30
METHADONE HCL SOLUTION METHADONE HCL
PA Required for > 1 Long Acting
Narcotics Fill 500 30
METHADONE HCL TABLETS DOLOPHINE
PA Required for > 1 Long Acting
Narcotics Fill 180 30
MORPHINE SULFATE SOLUTION MORPHINE SULFATE
PA Required for > 2 Short Acting
Narcotics Fill 500 30
MORPHINE SULFATE SUPPOSITORY MORPHINE SULFATE
PA Required for > 2 Short Acting
Narcotics Fill 180 30
MORPHINE SULFATE TABLETS MORPHINE SULFATE
PA Required for > 2 Short Acting
Narcotics Fill 90 30
MORPHINE SULFATE TABLET CONTROLLED RELEASE MS CONTIN
PA Required for > 1 Long Acting Narcotic
Fill 90 30
OXYCODONE HCL CAPSULES OXYCODONE HCL
PA Required for > 2 Short Acting
Narcotics Fill 180 30
OXYCODONE HCL CONCENTRATE OXYCODONE HCL PA Required
OXYCODONE HCL SOLUTION OXYCODONE HCL
PA Required for > 2 Short Acting
Narcotics Fill 180 30OXYCODONE HCL TABLET ABUSE DETERRANT 12-HOUR OXYCONTIN PA Required
OXYCODONE HCL TABLETS ROXICODONE
PA Required for > 2 Short Acting
Narcotics Fill 180 30
TRAMADOL HCL TABLETS ULTRAM
PA Required for > 2 Short Acting
Narcotics Fill 180 30
TRAMADOL HCL TABLET 24-HOUR TRAMADOL HCL ER
PA Required for > 1 Long Acting Narcotic
Fill 30 30OPIOID COMBINATIONS
ACETAMINOPHEN W/ CODEINE SOLUTION VARIOUS
PA Required for > 2 Short Acting
Narcotics Fill 180 30
ACETAMINOPHEN W/ CODEINE TABLETS VARIOUS
PA Required for > 2 Short Acting
Narcotics Fill 180 30
BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/ CODEINE CAPSULES FIORICET/CODEINE
PA Required for > 2 Short Acting
Narcotics Fill 180 30
BUTALBITAL-ASPIRIN-CAFFEINE W/COD CAPSULES FIORINAL/CODEINE
PA Required for > 2 Short Acting
Narcotics Fill 180 30
HYDROCODONE-ACETAMINOPHEN CAPSULES VARIOUS
PA Required for > 2 Short Acting
Narcotics Fill 180 30
3
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
HYDROCODONE-ACETAMINOPHEN SOLUTION VARIOUS
PA Required for > 2 Short Acting
Narcotics Fill 180 30
HYDROCODONE-ACETAMINOPHEN TABLETS VARIOUS
PA Required for > 2 Short Acting
Narcotics Fill 180 30
HYDROCODONE-IBUPROFEN TABLETS VARIOUS
PA Required for > 2 Short Acting
Narcotics Fill 180 30
OXYCODONE W/ ACETAMINOPHEN CAPSULES VARIOUS
PA Required for > 2 Short Acting
Narcotics Fill 180 30
OXYCODONE W/ ACETAMINOPHEN SOLUTION ROXICET
PA Required for > 2 Short Acting
Narcotics Fill 180 30
OXYCODONE W/ ACETAMINOPHEN TABLETS ENDOCET
PA Required for > 2 Short Acting
Narcotics Fill 180 30ANDROGENS-ANABOLICANDROGENSDANAZOL CAPSULES DANAZOLFLUOXYMESTERONE TABLETS ANDROXYTESTOSTERONE CYPIONATE SOLUTION DEPO-TESTOSTERONE PA RequiredTESTOSTERONE ENANTHATE SOLUTION TESTOSTERONE ENANTHATE PA RequiredTESTOSTERONE GEL ANDROGEL PA RequiredTESTOSTERONE PATCH ANDRODERM PA RequiredTESTOSTERONE SOLUTION AXIRON PA RequiredANORECTAL AGENTSINTRARECTAL STEROIDSHYDROCORTISONE (INTRARECTAL) ENEMA COLOCORTHYDROCORTISONE ACETATE (INTRARECTAL) FOAM CORTIFOAMRECTAL STEROIDSHYDROCORTISONE (RECTAL) CREAM PROCTOCORTANTHELMINTICSANTHELMINTICSALBENDAZOLE TABLETS ALBENZA PA RequiredIVERMECTIN TABLETS STROMECTOL PA RequiredPRAZIQUANTEL TABLETS BILTRICIDEANTIANGINAL AGENTSANTIANGINALS-OTHERRANOLAZINE TABLET 12-HOUR RANEXA PA RequiredNITRATESISOSORBIDE DINITRATE CAPSULE CONTROLLED RELEASE DILATRATE SRISOSORBIDE DINITRATE SUBLINGUAL ISOSORBIDE DINITRATEISOSORBIDE DINITRATE TABLETS ISORDIL TITRADOSEISOSORBIDE DINITRATE TABLET CONTROLLED RELEASE ISOSORBIDE DINITRATE ERISOSORBIDE MONONITRATE TABLETS ISOSORBIDE MONONITRATEISOSORBIDE MONONITRATE TABLET 24-HOUR IMDURNITROGLYCERIN AEROSOL NITROMIST
4
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
NITROGLYCERIN CAPSULE CONTROLLED RELEASE NITRO-TIMENITROGLYCERIN OINTMENT NITRO-BIDNITROGLYCERIN PATCH MINITRANNITROGLYCERIN SOLUTION NITROLINGUAL PUMPSPRAYNITROGLYCERIN SUBLINGUAL NITROSTATANTIANXIETY AGENTSANTIANXIETY AGENTS - MISC.BUSPIRONE HCL TABLETS BUSPIRONE HCL PA Required for > 1 Anxiolytics Fill 120 30HYDROXYZINE HCL SYRUP HYDROXYZINE HCLHYDROXYZINE HCL TABLETS HYDROXYZINE HCLHYDROXYZINE PAMOATE CAPSULES VISTARILBENZODIAZEPINESALPRAZOLAM CONCENTRATE ALPRAZOLAM INTENSOL PA Required for > 1 Anxiolytics Fill 120 30ALPRAZOLAM TABLETS XANAX PA Required for > 1 Anxiolytics Fill 120 30CHLORDIAZEPOXIDE HCL CAPSULES CHLORDIAZEPOXIDE HCL PA Required for > 1 Anxiolytics Fill 120 30CLORAZEPATE DIPOTASSIUM TABLETS TRANXENE T PA Required for > 1 Anxiolytics Fill 120 30DIAZEPAM CONCENTRATE DIAZEPAM INTENSOL PA Required for > 1 Anxiolytics Fill 120 30DIAZEPAM SOLUTION DIAZEPAM PA Required for > 1 Anxiolytics Fill 120 30DIAZEPAM TABLETS VALIUM PA Required for > 1 Anxiolytics Fill 120 30LORAZEPAM CONCENTRATE LORAZEPAM INTENSOL PA Required for > 1 Anxiolytics Fill 120 30LORAZEPAM TABLETS ATIVAN PA Required for > 1 Anxiolytics Fill 120 30OXAZEPAM CAPSULES OXAZEPAM PA Required for > 1 Anxiolytics Fill 120 30ANTIARRHYTHMICSANTIARRHYTHMICS TYPE I-ADISOPYRAMIDE PHOSPHATE CAPSULES NORPACEDISOPYRAMIDE PHOSPHATE CAPSULE 12-HOUR NORPACE CRQUINIDINE GLUCONATE TABLET CONTROLLED RELEASE QUINIDINE GLUCONATE CRQUINIDINE SULFATE TABLETS QUINIDINE SULFATEQUINIDINE SULFATE TABLET CONTROLLED RELEASE QUINIDINE SULFATE ERANTIARRHYTHMICS TYPE I-BMEXILETINE HCL CAPSULES MEXILETINE HCLANTIARRHYTHMICS TYPE I-CFLECAINIDE ACETATE TABLETS TAMBOCORPROPAFENONE HCL CAPSULE 12-HOUR RYTHMOL SRPROPAFENONE HCL TABLETS RYTHMOLANTIARRHYTHMICS TYPE IIIAMIODARONE HCL TABLETS PACERONEDOFETILIDE CAPSULES TIKOSYN PA RequiredDRONEDARONE HCL TABLETS MULTAQ PA RequiredANTIASTHMATIC AND BRONCHODILATOR AGENTSANTI-INFLAMMATORY AGENTSCROMOLYN SODIUM NEBULIZER CROMOLYN SODIUMBRONCHODILATORS - ANTICHOLINERGICS
5
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
ACLIDINIUM BROMIDE AEROSOL POWDER BREATH ACTIVATED TUDORZA PRESSAIRIPRATROPIUM BROMIDE HFA AEROSOL ATROVENT HFAIPRATROPIUM BROMIDE SOLUTION IPRATROPIUM BROMIDETIOTROPIUM BROMIDE MONOHYDRATE AEROSOL SPIRIVA RESPIMATTIOTROPIUM BROMIDE MONOHYDRATE CAPSULES SPIRIVA HANDIHALERLEUKOTRIENE MODULATORSMONTELUKAST SODIUM CHEWABLE TABLETS SINGULAIR 30 30MONTELUKAST SODIUM TABLETS SINGULAIR 30 30ZAFIRLUKAST TABLETS ACCOLATESTEROID INHALANTSBECLOMETHASONE DIPROPIONATE AEROSOL QVARBUDESONIDE (INHALATION) AEROSOL POWDER BREATH ACTIVATED PULMICORT FLEXHALER PA RequiredBUDESONIDE (INHALATION) SUSPENSION PULMICORT PA RequiredFLUTICASONE PROPIONATE HFA AEROSOL FLOVENT HFAFLUTICASONE PROPIONATE (INHALATION) AEROSOL POWDER BREATH
ACTIVATED FLOVENT DISKUS
MOMETASONE FUROATE (INHALATION) AEROSOL POWDER BREATH ACTIVATED
ASMANEX TWISTHALER 30
METERED DOSESMOMETASONE FUROATE (INHALATION) AEROSOL ASMANEX HFASYMPATHOMIMETICSALBUTEROL SULFATE AEROSOL PROAIR HFAALBUTEROL SULFATE NEBULIZER ALBUTEROL SULFATEALBUTEROL SULFATE SYRUP ALBUTEROL SULFATE
BUDESONIDE-FORMOTEROL FUMARATE DIHYDRATE AEROSOL SYMBICORT Step Therapy
Patient must have tried one
steroid inhaler:
Beclomethasone
Dipropionate, Budesonide,
Fluticasone Propionate, or
Mometasone
FLUTICASONE-SALMETEROL AEROSOL POWDER BREATH ACTIVATED ADVAIR DISKUS Step Therapy
Patient must have tried one
steroid inhaler:
Beclomethasone
Dipropionate, Budesonide,
Fluticasone Propionate, or
Mometasone
6
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
FLUTICASONE-SALMETEROL AEROSOL ADVAIR HFA Step Therapy
Patient must have tried one
steroid inhaler:
Beclomethasone
Dipropionate, Budesonide,
Fluticasone Propionate, or
MometasoneFORMOTEROL FUMARATE CAPSULES FORADIL AEROSOLLIZER PA RequiredIPRATROPIUM-ALBUTEROL AEROSOL COMBIVENTIPRATROPIUM-ALBUTEROL AEROSOL COMBIVENT RESPIMATIPRATROPIUM-ALBUTEROL SOLUTION DUONEBMETAPROTERENOL SULFATE TABLETS METAPROTERENOL SULFATE
MOMETASONE FUROATE-FORMOTEROL FUMARATE DIHYDRATE AEROSOL DULERA Step Therapy
Patient must have tried one
steroid inhaler:
Beclomethasone
Dipropionate, Budesonide,
Fluticasone Propionate, or
MometasoneSALMETEROL XINAFOATE AEROSOL POWDER BREATH ACTIVATED SEREVENT DISKUS PA RequiredANTICOAGULANTSCOUMARIN ANTICOAGULANTSWARFARIN SODIUM TABLETS COUMADINDIRECT FACTOR XA INHIBITORSAPIXABAN TABLETS ELIQUIS PA RequiredRIVAROXABAN TABLETS XARELTO PA RequiredHEPARINS AND HEPARINOID-LIKE AGENTSENOXAPARIN SODIUM SOLUTION LOVENOX 6 10HEPARIN SODIUM LOCK FLUSH SOLUTION HEPARIN LOCK FLUSHHEPARIN SODIUM SOLUTION HEPARIN SODIUMTHROMBIN INHIBITORSDABIGATRAN ETEXILATE MESYLATE CAPSULES PRADAXA PA RequiredANTICONVULSANTSANTICONVULSANTS - BENZODIAZEPINESCLOBAZAM SUSPENSION ONFI PA RequiredCLOBAZAM TABLETS ONFI PA RequiredCLONAZEPAM TABLETS KLONOPIN PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM ORALLY DISINTEGRATING TABLETS CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 120 30DIAZEPAM (ANTICONVULSANT) GEL DIASTAT PEDIATRICANTICONVULSANTS - MISC.CARBAMAZEPINE CHEWABLE TABLETS CARBAMAZEPINECARBAMAZEPINE CAPSULE 12-HOUR CARBATROLCARBAMAZEPINE SUSPENSION TEGRETOL
7
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
CARBAMAZEPINE TABLETS EPITOLCARBAMAZEPINE CAPSULE 12-HOUR EQUETROCARBAMAZEPINE TABLET 12-HOUR TEGRETOL-XRGABAPENTIN CAPSULES NEURONTINGABAPENTIN SOLUTION NEURONTINGABAPENTIN TABLETS NEURONTINLACOSAMIDE SOLUTION VIMPAT PA RequiredLACOSAMIDE TABLETS VIMPAT PA RequiredLAMOTRIGINE CHEWABLE TABLETS LAMICTAL+B135LAMOTRIGINE TABLETS LAMICTALLAMOTRIGINE TABLET 24-HOUR LAMICTAL XRLAMOTRIGINE ORALLY DISINTEGRATING TABLETS LAMICTAL ODTLEVETIRACETAM SOLUTION KEPPRALEVETIRACETAM TABLETS KEPPRALEVETIRACETAM TABLET 24-HOUR KEPPRA XROXCARBAZEPINE SUSPENSION TRILEPTALOXCARBAZEPINE TABLETS TRILEPTALPREGABALIN CAPSULES LYRICA PA RequiredPREGABALIN SOLUTION LYRICA PA RequiredPRIMIDONE TABLETS MYSOLINERUFINAMIDE SUSPENSION BANZEL PA RequiredRUFINAMIDE TABLETS BANZEL PA RequiredTOPIRAMATE SPRINKLE CAPSULES TOPAMAX SPRINKLESTOPIRAMATE TABLETS TOPAMAXZONISAMIDE CAPSULES ZONEGRANCARBAMATESFELBAMATE SUSPENSION FELBATOLFELBAMATE TABLETS FELBATOLGABA MODULATORSTIAGABINE HCL TABLETS GABITRIL PA RequiredHYDANTOINSPHENYTOIN CHEWABLE TABLETS DILANTIN INFATABLETSPHENYTOIN SODIUM EXTENDED CAPSULES DILANTINPHENYTOIN SUSPENSION DILANTIN-125SUCCINIMIDESETHOSUXIMIDE CAPSULES ZARONTINETHOSUXIMIDE SOLUTION ZARONTINVALPROIC ACIDDIVALPROEX SODIUM SPRINKLE CAPSULES DEPAKOTE SPRINKLESDIVALPROEX SODIUM TABLET 24-HOUR DEPAKOTE ERDIVALPROEX SODIUM TABLET ENTERIC COATED DEPAKOTEVALPROATE SODIUM SYRUP DEPAKENE+B252VALPROIC ACID CAPSULES DEPAKENE
8
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
ANTIDEPRESSANTSALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)MIRTAZAPINE TABLETS MIRTAZAPINEMIRTAZAPINE ORALLY DISINTEGRATING TABLETS REMERON SOLTABANTIDEPRESSANTS - MISC.BUPROPION HCL TABLETS WELLBUTRINBUPROPION HCL TABLET 12-HOUR BUDEPRION SRBUPROPION HCL TABLET 24-HOUR WELLBUTRIN XLMAPROTILINE HCL TABLETS MAPROTILINE HCLSELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)CITALOPRAM HYDROBROMIDE SOLUTION CELEXACITALOPRAM HYDROBROMIDE TABLETS CELEXAESCITALOPRAM OXALATE SOLUTION LEXAPROESCITALOPRAM OXALATE TABLETS LEXAPROFLUOXETINE HCL CAPSULES PROZACFLUOXETINE HCL SOLUTION PROZACFLUOXETINE HCL TABLETS PROZACFLUVOXAMINE MALEATE TABLETS LUVOXPAROXETINE HCL SUSPENSION PAXILPAROXETINE HCL TABLETS PAXILSERTRALINE HCL CONCENTRATE ZOLOFTSERTRALINE HCL TABLETS ZOLOFTSEROTONIN MODULATORSTRAZODONE HCL TABLETS TRAZODONE HCLSEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRI)VENLAFAXINE HCL CAPSULE CONTROLLED RELEASE EFFEXOR XRVENLAFAXINE HCL TABLETS VENLAFAXINE HCLVENLAFAXINE HCL TABLET 24-HOUR VENLAFAXINE HCL ERTRICYCLIC AGENTSAMITRIPTYLINE HCL TABLETS AMITRIPTYLINE HCL PA Required for ages < 6 yearsCLOMIPRAMINE HCL CAPSULES ANAFRANIL Long Term Care OnlyDESIPRAMINE HCL TABLETS NORPRAMIN PA Required for ages < 6 yearsDOXEPIN HCL CAPSULES DOXEPIN HCL Long Term Care OnlyDOXEPIN HCL CONCENTRATE DOXEPIN HCL Long Term Care OnlyIMIPRAMINE HCL TABLETS TOFRANIL PA Required for ages < 6 yearsIMIPRAMINE PAMOATE CAPSULES TOFRANIL-PM PA Required for ages < 6 yearsNORTRIPTYLINE HCL CAPSULES PAMELOR PA Required for ages < 6 yearsNORTRIPTYLINE HCL SOLUTION NORTRIPTYLINE HCL PA Required for ages < 6 yearsPROTRIPTYLINE HCL TABLETS VIVACTIL PA Required for ages < 6 yearsANTIDIABETICSALPHA-GLUCOSIDASE INHIBITORSACARBOSE TABLETS PRECOSEANTIDIABETIC COMBINATIONS
9
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
GLIPIZIDE-METFORMIN HCL TABLETS GLIPIZIDE/METFORMIN HCLGLYBURIDE-METFORMIN HCL TABLETS GLUCOVANCEPIOGLITAZONE HCL-METFORMIN HCL TABLETS ACTOPLUS METPIOGLITAZONE HCL-METFORMIN HCL TABLET 24-HOUR ACTOPLUS MET XRSITAGLIPTIN-METFORMIN HCL TABLETS JANUMET PA RequiredSITAGLIPTIN-METFORMIN HCL TABLET 24-HOUR JANUMET XR PA RequiredBIGUANIDESMETFORMIN HCL SOLUTION RIOMETMETFORMIN HCL TABLETS GLUCOPHAGEMETFORMIN HCL TABLET 24-HOUR GLUCOPHAGE XRDIABETIC OTHERGLUCAGON (RDNA) KIT GLUCAGON EMERGENCY KIT 1 30DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORSSITAGLIPTIN PHOSPHATE TABLETS JANUVIA PA RequiredINCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)EXENATIDE SUSPENSION BYETTA PA RequiredINSULIN SENSITIZING AGENTSPIOGLITAZONE HCL TABLETS ACTOSINSULIN
INSULIN ASPART PROTAMINE & ASPART (HUMAN) SUSPENSION
NOVOLOG MIX 70/30 PREFILLED
FLEXPEN PA RequiredINSULIN ASPART PROTAMINE & ASPART (HUMAN) SUSPENSION NOVOLOG MIX 70/30INSULIN ASPART SOLUTION NOVOLOGINSULIN DETEMIR SOLUTION LEVEMIRINSULIN DETEMIR SUSPENSION LEVEMIR FLEXPEN PA RequiredINSULIN GLARGINE SOLUTION LANTUSINSULIN GLARGINE SUSPENSION LANTUS SOLOSTAR PA RequiredINSULIN LISPRO (HUMAN) SOLUTION HUMALOGINSULIN LISPRO (HUMAN) SUSPENSION HUMALOG KWIKPEN PA Required
INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION HUMALOG MIX 75/25 KWIKPEN PA RequiredINSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION HUMALOG MIX 75/25INSULIN NPH (HUMAN) (ISOPHANE) SUSPENSION HUMULIN N KWIKPEN PA RequiredINSULIN NPH (HUMAN) (ISOPHANE) SUSPENSION HUMULIN NINSULIN NPH ISOPHANE & REG (HUMAN) SUSPENSION HUMULIN 70/30
INSULIN REGULAR (HUMAN) SOLUTION
HUMULIN R U-500
(CONCENTRATEENTRATED)MEGLITINIDE ANALOGUESNATEGLINIDE TABLETS STARLIXREPAGLINIDE TABLETS PRANDINSULFONYLUREASGLIMEPIRIDE TABLETS AMARYLGLIPIZIDE TABLETS GLUCOTROL
10
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
GLIPIZIDE TABLET 24-HOUR GLUCATROL XLGLYBURIDE MICRONIZED TABLETS GLYNASEGLYBURIDE TABLETS DIABETAANTIDIARRHEALSANTIPERISTALTIC AGENTSDIPHENOXYLATE W/ ATROPINE LIQUID DIPHENOXYLATE/ATROPINEDIPHENOXYLATE W/ ATROPINE TABLETS LOMOTILLOPERAMIDE HCL CAPSULES LOPERAMIDE HCLLOPERAMIDE HCL CHEWABLE TABLETS IMODIUM A-DLOPERAMIDE HCL LIQUID LOPERAMIDE HCLLOPERAMIDE HCL SUSPENSION IMODIUM A-DLOPERAMIDE HCL TABLETS IMODIUM A-DANTIEMETICS5-HT3 RECEPTOR ANTAGONISTSDOLASETRON MESYLATE TABLETS ANZEMET PA RequiredGRANISETRON HCL SOLUTION VARIOUS PA RequiredGRANISETRON HCL TABLETS VARIOUS PA RequiredONDANSETRON HCL TABLETS ZOFRAN PA Required for tablets > 8mg 30 30SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTAPREPITANT CAPSULES EMEND 6 21ANTIFUNGALSANTIFUNGALSFLUCYTOSINE CAPSULES ANCOBON PA RequiredGRISEOFULVIN MICROSIZE SUSPENSION GRISEOFULVIN MICROSIZEGRISEOFULVIN MICROSIZE TABLETS GRIFULVIN VGRISEOFULVIN ULTRAMICROSIZE TABLETS GRIS-PEGNYSTATIN CAPSULES BIO-STATINNYSTATIN POWDER NYSTATINNYSTATIN TABLETS NYSTATINTERBINAFINE HCL PACKETS LAMISIL 90 365TERBINAFINE HCL TABLETS LAMISIL 90 365IMIDAZOLE-RELATED ANTIFUNGALSFLUCONAZOLE SUSPENSION DIFLUCAN 600 30FLUCONAZOLE TABLETS DIFLUCAN 60 30ITRACONAZOLE CAPSULES SPORANOX PA RequiredITRACONAZOLE SOLUTION SPORANOX PA RequiredITRACONAZOLE TABLETS ONMEL PA RequiredKETOCONAZOLE TABLETS KETOCONAZOLEPOSACONAZOLE SUSPENSION NOXAFIL PA RequiredPOSACONAZOLE TABLET ENTERIC COATED NOXAFIL PA RequiredVORICONAZOLE SUSPENSION VFEND PA RequiredVORICONAZOLE TABLETS VFEND PA RequiredANTIHISTAMINES
11
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
ANTIHISTAMINES - ALKYLAMINESBROMPHENIRAMINE MALEATE J-TAN PD
CHLORPHINERAMINE MALEATE CHLORPHENIRAMINE MALEATE
DEXCHLORPHENIRAMINE MALEATE SYRUP
DEXCHLORPHENIRAMINE
MALEATEANTIHISTAMINES - ETHANOLAMINESCLEMASTINE FUMARATE SYRUP CLEMASTINE FUMARATECLEMASTINE FUMARATE TABLETS CLEMASTINE FUMARATEDIPHENHYDRAMINE HCL CAPSULES VARIOUSDIPHENHYDRAMINE HCL CHEWABLE TABLETS VARIOUSDIPHENHYDRAMINE HCL ELIXIR VARIOUSDIPHENHYDRAMINE HCL LIQUID VARIOUSDIPHENHYDRAMINE HCL SOLUTION VARIOUSDIPHENHYDRAMINE HCL SUSPENSION VARIOUSDIPHENHYDRAMINE HCL SYRUP VARIOUSDIPHENHYDRAMINE HCL TABLETS VARIOUSANTIHISTAMINES - NON-SEDATINGCETIRIZINE HCL CAPSULES ZYRTEC ALLERGY 30 30CETIRIZINE HCL CHEWABLE TABLETS VARIOUS 30 30CETIRIZINE HCL SYRUP VARIOUS 150 30CETIRIZINE HCL TABLETS VARIOUS 30 30CETIRIZINE HCL ORALLY DISINTEGRATING TABLETS ZYRTEC ALLERGY 30 30FEXOFENADINE HCL SUSPENSION ALLEGRA ALLERGY CHILDRENS 150 30FEXOFENADINE HCL TABLETS ALLEGRA ALLERGY CHILDRENS 30 30FEXOFENADINE HCL ORALLY DISINTEGRATING TABLETS ALLEGRA ALLERGY CHILDRENS 30 30LORATADINE CAPSULES CLARITIN 30 30LORATADINE CHEWABLE TABLETS CLARITIN 30 30LORATADINE SYRUP CLARITIN 150 30LORATADINE TABLETS ALAVERT 30 30LORATADINE ORALLY DISINTEGRATING TABLETS CLARITIN REDITABS 30 30ANTIHISTAMINES - PHENOTHIAZINESPROMETHAZINE HCL SUPPOSITORY PHENERGANPROMETHAZINE HCL TABLETS PROMETHAZINE HCLANTIHISTAMINES - PIPERIDINESCYPROHEPTADINE HCL SYRUP CYPROHEPTADINE HCLCYPROHEPTADINE HCL TABLETS CYPROHEPTADINE HCLANTIHYPERLIPIDEMICSBILE ACID SEQUESTRANTSCHOLESTYRAMINE LIGHT PACKETS PREVALITECHOLESTYRAMINE LIGHT POWDER PREVALITECHOLESTYRAMINE PACKETS QUESTRANCHOLESTYRAMINE POWDER QUESTRAN
12
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
COLESTIPOL HCL GRANULES COLESTIDCOLESTIPOL HCL PACKETS COLESTIDCOLESTIPOL HCL TABLETS COLESTIDFIBRIC ACID DERIVATIVESFENOFIBRATE CAPSULES LIPOFENFENOFIBRATE MICRONIZED CAPSULES ANTARAFENOFIBRATE TABLETS FENOGLIDEFENOFIBRIC ACID TABLETS FIBRICORGEMFIBROZIL TABLETS LOPIDHMG COA REDUCTASE INHIBITORSATORVASTATIN CALCIUM TABLETS LIPITOR 30 30LOVASTATIN TABLETS MEVACOR 30 30PRAVASTATIN SODIUM TABLETS PRAVACOL 30 30SIMVASTATIN TABLETS ZOCOR 30 30INTESTINAL CHOLESTEROL ABSORPTION INHIBITORSEZETIMIBE TABLETS ZETIA PA RequiredNICOTINIC ACID DERIVATIVESNIACIN (ANTIHYPERLIPIDEMIC) TABLETS NIACORNIACIN (ANTIHYPERLIPIDEMIC) CAPSULE CONTROLLED RELEASE NIASPANANTIHYPERTENSIVESACE INHIBITORSBENAZEPRIL HCL TABLETS BENAZEPRIL HCLCAPTOPRIL TABLETS CAPTOPRILENALAPRIL MALEATE SOLUTION EPANEDENALAPRIL MALEATE TABLETS VASOTECFOSINOPRIL SODIUM TABLETS FOSINOPRIL SODIUMLISINOPRIL TABLETS ZESTRILMOEXIPRIL HCL TABLETS UNIVASCPERINDOPRIL ERBUMINE TABLETS ACEONQUINAPRIL HCL TABLETS ACCUPRILRAMIPRIL CAPSULES ALTACETRANDOLAPRIL TABLETS MAVIKANGIOTENSIN II RECEPTOR ANTAGONISTSIRBESARTAN TABLETS AVAPROLOSARTAN POTASSIUM TABLETS COZAAR
OLMESARTAN MEDOXOMIL TABLETS BENICAR Step Therapy
Member must have tried
losartan & IrbesartanVALSARTAN TABLETS DIOVANANTIADRENERGIC ANTIHYPERTENSIVESCLONIDINE HCL PATCH-WEEKLY CATAPRES-TTS-1CLONIDINE HCL TABLETS CATAPRESDOXAZOSIN MESYLATE TABLETS CARDURAGUANFACINE HCL TABLETS TENEX
13
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
METHYLDOPA TABLETS METHYLDOPAPRAZOSIN HCL CAPSULES MINIPRESSTERAZOSIN HCL CAPSULES TERAZOSIN HCLANTIHYPERTENSIVE COMBINATIONSATENOLOL & CHLORTHALIDONE TABLETS TENORETIC 50
BENAZEPRIL & HYDROCHLOROTHIAZIDE TABLETS
BENAZEPRIL
HCL/HYDROCHLOROTHIAZIDE
CAPTOPRIL & HYDROCHLOROTHIAZIDE TABLETS
CAPTOPRIL/
HYDROCHLOROTHIAZIDE
ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TABLETS
ENALAPRIL MALEATE/
HYDROCHLOROTHIAZIDE
FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TABLETS
FOSINOPRIL SODIUM/
HYDROCHLOROTHIAZIDELISINOPRIL & HYDROCHLOROTHIAZIDE TABLETS ZESTORETICLOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TABLETS HYZAARMOEXIPRIL - HYDROCHLOROTHIAZIDE TABLETS UNIRETIC
OLMESARTAN MEDOXOMIL - HYDROCHLOROTHIAZIDE TABLETS BENICAR HCT Step Therapy
Member must have tried
Losartan Potassium/HCTZ &
Irbesartan/HCTZQUINAPRIL - HYDROCHLOROTHIAZIDE TABLETS ACCURETICVALSARTAN - HYDROCHLOROTHIAZIDE TABLETS DIOVAN HCTSELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)EPLERENONE TABLETS INSPRA PA RequiredVASODILATORSHYDRALAZINE HCL TABLETS HYDRALAZINE HCLMINOXIDIL TABLETS MINOXIDILANTI-INFECTIVE AGENTS - MISC.ANTI-INFECTIVE AGENTS - MISC.VANCOMYCIN HCL CAPSULES VANCOCIN HCL PA RequiredVANCOMYCIN HCL SOLUTION FIRST-VANCOMYCIN 25 PA RequiredANTI-INFECTIVE MISC. - COMBINATIONSERYTHROMYCIN-SULFISOXAZOLE SUSPENSION E.S.P.SULFAMETHOXAZOLE-TRIMETHOPRIM SUSPENSION SULFATRIM PEDIATRICSULFAMETHOXAZOLE-TRIMETHOPRIM TABLETS BACTRIMLEPROSTATICSDAPSONE TABLETS DAPSONEOXAZOLIDINONESLINEZOLID SUSPENSION ZYVOX PA RequiredLINEZOLID TABLETS ZYVOX PA RequiredANTIMALARIALSANTIMALARIAL COMBINATIONSARTEMETHER-LUMEFANTRINE TABLETS COARTEM
14
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
ATOVAQUONE-PROGUANIL HCL TABLETS MALARONEANTIMALARIALSCHLOROQUINE PHOSPHATE TABLETS CHLOROQUINE PHOSPHATEHYDROXYCHLOROQUINE SULFATE TABLETS PLAQUENILPRIMAQUINE PHOSPHATE TABLETS PRIMAQUINE PHOSPHATEQUININE SULFATE CAPSULES QUALAQUINANTIMYCOBACTERIAL AGENTSETHAMBUTOL HCL TABLETS MYAMBUTOLISONIAZID SYRUP ISONIAZIDISONIAZID TABLETS ISONIAZIDPYRAZINAMIDE TABLETS PYRAZINAMIDERIFAMPIN CAPSULES RIFADINANTIMETABOLITESMERCAPTOPURINE SUSPENSION PURIXANMERCAPTOPURINE TABLETS PURINETHOLMETHOTREXATE SODIUM TABLETS METHOTREXATEANTINEOPLASTIC - HORMONAL AND RELATED AGENTSANASTROZOLE TABLETS ARIMIDEX PA RequiredEXEMESTANE TABLETS AROMASIN PA RequiredFLUTAMIDE CAPSULES FLUTAMIDELEUPROLIDE ACETATE (3 MONTH) KIT LUPRON DEPOT PA RequiredLEUPROLIDE ACETATE (4 MONTH) KIT LUPRON DEPOT PA RequiredLEUPROLIDE ACETATE KIT LUPRON DEPOT PA RequiredTAMOXIFEN CITRATE TABLETS TAMOXIFEN CITRATETOREMIFENE CITRATE TABLETS FARESTON PA RequiredANTINEOPLASTIC ENZYME INHIBITORSAXITINIB TABLETS INLYTA PA RequiredCRIZOTINIB CAPSULES XALKORI PA RequiredDASATINIB TABLETS SPRYCEL PA RequiredERLOTINIB HCL TABLETS TARCEVA PA RequiredEVEROLIMUS TABLETS AFINITOR PA RequiredEVEROLIMUS SOLUBLE TABLET AFINITOR DISPERZ PA RequiredGEFITINIB TABLETS IRESSA PA RequiredIBRUTINIB CAPSULES IMBRUVICA PA RequiredIMATINIB MESYLATE TABLETS GLEEVEC PA RequiredLAPATINIB DITOSYLATE TABLETS TYKERB PA RequiredNILOTINIB HCL CAPSULES TASIGNA PA RequiredPAZOPANIB HCL TABLETS VOTRIENT PA RequiredPONATINIB HCL TABLETS ICLUSIG PA RequiredRUXOLITINIB PHOSPHATE TABLETS JAKAFI PA RequiredSORAFENIB TOSYLATE TABLETS NEXAVAR PA RequiredSUNITINIB MALATE CAPSULES SUTENT PA RequiredVANDETANIB TABLETS CAPRELSA PA Required
15
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
VEMURAFENIB TABLETS ZELBORAF PA RequiredVORINOSTAT CAPSULES ZOLINZA PA RequiredANTINEOPLASTICS - MISC.BEXAROTENE CAPSULES TARGRETIN PA RequiredHYDROXYUREA CAPSULES HYDREAINTERFERON ALFA-2B SOLUTION INTRON A PA RequiredINTERFERON ALFA-2B SOLUTION INTRON A PA RequiredINTERFERON ALFA-N3 SOLUTION ALFERON N PA RequiredINTERFERON ALFACON-1 INFERGEN PA RequiredINTERFERON GAMMA-1B SOLUTION ACTIMMUNE PA RequiredPEGINTERFERON ALFA-2B (ANTINEOPLASTIC) KIT SYLATRON PA RequiredPROCARBAZINE HCL CAPSULES MATULANETRETINOIN (CHEMOTHERAPY) CAPSULES TRETINOIN PA Required For > 26 Years of AgeCHEMOTHERAPY RESCUE/ANTIDOTE AGENTSLEUCOVORIN CALCIUM TABLETS LEUCOVORIN CALCIUM PA RequiredMITOTIC INHIBITORSETOPOSIDE CAPSULES ETOPOSIDE PA RequiredANTIPARKINSON AGENTSANTIPARKINSON ANTICHOLINERGICSBENZTROPINE MESYLATE TABLETS BENZTROPINE MESYLATETRIHEXYPHENIDYL HCL ELIXIR TRIHEXYPHENIDYL HCLTRIHEXYPHENIDYL HCL TABLETS TRIHEXYPHENIDYL HCLANTIPARKINSON COMT INHIBITORSENTACAPONE TABLETS COMTANANTIPARKINSON DOPAMINERGICSAMANTADINE HCL CAPSULES AMANTADINE HCLAMANTADINE HCL SYRUP AMANTADINE HCLAMANTADINE HCL TABLETS AMANTADINE HCLBROMOCRIPTINE MESYLATE CAPSULES PARLODELBROMOCRIPTINE MESYLATE TABLETS PARLODELCARBIDOPA-LEVODOPA TABLETS SINEMETCARBIDOPA-LEVODOPA ORALLY DISINTEGRATING TABLETS VARIOUSPRAMIPEXOLE DIHYDROCHLORIDE TABLETS MIRAPEXROPINIROLE HYDROCHLORIDE TABLETS REQUIPANTIPARKINSON MONOAMINE OXIDASE INHIBITORSSELEGILINE HCL CAPSULES ELDEPRYLSELEGILINE HCL TABLETS VARIOUSANTIPSYCHOTICS/ANTIMANIC AGENTSANTIMANIC AGENTSLITHIUM CARBONATE CAPSULES LITHIUM CARBONATE Long Term Care OnlyLITHIUM CARBONATE TABLETS LITHIUM CARBONATE Long Term Care OnlyLITHIUM CARBONATE TABLET CONTROLLED RELEASE LITHOBID Long Term Care OnlyLITHIUM SOLUTION LITHIUM Long Term Care Only
16
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
ANTIPSYCHOTICS - MISC.ZIPRASIDONE HCL CAPSULES GEODON Long Term Care Only 60 30BENZISOXAZOLESRISPERIDONE SOLUTION RISPERDAL Long Term Care Only 60 30RISPERIDONE TABLETS RISPERDAL Long Term Care Only 60 30
RISPERIDONE ORALLY DISINTEGRATING TABLETS
RISPERIDONE ORALLY
DISINTEGRATING TABLETS Long Term Care Only 60 30BUTYROPHENONESHALOPERIDOL DECANOATE SOLUTION HALDOL DECANOATE 50 Long Term Care OnlyHALOPERIDOL LACTATE CONCENTRATE HALOPERIDOL Long Term Care OnlyHALOPERIDOL TABLETS HALOPERIDOL Long Term Care OnlyDIBENZAPINESCLOZAPINE SUSPENSION VERSACLOZ Long Term Care Only 150 30CLOZAPINE TABLETS CLOZARIL Long Term Care Only 150 30CLOZAPINE ORALLY DISINTEGRATING TABLETS FAZACLO Long Term Care Only, PA Required 150 30LOXAPINE SUCCINATE CAPSULES LOXITANE Long Term Care OnlyOLANZAPINE TABLETS ZYPREXA Long Term Care Only 30 30OLANZAPINE ORALLY DISINTEGRATING TABLETS ZYPREXA ZYDIS Long Term Care Only 30 30QUETIAPINE FUMARATE TABLETS SEROQUEL Long Term Care Only 60 30QUETIAPINE FUMARATE TABLET 24-HOUR SEROQUEL XR Long Term Care Only, PA RequiredPHENOTHIAZINESCHLORPROMAZINE HCL SOLUTION CHLORPROMAZINE HCL Long Term Care Only, PA RequiredCHLORPROMAZINE HCL TABLETS CHLORPROMAZINE HCL Long Term Care Only, PA RequiredFLUPHENAZINE DECANOATE SOLUTION FLUPHENAZINE DECANOATE Long Term Care OnlyFLUPHENAZINE HCL CONCENTRATE FLUPHENAZINE HCL Long Term Care OnlyFLUPHENAZINE HCL ELIXIR FLUPHENAZINE HCL Long Term Care OnlyFLUPHENAZINE HCL TABLETS FLUPHENAZINE HCL Long Term Care OnlyPERPHENAZINE TABLETS PERPHENAZINE Long Term Care OnlyPROCHLORPERAZINE MALEATE TABLETS COMPAZINEPROCHLORPERAZINE SUPPOSITORY COMPAZINETHIORIDAZINE HCL TABLETS THIORIDAZINE HCL Long Term Care OnlyTRIFLUOPERAZINE HCL TABLETS TRIFLUOPERAZINE HCL Long Term Care OnlyQUINOLINONE DERIVATIVESARIPIPRAZOLE SOLUTION ABILIFY Brand Only Long Term Care Only, PA Required 150 30ARIPIPRAZOLE TABLETS ABILIFY Brand Only Long Term Care Only, PA Required 30 30ARIPIPRAZOLE ORALLY DISINTEGRATING TABLETS ABILIFY DISCMELT Brand Only Long Term Care Only, PA Required 30 30THIOXANTHENESTHIOTHIXENE CAPSULES THIOTHIXENE Long Term Care OnlyANTIVIRALSANTIRETROVIRALSABACAVIR SULFATE SOLUTION ZIAGENABACAVIR SULFATE TABLETS ZIAGENABACAVIR SULFATE-LAMIVUDINE TABLETS EPZICOM
17
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE TABLETS TRIZIVIRABACAVIR-DOLUTEGRAVIR-LAMIVUDINE TABLETS TRIUMEQATAZANAVIR SULFATE CAPSULES REYATAZATAZANAVIR SULFATE PACKETS REYATAZATAZANAVIR SULFATE-COBICISTAT TABLETS EVOTAZCOBICISTAT TABLETS TYBOST PA Required 30 30DARUNAVIR ETHANOLATE SUSPENSION PREZISTADARUNAVIR ETHANOLATE TABLETS PREZISTADARUNAVIR-COBICISTAT TABLETS PREZCOBIXDELAVIRDINE MESYLATE TABLETS RESCRIPTORDIDANOSINE CAPSULE DELAYED RELEASE VIDEX ECDIDANOSINE SOLUTION VIDEX PEDIATRICDOLUTEGRAVIR TIVICAY PA RequiredEFAVIRENZ CAPSULES SUSTIVAEFAVIRENZ TABLETS SUSTIVAEFAVIRENZ-EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS ATRIPLAELVITEGRAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR TABLETS STRIBILD PA RequiredEMTRICITABINE CAPSULES EMTRIVAEMTRICITABINE SOLUTION EMTRIVAEMTRICITABINE-RILPIVIRINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS COMPLERAEMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS TRUVADA PA RequiredENFUVIRTIDE SOLUTION FUZEON PA Required 1 30ETRAVIRINE TABLETS INTELENCEFOSAMPRENAVIR CALCIUM SUSPENSION LEXIVAFOSAMPRENAVIR CALCIUM TABLETS LEXIVAINDINAVIR SULFATE CAPSULES CRIXIVANLAMIVUDINE SOLUTION EPIVIRLAMIVUDINE TABLETS EPIVIRLAMIVUDINE-ZIDOVUDINE TABLETS COMBIVIRLOPINAVIR-RITONAVIR SOLUTION KALETRALOPINAVIR-RITONAVIR TABLETS KALETRAMARAVIROC TABLETS SELZENTRY PA RequiredNELFINAVIR MESYLATE TABLETS VIRACEPTNEVIRAPINE SUSPENSION VIRAMUNENEVIRAPINE TABLETS VIRAMUNENEVIRAPINE TABLET 24-HOUR VIRAMUNE XRRALTEGRAVIR POTASSIUM CHEWABLE TABLETS ISENTRESSRALTEGRAVIR POTASSIUM PACKETS ISENTRESSRALTEGRAVIR POTASSIUM TABLETS ISENTRESSRILPIVIRINE HCL TABLETS EDURANTRITONAVIR CAPSULES NORVIRRITONAVIR SOLUTION NORVIRRITONAVIR TABLETS NORVIR
18
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
SAQUINAVIR MESYLATE CAPSULES INVIRASESAQUINAVIR MESYLATE TABLETS INVIRASESTAVUDINE CAPSULES ZERITSTAVUDINE SOLUTION ZERITTENOFOVIR DISOPROXIL FUMARATE TABLETS VIREADTIPRANAVIR CAPSULES APTIVUSTIPRANAVIR SOLUTION APTIVUSZIDOVUDINE CAPSULES RETROVIRZIDOVUDINE SYRUP RETROVIRZIDOVUDINE TABLETS ZIDOVUDINECMV AGENTSCIDOFOVIR IV VISTIDE PA RequiredFOSCARENT SODIUM FOSCAVIR PA RequiredGANCICLOVIR SODIUM CYTOVENE PA RequiredVALGANCICLOVIR HCL SOLUTION VALCYTE PA RequiredVALGANCICLOVIR HCL TABLETS VALCYTE PA RequiredHEPATITIS B AGENTSADEFOVIR DIPIVOXIL TABLETS HEPSERA PA RequiredENTECAVIR SOLUTION BARACLUDE PA RequiredENTECAVIR TABLETS BARACLUDE PA RequiredTELBIVUDINE TABLETS TYZEKA PA RequiredHEPATITIS C AGENTSSOFOSBUVIR TABLETS SOVALDI Preferred Drug PA RequiredLEDIPASVIR-SOFOSBUVIR TABLETS HARVONI Preferred Drug PA RequiredRIBAVIRIN CAPSULES VARIOUS PA RequiredRIBAVIRIN SOLUTION REBATROL PA RequiredRIBAVIRIN TABLETS VARIOUS PA RequiredPEGINTERFERON ALFA-2A SOLUTION PEGASYS PA RequiredPEGINTERFERON ALFA-2B KIT PEGINTRON PA RequiredHERPES AGENTSACYCLOVIR SUSPENSION ZOVIRAXACYCLOVIR TABLETS ZOVIRAXFAMCICLOVIR TABLETS FAMVIR PA RequiredVALACYCLOVIR HCL TABLETS VALTREX PA RequiredINFLUENZA AGENTSOSELTAMIVIR PHOSPHATE CAPSULES TAMIFLU 20 270OSELTAMIVIR PHOSPHATE SUSPENSION TAMIFLURIMANTADINE HYDROCHLORIDE TABLETS FLUMADINEZANAMIVIR AEROSOL POWDER BREATH ACTIVATED RELENZA DISKHALER 40 270ASSORTED CLASSESCHELATING AGENTSPENICILLAMINE CAPSULES CUPRIMINEIMMUNOMODULATORS
19
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
LENALIDOMIDE CAPSULES REVLIMID PA RequiredTHALIDOMIDE CAPSULES THALOMID PA RequiredIMMUNOSUPPOSITORYRESSIVE AGENTSAZATHIOPRINE TABLETS IMURANCYCLOSPORINE CAPSULES SANDIMMUNECYCLOSPORINE MODIFIED (FOR MICROEMULSION) CAPSULES GENGRAFCYCLOSPORINE MODIFIED (FOR MICROEMULSION) SOLUTION GENGRAFCYCLOSPORINE SOLUTION SANDIMMUNEEVEROLIMUS (IMMUNOSUPPOSITORYRESSANT) TABLETS ZORTRESS PA RequiredMYCOPHENOLATE MOFETIL CAPSULES CELLCEPTMYCOPHENOLATE MOFETIL SUSPENSION CELLCEPTMYCOPHENOLATE MOFETIL TABLETS CELLCEPTSIROLIMUS SOLUTION RAPAMUNESIROLIMUS TABLETS RAPAMUNETACROLIMUS CAPSULES HECORIATACROLIMUS CAPSULE CONTROLLED RELEASE ASTAGRAF XLPOTASSIUM REMOVING RESINSSODIUM POLYSTYRENE SULFONATE POWDER KAYEXALATESODIUM POLYSTYRENE SULFONATE SUSPENSION KIONEXBETA BLOCKERSALPHA-BETA BLOCKERSCARVEDILOL TABLETS COREGLABETALOL HCL TABLETS TRANDATEBETA BLOCKERS CARDIO-SELECTIVEATENOLOL TABLETS TENORMINMETOPROLOL SUCCINATE TABLET 24-HOUR TOPROL XLMETOPROLOL TARTRATE TABLETS METOPROLOL TARTRATEBETA BLOCKERS NON-SELECTIVENADOLOL TABLETS CORGARDPINDOLOL TABLETS PINDOLOLPROPRANOLOL HCL CAPSULE CONTROLLED RELEASE INDERAL LAPROPRANOLOL HCL SOLUTION PROPRANOLOL HCLPROPRANOLOL HCL TABLETS INDERALSOTALOL HCL SOLUTION SOTYLIZESOTALOL HCL TABLETS BETAPACECALCIUM CHANNEL BLOCKERSCALCIUM CHANNEL BLOCKERSAMLODIPINE BESYLATE TABLETS NORVASC 30 30DILTIAZEM HCL COATED BEADS CAPSULE CONTROLLED RELEASE CARDIZEM CD 30 30DILTIAZEM HCL COATED BEADS TABLET 24-HOUR CARDIZEM LADILTIAZEM HCL CAPSULE 12-HOUR DILTIAZEM HCL ERDILTIAZEM HCL CAPSULE CONTROLLED RELEASE DILTIAZEM HCL ERDILTIAZEM HCL EXTENDED RELEASE BEADS CAPSULE CONTROLLED RELEASE TAZTIA XT 30 30
20
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
DILTIAZEM HCL TABLETS CARDIZEMFELODIPINE TABLET 24-HOUR FELODIPINE ERISRADIPINE CAPSULES ISRADIPINENICARDIPINE HCL CAPSULES NICARDIPINE HCLNICARDIPINE HCL CAPSULE 12-HOUR CARDENE SRNIFEDIPINE CAPSULES PROCARDIANIFEDIPINE TABLET 24-HOUR ADALAT CC 30 30NIMODIPINE CAPSULES NIMODIPINENIMODIPINE SOLUTION NYMALIZENISOLDIPINE TABLET 24-HOUR SULARVERAPAMIL HCL CAPSULE CONTROLLED RELEASE VERELAN PM 30 30VERAPAMIL HCL TABLETS VERAPAMIL HCLVERAPAMIL HCL TABLET CONTROLLED RELEASE CALAN SR 30 30CARDIOTONICSCARDIAC GLYCOSIDESDIGOXIN SOLUTION DIGOXINDIGOXIN TABLETS LANOXINCARDIOVASCULAR AGENTS - MISC.PROSTAGLANDIN VASODILATORSEPOPROSTENOL SODIUM SOLUTION FLOLAN PA RequiredILOPROST SOLUTION VENTAVIS PA RequiredTREPROSTINIL SODIUM SOLUTION REMODULIN PA RequiredTREPROSTINIL SOLUTION TYVASO PA RequiredPULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGAMBRISENTAN TABLETS LETAIRIS PA RequiredBOSENTAN TABLETS TRACLEER PA RequiredPULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITSILDENAFIL CITRATE (PULMONARY HYPERTENSION) SUSPENSION REVATIO PA RequiredSILDENAFIL CITRATE (PULMONARY HYPERTENSION) TABLETS REVATIO PA RequiredTADALAFIL (PULMONARY HYPERTENSION) TABLETS ADCIRCA PA RequiredCEPHALOSPORINSCEPHALOSPORINS - 1ST GENERATIONCEFADROXIL CAPSULES CEFADROXILCEFADROXIL SUSPENSION CEFADROXILCEFADROXIL TABLETS CEFADROXILCEPHALEXIN CAPSULES KEFLEXCEPHALEXIN SUSPENSION CEPHALEXINCEPHALEXIN TABLETS CEPHALEXINCEPHALOSPORINS - 2ND GENERATIONCEFACLOR CAPSULES CEFACLORCEFACLOR SUSPENSION CEFACLORCEFPROZIL SUSPENSION CEFPROZILCEFPROZIL TABLETS CEFPROZIL
21
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
CEFUROXIME AXETIL SUSPENSION CEFTINCEFUROXIME AXETIL TABLETS CEFTINCEPHALOSPORINS - 3RD GENERATIONCEFDINIR CAPSULES CEFDINIRCEFDINIR SUSPENSION CEFDINIRCEFIXIME CAPSULES SUPRAX 1 30CEFIXIME CHEWABLE TABLETS SUPRAX 1 30CEFIXIME SUSPENSION SUPRAX 1 30CEFIXIME TABLETS SUPRAX 1 30CEFPODOXIME PROXETIL SUSPENSION CEFPODOXIME PROXETILCEFPODOXIME PROXETIL TABLETS CEFPODOXIME PROXETILCONTRACEPTIVESCOMBINATION CONTRACEPTIVES - ORALDESOGESTREL & ETHINYL ESTRADIOL TABLETS APRIDESOGESTREL-ETHINYL ESTRADIOL (BIPHASIC) TABLETS AZURETTEDESOGESTREL-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS CAZIANTDROSPIRENONE-ETHINYL ESTRADIOL TABLETS OCELLAETHYNODIOL DIACET & ETHINYL ESTRADIOL TABLETS KELNOR 1/35LEVONORGESTREL & ETHINYL ESTRADIOL TABLETS AUBRALEVONORGESTREL-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS ENPRESSE-28LEVONORGESTREL-ETHINYL ESTRADIOL (91-DAY) TABLETS AMETHIA LONORETHINDRONE & ETHINYL ESTRADIOL TABLETS BALZIVA NORETHINDRONE & MESTRANOL TABLETS NECON 1/50-28NORETHINDRONE ACETATE & ETHINYL ESTRADIOL TABLETS GILDESS 1/20NORETHINDRONE ACETATE-ETHINYL ESTRADIOL-FE TABLETS ESTROSTEP FENORETHINDRONE-ETHINYL ESTRADIOL (BIPHASIC) TABLETS NECON 10/11-28NORETHINDRONE-ETHINYL ESTRADIO+A894L (TRIPHASIC) TABLETS CYCLAFEM 7/7/7NORGESTIMATE-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS ORTHO TRI-CYCLENNORGESTIMATE-ETHINYL ESTRADIOL TABLETS ESTARYLLANORGESTREL & ETHINYL ESTRADIOL TABLETS CRYSELLE-28COMBINATION CONTRACEPTIVES - VAGINALETONOGESTREL-ETHINYL ESTRADIOL RING NUVARINGEMERGENCY CONTRACEPTIVESLEVONORGESTREL TABLETS PLAN BPROGESTIN CONTRACEPTIVES - INJECTABLE
MEDROXYPROGESTERONE ACETATE SUSPENSION
DEPO-PROVERA
CONTRACEPTIVEPROGESTIN CONTRACEPTIVES - ORALNORETHINDRONE TABLETS CAMILACORTICOSTEROIDSGLUCOCORTICOSTEROIDSDEXAMETHASONE CONCENTRATE DEXAMETHASONE INTENSOLDEXAMETHASONE ELIXIR VARIOUS
22
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
DEXAMETHASONE SOLUTION DEXAMETHASONEDEXAMETHASONE TABLETS DEXAMETHASONEHYDROCORTISONE SOD SUCCINATE SOLUTION (INJECTABLE) A-HYDROCORT Long Term Care OnlyMETHYLPREDNISOLONE ACETATE SUSPENSION (INJECTABLE) DEPO-MEDROL Long Term Care OnlyMETHYLPREDNISOLONE SOD SUCC SOLUTION (INJECTABLE) A-METHAPRED Long Term Care OnlyMETHYLPREDNISOLONE TABLETS MEDROLPREDNISOLONE SODIUM PHOSPHATE SOLUTION ORAPREDPREDNISOLONE SODIUM PHOSPHATE ORALLY DISINTEGRATING TABLETS ORAPRED ODTPREDNISOLONE SYRUP PRELONEPREDNISOLONE TABLETS VARIOUSPREDNISONE CONCENTRATE PREDNISONE INTENSOLPREDNISONE SOLUTION PREDNISONEPREDNISONE TABLETS PREDNISONETRIAMCINOLONE ACETONIDE SUSPENSION (INJECTABLE) KENALOG-10 Long Term Care OnlyTRIAMCINOLONE DIACETATE SUSPENSION (INJECTABLE) TRIAMCINOLONE Long Term Care Only
TRIAMCINOLONE HEXACETONIDE SUSPENSION (INJECTABLE)
ARISTOSPAN INTRALESIONAL &
INTRA-ARTICULAR Long Term Care OnlyMINERALOCORTICOIDSFLUDROCORTISONE ACETATE TABLETS FLORINEFCOUGH/COLD/ALLERGYANTITUSSIVESBENZONATATE CAPSULES TESSALON PERLESHYDROCODONE W/ HOMATROPINE SYRUP VARIOUS 240 12HYDROCODONE W/ HOMATROPINE TABLETS VARIOUSCOUGH/COLD/ALLERGY COMBINATIONSBROMPHENIRAMINE & PSEUDOEPHEDRINE LIQUID VARIOUSBROMPHENIRAMINE &PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUS
BROMPHENIRAMINE-DEXTROMETHORPHAN-PHENYLEPHRINE LIQUID/TABLETS VARIOUSCETIRIZINE-PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUS 30 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE CHEWABLE TABLETS VARIOUSCHLORPHENIRAMINE &PSEUDOEPHEDRINE LIQUID VARIOUS 480 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE SOLUTION VARIOUS 480 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE SYRUP VARIOUS 480 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE TABLETS VARIOUSDEXTROMETHORPHAN-GUAIFENESIN TABLET VARIOUSDEXTROMETHORPHAN-GUAIFENESIN LIQUID VARIOUS 480 30DEXTROMETHORPHAN-GUAIFENESIN TABLET 12-HOUR MUCINEX DMFEXOFENADINE-PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUS 30 30FEXOFENADINE-PSEUDOEPHEDRINE TABLET 24-HOUR VARIOUS 30 30GUAIFENESIN-CODEINE SYRUP ROBITUSSIN AC 240 12LORATADINE & PSEUDOEPHEDRINE TABLET 12-HOUR ALAVERT ALLERGY/SINUS 30 30LORATADINE & PSEUDOEPHEDRINE TABLET 24-HOUR CLARITIN-D 24 HOUR 30 30
23
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN CAPSULES VARIOUS
PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN LIQUID
ROBITUSSIN CHILDRENS COUGH
& COLD CF 480 30PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN SYRUP VARIOUS 480 30PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN TABLETS VARIOUSPHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN TABLET 12-HOUR VARIOUSPHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN ELIXIR VARIOUS 480 30
PHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN LIQUID
DIMETAPP
DEXTROMETHORPHAN COLD & 480 30PHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN SYRUP VARIOUS 480 30PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN LIQUID VARIOUS 480 30PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN DROPS VARIOUS PA Required for < 6 years oldPHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN SYRUP VARIOUS 480 30PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN TABLETS VARIOUSPHENYLEPHRINE-GUAIFENESIN CAPSULES VARIOUS
PHENYLEPHRINE-GUAIFENESIN LIQUID
TRIAMINIC CHEST/ NASAL
CONGESTION 480 30
PHENYLEPHRINE-GUAIFENESIN SYRUP
TRIAMINIC CHEST & NASAL
CONGESTION 480 30PHENYLEPHRINE-GUAIFENESIN TABLETS VARIOUS
PROMETHAZINE & PHENYLEPHRINE SYRUP
PROMETHAZINE/
PHENYLEPHRINE 480 30PROMETHAZINE W/CODEINE SYRUP PROMETHAZINE/CODEINE 240 12
PROMETHAZINE-DEXTROMETHORPHAN SYRUP
PROMETHAZINE/
DEXTROMETHORPHAN 480 30PSEUDOEPHEDRINE W/ CODEINE-GUAIFENESIN SYRUP VARIOUS 240 12EXPECTORANTSGUAIFENESIN LIQUID VARIOUS 480 30GUAIFENESIN SYRUP VARIOUS 480 30GUAIFENESIN TABLETS VARIOUSGUAIFENESIN TABLET 12-HOUR VARIOUSDERMATOLOGICALSACNE PRODUCTSBENZOYL PEROXIDE BAR VARIOUSBENZOYL PEROXIDE CREAM VARIOUSBENZOYL PEROXIDE FOAM VARIOUSBENZOYL PEROXIDE GEL VARIOUSBENZOYL PEROXIDE LIQUID VARIOUSBENZOYL PEROXIDE LOTION VARIOUSCLINDAMYCIN PHOSPHATE GEL CLEOCIN-TCLINDAMYCIN PHOSPHATE LOTION CLEOCIN-TCLINDAMYCIN PHOSPHATE SOLUTION CLEOCIN-TERYTHROMYCIN GEL ERYGEL
24
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
ERYTHROMYCIN SOLUTION ERYTHROMYCINISOTRETINOIN CAPSULES AMNESTEEM PA RequiredSULFACETAMIDE SODIUM LOTION KLARONTRETINOIN CREAM RETIN-A PA Required FOR > 26 Years of AgeTRETINOIN GEL RETIN-A PA Required FOR > 26 Years of AgeANTIBIOTICS - TOPICALBACITRACIN OINTMENT BACIGUENTBACITRACIN ZINC OINTMENT BACITRACINBACITRACIN-POLYMYXIN B OINTMENT POLYSPORINBACITRACIN-POLYMYXIN-NEOMYCIN HC OINTMENT CORTISPORINGENTAMICIN SULFATE CREAM GENTAMICIN SULFATEGENTAMICIN SULFATE OINTMENT GENTAMICIN SULFATEMUPIROCIN CALCIUM CREAM BACTROBANMUPIROCIN OINTMENT BACTROBANNEOMYCIN-BACITRACIN-POLYMYXIN OINTMENT NEOSPORINANTIFUNGALS - TOPICALCLOTRIMAZOLE CREAM LOTRIMINCLOTRIMAZOLE OINTMENT LOTRIMINCLOTRIMAZOLE SOLUTION VARIOUSCLOTRIMAZOLE W/ BETAMETHASONE CREAM LOTRISONE
CLOTRIMAZOLE W/ BETAMETHASONE LOTION
CLOTRIMAZOLE/
BETAMETHASONE
DIPROPIONATEKETOCONAZOLE CREAM VARIOUSKETOCONAZOLE GEL VARIOUSKETOCONAZOLE SHAMPOO VARIOUSMICONAZOLE NITRATE CREAM VARIOUSMICONAZOLE NITRATE LIQUID VARIOUSMICONAZOLE NITRATE POWDER VARIOUSNYSTATIN CREAM VARIOUSNYSTATIN OINTMENT VARIOUSNYSTATIN POWDER NYAMYCNYSTATIN-TRIAMCINOLONE CREAM NYSTATIN/TRIAMCINOLONENYSTATIN-TRIAMCINOLONE OINTMENT NYSTATIN/TRIAMCINOLONEANTIHISTAMINES-TOPICAL
DIPHENHYDRAMINE HCL CREAM
ANTI-ITCH MAXIMUM
STRENGTHDIPHENHYDRAMINE HCL GEL BENADRYL ITCH STOPPING
DIPHENHYDRAMINE HCL SOLUTION
BENADRYL MAXIMUM
STRENGTHANTISEBORRHEIC TOPICAL PRODUCTSSELENIUM SULFIDE LOTION SELSUN SHAMPOOPOOANTIVIRALS - TOPICAL
25
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
DOCOSANOL 10% CREAM ABREVAPENCICLOVIR CREAM DENAVIRBURN PRODUCTSSILVER SULFADIAZINE CREAM SILVADENECORTICOSTEROIDS - TOPICALALCLOMETASONE DIPROPIONATE CREAM ACLOVATEALCLOMETASONE DIPROPIONATE OINTMENT ACLOVATEBETAMETHASONE DIPROPIONATE AUGMENTED CREAM DIPROLENE AFBETAMETHASONE DIPROPIONATE AUGMENTED GEL DIPROLENE AFBETAMETHASONE DIPROPIONATE AUGMENTED LOTION DIPROLENEBETAMETHASONE DIPROPIONATE AUGMENTED OINTMENT DIPROLENEBETAMETHASONE VALERATE CREAM VARIOUSBETAMETHASONE VALERATE LOTION VARIOUSBETAMETHASONE VALERATE OINTMENT VARIOUSCLOBETASOL PROPIONATE CREAM VARIOUSCLOBETASOL PROPIONATE EMULSION FOAM VARIOUSCLOBETASOL PROPIONATE FOAM VARIOUSCLOBETASOL PROPIONATE GEL VARIOUSCLOBETASOL PROPIONATE LOTION VARIOUSCLOBETASOL PROPIONATE OINTMENT VARIOUSCLOBETASOL PROPIONATE SHAMPOO VARIOUSCLOBETASOL PROPIONATE SOLUTION VARIOUSDESONIDE CREAM DESOWENDESONIDE GEL DESONATEDESONIDE LOTION DESOWENDESONIDE OINTMENT DESOWENDIFLORASONE DIACETATE EMOLLIENT BASE CREAM APEXICON EFLUOCINOLONE ACETONIDE CREAM FLUOCINOLONE ACETONIDEFLUOCINOLONE ACETONIDE OIL DERMA-SMOOTHE/FS BODYFLUOCINOLONE ACETONIDE OINTMENT SYNALARFLUOCINOLONE ACETONIDE SHAMPOO CAPEXFLUOCINOLONE ACETONIDE SOLUTION SYNALARFLUOCINONIDE CREAM VARIOUSFLUOCINONIDE EMULSIFIED BASE CREAM VARIOUSFLUOCINONIDE GEL VARIOUSFLUOCINONIDE OINTMENT VARIOUSFLUOCINONIDE SOLUTION VARIOUSFLURANDRENOLIDE CREAM CORDRANFLURANDRENOLIDE LOTION CORDRANFLURANDRENOLIDE OINTMENT CORDRANFLURANDRENOLIDE TAPE CORDRAN TAPEFLUTICASONE PROPIONATE CREAM VARIOUSFLUTICASONE PROPIONATE LOTION VARIOUS
26
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
FLUTICASONE PROPIONATE OINTMENT VARIOUSHYDROCORTISONE CREAM VARIOUSHYDROCORTISONE LOTION VARIOUSHYDROCORTISONE OINTMENT VARIOUSHYDROCORTISONE SOLUTION VARIOUS
HYDROCORTISONE BUTYRATE CREAM VARIOUS
HYDROCORTISONE BUTYRATE LOTION VARIOUS
HYDROCORTISONE BUTYRATE OINTMENT VARIOUS
HYDROCORTISONE BUTYRATE SOLUTION VARIOUS
HYDROCORTISONE VALERATE CREAM VARIOUSHYDROCORTISONE VALERATE OINTMENT VARIOUSMOMETASONE FUROATE CREAM ELOCONMOMETASONE FUROATE OINTMENT ELOCONMOMETASONE FUROATE SOLUTION ELOCONPRAMOXINE-HC FOAM EPIFOAMTRIAMCINOLONE ACETONIDE (TOPICAL) AEROSOL VARIOUSTRIAMCINOLONE ACETONIDE (TOPICAL) CREAM VARIOUSTRIAMCINOLONE ACETONIDE (TOPICAL) LOTION VARIOUSTRIAMCINOLONE ACETONIDE (TOPICAL) OINTMENT VARIOUSKERATOLYTIC/ANTIMITOTIC AGENTSSALICYLIC ACID CREAM SALACYNSALICYLIC ACID FOAM SALVAXSALICYLIC ACID GEL KERALYTSALICYLIC ACID LIQUID VIRASALSALICYLIC ACID LOTION SALACYNSALICYLIC ACID SHAMPOO SALEXSALICYLIC ACID SOLUTION VARIOUSLOCAL ANESTHETICS - TOPICALLIDOCAINE HCL CREAM VARIOUSLIDOCAINE HCL SOLUTION VARIOUSLIDOCAINE OINTMENT VARIOUSLIDOCAINE PATCH LIDODERM PA RequiredLIDOCAINE-PRILOCAINE CREAM EMLATOPICAL - MISC.ALUMINUM CHLORIDE SOLUTION DRYSOLROSACEA TOPICAL AGENTSMETRONIDAZOLE CREAM METROCREAMMETRONIDAZOLE GEL METROGELMETRONIDAZOLE LOTION METROLOTIONSCABICIDES & PEDICULICIDES TOPICAl AGENTS+A1106CROTAMITON CREAM EURAXCROTAMITON LOTION EURAX
27
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
IVERMECTIN LOTION SKLICE PA RequiredPERMETHRIN CREAM ACTICINPYRETHRINS-PIPERONYL BUTOXIDE GEL A-200PYRETHRINS-PIPERONYL BUTOXIDE LIQUID BARCPYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO LICIDESPINOSAD SUSPENSION NATROBA PA RequiredDIAGNOSTIC PRODUCTSDIAGNOSTIC TESTSBLOOD GLUCOSE MONITORS & STRIPS VARIOUSDIGESTIVE AIDSDIGESTIVE ENZYMESPANCRELIPASE (LIPASE-PROTEASE-AMYLASE) CAPSULE DELAYED RELEASE
ENTERIC COATED CREON 500 30PANCRELIPASE (LIPASE-PROTEASE-AMYLASE) TABLETS VIOKACE 500 30SACROSIDASE SOLUTION SUCRAID PA RequiredDIURETICSCARBONIC ANHYDRASE INHIBITORSACETAZOLAMIDE CAPSULE 12-HOUR DIAMOXACETAZOLAMIDE TABLETS ACETAZOLAMIDEMETHAZOLAMIDE TABLETS NEPTAZANEDIURETIC COMBINATIONSSPIRONOLACTONE & HYDROCHLOROTHIAZIDE TABLETS ALDACTAZIDETRIAMTERENE & HYDROCHLOROTHIAZIDE CAPSULES DYAZIDETRIAMTERENE & HYDROCHLOROTHIAZIDE TABLETS MAXZIDE-25LOOP DIURETICSBUMETANIDE TABLETS BUMETANIDEFUROSEMIDE SOLUTION FUROSEMIDEFUROSEMIDE TABLETS LASIXTORSEMIDE TABLETS DEMADEXPOTASSIUM SPARING DIURETICSSPIRONOLACTONE TABLETS ALDACTONETHIAZIDES AND THIAZIDE-LIKE DIURETICSCHLOROTHIAZIDE SUSPENSION DIURILCHLOROTHIAZIDE TABLETS CHLOROTHIAZIDECHLORTHALIDONE TABLETS CHLORTHALIDONEHYDROCHLOROTHIAZIDE CAPSULES MICROZIDEHYDROCHLOROTHIAZIDE TABLETS HYDROCHLOROTHIAZIDEINDAPAMIDE TABLETS INDAPAMIDEMETOLAZONE TABLETS ZAROXOLYNENDOCRINE AND METABOLIC AGENTS - MISC.BONE DENSITY REGULATORSALENDRONATE SODIUM TABLETS ALENDRONATE SODIUMCALCITONIN (SALMON) SOLUTION MIACALCIN
28
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
GROWTH HORMONES
SOMATROPIN NORDITROPIN Preferred Drug PA Required
SOMATROPIN NUTROPIN AQ Preferred Drug PA RequiredSOMATROPIN GENOTROPIN Preferred Drug PA RequiredHORMONE RECEPTOR MODULATORSRALOXIFENE HCL TABLETS EVISTAINSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)MECASERMIN SOLUTION INCRELEX PA RequiredLHRH/GNRH AGONIST ANALOG PITUITARY SUPPOSITORYRESSANTSLEUPROLIDE ACETATE (CPP) (3 MONTH) KIT LUPRON DEPOT-PED PA RequiredLEUPROLIDE ACETATE (CPP) KIT LUPRON DEPOT-PED PA RequiredMETABOLIC MODIFIERSCINACALCET HCL TABLETS SENSIPAR PA RequiredIDURSULFASE SOLUTION ELAPRASE PA RequiredPOSTERIOR PITUITARY HORMONESDESMOPRESSIN ACETATE REFRIGERATED SOLUTION VARIOUSDESMOPRESSIN ACETATE SOLUTION VARIOUSDESMOPRESSIN ACETATE SPRAY REFRIGERATED SOLUTION VARIOUSDESMOPRESSIN ACETATE SPRAY SOLUTION VARIOUSDESMOPRESSIN ACETATE TABLETS VARIOUS PA RequiredESTROGENSESTROGEN COMBINATIONSCONJUGATED ESTROGENS-MEDROXYPROGESTERONE ACETATE TABLETS PREMPROESTRADIOL-LEVONORGESTREL PATCH-WEEKLY CLIMARA PATCHESTROGENSESTERIFIED ESTROGENS TABLETS MENESTESTRADIOL PATCH-TWICE WEEKLY ALORAESTRADIOL PATCH-WEEKLY MENOSTARESTRADIOL TABLETS ESTRACEESTROGENS, CONJUGATED SYNTHETIC A TABLETS CENESTINESTROGENS, CONJUGATED TABLETS PREMARINESTROPIPATE TABLETS ORTHO-ESTFLUOROQUINOLONESFLUOROQUINOLONESCIPROFLOXACIN HCL TABLETS CIPROFLOXACIN HCLLEVOFLOXACIN SOLUTION LEVAQUINLEVOFLOXACIN TABLETS LEVAQUINOFLOXACIN TABLETS OFLOXACINGASTROINTMENTESTINAL AGENTS - MISC.
29
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
GALLSTONE SOLUBILIZING AGENTSURSODIOL CAPSULES ACTIGALLURSODIOL TABLETS URSO 250GASTROINTMENTESTINAL CHLORIDE CHANNEL ACTIVATORSLUBIPROSTONE CAPSULES AMITIZA PA RequiredGASTROINTMENTESTINAL STIMULANTSMETOCLOPRAMIDE HCL SOLUTION VARIOUSMETOCLOPRAMIDE HCL TABLETS VARIOUSMETOCLOPRAMIDE HCL ORALLY DISINTEGRATING TABLETS VARIOUSINFLAMMATORY BOWEL AGENTSBALSALAZIDE DISODIUM CAPSULES COLAZAL 270 30BALSALAZIDE DISODIUM TABLETS GIAZO 270 30BUDESONIDE CAPSULES ENTOCORT ECMESALAMINE CAPSULE CONTROLLED RELEASE PENTASA 270 30MESALAMINE ENEMA MESALAMINE 240 30MESALAMINE TABLET ENTERIC COATED ASACOL HD 120 30MESALAMINE W/ CLEANSER KIT ROWASA 240 30OLSALAZINE SODIUM CAPSULES DIPENTUM 120 30SULFASALAZINE TABLETS AZULFIDINE 240 30SULFASALAZINE TABLET ENTERIC COATED AZULFIDINE EN-TABLETS 240 30IRRITABLE BOWEL SYNDROME (IBS) AGENTSLINACLOTIDE CAPSULES LINZESS PA RequiredPHOSPHATE BINDER AGENTSCALCIUM ACETATE (PHOSPHATE BINDER) CAPSULES PHOSLOCALCIUM ACETATE (PHOSPHATE BINDER) SOLUTION PHOSLYRACALCIUM ACETATE (PHOSPHATE BINDER) TABLETS ELIPHOSLANTHANUM CARBONATE CHEWABLE TABLETS FOSRENOL PA RequiredLANTHANUM CARBONATE PACKETS FOSRENOL PA RequiredSEVELAMER CARBONATE PACKETS RENVELA PA RequiredSEVELAMER CARBONATE TABLETS RENVELA PA RequiredSEVELAMER HCL TABLETS RENAGEL PA RequiredGENITOURINARY AGENTS - MISC.INTERSTITIAL CYSTITIS AGENTSPENTOSAN POLYSULFATE SODIUM CAPSULES ELMIRON PA RequiredPROSTATIC HYPERTROPHY AGENTSDOXAZOSIN MESYLATE TABLET 24-HOUR CARDURA XLFINASTERIDE TABLETS PROSCARTAMSULOSIN HCL CAPSULES FLOMAXURINARY ANALGESICSPHENAZOPYRIDINE HCL TABLETS PYRIDIUMGOUT AGENTSGOUT AGENTSALLOPURINOL TABLETS ZYLOPRIM
30
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
COLCHICINE TABLETS COLCRYS PA RequiredFEBUXOSTAT TABLETS ULORIC PA RequiredURICOSURICSPROBENECID TABLETS PROBENECIDHEMATOLOGICAL AGENTS - MISC.PLATELET AGGREGATION INHIBITORSCILOSTAZOL TABLETS PLETALCLOPIDOGREL BISULFATE TABLETS PLAVIXDIPYRIDAMOLE TABLETS PERSANTINETICAGRELOR TABLETS BRILINTA PA RequiredHEMATOPOIETIC AGENTSAGENTS FOR GAUCHER DISEASEIMIGLUCERASE SOLUTION CEREZYME PA RequiredHEMATOPOIETIC GROWTH FACTORSELTROMBOPAG OLAMINE TABLETS PROMACTA PA RequiredEPOETIN ALFA SOLUTION EPOGEN PA RequiredFILGRASTIM SOLUTION NEUPOGEN PA RequiredPEGFILGRASTIM SOLUTION NEULASTA PA RequiredHEMOSTATICSHEMOSTATICS - SYSTEMICAMINOCAPROIC ACID SYRUP AMICARAMINOCAPROIC ACID TABLETS AMICARHYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTBARBITURATE HYPNOTICSPHENOBARBITAL SOLUTION PHENOBARBITALPHENOBARBITAL TABLETS PHENOBARBITALNON-BARBITURATE HYPNOTICSCHLORAL HYDRATE SOMNOTE PA Required for > 1 Hypnotic Fill 30 30ESTAZOLAM TABLETS ESTAZOLAM PA Required for > 1 Hypnotic Fill 30 30FLURAZEPAM HCL CAPSULES FLURAZEPAM HCL PA Required for > 1 Hypnotic Fill 30 30TEMAZEPAM CAPSULES RESTORIL PA Required for > 1 Hypnotic Fill 30 30ZALEPLON CAPSULES SONATA PA Required for > 1 Hypnotic Fill 30 30
ZOLPIDEM TARTRATE TABLETS AMBIEN PA Required for > 1 Hypnotic Fill
60: 5MG
30: 10MG
30
30SELECTIVE MELATONIN RECEPTOR AGONISTS
RAMELTEON TABLETS ROZEREM
PA Required
PA Required for > 1 Hypnotic FillLAXATIVESLAXATIVE COMBINATIONSPEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE SOLUTION COLYTELAXATIVES - MISC.LACTULOSE SOLUTION LACTULOSEMACROLIDES
31
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
AZITHROMYCINAZITHROMYCIN PACKETS ZITHROMAXAZITHROMYCIN SUSPENSION ZITHROMAXAZITHROMYCIN TABLETS ZITHROMAXCLARITHROMYCINCLARITHROMYCIN SUSPENSION CLARITHROMYCINCLARITHROMYCIN TABLETS BIAXINCLARITHROMYCIN TABLET 24-HOUR BIAXIN XLERYTHROMYCINSERYTHROMYCIN BASE (COATED) TABLET ENTERIC COATED PCEERYTHROMYCIN BASE CPEP ERYTHROMYCINERYTHROMYCIN BASE TABLETS ERYTHROMYCIN BASEERYTHROMYCIN BASE TABLET ENTERIC COATED ERY-TABERYTHROMYCIN ETHYLSUCCINATE SUSPENSION E.E.S. GRANULESULESERYTHROMYCIN ETHYLSUCCINATE TABLETS E.E.S. 400ERYTHROMYCIN STEARATE TABLETS ERYTHROCIN STEARATEMEDICAL DEVICESCONTRACEPTIVESCONDOMS - FEMALE MISC. FC FEMALE CONDOMCONDOMS - MALE MISC. LIFESTYLES ASSORTED COLORSDIAPHRAGM ARC-SPRING DPRH CAYA
DIAPHRAGM COIL SPRING KIT
ORTHO DIAPHRAGM COIL
SPRING KIT 50
DIAPHRAGM FLAT SPRING KIT
ORTHO DIAPHRAGM FLAT
SPRING KIT 55
DIAPHRAGM WIDE SEAL DPRH
WIDE-SEAL SILICONE
DIAPHRAGM KIT 60DIAPHRAGMS - OTHER+A1294 OMNIFLEX DIAPHRAGMDIABETIC SUPPOSITORYLIESBLOOD GLUCOSE MONITORING KIT W/ DEVICE VARIOUSBLOOD GLUCOSE MONITORING DEVICES VARIOUSLANCET DEVICES MISC. VARIOUSLANCETS MISC. VARIOUSDEVICES - MISC.
ALCOHOL SWABS PADS
ALCOH-GLOVE CONTOURED
WIPERESPIRATORY THERAPY SUPPOSITORYLIES
SPACER/AEROSOL-HOLDING CHAMBER SUPPOSITORYLIES - MASKS
MASK VORTEX/ BABY
WHIRL DUCKLING 2 365
SPACER/AEROSOL-HOLDING CHAMBERS DEVICE
AEROCHAMBER MINI
AEROCHAMBER 2 365MIGRAINE PRODUCTSMIGRAINE COMBINATIONS
32
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
ERGOTAMINE W/ CAFFEINE SUPPOSITORY MIGERGOT 12 30ERGOTAMINE W/ CAFFEINE TABLETS CAFERGOTSEROTONIN AGONISTSNARATRIPTAN HCL TABLETS AMERGE 9 30SUMATRIPTAN NASAL SOLUTION IMITREX 6 30SUMATRIPTAN SUCCINATE SUBCUTANEOUS SOLUTION IMITREX 2 30SUMATRIPTAN SUCCINATE TABLETS IMITREX 9 30MOUTH/THROAT/DENTAL AGENTSANTI-INFECTIVES - THROATCLOTRIMAZOLE TROC CLOTRIMAZOLESTEROIDS - MOUTH/THROATTRIAMCINOLONE ACETONIDE ORAL PASTE ORALONEMULTIVITAMINSPRENATAL VITAMINSPRENATAL MULTIVITAMINS WITH OR WITHOUT MINERALS W/ FOLATE VARIOUSPRENATAL MULTIVITAMINES WITH MINERAL W/FE-FA VARIOUSMUSCULOSKELETAL THERAPY AGENTSCENTRAL MUSCLE RELAXANTSBACLOFEN TABLETS BACLOFEN
CYCLOBENZAPRINE HCL TABLETS FLEXERIL
PA Required for dosages other than 5mg
and 10mg tabletsMETHOCARBAMOL TABLETS ROBAXINTIZANIDINE HCL CAPSULES ZANAFLEXTIZANIDINE HCL TABLETS TIZANIDINE HCLDIRECT MUSCLE RELAXANTSDANTROLENE SODIUM CAPSULES DANTRIUMNASAL AGENTS - SYSTEMIC AND TOPICALNASAL ANTIALLERGYAZELASTINE HCL SOLUTION ASTELINNASAL ANTICHOLINERGICSIPRATROPIUM BROMIDE SOLUTION ATROVENTNASAL STEROIDSFLUNISOLIDE SOLUTION FLUNISOLIDEFLUTICASONE PROPIONATE SUSPENSION FLONASETRIAMCINOLONE ACETONIDE NASACORT AQSYMPATHOMIMETIC DECONGESTANTSPSEUDOEPHEDRINE HCL LIQUID SUDAFED CHILDRENSPSEUDOEPHEDRINE HCL SYRUP PSEUDOEPHEDRINEPSEUDOEPHEDRINE HCL TABLETS SUDAFEDPSEUDOEPHEDRINE HCL TABLET 12-HOUR NASAL DECONGESTANTPSEUDOEPHEDRINE HCL TABLET 24-HOUR SUDAFED 24 HOUROPHTHALMIC AGENTSOPHTHALMIC - BETA-BLOCKERS
33
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
BETAXOLOL HCL SOLUTION BETAXOLOL HCLBETAXOLOL HCL SUSPENSION BETOPTIC-SCARTEOLOL HCL SOLUTION CARTEOLOL HCLDORZOLAMIDE HCL-TIMOLOL MALEATE SOLUTION COSOPTLEVOBUNOLOL HCL SOLUTION LEVOBUNOLOL HCLMETIPRANOLOL SOLUTION METIPRANOLOLTIMOLOL MALEATE SOLUTION TIMOPTIC-XETIMOLOL MALEATE SOLUTION TIMOPTICOPHTHALMIC - CYCLOPLEGIC MYDRIATICSATROPINE SULFATE OINTMENT ATROPINE SULFATEATROPINE SULFATE SOLUTION ISOPTO ATROPINECYCLOPENTOLATE HCL SOLUTION CYCLOGYLHOMATROPINE HBR SOLUTION ISOPTO HOMATROPINEOPHTHALMIC - MIOTICSPILOCARPINE HCL GEL PILOPINE HSPILOCARPINE HCL SOLUTION ISOPTO CARPINEOPHTHALMIC - ANTI-INFECTIVESBACITRACIN OINTMENT BACITRACINBACITRACIN-POLYMYXIN B OINTMENT POLYCINCIPROFLOXACIN HCL OINTMENT CILOXANCIPROFLOXACIN HCL SOLUTION CILOXANERYTHROMYCIN OINTMENT ILOTYCINGENTAMICIN SULFATE OINTMENT GARAMYCINGENTAMICIN SULFATE SOLUTION GARAMYCINMOXIFLOXACIN HCL SOLUTION VIGAMOXNATAMYCIN SUSPENSION NATACYNNEOMYCIN-BACITRACIN ZN-POLYMYXIN OINTMENT NEO-POLYCINNEOMYCIN-POLYMYXIN-GRAMICIDIN SOLUTION NEOSPORINOFLOXACIN SOLUTION OCUFLOXPOLYMYXIN B-TRIMETHOPRIM SOLUTION POLYTRIMSULFACETAMIDE SODIUM OINTMENT SULFACETAMIDE SODIUMSULFACETAMIDE SODIUM SOLUTION BLEPH-10TOBRAMYCIN OINTMENT TOBREXTOBRAMYCIN SOLUTION TOBREXTRIFLURIDINE SOLUTION VIROPTICOPHTHALMIC - DECONGESTANTSNAPHAZOLINE HCL SOLUTION VASOCLEARNAPHAZOLINE W/ PHENIRAMINE SOLUTION NAPHCON-AOPHTHALMIC - IMMUNOMODULATORSCYCLOSPORINE EMULSION RESTASIS PA RequiredOPHTHALMIC - STEROIDSBACITRACIN-POLY-NEOMYCIN-HC OINTMENT NEO-POLYCIN HCDEXAMETHASONE SUSPENSION MAXIDEX
34
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
DEXAMETHASONE SODIUM PHOSPHATE SOLUTION
DEXAMETHASONE SODIUM
PHOSPHATEFLUOROMETHOLONE OINTMENT FMLFLUOROMETHOLONE SUSPENSION FML LIQUIFILMGENTAMICIN-PREDNISOLONE ACETATE OINTMENT PRED-G S.O.P.GENTAMICIN-PREDNISOLONE ACETATE SUSPENSION PRED-GNEOMYCIN-POLYMY-DEXAMETH OINTMENT MAXITROLNEOMYCIN-POLYMY-DEXAMETH SUSPENSION MAXITROLPREDNISOLONE ACETATE SUSPENSION PRED MILD
PREDNISOLONE SODIUM PHOSPHATE SOLUTION
PREDNISOLONE SODIUM
PHOSPHATESULFACETAMIDE SOD-PREDNISOLONE OINTMENT BLEPHAMIDE S.O.P.
SULFACETAMIDE SOD-PREDNISOLONE SOLUTION
SULFACETAMIDE
SODIUM/PREDNISOLONE
SODIUM PHOSPHATESULFACETAMIDE SOD-PREDNISOLONE SUSPENSION BLEPHAMIDETOBRAMYCIN-DEXAMETHASONE OINTMENT TOBRADEXTOBRAMYCIN-DEXAMETHASONE SUSPENSION TOBRADEX STOPHTHALMICS - MISC.BRINZOLAMIDE SUSPENSION AZOPT PA RequiredCROMOLYN SODIUM SOLUTION CROMOLYN SODIUMDICLOFENAC SODIUM SOLUTION DICLOFENAC SODIUMDORZOLAMIDE HCL SOLUTION TRUSOPTFLURBIPROFEN SODIUM SOLUTION OCUFENKETOROLAC TROMETHAMINE SOLUTION ACULAR LSKETOTIFEN FUMARATE SOLUTION ALAWAYOPHTHALMIC - PROSTAGLANDINSLATANOPROST SOLUTION XALATAN 2.5 30TAFLUPROST SOLUTION ZIOPTAN PA RequiredTRAVOPROST SOLUTION TRAVATAN Z PA RequiredOTIC AGENTSOTIC AGENTS - MISCELLANEOUSACETIC ACID SOLUTION ACETIC ACIDOTIC ANTI-INFECTIVESOFLOXACIN SOLUTION OFLOXACINOTIC COMBINATIONSANTIPYRINE-BENZOCAINE SOLUTION AURODEXANTIPYRINE-BENZOCAINE-POLYCOSANOL SOLUTION OTIC CARECIPROFLOXACIN-DEXAMETHASONE CIPRODEXCIPROFLOXACIN-HYDROCORTISONE SUSPENSION CIPRO HCNEOMYCIN-POLYMYXIN-HC SOLUTION CORTISPORIN
NEOMYCIN-POLYMYXIN-HC SUSPENSION NEO/POLYMYXIN/HC 5-10000-1
35
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
OTIC STEROIDSHYDROCORTISONE W/ACETIC ACID SOLUTION ACETASOL HCOXYTOCICSOXYTOCICSMETHYLERGONOVINE MALEATE TABLETS METHERGINEPASSIVE IMMUNIZING AGENTSMONOCLONAL ANTIBODIES
PALIVIZUMAB SOLUTION SYNAGIS
PA Required - if approved the prescriber
may be required to buy and bill a
medical claim for the drugPENICILLINSAMINOPENICILLINSAMOXICILLIN CAPSULES AMOXICILLINAMOXICILLIN CHEWABLE TABLETS AMOXICILLINAMOXICILLIN SUSPENSION AMOXICILLINAMOXICILLIN TABLETS AMOXICILLINAMPICILLIN CAPSULES AMPICILLINAMPICILLIN SUSPENSION AMPICILLINNATURAL PENICILLINSPENICILLIN V POTASSIUM SOLUTION PENICILLIN V POTASSIUMPENICILLIN V POTASSIUM TABLETS PENICILLIN V POTASSIUMPENICILLIN COMBINATIONSAMOXICILLIN & POT CLAVULANATE CHEWABLE TABLETS AUGMENTINAMOXICILLIN & POT CLAVULANATE SUSPENSION AUGMENTINAMOXICILLIN & POT CLAVULANATE TABLET 12-HOUR AUGMENTIN XRPENICILLINASE-RESISTANT PENICILLINSDICLOXACILLIN SODIUM CAPSULES DICLOXACILLIN SODIUMPROGESTINSPROGESTINSMEDROXYPROGESTERONE ACETATE TABLETS PROVERANORETHINDRONE ACETATE TABLETS AYGESTINPROGESTERONE MICRONIZED CAPSULES PROMETRIUMPSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTANTIDEMENTIA AGENTSDONEPEZIL HYDROCHLORIDE TABLETS ARICEPT PA RequiredDONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TABLETS ARICEPT ODT PA RequiredGALANTAMINE HYDROBROMIDE CAPSULE CONTROLLED RELEASE RAZADYNE ER PA RequiredGALANTAMINE HYDROBROMIDE SOLUTION RAZADYNE PA RequiredGALANTAMINE HYDROBROMIDE TABLETS RAZADYNE PA RequiredMEMANTINE HCL SOLUTION NAMENDA PA RequiredMEMANTINE HCL TABLETS NAMENDA PA RequiredRIVASTIGMINE PATCH EXELON PA Required
36
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
RIVASTIGMINE TARTRATE CAPSULES EXELON PA RequiredRIVASTIGMINE TARTRATE SOLUTION EXELON PA RequiredMULTIPLE SCLEROSIS AGENTSFINGOLIMOD HCL CAPSULES GILENYA PA RequiredGLATIRAMER ACETATE COPAXONE PA RequiredINTERFERON BETA-1A KIT AVONEX PA RequiredINTERFERON BETA-1A SOLUTION REBIF REBIDOSE PA RequiredINTERFERON BETA-1B KIT BETASERON PA RequiredSMOKING DETERRENTS
BUPROPION HCL (SMOKING DETERRENT) TABLET 12-HOUR BUPROBAN
84-day
supply 180
NICOTINE INHA NICOTROL INHALER
84-day
supply 180
NICOTINE POLACRILEX GUM NICORETTE GUM
84-day
supply 180
NICOTINE POLACRILEX LOZENGE COMMIT
84-day
supply 180
NICOTINE PATCH NICODERM CQ
84-day
supply 180
NICOTINE SOLUTION NICOTROL NS
84-day
supply 180
VARENICLINE TARTRATE TABLETS CHANTIX
84-day
supply 180RESPIRATORY AGENTS - MISC.ALPHA-PROTEINASE INHIBITOR (HUMAN)ALPHA1-PROTEINASE INHIBITOR (HUMAN) SOLUTION ARALAST NP PA RequiredCYSTIC FIBROSIS AGENTSDORNASE ALFA SOLUTION PULMOZYME PA RequiredSULFONAMIDESSULFONAMIDESSULFADIAZINE TABLETS SULFADIAZINETETRACYCLINESTETRACYCLINESDEMECLOCYCLINE HCL TABLETS DEMECLOCYCLINE HCL PA RequiredDOXYCYCLINE HYCLATE CAPSULES ORAXYLDOXYCYCLINE HYCLATE TABLETS DOXYCYCLINE HYCLATEDOXYCYCLINE HYCLATE TABLET ENTERIC COATED DORYXMINOCYCLINE HCL CAPSULES MINOCINMINOCYCLINE HCL TABLETS DYNACINTETRACYCLINE HCL CAPSULES TETRACYCLINE HCLTHYROID AGENTSANTITHYROID AGENTSMETHIMAZOLE TABLETS TAPAZOLE
37
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
PROPYLTHIOURACIL TABLETS PROPYLTHIOURACILTHYROID HORMONESLEVOTHYROXINE SODIUM TABLETS LEVO-TLIOTHYRONINE SODIUM TABLETS CYTOMELTHYROID TABLETS ARMOUR THYROIDULCER DRUGSANTISPASMODICSDICYCLOMINE HCL CAPSULES VARIOUSDICYCLOMINE HCL SOLUTION VARIOUSDICYCLOMINE HCL TABLETS VARIOUSGLYCOPYRROLATE SOLUTION VARIOUSGLYCOPYRROLATE TABLETS VARIOUSHYOSCYAMINE SULFATE ELIXIR VARIOUSHYOSCYAMINE SULFATE SOLUTION VARIOUSHYOSCYAMINE SULFATE SUBLINGUAL VARIOUSHYOSCYAMINE SULFATE TABLETS VARIOUSHYOSCYAMINE SULFATE TABLET 12-HOUR VARIOUSHYOSCYAMINE SULFATE CONTROLLED RELEASE TABLET VARIOUSHYOSCYAMINE SULFATE ORALLY DISINTEGRATING TABLETS VARIOUSPROPANTHELINE BROMIDE TABLETS VARIOUSH-2 ANTAGONISTSFAMOTIDINE CHEWABLE TABLETS PEPCID ACFAMOTIDINE SUSPENSION PEPCIDFAMOTIDINE TABLETS PEPCID ACRANITIDINE HCL CAPSULES RANITIDINE HCLRANITIDINE HCL SUSPENSION DEPRIZINE FUSEPAQRANITIDINE HCL SYRUP ZANTACRANITIDINE HCL TABLETS ZANTAC 75ANTI-ULCER - MISC.SUCRALFATE TABLETS CARAFATEPROTON PUMP INHIBITORSLANSOPRAZOLE CAPSULE DELAYED RELEASE PREVACIDLANSOPRAZOLE SUSPENSION FIRST-LANSOPRAZOLEOMEPRAZOLE CAPSULE DELAYED RELEASE PRILOSECOMEPRAZOLE SUSPENSION FIRST-OMEPRAZOLEPANTOPRAZOLE SODIUM TABLET ENTERIC COATED PROTONIXURINARY ANTISPASMODICSURINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLI)OXYBUTYNIN CHLORIDE SYRUP VARIOUSOXYBUTYNIN CHLORIDE TABLETS VARIOUSOXYBUTYNIN CHLORIDE TABLET 24-HOUR DITROPAN XL
TOLTERODINE TARTRATE CAPSULE CONTROLLED RELEASE DETROL LA Step Therapy
Member must have tried
oxybutynin & tolterodine
38
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred Drug
Status PA Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
AHCCCS DRUG LIST
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only AHCCCS Drug List Effective Date: 1/1/2016
• Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization
TOLTERODINE TARTRATE TABLETS DETROL Step Therapy
Member must have tried
oxybutynin TROSPIUM CHLORIDE TABLETS SANCTURAVAGINAL PRODUCTSSPERMICIDES
NONOXYNOL-9 FOAM
VCF VAGINAL CONTRACEPTIVE
FOAMNONOXYNOL-9 GEL SHUR-SEALVAGINAL ANTI-INFECTIVESCLINDAMYCIN PHOSPHATE VAGINAL CREAM CLEOCINCLINDAMYCIN PHOSPHATE VAGINAL SUPPOSITORY CLEOCINCLOTRIMAZOLE VAGINAL CREAM GYNE-LOTRIMINMETRONIDAZOLE VAGINAL GEL METROGEL-VAGINAL
MICONAZOLE NITRATE VAGINAL
MONISTAT 3 COMBINATION
PACKETSMICONAZOLE NITRATE VAGINAL SUPPOSITORY MICONAZOLE 3SULFANILAMIDE VAGINAL CREAM AVCVAGINAL ESTROGENSESTRADIOL ACETATE VAGINAL RING FEMRING PA RequiredESTRADIOL VAGINAL RING ESTRINGESTRADIOL VAGINAL TABLETS VAGIFEMESTROGENS, CONJUGATED VAGINAL CREAM PREMARIN PA RequiredVASOPRESSORSANAPHYLAXIS THERAPY AGENTSEPINEPHRINE SELF-INJECTED EPIPEN-JR 2-PAK Preferred Drug PA Required for > 2 Per Month 2 30EPINEPHRINE SELF-INJECTED EPIPEN 2-PAK Preferred Drug PA Required for > 2 Per Month 2 30
39
