Drug Class/Drug Name Reference Brand Name Brand Only / Generic Notes Preferred Drug Status PA Type Step Therapy Requirements Quantity Limit QL Days ADHD/ANTI-NARCOLEPSY AMPHETAMINES AMPHETAMINE SUSPENSION EXTENDED RELEASE DYANAVEL XR Preferred Drug PA Required for Ages < 6 years 240.00 30.00 AMPHETAMINE-DEXTROAMPHETAMINE CAPSULE 24-HOUR ADDERALL XR Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00 AMPHETAMINE-DEXTROAMPHETAMINE TABLETS ADDERALL Brand and Generic Preferred Drug PA Required for Ages < 6 years 60.00 30.00 DEXTROAMPHETAMINE SULFATE TABLETS VARIOUS Preferred Drug PA Required for Ages < 6 years 60.00 30.00 LISDEXAMFETAMINE DIMESYLATE CAPSULES VYVANSE Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00 LISDEXAMFETAMINE DIMESYLATE CHEWABLE TABLETS VYVANSE CHEWABLES Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00 STIMULANTS DEXMETHYLPHENIDATE HCL CAPSULE 24-HOUR FOCALIN XR Brand Only Preferred Drug PA Required for Ages < 6 years 60.00 30.00 DEXMETHYLPHENIDATE HCL TABLETS FOCALIN Preferred Drug PA Required for Ages < 6 years 60.00 30.00 METHYLPHENIDATE HCL CHEWABLE TABLETS METHYLIN Brand Only Preferred Drug PA Required for Ages < 6 years 90.00 30.00 METHYLPHENIDATE HCL CHEWABLE TABLETS EXTENDED RELEASE QUILLICHEW ER Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00 METHYLPHENIDATE HCL CAPSULE 24-HOUR RITALIN LA /APTENSIO XR Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00 METHYLPHENIDATE HCL CAPSULE 24-HOUR VARIOUS Preferred Drug PA Required for Ages < 6 years 30.00 30.00 METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE VARIOUS Preferred Drug PA Required for Ages < 6 years 30.00 30.00 METHYLPHENIDATE PATCH DAYTRANA Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00 METHYLPHENIDATE HCL SOLUTION METHYLIN Brand Only Preferred Drug PA Required for Ages < 6 years 300.00 30.00 METHYLPHENIDATE HCL SUSPENSION QUILLIVANT XR Brand Only Preferred Drug PA Required for Ages < 6 years 150.00 30.00 METHYLPHENIDATE HCL TABLETS VARIOUS Preferred Drug PA Required for Ages < 6 years 90.00 30.00 METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE CONCERTA ONLY Brand Only Preferred Drug PA Required for Ages < 6 years 60.00 30.00 MISCELLANEOUS AGENTS ATOMOXETINE HCL CAPSULES VARIOUS Preferred Drug PA Required for Ages < 6 years 30.00 30.00 CENTRAL ALPHA-AGONISTS CLONIDINE HCL TABLETS CATAPRES PA Required for Ages < 6 years CLONIDINE HCL TD PATCH WEEKLY CATAPRES PATCHES PA Required for Ages < 6 years 4 28 CLONIDINE HCL (ADHD) TABLET 12-HOUR CLONIDINE ER PA Required for Ages < 6 years 120.00 30.00 GUANFACINE HCL (ADHD) TABLET 24-HOUR GUANFACINE ER Preferred Drug PA Required for Ages < 6 years 30.00 30.00 GUANFACINE HCL TABLETS TENEX PA Required for Ages < 6 years AMINOGLYCOSIDES AMINOGLYCOSIDES NEOMYCIN SULFATE TABLETS NEOMYCIN SULFATE PAROMOMYCIN SULFATE CAPSULES PAROMOMYCIN SULFATE TOBRAMYCIN NEBULIZED KITABIS AND BETHKIS Preferred Drug PA Required ANALGESICS - ANTI-INFLAMMATORY ANTIRHEUMATIC ANTIMETABOLITES METHOTREXATE SODIUM (ANTIRHEUMATIC) TABLETS RHEUMATREX ANTIRHEUMATIC - ENZYME INHIBITORS TOFACITINIB CITRATE XELJANZ IMMEDIATE RELEASE ONLY Brand Only Preferred Drug PA Required ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES ADALIMUMAB HUMIRA Preferred Drug PA Required NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) CELECOXIB CAPSULES CELEBREX DICLOFENAC SODIUM TABLET 24-HOUR VOLTAREN-XR 30.00 30.00 DICLOFENAC SODIUM TABLET ENTERIC COATED DICLOFENAC SODIUM DR DICLOFENAC TABLET ENTERIC COATED DICLOFENAC SODIUM EC ETODOLAC CAPSULES ETODOLAC ETODOLAC TABLETS ETODOLAC ETODOLAC TABLET 24-HOUR ETODOLAC ER FENOPROFEN CALCIUM CAPSULES NALFON FENOPROFEN CALCIUM TABLETS FENOPROFEN CALCIUM FLURBIPROFEN TABLETS FLURBIPROFEN CMDP Preferred Drug List • Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
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CMDP Preferred Drug List - AZ Preferred Drug List October 2019.pdfPreferred Drug Status PA Type Step Therapy Requirements Quantity Limit QL Days ADHD/ANTI-NARCOLEPSY AMPHETAMINES AMPHETAMINE
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Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days ADHD/ANTI-NARCOLEPSYAMPHETAMINESAMPHETAMINE SUSPENSION EXTENDED RELEASE DYANAVEL XR Preferred Drug PA Required for Ages < 6 years 240.00 30.00AMPHETAMINE-DEXTROAMPHETAMINE CAPSULE 24-HOUR ADDERALL XR Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00AMPHETAMINE-DEXTROAMPHETAMINE TABLETS ADDERALL Brand and Generic Preferred Drug PA Required for Ages < 6 years 60.00 30.00DEXTROAMPHETAMINE SULFATE TABLETS VARIOUS Preferred Drug PA Required for Ages < 6 years 60.00 30.00LISDEXAMFETAMINE DIMESYLATE CAPSULES VYVANSE Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00LISDEXAMFETAMINE DIMESYLATE CHEWABLE TABLETS VYVANSE CHEWABLES Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00STIMULANTSDEXMETHYLPHENIDATE HCL CAPSULE 24-HOUR FOCALIN XR Brand Only Preferred Drug PA Required for Ages < 6 years 60.00 30.00DEXMETHYLPHENIDATE HCL TABLETS FOCALIN Preferred Drug PA Required for Ages < 6 years 60.00 30.00METHYLPHENIDATE HCL CHEWABLE TABLETS METHYLIN Brand Only Preferred Drug PA Required for Ages < 6 years 90.00 30.00METHYLPHENIDATE HCL CHEWABLE TABLETS EXTENDED RELEASE QUILLICHEW ER Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00METHYLPHENIDATE HCL CAPSULE 24-HOUR RITALIN LA /APTENSIO XR Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00METHYLPHENIDATE HCL CAPSULE 24-HOUR VARIOUS Preferred Drug PA Required for Ages < 6 years 30.00 30.00METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE VARIOUS Preferred Drug PA Required for Ages < 6 years 30.00 30.00METHYLPHENIDATE PATCH DAYTRANA Brand Only Preferred Drug PA Required for Ages < 6 years 30.00 30.00METHYLPHENIDATE HCL SOLUTION METHYLIN Brand Only Preferred Drug PA Required for Ages < 6 years 300.00 30.00METHYLPHENIDATE HCL SUSPENSION QUILLIVANT XR Brand Only Preferred Drug PA Required for Ages < 6 years 150.00 30.00METHYLPHENIDATE HCL TABLETS VARIOUS Preferred Drug PA Required for Ages < 6 years 90.00 30.00METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE CONCERTA ONLY Brand Only Preferred Drug PA Required for Ages < 6 years 60.00 30.00MISCELLANEOUS AGENTSATOMOXETINE HCL CAPSULES VARIOUS Preferred Drug PA Required for Ages < 6 years 30.00 30.00CENTRAL ALPHA-AGONISTSCLONIDINE HCL TABLETS CATAPRES PA Required for Ages < 6 yearsCLONIDINE HCL TD PATCH WEEKLY CATAPRES PATCHES PA Required for Ages < 6 years 4 28CLONIDINE HCL (ADHD) TABLET 12-HOUR CLONIDINE ER PA Required for Ages < 6 years 120.00 30.00GUANFACINE HCL (ADHD) TABLET 24-HOUR GUANFACINE ER Preferred Drug PA Required for Ages < 6 years 30.00 30.00GUANFACINE HCL TABLETS TENEX PA Required for Ages < 6 yearsAMINOGLYCOSIDESAMINOGLYCOSIDESNEOMYCIN SULFATE TABLETS NEOMYCIN SULFATEPAROMOMYCIN SULFATE CAPSULES PAROMOMYCIN SULFATETOBRAMYCIN NEBULIZED KITABIS AND BETHKIS Preferred Drug PA Required ANALGESICS - ANTI-INFLAMMATORYANTIRHEUMATIC ANTIMETABOLITESMETHOTREXATE SODIUM (ANTIRHEUMATIC) TABLETS RHEUMATREXANTIRHEUMATIC - ENZYME INHIBITORS
TOFACITINIB CITRATEXELJANZ IMMEDIATE
RELEASE ONLY Brand Only Preferred Drug PA Required ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIESADALIMUMAB HUMIRA Preferred Drug PA Required NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)CELECOXIB CAPSULES CELEBREXDICLOFENAC SODIUM TABLET 24-HOUR VOLTAREN-XR 30.00 30.00DICLOFENAC SODIUM TABLET ENTERIC COATED DICLOFENAC SODIUM DRDICLOFENAC TABLET ENTERIC COATED DICLOFENAC SODIUM ECETODOLAC CAPSULES ETODOLACETODOLAC TABLETS ETODOLACETODOLAC TABLET 24-HOUR ETODOLAC ERFENOPROFEN CALCIUM CAPSULES NALFONFENOPROFEN CALCIUM TABLETS FENOPROFEN CALCIUMFLURBIPROFEN TABLETS FLURBIPROFEN
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
100mcg Preferred Drug PA RequiredMORPHINE-NALTREXONE CAPSULE CONTROLLED RELEASE EMBEDA Preferred Drug PA RequiredMORPHINE SULFATE TABLET CONTROLLED RELEASE MS CONTIN Preferred Drug PA RequiredOXYCODONE CAPSULE ER 12-HOUR ABUSE-DETERRENT XTAMPZA ER Preferred Drug PA RequiredTRAMADOL HCL ER TABLET 24-HOUR TRAMADOL HCL ER Preferred Drug PA RequiredSHORT-ACTING OPIOID AGONISTS
HYDROMORPHONE HCL LIQUID DILAUDID
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period.
HYDROMORPHONE HCL SUPPOSITORY HYDROMORPHONE HCL
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period.
HYDROMORPHONE HCL TABLETS DILAUDID
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period.
MEPERIDINE HCL TABLETS DEMEROL
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period.
MORPHINE SULFATE SOLUTION MORPHINE SULFATE
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period.
MORPHINE SULFATE SUPPOSITORY MORPHINE SULFATE
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period.
MORPHINE SULFATE TABLETS MORPHINE SULFATE
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period.
OXYCODONE HCL CAPSULES OXYCODONE HCL
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period.
OXYCODONE HCL CONCENTRATE OXYCODONE HCL
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period.
OXYCODONE HCL SOLUTION OXYCODONE HCL
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period.
OXYCODONE HCL TABLETS ROXICODONE
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period.
TRAMADOL HCL TABLETS ULTRAM
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period.
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period.
OXYCODONE W/ ACETAMINOPHEN SOLUTION ROXICET
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period.
OXYCODONE W/ ACETAMINOPHEN TABLETS ENDOCET
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period.
OXYCODONE-IBUPROFEN TABLETS OXYCODONE/IBUPROFEN
PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period. OPIOID PARTIAL AGONISTS
BUPRENORPHINE VARIOUS VARIOUS
PA Required unless the member is pregnant- the prescriber must note 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 Postpartum Nursing Mothers. The first digit of the diagnosis code is the Letter - O and the second is a Zero - 0
BUPRENORPHINE PATCH WEEKLY BUTRANS Brand Only Preferred Drug PA RequiredBUPRENORPHINE SOLUTION PREFILLED SYRINGE SUBLOCADE Preferred Drug PA RequiredBUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE FILM SUBOXONE FILM Brand Only Preferred Drug
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
METHADONE VARIOUSOnly avaliable at an Opioid Treatment
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
ALPRAZOLAM TAB 0.25 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 120.00 30.00
ALPRAZOLAM TAB 0.5 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 120.00 30.00
ALPRAZOLAM TAB 1 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 120.00 30.00
ALPRAZOLAM TAB 2 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 60.00 30.00
ALPRAZOLAM TAB SR 24HR 0.5 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 30.00 30.00
ALPRAZOLAM TAB SR 24HR 1 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 30.00 30.00
ALPRAZOLAM TAB SR 24HR 2 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 30.00 30.00
ALPRAZOLAM TAB SR 24HR 3 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 30.00 30.00
CHLORDIAZEPOXIDE HCL CAP 10 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 60.00 30.00
CHLORDIAZEPOXIDE HCL CAP 25 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 60.00 30.00
CHLORDIAZEPOXIDE HCL CAP 5 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 60.00 30.00
CLONAZEPAM 0.5 MG KlonopinPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 120.00 30.00
CLONAZEPAM 1.0 MG KlonopinPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 120.00 30.00
CLONAZEPAM 2 MG KlonopinPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 60.00 30.00
CLONAZEPAM ODT 0.125MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 120.00 30.00
CLONAZEPAM ODT 0.25MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 120.00 30.00
CLONAZEPAM ODT 0.5 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 120.00 30.00
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
CLONAZEPAM ODT 1MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 120.00 30.00
CLONAZEPAM ODT 2MG VARIOUSPA Required for > 1 Anxiolytic
LORAZEPAM TAB 0.5 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 120.00 30.00
LORAZEPAM TAB 1 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 120.00 30.00
LORAZEPAM TAB 2 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 60.00 30.00
OXAZEPAM CAP 10 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 60.00 30.00
OXAZEPAM CAP 15 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 60.00 30.00
OXAZEPAM CAP 30 MG VARIOUSPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 60.00 30.00ANTIARRHYTHMICSANTIARRHYTHMICS 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 100MG & 200MG PACERONEDOFETILIDE CAPSULES TIKOSYN PA RequiredDRONEDARONE HCL TABLETS MULTAQ PA RequiredANTIASTHMATIC AND BRONCHODILATOR AGENTSANTI-INFLAMMATORY AGENTS
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
CROMOLYN SODIUM NEBULIZED CROMOLYN SODIUMBRONCHODILATORS - ANTICHOLINERGICSACLIDINIUM BROMIDE AEROSOL SOLUTION TUDORZA PRESSAIR Preferred DrugIPRATROPIUM BROMIDE HFA AEROSOL SOLUTION ATROVENT HFA Preferred DrugIPRATROPIUM BROMIDE SOLUTION IPRATROPIUM BROMIDE Preferred DrugTIOTROPIUM BROMIDE MONOHYDRATE CAPSULES SPIRIVA HANDIHALER Preferred DrugLEUKOTRIENE MODULATORSMONTELUKAST SODIUM CHEWABLE TABLETS SINGULAIR 30.00 30.00MONTELUKAST SODIUM GRANULES SINGULAIR PA Required for > 4 Years of AgeMONTELUKAST SODIUM TABLETS SINGULAIR 30.00 30.00STEROID INHALANTSBUDESONIDE (INHALATION) SUSPENSION 0.25MG/2ML, 0.5MG/2ML PULMICORT Brand Only Preferred Drug PA Required for > 4 Years of Age BUDESONIDE (INHALATION) SUSPENSION 1MG/2ML PULMICORT Preferred Drug PA Required for > 4 Years of Age BUDESONIDE (INHALATION) AEROSOL POWDER PULMICORT FLEXHALER Preferred DrugFLUTICASONE PROPIONATE HFA AERO FLOVENT HFA Preferred DrugMOMETASONE FUROATE (INHALATION) AEPB ASMANEX TWISTHALER Preferred DrugSYMPATHOMIMETICSALBUTEROL SULFATE TABLETS ALBUTEROL SULFATEALBUTEROL SULFATE TABLET 12-HOUR ALBUTEROL SULFATE ER
ALBUTEROL SULFATE INHALER ProAir Brand OnlyPreferred Drug Only
BUDESONIDE-FORMOTEROL FUMARATE DIHYDRATE INHALER SYMBICORT Preferred Drug Step Therapy
Patient must have tried one steriod inhaler: Beclomethasone Dipropionate, Budesonide, Fluticasone Propionate, or Mometasone
FLUTICASONE-SALMETEROL INHALER ADVAIR HFA Preferred Drug Step Therapy
Patient must have tried one steriod inhaler: Beclomethasone Dipropionate, Budesonide, Fluticasone Propionate, or Mometasone
GLYCOPYRROLATE-FORMOTEROL FUMARATE AEROSOL SOLUTION BEVESPI AEROSPHERE Preferred Drug PA Required 1.00 30.00IPRATROPIUM-ALBUTEROL INHALER COMBIVENT Preferred DrugIPRATROPIUM-ALBUTEROL AEROSOL SOLUTION COMBIVENT RESPIMAT Preferred DrugIPRATROPIUM-ALBUTEROL SOLUTION DUONEB Preferred DrugLEVALBUTEROL HCL NEBULIZED XOPENEX PA Required for > 4 Years of Age
MOMETASONE FUROATE-FORMOTEROL FUMARATE DIHYDRATE INHALER DULERA Preferred Drug Step Therapy
Patient must have tried one steriod inhaler: Beclomethasone Dipropionate, Budesonide, Fluticasone Propionate, or Mometasone
SALMETEROL XINAFOATE INHALER BREATH ACTIVATED SEREVENT DISKUS Preferred Drug PA RequiredTIOTROPIUM BROMIDE-OLODATEROL HCL AEROSOL SOLUTION STIOLTO RESPIMAT Preferred Drug PA Required 1.00 30.00XANTHINESTHEOPHYLLINE CAPSULE 24-HOUR THEO-24THEOPHYLLINE ELIXIR ELIXIROPHYLLINTHEOPHYLLINE SOLUTION THEOPHYLLINETHEOPHYLLINE TABLET 12-HOUR THEOCHRONTHEOPHYLLINE TABLET 24-HOUR THEOPHYLLINE ERANTICOAGULANTSCOUMARIN ANTICOAGULANTSWARFARIN SODIUM TABLETS COUMADINDIRECT FACTOR XA INHIBITORSAPIXABAN TABLETS ELIQUIS Brand Only Preferred Drug 60.00 30.00
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
APIXABAN TABLETS STARTER PACK ELIQUIS STARTER PACK Brand Only Preferred Drug 74.00 365.00RIVAROXABAN TABLETS XARELTO Brand Only Preferred Drug 60.00 30.00RIVAROXABAN TABLETS THERAPY PACK XARELTO STARTER PACK Brand Only Preferred Drug 51.00 30.00HEPARINS AND HEPARINOID-LIKE AGENTSENOXAPARIN SODIUM INJ 100 MG/ML VARIOUS Preferred Drug 60.00 30.00ENOXAPARIN SODIUM INJ 120 MG/0.8ML VARIOUS Preferred Drug 60.00 30.00ENOXAPARIN SODIUM INJ 150 MG/ML VARIOUS Preferred Drug 60.00 30.00ENOXAPARIN SODIUM INJ 30 MG/0.3ML VARIOUS Preferred Drug 60.00 30.00ENOXAPARIN SODIUM INJ 300 MG/3ML VARIOUS Preferred Drug 60.00 30.00ENOXAPARIN SODIUM INJ 40 MG/0.4ML VARIOUS Preferred Drug 60.00 30.00ENOXAPARIN SODIUM INJ 60 MG/0.6ML VARIOUS Preferred Drug 60.00 30.00ENOXAPARIN SODIUM INJ 80 MG/0.8ML VARIOUS Preferred Drug 60.00 30.00HEPARIN (PORCINE) IN SODIUM CHLORIDE SOLUTION HEPARIN SODIUM/NACL 0.9%HEPARIN SOD (PORCINE) IN D5W SOLUTION HEPARIN SODIUM/D5WHEPARIN SODIUM (PORCINE) LOCK FLUSH & NACL LOCK FLUSH KIT HEPARIN SODIUM LOCK FLUSHHEPARIN SODIUM (PORCINE) LOCK FLUSH SOLUTION HEPARIN LOCK FLUSHTHROMBIN INHIBITORSDABIGATRAN ETEXILATE MESYLATE CAPSULES PRADAXA Brand Only Preferred Drug 60.00 30.00ANTICONVULSANTSANTICONVULSANTS - BENZODIAZEPINESCLOBAZAM SUSPENSION ONFI PA RequiredCLOBAZAM TABLETS ONFI PA Required
CLONAZEPAM TAB 0.5 MG KLONOPINPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 120.00 30.00
CLONAZEPAM TAB 1 MG KLONOPINPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 120.00 30.00
CLONAZEPAM TAB 2 MG KLONOPINPA Required for > 1 Anxiolytic
Medication in a 30-day time period. 60.00 30.00DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG DIASTAT 2.00 30.00DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG DIASTAT 2.00 30.00DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG DIASTAT 2.00 30.00ANTICONVULSANTS - MISC.CARBAMAZEPINE (ANTIPSYCHOTIC) CAPSULE 12-HOUR EQUETROCARBAMAZEPINE CHEWABLE TABLETS CARBAMAZEPINECARBAMAZEPINE CAPSULE 12-HOUR CARBATROLCARBAMAZEPINE SUSPENSION TEGRETOLCARBAMAZEPINE TABLETS EPITOLCARBAMAZEPINE TABLET 12-HOUR TEGRETOL-XREZOGABINE TABLETS POTIGA PA RequiredGABAPENTIN CAPSULES NEURONTINGABAPENTIN SOLUTION NEURONTINGABAPENTIN TABLETS NEURONTINGABAPENTIN (ONCE-DAILY) TABLETS GRALISE PA Required
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
GABAPENTIN ENACARBIL TABLET CONTROLLED RELEASE HORIZANT PA RequiredLACOSAMIDE SOLUTION VIMPAT PA RequiredLACOSAMIDE TABLETS VIMPAT PA RequiredLAMOTRIGINE CHEWABLE TABLETS LAMICTALLAMOTRIGINE KIT LAMICTAL STARTER/TAKING VALPROATELAMOTRIGINE TABLETS LAMICTALLAMOTRIGINE TABLET 24-HOUR LAMICTAL XRLAMOTRIGINE ORALLY DISPERSABLE TABLET LAMICTAL ODTLEVETIRACETAM SOLUTION KEPPRALEVETIRACETAM TABLETS KEPPRALEVETIRACETAM TABLET 24-HOUR KEPPRA XROXCARBAZEPINE SUSPENSION TRILEPTALOXCARBAZEPINE TABLETS TRILEPTALOXCARBAZEPINE TABLET 24-HOUR OXTELLAR XRPREGABALIN CAPSULES (25MG, 50MG, 75MG, 100MG, 150MG, 200MG) LYRICA 90.00 30.00PREGABALIN CAPSULES (225MG, 300MG) LYRICA 60.00 30.00PREGABALIN SOLUTION LYRICA 900.00 30.00PRIMIDONE TABLETS MYSOLINERUFINAMIDE SUSPENSION BANZEL PA RequiredRUFINAMIDE TABLETS BANZEL PA RequiredTOPIRAMATE CAPSULE 24-HOUR TROKENDI XRTOPIRAMATE SPRINKLE CAPSULES TOPAMAX SPRINKLETOPIRAMATE 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 DEPAKENEVALPROIC ACID CAPSULES DEPAKENEVALPROIC ACID CAPSULE DELAYED RELEASE STAVZORANTIDEPRESSANTSALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)MIRTAZAPINE TABLETS REMERON PA Required for Ages < 6 years 30.00 30.00MIRTAZAPINE ORALLY DISPERSABLE TABLET REMERON SOLTAB PA Required for Ages < 6 years 30.00 30.00NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIBITORS (NDRIS)BUPROPION HCL TABLETS WELLBUTRIN PA Required for Ages < 6 years 120.00 30.00BUPROPION HCL TABLET 12-HOUR BUDEPRION SR PA Required for Ages < 6 years 60.00 30.00BUPROPION HCL TABLET 24-HOUR WELLBUTRIN XL PA Required for Ages < 6 years 30.00 30.00SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
CITALOPRAM HYDROBROMIDE SOLUTION CELEXAPA Required for Ages < 6 years and for >
the age of 12 years of age 600.00 30.00CITALOPRAM HYDROBROMIDE TABLETS 10MG CELEXA PA Required for Ages < 6 years 60.00 30.00CITALOPRAM HYDROBROMIDE TABLETS 20MG CELEXA PA Required for Ages < 6 years 30.00 30.00CITALOPRAM HYDROBROMIDE TABLETS 40MG CELEXA PA Required for Ages < 6 years 30.00 30.00ESCITALOPRAM OXALATE TABLETS 5MG LEXAPRO PA Required for Ages < 6 years 60.00 30.00ESCITALOPRAM OXALATE TABLETS 10MG LEXAPRO PA Required for Ages < 6 years 30.00 30.00ESCITALOPRAM OXALATE TABLETS 20MG LEXAPRO PA Required for Ages < 6 years 30.00 30.00FLUOXETINE HCL CAPSULES ONLY 10MG PROZAC PA Required for Ages < 6 years 60.00 30.00FLUOXETINE HCL CAPSULES ONLY 20MG PROZAC PA Required for Ages < 6 years 120.00 30.00FLUOXETINE HCL CAPSULES ONLY 40MG PROZAC PA Required for Ages < 6 years 60.00 30.00
FLUOXETINE HCL SOLUTION FLUOXETINE HCLPA Required for Ages < 6 years and for >
the age of 12 years of age 600.00 30.00FLUVOXAMINE MALEATE TABLETS 25MG LUVOX PA Required for Ages < 6 years 60.00 30.00FLUVOXAMINE MALEATE TABLETS 50MG LUVOX PA Required for Ages < 6 years 180.00 30.00FLUVOXAMINE MALEATE TABLETS 100MG LUVOX PA Required for Ages < 6 years 90.00 30.00PAROXETINE HCL TABLETS 10MG PAXIL PA Required for Ages < 6 years 30.00 30.00PAROXETINE HCL TABLETS 20MG PAXIL PA Required for Ages < 6 years 30.00 30.00PAROXETINE HCL TABLETS 30MG PAXIL PA Required for Ages < 6 years 30.00 30.00PAROXETINE HCL TABLETS 40MG PAXIL PA Required for Ages < 6 years 45.00 30.00
SERTRALINE HCL CONCENTRATE ZOLOFTPA Required for Ages < 6 years and for >
the age of 12 years of age 300.00 30.00SERTRALINE HCL TABLETS 25MG ZOLOFT PA Required for Ages < 6 years 90.00 30.00SERTRALINE HCL TABLETS 50MG ZOLOFT PA Required for Ages < 6 years 120.00 30.00SERTRALINE HCL TABLETS 100MG ZOLOFT PA Required for Ages < 6 years 60.00 30.00SEROTONIN MODULATORSTRAZODONE HCL TABLETS 50MG TRAZODONE HCL PA Required for Ages < 6 years 90.00 30.00TRAZODONE HCL TABLETS 100MG TRAZODONE HCL PA Required for Ages < 6 years 120.00 30.00TRAZODONE HCL TABLETS 150MG TRAZODONE HCL PA Required for Ages < 6 years 60.00 30.00TRAZODONE HCL TABLETS 300MG TRAZODONE HCL PA Required for Ages < 6 years 30.00 30.00SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRI)DULOXETINE HCL CAPSULE DELAYED RELEASE 20MG CYMBALTA PA Required for Ages < 6 years 120.00 30.00DULOXETINE HCL CAPSULE DELAYED RELEASE 30MG CYMBALTA PA Required for Ages < 6 years 120.00 30.00DULOXETINE HCL CAPSULE DELAYED RELEASE 60MG CYMBALTA PA Required for Ages < 6 years 60.00 30.00VENLAFAXINE HCL CONTROLLED RELEASE - CAPSULES ONLY 37.5MG EFFEXOR XR PA Required for Ages < 6 years 90.00 30.00VENLAFAXINE HCL CONTROLLED RELEASE - CAPSULES ONLY 75MG EFFEXOR XR PA Required for Ages < 6 years 90.00 30.00VENLAFAXINE HCL CONTROLLED RELEASE - CAPSULES ONLY 150MG EFFEXOR XR PA Required for Ages < 6 years 30.00 30.00
VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 25MG- TABLETS ONLY VENLAFAXINE HCL PA Required for Ages < 6 years 120.00 30.00
VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 37.5MG- TABLETS ONLY VENLAFAXINE HCL PA Required for Ages < 6 years 90.00 30.00
VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 50MG- TABLETS ONLY VENLAFAXINE HCL PA Required for Ages < 6 years 90.00 30.00
VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 75MG- TABLETS ONLY VENLAFAXINE HCL PA Required for Ages < 6 years 150.00 30.00
VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 100MG- TABLETS ONLY VENLAFAXINE HCL PA Required for Ages < 6 years 90.00 30.00TRICYCLIC AGENTSAMITRIPTYLINE HCL TABLETS AMITRIPTYLINE HCL PA Required for Ages < 6 yearsAMOXAPINE TABLETS VARIOUS PA Required for ages < 6 yearsCLOMIPRAMINE HCL CAPSULES ANAFRANIL PA Required for Ages < 6 yearsDESIPRAMINE HCL TABLETS NORPRAMIN PA Required for Ages < 6 yearsDOXEPIN HCL CAPSULES DOXEPIN HCL PA Required for Ages < 6 years 90.00 30.00
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
DOXEPIN HCL CONCENTRATE DOXEPIN HCL PA Required for Ages < 6 years 180.00 30.00IMIPRAMINE HCL TABLETS TOFRANIL PA Required for Ages < 6 yearsIMIPRAMINE PAMOATE CAPSULES TOFRANIL-PM PA Required for Ages < 6 years 30.00 30.00NORTRIPTYLINE 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 yearsTRIMIPRAMINE MALEATE SURMONTIL PA Required for Ages < 6 yearsANTIDIABETICSALPHA-GLUCOSIDASE INHIBITORSACARBOSE TABLETS PRECOSEANTIDIABETIC - AMYLIN ANALOGSPRAMLINTIDE ACETATE SOLUTION PEN INJECTION SYMLINPEN 60 Preferred Drug PA RequiredANTIDIABETIC COMBINATIONSEMPAGLIFLOZIN-LINAGLIPTIN TABLETS GLYXAMBI Preferred Drug PA RequiredGLYBURIDE-METFORMIN HCL TABLETS GLYBURIDE/METFORMIN HCLPIOGLITAZONE HCL-METFORMIN HCL TABLETS ACTOPLUS METPIOGLITAZONE HCL-METFORMIN HCL TABLET 24-HOUR ACTOPLUS MET XRSITAGLIPTIN-METFORMIN HCL TABLETS JANUMET Preferred Drug PA RequiredSITAGLIPTIN-METFORMIN HCL TABLET 24-HOUR JANUMET XR Preferred Drug PA RequiredBIGUANIDESMETFORMIN HCL TABLETS GLUCOPHAGE
Release Products DIABETIC OTHERGLUCAGON (RDNA) KIT GLUCAGON EMERGENCY KIT 1.00 30.00GLUCAGON HCL (RDNA) SOLUTION GLUCAGEN HYPOKIT 1.00 30.00MIFEPRISTONE (HYPERGLYCEMIA) TABLETS KORLYM PA RequiredDIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORSALOGLIPTIN BENZOATE TABLETS NESINALINAGLIPTIN TABLETS TRADJENTA Preferred Drug PA RequiredLINAGLIPTIN-METFORMIN HCL TABLETS JENTADUETO Preferred Drug PA RequiredLIRAGLUTIDE SOLUTION PEN INJECTION VICTOZA Preferred Drug PA RequiredSAXAGLIPTIN HCL TABLETS ONGLYZA Preferred Drug PA RequiredSAXAGLIPTIN-METFORMIN HCL TABLETS KOMBIGLYZE XR Preferred Drug PA RequiredSITAGLIPTIN PHOSPHATE TABLETS JANUVIA Preferred Drug PA RequiredINCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)EXENATIDE SOLUTION PEN INJECTION BYETTA Preferred Drug PA RequiredEXENATIDE PEN BYDUREON Preferred Drug PA RequiredEXENATIDE SUSPENSION EXTENDED RELEASE BYDUREON Preferred Drug PA RequiredINSULIN SENSITIZING AGENTSPIOGLITAZONE HCL TABLETS ACTOSINSULININSULIN ASPART SOLUTION NOVOLOG Preferred DrugINSULIN ASPART SOCT NOVOLOG PENFILL Preferred DrugINSULIN ASPART SOLUTION PEN INJECTION NOVOLOG FLEXPEN Preferred DrugINSULIN ASPART PROTAMINE & ASPART (HUMAN) SUSPENSION (70/30) NOVOLOG MIX 70/30INSULIN ASPART PROTAMINE & ASPART (HUMAN) SUSPENSION PEN INJECTION (70/30) NOVOLOG MIX 70/30 PREFILLED FLEXPENINSULIN DETEMIR SOLUTION LEVEMIR Preferred DrugINSULIN DETEMIR SOLUTION PEN INJECTION LEVEMIR FLEXPEN Preferred DrugINSULIN GLARGINE SOLUTION LANTUS Preferred DrugINSULIN GLARGINE SOLUTION PEN INJECTION LANTUS SOLOSTAR Preferred Drug
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
CANDESARTAN CILEXETIL TABLETS ATACAND Step Therapy Patient must have tried Losaratan, Irbesartan
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
ONCOLOGY -FEDERALLY REIMBURSABLE ANTINEOPLASTIC AGENTS,NOT LISTED BELOW, ARE AVAILABLE THROUGH PRIOR AUTHORIZATION ANTINEOPLASTICS AND ADJUNCTIVE THERAPIESALKYLATING AGENTSALTRETAMINE CAPSULES HEXALEN PA RequiredCHLORAMBUCIL TABLETS LEUKERANCYCLOPHOSPHAMIDE CAPSULES CYCLOPHOSPHAMIDECYCLOPHOSPHAMIDE TABLETS CYCLOPHOSPHAMIDELOMUSTINE CAPSULES CEENUTEMOZOLOMIDE CAPSULES TEMODAR PA RequiredANTIMETABOLITESMERCAPTOPURINE TABLETS VARIOUSMETHOTREXATE SODIUM TABLETS METHOTREXATETHIOGUANINE TABLETS TABLOIDANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORSVISMODEGIB CAPSULES ERIVEDGE PA RequiredANTINEOPLASTIC - HORMONAL AND RELATED AGENTSABIRATERONE ACETATE TABLETS ZYTIGA PA RequiredANASTROZOLE TABLETS ARIMIDEX PA RequiredBICALUTAMIDE TABLETS CASODEXDEGARELIXIR ACETATE SOLUTION FIRMAGON PA RequiredESTRAMUSTINE PHOSPHATE SODIUM CAPSULES EMCYT PA RequiredEXEMESTANE TABLETS AROMASIN PA Required
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
FLUTAMIDE CAPSULES FLUTAMIDELETROZOLE TABLETS FEMARA PA RequiredLEUPROLIDE ACETATE (3 MONTH) KIT LUPRON DEPOT PA RequiredLEUPROLIDE ACETATE (4 MONTH) KIT LUPRON DEPOT PA RequiredLEUPROLIDE ACETATE (6 MONTH) KIT ELIGARD PA RequiredLEUPROLIDE ACETATE KIT LUPRON DEPOT PA RequiredMEGESTROL ACETATE SUSPENSION MEGACE ORALMEGESTROL ACETATE TABLETS MEGESTROL ACETATEMITOTANE TABLETS LYSODRENNILUTAMIDE TABLETS NILANDRON 60.00 30.00TAMOXIFEN CITRATE SOLUTION SOLTAMOXTAMOXIFEN CITRATE TABLETS TAMOXIFEN CITRATETOREMIFENE CITRATE TABLETS FARESTON PA RequiredANTINEOPLASTIC ENZYME INHIBITORSALECTINIB HCL CAPSULES ALECENSA PA RequiredAXITINIB TABLETS INLYTA PA RequiredCOBIMETINIB FUMARATE TABLETS COTELLIC PA RequiredCRIZOTINIB CAPSULES XALKORI PA RequiredDASATINIB TABLETS SPRYCEL PA RequiredERLOTINIB HCL TABLETS TARCEVA PA RequiredEVEROLIMUS TABLETS AFINITOR PA RequiredEVEROLIMUS TBSO AFINITOR DISPERZ PA RequiredGEFITINIB TABLETS IRESSA PA RequiredIBRUTINIB CAPSULES IMBRUVICA PA RequiredIMATINIB MESYLATE TABLETS GLEEVEC BRAND PREFERRED BRAND PREFERRED PA RequiredIBRUTINIB TABLETS IMBRUVICA PA RequiredLAPATINIB DITOSYLATE TABLETS TYKERB PA RequiredIXAZOMIB CITRATE CAPSULES NINLARO 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 RequiredVEMURAFENIB 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 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 CALCIUMMITOTIC INHIBITORSETOPOSIDE CAPSULES ETOPOSIDEANTIPARKINSON AGENTSANTIPARKINSON ADJUVANTS
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
Prior Authorization is not required when prescribed by a psychiatric clinician, a
behavioral pediatrician or other prescribers as approved by the FFS
Administration
LITHIUM SOLUTION LITHIUM
Prior Authorization is not required when prescribed by a psychiatric clinician, a
behavioral pediatrician or other prescribers as approved by the FFS
Administration
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL ORAL AGENTS
ARIPIPRAZOLE TABLETS ABILIFY Preferred Drug
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 30.00 30.00
CLOZAPINE ORALLY DISPERSABLE TABLET FAZACLO Preferred Drug
PA Required for Ages < 18 years Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 150.00 30.00
CLOZAPINE TABLETS CLOZARIL Preferred Drug
PA Required for Ages < 18 years Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 150.00 30.00
LURASIDONE HCL TABS LATUDA Preferred Drug
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 30.00 30.00
OLANZAPINE ORALLY DISPERSABLE TABLET 5MG ZYPREXA ZYDIS Preferred Drug
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 60.00 30.00
OLANZAPINE ORALLY DISPERSABLE TABLET 10MG ZYPREXA ZYDIS Preferred Drug
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 60.00 30.00
OLANZAPINE ORALLY DISPERSABLE TABLET 15MG ZYPREXA ZYDIS Preferred Drug
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 30.00 30.00
OLANZAPINE ORALLY DISPERSABLE TABLET 20MG ZYPREXA ZYDIS Preferred Drug
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 30.00 30.00
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
OLANZAPINE TABLETS ZYPREXA Preferred Drug
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 30.00 30.00
QUETIAPINE FUMARATE TABLETS SEROQUEL Preferred Drug
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 60.00 30.00
RISPERIDONE ORALLY DISPERSABLE TABLET RISPERIDONE ODT Preferred Drug
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 60.00 30.00
RISPERIDONE ORAL SOLUTION RISPERDAL Preferred Drug
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 240.00 30.00
RISPERIDONE TABLETS RISPERDAL Preferred Drug
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 60.00 30.00
ZIPRASIDONE HCL CAPSULES GEODON Preferred Drug
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 60.00 30.00
ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL LONG ACTING INJECTABLES
ARIPIPRAZOLE LAUROXIL ARISTADA Preferred Drug
PA Required for < 18 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 1.00 30.00
ARIPIPRAZOLE LAUROXIL PREFILLED SYRINGE ARISTADA INITIO Preferred Drug
PA Required for Ages < 18 years Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 2.00 365.00
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
ARIPIPRAZOLE SUSPENSION ABILIFY MAINTENA Preferred Drug
PA Required for < 18 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 1.00 30.00
PALIPERIDONE PALMITATE SUSPENSION INVEGA SUSTENNA Preferred Drug
PA Required for < 18 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 1.00 30.00
PALIPERIDONE PALMITATE SUSPENSION INVEGA TRINZA Preferred Drug
PA Required for < 18 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 1.00 84.00
RISPERIDONE MICROSPHERES SUSPENSION RISPERDAL CONSTA Preferred Drug
PA Required for < 18 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration. 2.00 30.00
ANTIPSYCHOTICS - FIRST GENERATION -TYPICAL ORAL AGENTS
CHLORPROMAZINE HCL SOLUTION VARIOUS
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration.
CHLORPROMAZINE HCL TABLETS VARIOUS
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration.
FLUPHENAZINE HCL CONCENTRATE VARIOUS
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration.
FLUPHENAZINE HCL ELIXIR VARIOUS
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration.
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
FLUPHENAZINE HCL TABLETS VARIOUS
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration.
HALOPERIDOL LACTATE CONCENTRATE VARIOUS
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration.
HALOPERIDOL TABLETS VARIOUS
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration.
LOXAPINE SUCCINATE CAPSULES LOXITANE
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration.
PERPHENAZINE TABLETS VARIOUS
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration.
PIMOZIDE ORAP
PA Required for < 6 years of age, Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration.
THIORIDAZINE HCL TABLETS VARIOUS
PA Required for < 6 years of age. Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration.
THIOTHIXENE CAPSULES VARIOUS
PA Required for < 12 years of age. Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration.
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
TRIFLUOPERAZINE HCL TABLETS VARIOUS
PA Required for < 6 years of age. Prior Authorization is not required when
prescribed by a psychiatric clinician, a behavioral pediatrician or other
prescribers as approved by the FFS Administration.
ANTIPSYCHOTICS - FIRST GENERATION -TYPICAL -LONG ACTING INJECTIONS
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS TRUVADAENFUVIRTIDE SOLUTION FUZEON PA Required 1.00 30.00ETRAVIRINE 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 PACK ISENTRESSRALTEGRAVIR POTASSIUM TABLETS ISENTRESSRILPIVIRINE HCL TABLETS EDURANTRITONAVIR CAPSULES NORVIRRITONAVIR SOLUTION NORVIRRITONAVIR TABLETS NORVIRSAQUINAVIR MESYLATE CAPSULES INVIRASESAQUINAVIR MESYLATE TABLETS INVIRASESTAVUDINE CAPSULES ZERITSTAVUDINE SOLUTION ZERITTENOFOVIR DISOPROXIL FUMARATE POWDER VIREADTENOFOVIR DISOPROXIL FUMARATE TABLETS VIREADTIPRANAVIR CAPSULES APTIVUSTIPRANAVIR SOLUTION APTIVUSZIDOVUDINE CAPSULES RETROVIRZIDOVUDINE SYRUP RETROVIRZIDOVUDINE TABLETS ZIDOVUDINECMV AGENTSVALGANCICLOVIR HCL SOLUTION VALCYTE PA RequiredVALGANCICLOVIR HCL TABLETS VALCYTE PA RequiredHEPATITIS AGENTSADEFOVIR DIPIVOXIL TABLETS HEPSERA PA RequiredENTECAVIR SOLUTION BARACLUDE PA RequiredENTECAVIR TABLETS BARACLUDE PA RequiredGLECAPREVIR-PIBRENTASVIR TABLETS MAVYRET Preferred Drug PA RequiredLAMIVUDINE (HBV) SOLUTION EPIVIR HBVLAMIVUDINE (HBV) TABLETS EPIVIR HBVPEGINTERFERON ALFA-2A SOLUTION PEGASYS Preferred Drug PA RequiredPEGINTERFERON ALFA-2B KIT PEGINTRON Preferred Drug PA RequiredRIBAVIRIN (HEPATITIS C) CAPSULES VARIOUS Preferred Drug PA RequiredRIBAVIRIN (HEPATITIS C) TABLETS VARIOUS Preferred Drug PA Required
ONLY Preferred Drug PA RequiredTELBIVUDINE TABLETS TYZEKA PA RequiredHERPES AGENTSACYCLOVIR SUSPENSION ZOVIRAX
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
ACYCLOVIR TABLETS ZOVIRAXFAMCICLOVIR TABLETS FAMVIRVALACYCLOVIR HCL TABLETS VALTREX PA RequiredINFLUENZA AGENTSOSELTAMIVIR PHOSPHATE CAPSULES TAMIFLU 20.00 270.00OSELTAMIVIR PHOSPHATE SUSPENSION TAMIFLURIMANTADINE HYDROCHLORIDE TABLETS FLUMADINEZANAMIVIR AEPB RELENZA DISKHALER 40.00 270.00ASSORTED CLASSESBLOOD PRODUCTS - IMMUNE GLOBULINSIMMUNE GLOBULIN BIVIGAM (IV) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN CARIMUNE NF NANOFILTERED (IV) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN FLEBOGFAMMA DIF (IV) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN GAMASTAN S/D (IM) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN GAMMAGARD LIQUID (INJ) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN GAMMAGARD S-D LIQUID (INJ) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN GAMUNEX-C (INJ) BRAND ONLY PREFERRED DRUG PA REQUIREDIMMUNE GLOBULIN HIZENTRAL (SUBQ) BRAND ONLY PREFERRED DRUG PA REQUIREDCHELATING AGENTSPENICILLAMINE CAPSULES CUPRIMINEIMMUNOMODULATORSLENALIDOMIDE CAPSULES REVLIMID PA RequiredTHALIDOMIDE CAPSULES THALOMID PA RequiredIMMUNOSUPRESSIVE AGENTSAZATHIOPRINE TABLETS IMURANCYCLOSPORINE CAPSULES SANDIMMUNECYCLOSPORINE MODIFIED (FOR MICROEMULSION) CAPSULES GENGRAFCYCLOSPORINE MODIFIED (FOR MICROEMULSION) SOLUTION GENGRAFCYCLOSPORINE SOLUTION SANDIMMUNEEVEROLIMUS (IMMUNOSUPPRESSANT) TABLETS ZORTRESS PA RequiredMYCOPHENOLATE MOFETIL CAPSULES CELLCEPTMYCOPHENOLATE MOFETIL SUSPENSION CELLCEPTMYCOPHENOLATE MOFETIL TABLETS CELLCEPTSIROLIMUS SOLUTION RAPAMUNESIROLIMUS TABLETS RAPAMUNETACROLIMUS CAPSULES HECORIATACROLIMUS CAPSULE 24-HOUR ASTAGRAF XLPOTASSIUM REMOVING RESINSSODIUM POLYSTYRENE SULFONATE POWDER KAYEXALATESODIUM POLYSTYRENE SULFONATE SUSPENSION KIONEXBETA BLOCKERSALPHA-BETA BLOCKERSCARVEDILOL TABLETS COREGLABETALOL HCL TABLETS TRANDATEBETA BLOCKERS CARDIO-SELECTIVEATENOLOL TABLETS TENORMINBISOPROLOL FUMARATE TABLETS ZEBETAMETOPROLOL SUCCINATE TABLET 24-HOUR TOPROL XLMETOPROLOL TARTRATE TABLETS METOPROLOL TARTRATEBETA BLOCKERS NON-SELECTIVENADOLOL TABLETS CORGARDPROPRANOLOL HCL CAPSULE 24-HOUR INDERAL LAPROPRANOLOL HCL SOLUTION PROPRANOLOL HCL
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
SILDENAFIL CITRATE (PULMONARY HYPERTENSION) SUSPENSION REVATIO SUSPENSION BRAND ONLY
PREFERRED FOR UNDER THE AGE OF
12 PA Required FOR > 12 YEARS OF AGESILDENAFIL CITRATE (PULMONARY HYPERTENSION) TABLETS VARIOIUS PREFERRED DRUG PA RequiredTADALAFIL (PULMONARY HYPERTENSION) TABLETS ADCIRCA BRAND ONLY PREFERRED DRUG 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 CEFPROZILCEFUROXIME AXETIL SUSPENSION CEFTINCEFUROXIME AXETIL TABLETS CEFTINCEPHALOSPORINS - 3RD GENERATIONCEFDINIR CAPSULES CEFDINIRCEFDINIR SUSPENSION CEFDINIR
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
METHYLBROMIDE PA Required for < 18 years of age 240.00 12.00HYDROCODONE W/ HOMATROPINE TABLETS TUSSIGON PA Required for < 18 years of ageCOUGH/COLD/ALLERGY COMBINATIONSBROMPHENIRAMINE & PSEUDOEPH J-TAN D PDBROMPHENIRAMINE & PSEUDOEPH TABLET 12-HOUR BPM PSEUDOCETIRIZINE-PSEUDOEPHEDRINE TABLET 12-HOUR KLS ALLER-TEC D 30.00 30.00CHLORPHENIRAMINE & PSEUDOEPH CHEWABLE TABLETS DICELCHLORPHENIRAMINE & PSEUDOEPH LIQUID LOHIST-DCHLORPHENIRAMINE & PSEUDOEPH SOLUTION NEUTRAHISTCHLORPHENIRAMINE & PSEUDOEPH SYRUP EQ TRIACTING COLD/ALLERGYCHLORPHENIRAMINE & PSEUDOEPH TABLETS SUDOGEST SINUS & ALLERGYCHLORPHENIRAMINE W/ CODEINE LIQUID CODAR AR PA Required for < 18 years of age 240.00 12.00DEXTROMETHORPHAN-GUAIFENESIN BRONCOTRONDEXTROMETHORPHAN-GUAIFENESIN LIQUID NORTUSS-EXDEXTROMETHORPHAN-GUAIFENESIN TABLET 12-HOUR MUCINEX DM
DIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN LIQUID THERAFLU WARMING RELIEF FLU & SORE THROATDIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN PACK MUCINEX FAST-MAX NIGHT TIME COLD & FLUDIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN SUSPENSION TYLENOL CHILDRENS PLUS COLD & ALLERGYDIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN TABLETS BENADRYL ALLERGY & COLDFEXOFENADINE-PSEUDOEPHEDRINE TABLET 12-HOUR ALLEGRA-D 12 HOUR ALLERGY & CONGESTION 30.00 30.00FEXOFENADINE-PSEUDOEPHEDRINE TABLET 24-HOUR ALLEGRA-D 24 HOUR ALLERGY & CONGESTION 30.00 30.00GUAIFENESIN-CODEINE M-CLEAR PA Required for < 18 years of age 240.00 12.00GUAIFENESIN-CODEINE LIQUID DEX-TUSS PA Required for < 18 years of age 240.00 12.00LORATADINE & PSEUDOEPHEDRINE TABLET 12-HOUR ALAVERT ALLERGY/SINUS 30.00 30.00LORATADINE & PSEUDOEPHEDRINE TABLET 24-HOUR CLARITIN-D 24 HOUR 30.00 30.00PHENYLEPHRINE W/ DM-GG CAPSULES GILTUSS TRPHENYLEPHRINE W/ DM-GG LIQUID ROBITUSSIN CHILDRENS COUGH & COLD CFPHENYLEPHRINE W/ DM-GG SUSPENSION BRONCOTRON-DPHENYLEPHRINE W/ DM-GG SYRUP DESPEC DM
PHENYLEPHRINE W/ DM-GG TABLETSMUCINEX FAST-MAX SEVERE CONGESTION &
COUGHPHENYLEPHRINE W/ DM-GG TABLET 12-HOUR GILTUSS TRPHENYLEPHRINE-BROMPHENIRAMINE W/ CODEINE POLY-TUSSIN AC PA Required for < 18 years of age 240.00 12.00PHENYLEPHRINE-BROMPHENIRAMINE-DM ELIXIR DIMAPHEN DM COLD & COUGH 480.00 30.00PHENYLEPHRINE-BROMPHENIRAMINE-DM LIQUID DIMETAPP DM COLD & COUGH 480.00 30.00PHENYLEPHRINE-BROMPHENIRAMINE-DM SYRUP BPM-DM-PHEN 480.00 30.00PHENYLEPHRINE-CHLORPHEN-DM LIQUID GENCONTUSS PA RequiredPHENYLEPHRINE-CHLORPHEN-DM SOLUTION FATHER JOHNS MEDICINE PLUS PA RequiredPHENYLEPHRINE-CHLORPHEN-DM SYRUP BALAMINE DMPHENYLEPHRINE-CHLORPHEN-DM TABLETS PHENABID DM PA RequiredPHENYLEPHRINE-GUAIFENESIN CAPSULES DECONEXPHENYLEPHRINE-GUAIFENESIN LIQUID TRIAMINIC CHEST/NASAL CONGESTIONPHENYLEPHRINE-GUAIFENESIN SYRUP TRIAMINIC CHEST & NASAL CONGESTION
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
PHENYLEPHRINE-GUAIFENESIN TABLETS LIQUIBID PD-RPROMETHAZINE & PHENYLEPHRINE SYRUP PROMETHAZINE/PHENYLEPHRINEPROMETHAZINE W/CODEINE SYRUP PROMETHAZINE/CODEINE PA Required for < 18 years of age 240.00 12.00PROMETHAZINE-DM SYRUP PROMETHAZINE/DEXTROMETHORPHANPSEUDOEPHEDRINE W/ CODEINE-GG SUTTAR-2 240.00 12.00PSEUDOEPHEDRINE-BROMPHENIRAMINE-CODEINE LIQUID CPB WC PA Required for < 18 years of age 240.00 12.00PSEUDOEPHEDRINE-GUAIFENESIN CAPSULES RESPAIRE-30PSEUDOEPHEDRINE-GUAIFENESIN LIQUID TUSNEL PEDIATRICPSEUDOEPHEDRINE-GUAIFENESIN SYRUP ALTARUSSIN-PEPSEUDOEPHEDRINE-GUAIFENESIN TABLETS AMBI 40PSE/400GFNPSEUDOEPHEDRINE-GUAIFENESIN TABLET 12-HOUR MUCINEX DEXPECTORANTSGUAIFENESIN LIQUID HERBAL EXPECGUAIFENESIN PACK MUCINEX FOR KIDSGUAIFENESIN SOLUTION TRIACTIN CHEST CONGESTIONGUAIFENESIN SYRUP DIABETIC TUSSIN EXGUAIFENESIN TABLETS GUAIFENESINGUAIFENESIN TABLET 12-HOUR EQ MUCUS ERMISC. RESPIRATORY INHALANTSSODIUM CHLORIDE (INHALANT) NEBULIZED SODIUM CHLORIDEDERMATOLOGICALSACNE PRODUCTSADAPALENE CREAM DIFFERIN PA Required For > 26 Years of AgeADAPALENE GEL DIFFERIN PA Required For > 26 Years of AgeADAPALENE LOTION DIFFERIN PA Required For > 26 Years of AgeAZELAIC ACID (ACNE) CREAM AZELEX PA Required For > 26 Years of AgeBENZOYL PEROXIDE BAR PANOXYL
BENZOYL PEROXIDE CREAM NEUTROGENA ON-THE-SPOT ACNE TREATMENTBENZOYL PEROXIDE FOAM BENZEFOAMBENZOYL PEROXIDE GEL BENZOYL PEROXIDEBENZOYL PEROXIDE LIQUID PANOXYLBENZOYL PEROXIDE LOTION BP CLEANSING LOTIONBENZOYL PEROXIDE SOLUTION EFFACLAR DUOBENZOYL PEROXIDE-ERYTHROMYCIN GEL BENZAMYCINBENZOYL PEROXIDE-ERYTHROMYCIN PACK BENZAMYCINPAKCLINDAMYCIN PHOSPHATE (TOPICAL) FOAM EVOCLINCLINDAMYCIN PHOSPHATE (TOPICAL) GEL CLEOCIN-TCLINDAMYCIN PHOSPHATE (TOPICAL) LOTION CLEOCIN-TCLINDAMYCIN PHOSPHATE (TOPICAL) SOLUTION CLEOCIN-TCLINDAMYCIN PHOSPHATE (TOPICAL) SWAB CLEOCIN-TCLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE GEL BENZACLINERYTHROMYCIN (ACNE AID) GEL ERYGELERYTHROMYCIN (ACNE AID) OINTMENT AKNE-MYCINERYTHROMYCIN (ACNE AID) PADS ERYTHROMYCINERYTHROMYCIN (ACNE AID) SOLUTION ERYTHROMYCINISOTRETINOIN CAPSULES ABSORICA PA RequiredSULFACETAMIDE SODIUM (ACNE) LOTION KLARONTRETINOIN CREAM VARIOUS PA Required For > 26 Years of AgeTRETINOIN GEL VARIOUS PA Required For > 26 Years of AgeANTIBIOTICS - TOPICALBACITRACIN (TOPICAL) OINTMENT BACIGUENTBACITRACIN ZINC OINTMENT BACITRACIN
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
SALICYLIC ACID SOLUTION SALICYLIC ACIDLOCAL ANESTHETICS - TOPICALLIDOCAINE CREAM 4% ASPERCREME W/LIDOCAINELIDOCAINE HCL GEL 2% GLYDOLIDOCAINE HCL LOTION LIDOCAINE HCLLIDOCAINE OINTMENT LIDOCAINE PA RequiredLIDOCAINE PATCH LIDODERM PA RequiredLIDOCAINE-PRILOCAINE CREAM EMLAMISC. TOPICALALUMINUM CHLORIDE SOLUTION DRYSOLZINC OXIDE (TOPICAL) OINTMENT ZINC OXIDEZINC OXIDE (TOPICAL) PASTE ZINC OXIDEPIGMENTING-DEPIGMENTING AGENTSMETHOXSALEN (TOPICAL) LOTION OXSORALENROSACEA AGENTSMETRONIDAZOLE (TOPICAL) CREAM 0.75% METROCREAMMETRONIDAZOLE (TOPICAL) GEL 0.75% ROSADANMETRONIDAZOLE (TOPICAL) LOTION METROLOTIONSCABICIDES & PEDICULICIDESCROTAMITON CREAM EURAXCROTAMITON LOTION EURAXIVERMECTIN (PEDICULICIDE) LOTION SKLICE PA RequiredLINDANE LOTION LINDANE PA RequiredLINDANE SHAMPOO LINDANE PA RequiredMALATHION LOTION OVIDEPERMETHRIN 1%, 5% NIX, ELIMITEPERMETHRIN CREAM ACTICINPERMETHRIN LIQUID NIX CREME RINSEPERMETHRIN LOTION LICE TREATMENTPYRETHRINS-PIPERONYL BUTOXIDE GEL A-200PYRETHRINS-PIPERONYL BUTOXIDE KIT PRONTOPYRETHRINS-PIPERONYL BUTOXIDE LIQUID BARCPYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO LICIDESPINOSAD SUSPENSION NATROBA PA RequiredWOUND CARE PRODUCTSBECAPLERMIN GEL REGRANEX PA RequiredDIAGNOSTIC PRODUCTSDIAGNOSTIC TESTSGLUCOSE BLOOD STRIPS TRUETRACK AND ACCU-CHEK AVIVA 200.00 30.00DIGESTIVE AIDSDIGESTIVE ENZYMESLIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE CREON Brand Only Preferred Drug 300.00 30.00LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE ZENPEP Brand Only Preferred Drug 300.00 30.00LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE 5000 UNITS PANCRELIPASE 5000 UNITS Preferred Drug 300.00 30.00SACROSIDASE SOLUTION SUCRAID PA RequiredDIURETICSCARBONIC ANHYDRASE INHIBITORSACETAZOLAMIDE CAPSULE 12-HOUR DIAMOXACETAZOLAMIDE TABLETS ACETAZOLAMIDEMETHAZOLAMIDE TABLETS NEPTAZANEDIURETIC COMBINATIONSSPIRONOLACTONE & HYDROCHLOROTHIAZIDE TABLETS ALDACTAZIDETRIAMTERENE & HYDROCHLOROTHIAZIDE CAPSULES DYAZIDE
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
TRIAMTERENE & HYDROCHLOROTHIAZIDE TABLETS MAXZIDE-25LOOP DIURETICSBUMETANIDE TABLETS BUMETANIDEFUROSEMIDE SOLUTION FUROSEMIDEFUROSEMIDE TABLETS LASIXTORSEMIDE TABLETS DEMADEXPOTASSIUM SPARING DIURETICSAMILORIDE HCL TABLETS AMILORIDE HCLSPIRONOLACTONE TABLETS ALDACTONETRIAMTERENE CAPSULES DYRENIUMTHIAZIDES AND THIAZIDE-LIKE DIURETICSCHLOROTHIAZIDE SUSPENSION DIURILCHLOROTHIAZIDE TABLETS CHLOROTHIAZIDECHLORTHALIDONE TABLETS CHLORTHALIDONEHYDROCHLOROTHIAZIDE 12.5MG CAPSULES VARIOUSHYDROCHLOROTHIAZIDE TABLETS 25MG & 50MG HYDROCHLOROTHIAZIDEINDAPAMIDE TABLETS INDAPAMIDEMETHYCLOTHIAZIDE TABLETS METHYCLOTHIAZIDEMETOLAZONE TABLETS ZAROXOLYNENDOCRINE AND METABOLIC AGENTS - MISC.BONE DENSITY REGULATORSALENDRONATE SODIUM SOLUTION ALENDRONATE SODIUM PA RequiredALENDRONATE SODIUM TABLETS ALENDRONATE SODIUM 30.00 30.00CALCITONIN (SALMON) SOLUTION FORTICALRALOXIFENE TABLETS VARIOUSGROWTH HORMONE RECEPTOR ANTAGONISTSPEGVISOMANT SOLUTION SOMAVERT PA RequiredGROWTH HORMONESSOMATROPIN SOLUTION NORDITROPIN Brand Only Preferred Drug PA Required SOMATROPIN SOLUTION GENOTROPIN Brand Only Preferred Drug PA Required HORMONE RECEPTOR MODULATORSRALOXIFENE HCL TABLETS EVISTA 30.00 30.00INSULIN-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 RequiredNAFARELIN ACETATE SOLUTION SYNAREL PA RequiredMETABOLIC MODIFIERSCALCITRIOL CAPSULES ROCALTROLCALCITRIOL SOLUTION ROCALTROLCINACALCET HCL TABLETS SENSIPAR PA RequiredIDURSULFASE SOLUTION ELAPRASE PA RequiredLEVOCARNITINE (METABOLIC MODIFIERS) SOLUTION CARNITOR PA RequiredLEVOCARNITINE (METABOLIC MODIFIERS) TABLETS CARNITOR PA RequiredPOSTERIOR PITUITARY HORMONESDESMOPRESSIN ACETATE REFRIGERATED SOLUTION DDAVPDESMOPRESSIN ACETATE SOLUTION STIMATEDESMOPRESSIN ACETATE SPRAY REFRIGERATED SOLUTION DESMOPRESSIN ACETATEDESMOPRESSIN ACETATE SPRAY SOLUTION DDAVPDESMOPRESSIN ACETATE TABLETS DDAVPPROLACTIN INHIBITORSCABERGOLINE TABLETS CABERGOLINE PA Required
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
TALIGLUCERASE ALFA ELELYSO (IV) PA RequiredMIGLUSTAT MIGLUSTAT (AG) (oral) PA RequiredVELAGLUCERASE ALFA VPRIB 400 IU PA RequiredFOLIC ACID/FOLATESFOLIC ACID CAPSULES FA-8FOLIC ACID TABLETS FOLIC ACIDHEMATOPOIETIC GROWTH FACTORSELTROMBOPAG OLAMINE TABLETS PROMACTA BRAND ONLY PREFERRED DRUG PA RequiredEPOETIN ALFA-EPBX SOLUTION RETACRIT BRAND ONLY PREFERRED DRUG PA RequiredFILGRASTIM SOLUTION NEUPOGEN VIAL & DISPOSABLE SYRINGE BRAND ONLY PREFERRED DRUG PA RequiredPEGFILGRASTIM SOLUTION UDENYCA BRAND ONLY PREFERRED DRUG PA RequiredPEGFILGRASTIM- JMDB SOLUTION FULPHILIA BRAND ONLY PREFERRED DRUG PA RequiredROMIPLOSTIM NPLATE BRAND ONLY PREFERRED DRUG PA RequiredHEMATOPOIETIC MIXTURESFE FUMARATE-VITAMIN C-VITAMIN B12-FOLIC ACID CAPSULES HEMATOGEN FAFERROUS FUMARATE W/ B12-VIT C-FA-IFC CAPSULES TRICONFERROUS FUMARATE W/ FA-DSS-B COMPLEX-VIT C TABLETS NEPHRON FAFOLATE-VITAMIN B12-INTRINSIC FACTOR TABLETS INTRINSI B12/FOLATEIRON COMBINATIONS CORVITE 150IRON COMBINATIONS CAPSULES HEMATOGENIRON COMBINATIONS ELIXIR HEMOCYTE-FIRONFERROUS FUMARATE CAPSULES HIGH POTENCY IRONFERROUS FUMARATE TABLETS FEMIRONFERROUS FUMARATE TABLET CONTROLLED RELEASE IRONFERROUS GLUCONATE TABLETS FERATEFERROUS SULFATE DRIED TABLETS FEOSOLFERROUS SULFATE DRIED TABLET CONTROLLED RELEASE EQ SLOW-RELEASE IRONFERROUS SULFATE ELIXIR FEROSULFERROUS SULFATE LIQUID SPATONE PUR-ABSORB IRONFERROUS SULFATE SOLUTION BPROTECTED PEDIA IRONFERROUS SULFATE SYRUP FERROUS SULFATEFERROUS SULFATE TABLETS FERROUS SULFATEFERROUS SULFATE TABLET CONTROLLED RELEASE FERROUS SULFATEFERROUS SULFATE TABLET ENTERIC COATED FERROUS SULFATEHEMOSTATICSHEMOSTATICS - SYSTEMICAMINOCAPROIC ACID SYRUP AMICARAMINOCAPROIC ACID TABLETS AMICARHYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTANTIHISTAMINE HYPNOTICSDIPHENHYDRAMINE HCL (SLEEP) CAPSULES CVS NIGHTTIME SLEEP AIDDIPHENHYDRAMINE HCL (SLEEP) TABLET NIGHTTIME SLEEP-AIDDIPHENHYDRAMINE HCL (SLEEP) LIQUID ZZZQUILDIPHENHYDRAMINE HCL (SLEEP) TABLET DISPERSIBLE WAL-SOMBARBITURATE HYPNOTICSPHENOBARBITAL SOLUTION PHENOBARBITALPHENOBARBITAL TABLETS PHENOBARBITALNON-BARBITURATE HYPNOTICSTEMAZEPAM CAPSULES 15MG & 30MG RESTORIL PA Required for > 1 Hypnotic 30.00 30.00ZOLPIDEM TARTRATE TABLETS 5MG AMBIEN PA Required for > 1 Hypnotic 60.00 30.00ZOLPIDEM TARTRATE TABLETS 10MG AMBIEN PA Required for > 1 Hypnotic 30.00 30.00SELECTIVE MELATONIN RECEPTOR AGONISTS
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
RAMELTEON TABLETS ROZEREMPatient must have tried Temazepam and
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
PRENATAL VIT W/ DOCUSATE-FE FUMARATE-FOLIC ACID TABS PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID 30.00 30.00PRENATAL VIT W/ FE BISGLYCINATE CHELATE-FOLIC ACID TABS VINATE AZ EXTRA 30.00 30.00PRENATAL VIT W/ FE FUM-IRON POLYSACCH COMPLEX -FA-OMEGA 3 CAPS CONCEPT DHA 30.00 30.00PRENATAL VIT W/ FERROUS FUMARATE-FA-OMEGA 3 FATTY ACIDS CAPS VIVA DHA 30.00 30.00PRENATAL VIT W/ FERROUS FUMARATE-FOLIC ACID CHEW COMPLETENATE 30.00 30.00
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
PRENATAL VIT W/ FERROUS FUMARATE-FOLIC ACID TABS M-VIT 30.00 30.00PRENATAL VIT W/ FERROUS FUMARATE-L METHYLFOLATE-FOLIC ACID TABS ZATEAN-PN 30.00 30.00PRENATAL VIT W/ IRON CARBONYL-FE ASPART GLYC-FA-OMEGA 3 CAPS FOLCAPS OMEGA 3 30.00 30.00PRENATAL VIT W/ IRON CARBONYL-FOLIC ACID TABS PRENATABS RX 30.00 30.00PRENATAL VIT W/ SELENIUM-FE FUMARATE-FOLIC ACID TABS VINATE M 30.00 30.00PRENATAL W/O VIT A W/ FE FUMARATE-DSS-FA-DHA CAPS PRENEXA 30.00 30.00PRENATAL WITHOUT A VIT W/ FE FUMARATE-FOLIC ACID CHEW VINATE CARE 30.00 30.00PRENATAL WITHOUT A VIT W/ FE FUM-IRON POLYSACCH COMPLEX -FA CAPS CONCEPT OB 30.00 30.00PRENATAL WITHOUT VIT A W/ FE CARBONYL-FE GLUC-DOCUSATE-FA TABS CITRANATAL RX 30.00 30.00MUSCULOSKELETAL THERAPY AGENTSCENTRAL MUSCLE RELAXANTSBACLOFEN TABLETS BACLOFENCYCLOBENZAPRINE HCL TABLETS 5MG & 10MG ONLY FLEXERILMETAXALONE TABLETS METAXALONEMETHOCARBAMOL TABLETS ROBAXINORPHENADRINE CITRATE TABLET 12-HOUR ORPHENADRINE CITRATE CRTIZANIDINE HCL - 2mg and 4mg TABLETS ONLY TIZANIDINE HCLDIRECT MUSCLE RELAXANTSDANTROLENE SODIUM CAPSULES DANTRIUMNASAL AGENTS - SYSTEMIC AND TOPICALNASAL AGENTS - MISCELLANEOUSSALINE NASAL SPRAY SALINE NASAL SPRAYNASAL ANTIALLERGYAZELASTINE HCL SOLUTION 0.10% ASTELINNASAL ANTICHOLINERGICSIPRATROPIUM BROMIDE (NASAL) SOLUTION ATROVENTNASAL STEROIDSFLUNISOLIDE (NASAL) SOLUTION FLUNISOLIDEFLUTICASONE PROPIONATE (NASAL) SUSPENSION FLONASEMOMETASONE FUROATE (NASAL) SUSPENSION NASONEXSYMPATHOMIMETIC DECONGESTANTSPSEUDOEPHEDRINE HCL GEL ELIXIRSURE CONGESTIONPSEUDOEPHEDRINE HCL LIQUID SUDAFED CHILDRENSPSEUDOEPHEDRINE HCL SYRUP PSEUDOEPHEDRINE
STRENGTHPSEUDOEPHEDRINE HCL TABLET 12-HOUR SHOPKO NASAL DECONGESTANTPSEUDOEPHEDRINE HCL TABLET 24-HOUR SUDAFED 24 HOUROPHTHALMIC AGENTSARTIFICIAL TEARS AND LUBRICANTSARTIFICIAL TEAR GEL GEL VARIOUSARTIFICIAL TEAR OINTMENT VARIOUSARTIFICIAL TEAR SOLUTION SOLUTION VARIOUSCARBOXYMETHYLCELLULOSE-GLYCERIN SOLUTION VARIOUSCARBOXYMETHYLCELLULOSE-HYPROMELLOSE GEL VARIOUSCARBOXYMETHYLCELLULOSE SODIUM (OPHTH) SOUTION VARIOUSCARBOXYMETHYLCELLULOSE SODIUM (OPHTH) GEL VARIOUSHYPROMELLOSE (GONIOSCOPIC) SOLUTION VARIOUSPOLYETHYLENE GLYCOL 400 (OPHTH) GEL VARIOUSPOLYETHYLENE GLYCOL 400 (OPHTH) SOLUTION VARIOUSPOLYETHYLENE GLYCOL-PROPYLENE GLYCOL (OPHTH) SOLUTION VARIOUSPOLYSORBATE 80 (OPHTH) SOLUTION VARIOUSPOLYVINYL ALCOHOL SOLUTION VARIOUS
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
TETRAHYDROZOLINE-DEXTRAN-POLYETHYLENE GLYCOL-POVIDONE SOLUTION VISINE ADVANCED RELIEFTETRAHYDROZOLINE-GLYCERIN-HYPROMELLOSE-PEG 400 SOLUTION VISINE MAXIMUM REDNESS RELIEF
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
PA Required - if approved the prescriber must buy and bill a medical claim for the
drugPENICILLINSAMINOPENICILLINSAMOXICILLIN CAPSULES AMOXICILLINAMOXICILLIN CHEWABLE TABLETS AMOXICILLINAMOXICILLIN SUSPENSION AMOXICILLINAMOXICILLIN TABLETS AMOXICILLINAMOXICILLIN TABLET 24-HOUR MOXATAGAMPICILLIN 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 TABLETS AMOXICILLIN/CLAVULANATE POTASSIUMAMOXICILLIN & POT CLAVULANATE TABLET 12-HOUR AUGMENTIN XRPENICILLINASE-RESISTANT PENICILLINSDICLOXACILLIN SODIUM CAPSULES DICLOXACILLIN SODIUMPROGESTINSPROGESTINSHYDROXYPROGESTERONE CAPROATE OIL MAKENA 250 MG/ML BRAND ONLY PA RequiredHYDROXYPROGESTERONE CAPROATE SOLUTION AUTOINJECTOR MAKENA AUTO INJECTOR BRAND ONLY PA RequiredMEDROXYPROGESTERONE ACETATE TABLETS PROVERANORETHINDRONE ACETATE TABLETS AYGESTINPROGESTERONE MICRONIZED CAPSULES PROMETRIUMPSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTAGENTS FOR CHEMICAL DEPENDENCYACAMPROSATE CALCIUM TABLET DELAYED RELEASE VARIOUSDISULFIRAM TABLETS VARIOUSANTIDEMENTIA AGENTSDONEPEZIL HYDROCHLORIDE TABLETS ARICEPTDONEPEZIL HYDROCHLORIDE ORALLY DISPERSABLE TABLET ARICEPT ODTGALANTAMINE HYDROBROMIDE CAPSULE 24-HOUR RAZADYNE ER PA RequiredGALANTAMINE HYDROBROMIDE SOLUTION RAZADYNE PA RequiredGALANTAMINE HYDROBROMIDE TABLETS RAZADYNE PA Required
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
MEMANTINE HCL CAPSULE 24-HOUR NAMENDA XR PA RequiredMEMANTINE HCL SOLUTION NAMENDA PA RequiredMEMANTINE HCL TABLETS NAMENDA PA RequiredRIVASTIGMINE PATCH 24-HOUR EXELON PA RequiredRIVASTIGMINE TARTRATE CAPSULES EXELON PA RequiredRIVASTIGMINE TARTRATE SOLUTION EXELON PA RequiredMULTIPLE SCLEROSIS AGENTSFINGOLIMOD HCL CAPSULES GILENYA PA RequiredGLATIRAMER ACETATE 20MG COPAXONE 20mg BRAND ONLY Preferred Drug PA RequiredGLATIRAMER ACETATE 40MG GLATOPA 40MG BRAND ONLY Preferred Drug PA RequiredINTERFERON BETA-1A KIT AVONEX PA RequiredINTERFERON BETA-1A SOLUTION REBIF REBIDOSE TITRATION PACK PA RequiredINTERFERON BETA-1B KIT BETASERON PA RequiredPSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.ERGOLOID MESYLATES TABLETS ERGOLOID MESYLATES
PIMOZIDE TABLETS ORAPPrior Authorization is required for < 12
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
FOSFOMYCIN TROMETHAMINE PACK MONUROL Patient must have tried Cipro AND Macrobid NITROFURANTOIN MACROCRYSTAL CAPSULES MACRODANTINNITROFURANTOIN MONOHYD MACRO CAPSULES MACROBIDNITROFURANTOIN SUSPENSION FURADANTINURINARY ANTISPASMODICSURINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLIOXYBUTYNIN CHLORIDE GEL GELNIQUEOXYBUTYNIN CHLORIDE SYRUP OXYBUTYNIN CHLORIDEOXYBUTYNIN CHLORIDE TABLETS OXYBUTYNIN CHLORIDEOXYBUTYNIN CHLORIDE TABLET 24-HOUR DITROPAN XLTOLTERODINE TARTRATE CAPSULE 24-HOUR DETROL LATOLTERODINE TARTRATE TABLETS DETROLTROSPIUM CHLORIDE CAPSULE 24-HOUR SANCTURA XRTROSPIUM CHLORIDE TABLETS SANCTURAURINARY ANTISPASMODICS - CHOLINERGIC AGONISTSBETHANECHOL CHLORIDE TABLETS URECHOLINEURINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTSFLAVOXATE HCL TABLETS FLAVOXATE HCLVAGINAL PRODUCTSSPERMICIDESNONOXYNOL-9 FILM VCF VAGINAL CONTRACEPTIVE FILMNONOXYNOL-9 FOAM VCF VAGINAL CONTRACEPTIVE FOAMNONOXYNOL-9 GEL SHUR-SEALNONOXYNOL-9 MISC TODAY SPONGENONOXYNOL-9 SUPPOSITORY ENCAREVAGINAL ANTI-INFECTIVESCLINDAMYCIN PHOSPHATE VAGINAL CREAM CLEOCINCLINDAMYCIN PHOSPHATE VAGINAL SUPPOSITORY CLEOCINCLOTRIMAZOLE VAGINAL CREAM GYNE-LOTRIMINMETRONIDAZOLE VAGINAL GEL METROGEL-VAGINALMICONAZOLE NITRATE VAGINAL KIT MONISTAT 3 COMBINATION PACKMICONAZOLE NITRATE VAGINAL SUPPOSITORY MICONAZOLE 3SULFANILAMIDE VAGINAL CREAM AVCTERCONAZOLE VAGINAL CREAM TERAZOL 7TERCONAZOLE VAGINAL SUPPOSITORY TERAZOL 3TIOCONAZOLE VAGINAL MONISTAT 1-DAYVAGINAL ESTROGENSESTRADIOL ACETATE VAGINAL RING FEMRING PA Required 1.00 30.00ESTRADIOL VAGINAL CREAM ESTRADIOLESTRADIOL VAGINAL RING ESTRING 1.00 90.00ESTRADIOL VAGINAL TABLETS VAGIFEMESTROGENS, CONJUGATED VAGINAL CREAM PREMARIN 1.00 30.00VAGINAL PROGESTINSPROGESTERONE (VAGINAL) GEL CRINONE PA RequiredVASOPRESSORSANAPHYLAXIS THERAPY AGENTSEPINEPHRINE SELF-INJECTABLE EPINEPHRINE SELF-INJECTABLE (By Mylan) Mylan Generic Preferred Drug PA Required for > 2 Per Month 2.00 30.00EPINEPHRINE SELF-INJECTABLE EPINEPHRINE SELF-INJECTABLE (By Mylan) Mylan Generic Preferred Drug PA Required for > 2 Per Month 2.00 30.00SYMJEPI SELF-INJECTABLE EPINEPHRINE SELF-INJECTABLE Preferred Drug PA Required for > 2 Per Month 2.00 30.00VASOPRESSORSMIDODRINE HCL TABLETS MIDODRINE HCLVACCINES
Drug Class/Drug Name Reference Brand NameBrand Only /
Generic NotesPreferred Drug
Status PA Type Step Therapy RequirementsQuantity
Limit QL Days
CMDP Preferred Drug List
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2019
VIRAL VACCINESHEPATITIS B VACCINE (RECOMB) INJECTION ENGERIX-BHEPATITIS B VACCINE (RECOMB) SUSPENSION RECOMBIVAX HB