Drug Class/Drug Name Reference Brand Name Brand Only Preferred Drug Status Prior Authorization Type Step Therapy Requirements Quantity Limit QL Days ABACAVIR SULFATE SOLUTION ZIAGEN ABACAVIR SULFATE TABLETS ZIAGEN ABACAVIR SULFATE-LAMIVUDINE TABLETS EPZICOM ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE TABLETS TRIZIVIR ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE TABLETS TRIUMEQ ACAMPROSATE CAMPRAL Long Term Care Only ; See Behavioral Health Drug List ACARBOSE TABLETS PRECOSE ACEBUTOLOL HCL CAPSULES SECTRAL ACETAMINOPHEN CAPSULES VARIOUS ACETAMINOPHEN CHEWABLE TABLETS VARIOUS ACETAMINOPHEN ELIXIR VARIOUS ACETAMINOPHEN LIQUID VARIOUS ACETAMINOPHEN SUPPOSITORY FEVERALL INFANTS ACETAMINOPHEN SUSPENSION TYLENOL INFANTS ACETAMINOPHEN TABLETS VARIOUS ACETAMINOPHEN W/ CODEINE SOLUTION VARIOUS PA Required for > 2 Short Acting Narcotics Fill ACETAMINOPHEN W/ CODEINE TABLETS VARIOUS PA Required for > 2 Short Acting Narcotics Fill ACETAZOLAMIDE CAPSULE 12-HOUR DIAMOX ACETAZOLAMIDE TABLETS ACETAZOLAMIDE ACETIC ACID SOLUTION ACETIC ACID ACYCLOVIR BUCCAL TABLET ZOVIRAX ACYCLOVIR CAPSULES ZOVIRAX ACYCLOVIR CREAM ZOVIRAX ACYCLOVIR OINTMENT 15G ZOVIRAX 15 GM 30 ACYCLOVIR SUSPENSION ZOVIRAX ACYCLOVIR TABLETS ZOVIRAX ADALIMUMAB HUMIRA Preferred Drug PA Required ADEFOVIR DIPIVOXIL TABLETS HEPSERA PA Required ADEFOVIR DIPIVOXIL TABLETS HEPSERA PA Required ALBENDAZOLE TABLETS ALBENZA ALBUMIN (URINE) TEST STRIPS ALBUMIN TEST STRIPS ALBUTEROL SULFATE AEROSOL PROAIR HFA ALBUTEROL SULFATE NEBULIZER ALBUTEROL SULFATE ALBUTEROL SULFATE SYRUP ALBUTEROL SULFATE ALBUTEROL SULFATE TABLETS ALBUTEROL ALCLOMETASONE DIPROPIONATE CREAM ACLOVATE ALCOHOL SWABS PADS ALCOH-GLOVE CONTOURED WIPE ALENDRONATE SODIUM TABLETS ALENDRONATE SODIUM ALLOPURINOL TABLETS ZYLOPRIM CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME • Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1 Page 1 of 48
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Drug Class/Drug Name Reference Brand Name Brand Only
ACYCLOVIR CAPSULES ZOVIRAXACYCLOVIR CREAM ZOVIRAXACYCLOVIR OINTMENT 15G ZOVIRAX 15 GM 30ACYCLOVIR SUSPENSION ZOVIRAXACYCLOVIR TABLETS ZOVIRAXADALIMUMAB HUMIRA Preferred Drug PA RequiredADEFOVIR DIPIVOXIL TABLETS HEPSERA PA RequiredADEFOVIR DIPIVOXIL TABLETS HEPSERA PA Required
ALBENDAZOLE TABLETS ALBENZAALBUMIN (URINE) TEST STRIPS ALBUMIN TEST STRIPSALBUTEROL SULFATE AEROSOL PROAIR HFAALBUTEROL SULFATE NEBULIZER ALBUTEROL SULFATEALBUTEROL SULFATE SYRUP ALBUTEROL SULFATEALBUTEROL SULFATE TABLETS ALBUTEROL ALCLOMETASONE DIPROPIONATE CREAM ACLOVATE
ALCOHOL SWABS PADS
ALCOH-GLOVE CONTOURED
WIPEALENDRONATE SODIUM TABLETS ALENDRONATE SODIUM
ALLOPURINOL TABLETS ZYLOPRIM
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
Page 1 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
ALPHA1-PROTEINASE INHIBITOR (HUMAN) SOLUTION ARALAST NP PA RequiredALPHA-TOCOPHEROL CAPSULES VITAMIN E
ALPRAZOLAM CONC 1 MG/ML ALPRAZOLAM INTENSOL
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 ML 15
ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.25 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.5 MG VARIOUS
AMIODARONE HCL TABLETS 200MG PACERONEAMITRIPTYLINE HCL TABLETS ELAVIL PA Required for ages < 6 years
AMLODIPINE BESYLATE TABLETS NORVASC 30 30
Page 2 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
AMLODIPINE BESYLATE-BENAZEPRIL HCL CAPSULES LOTRELAMOXAPINE TABLETS ASENDIN PA Required for ages < 6 yearsAMOXICILLIN & POT CLAVULANATE CHEWABLE TABLETS AUGMENTINAMOXICILLIN & POT CLAVULANATE SUSPENSION AUGMENTINAMOXICILLIN & POT CLAVULANATE TABLET 12-HOUR AUGMENTIN XRAMOXICILLIN CAPSULES AMOXICILLINAMOXICILLIN CHEWABLE TABLETS AMOXICILLINAMOXICILLIN SUSPENSION AMOXICILLIN
AMOXICILLIN TABLETS AMOXICILLINAMPHETAMINE-DEXTROAMPHETAMINE CAPSULE 24-HOUR ADDERALL XR Brand Only Preferred Drug PA Required for Ages < 6 years 30 30
AMPHETAMINE-DEXTROAMPHETAMINE TABLETS ADDERALL Brand & Generic Preferred Drug PA Required for Ages < 6 years 60 30AMPICILLIN CAPSULES AMPICILLINAMPICILLIN SUSPENSION AMPICILLINANASTROZOLE TABLETS ARIMIDEX PA RequiredANTIPYRINE-BENZOCAINE SOLUTION AURODEX
ARIPIPRAZOLE SUSPENSION ABILIFY MAINTENA Preferred Drug
PA Required for Ages < 18 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 1 30
ARIPIPRAZOLE TABLETS ABILIFY Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 30 30ARTEMETHER-LUMEFANTRINE TABLETS COARTEMARTIFICAL TEARS TEARSARTIFICIAL SALIVA ARTIFICIAL SALIVAARTIFICIAL TEARS OINTMENT VARIOUS
ASENAPINE MALEATE SUBLINGUAL SAPHRIS Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 60 30
Page 3 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
BACITRACIN OINTMENT 500 UNIT/GM BACITRACIN 3.5GM 7BACITRACIN ZINC OINTMENT BACITRACINBACITRACIN-POLYMYXIN B OINTMENT POLYSPORINBACITRACIN-POLYMYXIN B OINTMENT POLYCINBACITRACIN-POLYMYXIN-NEOMYCIN HC OINTMENT CORTISPORINBACITRACIN-POLY-NEOMYCIN-HC OINTMENT NEO-POLYCIN HCBACLOFEN TABLETS BACLOFENBALSALAZIDE DISODIUM CAPSULES COLAZAL 270 30
BALSALAZIDE DISODIUM TABLETS GIAZO 270 30BECLOMETHASONE DIPROPIONATE INHALER QVAR Preferred DrugBENAZEPRIL HCL TABLETS BENAZEPRIL HCLBENZONATATE CAPSULES TESSALON PERLESBENZOYL PEROXIDE BAR VARIOUSBENZOYL PEROXIDE CREAM VARIOUSBENZOYL PEROXIDE FOAM VARIOUSBENZOYL PEROXIDE GEL VARIOUS
BENZOYL PEROXIDE LIQUID VARIOUSBENZOYL PEROXIDE LOTION VARIOUS
BENZTROPINE MESYLATE TABLETS BENZTROPINE MESYLATE
Page 4 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
BROMPHENIRAMINE-DEXTROMETHORPHAN-PHENYLEPHRINE LIQUID/TABLETS VARIOUS
BUDESONDIE INHALATION POWDER PULMICORT FLEXHALER Brand Only Preferred Drug PA RequiredBUDESONIDE (INHALATION) SUSPENSION PULMICORT RESPULES Brand Only Preferred Drug PA RequiredBUDESONIDE CAPSULES ENTOCORT EC
Page 5 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
BUDESONIDE-FORMOTEROL FUMARATE DIHYDRATE AEROSOL SYMBICORT Preferred Drug Step Therapy
Patient must have tried
one steroid inhaler:
Beclomethasone
Dipropionate,
Budesonide,
Fluticasone Propionate,
or MometasoneBUMETANIDE TABLETS BUMETANIDE
BUPRENORPHINE SUBUTEXPA Required; See Behavioral Health
Drug ListBUPRENORPHINE PATCH WEEKLY BUTRANS Preferred PA Required
supply 180BUPROPION HCL TABLET 12-HOUR BUDEPRION SR PA Required for Ages < 6 years 60 30BUPROPION HCL TABLET 24-HOUR 150MG WELLBUTRIN XL PA Required for Ages < 6 years 30 30BUPROPION HCL TABLET 24-HOUR 300MG WELLBUTRIN XL PA Required for Ages < 6 years 30 30BUPROPION HCL TABLETS 75MG, 100MG WELLBUTRIN PA Required for Ages < 6 years 120 30
BUSPIRONE HCL TAB 10 MG BUSPIRONE HCL
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
BUSPIRONE HCL TAB 15 MG BUSPIRONE HCL
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
BUSPIRONE HCL TAB 5 MG BUSPIRONE HCL
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
BUSPIRONE HCL TAB 7.5 MG BUSPIRONE HCL
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
BUSPIRONE HCL TABLETS 30 MG BUSPIRONE HCL
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30BUTALBITAL-ACETAMINOPHEN CAPSULES TENCON
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
CETIRIZINE HCL CAPSULES ZYRTEC ALLERGY 30 30CETIRIZINE HCL CHEWABLE TABLETS VARIOUS 30 30CETIRIZINE HCL ORALLY DISINTEGRATING TABLETS ZYRTEC ALLERGY 30 30CETIRIZINE HCL SYRUP VARIOUS 150 ML 30CETIRIZINE HCL TABLETS VARIOUS 30 30CETIRIZINE-PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUS 30 30
CHLORDIAZEPOXIDE HCL CAP 10 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30
CHLORDIAZEPOXIDE HCL CAP 25 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30
CHLORDIAZEPOXIDE HCL CAP 5 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30CHLORHEXIDINE GLUCONATE SOLUTION PERIOGARDCHLOROQUINE PHOSPHATE TABLETS CHLOROQUINE PHOSPHATECHLOROTHIAZIDE SUSPENSION DIURILCHLOROTHIAZIDE TABLETS CHLOROTHIAZIDE
CHLORPHENIRAMINE &PSEUDOEPHEDRINE CHEWABLE TABLETS VARIOUSCHLORPHENIRAMINE &PSEUDOEPHEDRINE LIQUID VARIOUS 480 ML 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE SOLUTION VARIOUS 480 ML 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE SYRUP VARIOUS 480 ML 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE TABLETS VARIOUSCHLORPHENIRAMINE MALEAT TABLET CHLORPHENIRAMINE
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
CHLORPROMAZINE HCL SOLUTION VARIOUS
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medications
CHLORPROMAZINE HCL TABLETS VARIOUS
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medicationsCHLORPROPAMIDE TABLETS CHLORPROPAMIDECHLORTHALIDONE TABLETS CHLORTHALIDONECHOLECALCIFEROL CAPSULES VITAMIN D3
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
CLOBAZAM TABLETS ONFI PA RequiredCLOBETASOL PROPIONATE CREAM 0.05% TEMOVATE 60 GM 30CLOBETASOL PROPIONATE EMULSION FOAM 0.05% TEMOVATECLOBETASOL PROPIONATE FOAM 0.05% OLUX 100 ML 30CLOBETASOL PROPIONATE GEL 0.05% TEMOVATE 60 GM 30CLOBETASOL PROPIONATE LOTION 0.05% CLOBEX 118 ML 30CLOBETASOL PROPIONATE OINTMENT 0.05% TEMOVATE 60 GM 30CLOBETASOL PROPIONATE SHAMPOO VARIOUS
CLOBETASOL PROPIONATE SOLUTION VARIOUSCLOMIPRAMINE HCL TABLETS ANAFRANIL PA Required for ages < 6 years
CLONAZEPAM 0.5 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic120 30
CLONAZEPAM 1.0 MGVARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic120 30
CLONAZEPAM 2 MGVARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic60 30
CLONAZEPAM ODT 0.125MGVARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic120 30
CLONAZEPAM ODT 0.25MGVARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic120 30
CLONAZEPAM ODT 0.5 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic120 30
CLONAZEPAM ODT 1MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic120 30
CLONAZEPAM ODT 2MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic60 30
CLONAZEPAM ORALLY DISINTEGRATING TAB 0.125 MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM ORALLY DISINTEGRATING TAB 0.25 MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM ORALLY DISINTEGRATING TAB 0.5 MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM ORALLY DISINTEGRATING TAB 1 MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM ORALLY DISINTEGRATING TAB 2 MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 60 30CLONAZEPAM TAB 0.5 MG KLONOPIN PA Required for > 1 Anxiolytics Fill 120 30
CLONAZEPAM TAB 1 MG KLONOPIN PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM TAB 2 MG KLONOPIN PA Required for > 1 Anxiolytics Fill 60 30
CLONIDINE HCL CATAPRES PA Required for ages < 6 years
Page 10 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
CLONIDINE HCl (ADHD) TABLET 12-HOUR KAPVAY Brand Only Preferred Drug PA Required for ages < 6 years 120 30CLONIDINE HCL (ADHD) TABLET 12-HOUR KAPVAY Brand Only Preferred Drug PA Required for Ages < 6 years 120 30CLONIDINE HCL PATCH-WEEKLY CATAPRES-TTS-1 PA Required for Ages <6 years 4 28CLONIDINE HCL TABLETS CATAPRES PA Required for Ages <6 years
CLONIDINE HCL TRANSDERMAL PATCH CATAPRES PATCHES PA Required for Ages < 6 years 4 28CLOPIDOGREL BISULFATE TABLETS PLAVIX
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
CONDOMS - FEMALE MISC. FC FEMALE CONDOM
CONDOMS - MALE MISC. LIFESTYLES ASSORTED COLORSCONJUGATED ESTROGENS-MEDROXYPROGESTERONE ACETATE TABLETS PREMPROCRIZOTINIB CAPSULES XALKORI PA RequiredCROMOLYN SODIUM NASAL AEROSOL CROMOLYN SODIUMCROMOLYN SODIUM NEBULIZER CROMOLYN SODIUMCROMOLYN SODIUM ORAL CONCENTATE VARIOUS
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
DESONIDE CREAM DESOWENDESONIDE GEL DESONATEDESONIDE LOTION DESOWENDESONIDE OINTMENT DESOWEN
DESVENLAFAXINE ER TABLETS PRISTIQ PA Required for Ages < 6 years
DEXMETHYLPHENIDATE HCL ER CAPSULE FOCALIN XR Brand Only Preferred Drug PA Required for ages < 6 years 60 30DEXMETHYLPHENIDATE HCL TABLETS FOCALIN Brand Only Preferred Drug PA Required for ages < 6 years 60 30DEXTROAMPHETAMINE SULFATE VARIOUS Preferred Drug PA Required for ages < 6 years 60 30DEXTROAMPHETAMINE SULFATE CAPSULE 24-HOUR VARIOUS Preferred Drug PA Required for ages < 6 years 60 30DEXTROMETHORPHAN HBR CAPSULE ROBITUSSINDEXTROMETHORPHAN HBR SYRUP ROBITUSSINDEXTROMETHORPHAN POLISTIREX LIQUID DELSYMDEXTROMETHORPHAN-GUAIFENESIN LIQUID VARIOUS 480 ML 30
DEXTROMETHORPHAN-GUAIFENESIN SYRUP VARIOUS 480 ML 30DEXTROMETHORPHAN-GUAIFENESIN TABLET VARIOUSDEXTROMETHORPHAN-GUAIFENESIN TABLET 12-HOUR MUCINEX DMDIAPHRAGM ARC-SPRING DPRH CAYA
PA Required for > 1 Anxiolytic 60 ML 30DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG DIASTAT PA Required for > 1 Anxiolytics Fill 2 30DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG DIASTAT PA Required for > 1 Anxiolytics Fill 2 30DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG DIASTAT PA Required for > 1 Anxiolytics Fill 2 30
DIAZEPAM SOLN 1 MG/ML VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 300 ML 30
Page 13 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
DIAZEPAM TAB 10 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
DIAZEPAM TAB 2 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
DIAZEPAM TAB 5 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30DICLOFENAC POTASSIUM CAPSULE VOLTARENDICLOFENAC POTASSIUM PACKET DICLOFENAC
STRENGTHDIPHENHYDRAMINE HCl CREAM BENADRYLDIPHENHYDRAMINE HCL ELIXIR VARIOUS
DIPHENHYDRAMINE HCL GEL BENADRYL ITCH STOPPINGDIPHENHYDRAMINE HCL LIQUID VARIOUS
DIPHENHYDRAMINE HCL SOLUTION VARIOUS
Page 14 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
DULOXETINE CAPSULES CYMBALTA PA Required for Ages < 6 years
20mg: 120
30mg: 120
60mg: 60
30
30
30ECONAZOLE NITRATE CREAM SPECTAZOLE
EFAVIRENZ CAPSULES SUSTIVA
Page 15 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
EFAVIRENZ TABLETS SUSTIVA
EFAVIRENZ-EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS ATRIPLAELBASVIR-GRAZOPREVIR TABLETS ZEPATIER Preferred Drug PA RequiredELTROMBOPAG OLAMINE TABLETS PROMACTA PA RequiredELVITEGRAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR TABLETS STRIBILDEMTRICITABINE CAPSULES EMTRIVAEMTRICITABINE SOLUTION EMTRIVA
ENTACAPONE TABLETS COMTANENTECAVIR SOLUTION BARACLUDE PA RequiredENTECAVIR SOLUTION BARACLUDE PA RequiredENTECAVIR TABLETS BARACLUDE PA RequiredENTECAVIR TABLETS BARACLUDE PA RequiredEPINEPHRINE 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 30EPLERENONE TABLETS INSPRA PA Required
EPOETIN ALFA SOLUTION EPOGEN PA RequiredEPOPROSTENOL SODIUM SOLUTION FLOLAN PA Required
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
ESCITALOPRAM OXALATE SOLUTION LEXAPRO PA Required for Ages < 6 years 600 ML 30ESCITALOPRAM OXALATE TABLETS LEXAPRO PA Required for Ages < 6 years 5mg: 60 30ESTAZOLAM TABLETS ESTAZOLAM PA Required for Ages <6 years 30 30ESTERIFIED ESTROGENS TABLETS MENESTESTRADIOL & NORETHINDRONE ACETATE TABLETS VARIOUSESTRADIOL ACETATE VAGINAL RING FEMRINGESTRADIOL PATCH-TWICE WEEKLY ALORAESTRADIOL PATCH-WEEKLY MENOSTARESTRADIOL TABLETS ESTRACE
PA Required for > 1 Hypnotic Drug 30 30ETANERCEPT ENBREL Preferred Drug PA RequiredETHAMBUTOL HCL TABLETS MYAMBUTOLETHOSUXIMIDE CAPSULES ZARONTINETHOSUXIMIDE SOLUTION ZARONTINETHYNODIOL DIACET & ETHINYL ESTRADIOL TABLETS KELNOR 1/35ETODOLAC CAPSULES LODINE
ETODOLAC TABLETS LODINEETODOLAC TABLETS EXTENDED RELEASE ETODOLAC ERETONOGESTREL-ETHINYL ESTRADIOL RING NUVARINGETOPOSIDE CAPSULES ETOPOSIDE PA RequiredETRAVIRINE TABLETS INTELENCEEVEROLIMUS (IMMUNOSUPPOSITORYRESSANT) TABLETS ZORTRESS PA RequiredEVEROLIMUS SOLUBLE TABLET AFINITOR DISPERZ PA RequiredEVEROLIMUS TABLETS AFINITOR PA Required
EXEMESTANE TABLETS AROMASIN PA RequiredEXENATIDE PEN BYDUREON PEN Preferred Drug PA RequiredEXENATIDE SUSPENSION PEN BYETTA PEN Preferred Drug PA RequiredEXENATIDE VIAL BYDUREON Preferred Drug PA RequiredEZETIMIBE TABLETS ZETIA PA RequiredFAMCICLOVIR TABLETS FAMVIR PA RequiredFAMOTIDINE CHEWABLE TABLETS PEPCID AC
FAMOTIDINE SUSPENSION PEPCIDFAMOTIDINE TABLETS PEPCID ACFEBUXOSTAT TABLETS ULORIC PA Required
FELBAMATE SUSPENSION FELBATOL
Page 17 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
FLUOCINOLONE ACETONIDE SOLUTION SYNALARFLUOCINONIDE CREAM 0.05% VARIOUSFLUOCINONIDE EMULSIFIED BASE CREAM VARIOUSFLUOCINONIDE GEL 0.05% VARIOUS 60 GM 30FLUOCINONIDE OINTMENT 0.05% VARIOUS 60 GM 30FLUOCINONIDE SOLUTION VARIOUSFLUOROMETHOLONE OINTMENT FMLFLUOROMETHOLONE SUSPENSION FML LIQUIFILM
FLUOXETINE HCL CAPSULES PROZAC PA Required for Ages < 6 years
10mg: 60
20mg: 120
40mg: 60
30
30
30
Page 18 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
FLUOXETINE HCL DR CAPSULES PROZAC WEEKLY PA RequiredFLUOXETINE HCL SOLUTION PROZAC PA Required for Ages < 6 years 600 ML 30FLUOXYMESTERONE TABLETS ANDROXY
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
FUROSEMIDE TABLETS LASIXGABAPENTIN CAPSULES 100MG, 300MG, 400MG NEURONTINGABAPENTIN SOLUTION NEURONTINGABAPENTIN TABLETS 600MG NEURONTINGABAPENTIN TABLETS 800MG NEURONTINGABAPENTIN TABLETS EXTENDED RELEASE GRALISE PA RequiredGABAPENTIN TABLETS EXTENDED RELEASE HORIZANT PA RequiredGALANTAMINE HYDROBROMIDE CAPSULE CONTROLLED RELEASE RAZADYNE ER PA Required
GALANTAMINE HYDROBROMIDE SOLUTION RAZADYNE PA RequiredGALANTAMINE HYDROBROMIDE TABLETS RAZADYNE PA RequiredGANCICLOVIR GEL ZIRGAN
Page 20 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
GLUCAGON GEL VARIOUSGLYBURIDE MICRONIZED TABLETS GLYNASEGLYBURIDE TABLETS DIABETAGLYBURIDE-METFORMIN HCL TABLETS GLUCOVANCEGLYCOPYRROLATE SOLUTION VARIOUSGLYCOPYRROLATE TABLETS VARIOUSGRANISETRON HCL SOLUTION VARIOUS PA RequiredGRANISETRON HCL TABLETS VARIOUS PA Required
GRISEOFULVIN MICROSIZE SUSPENSION GRISEOFULVIN MICROSIZEGRISEOFULVIN MICROSIZE TABLETS GRIFULVIN VGRISEOFULVIN ULTRAMICROSIZE TABLETS GRIS-PEGGUAIFENESIN LIQUID VARIOUS 480 ML 30GUAIFENESIN SYRUP VARIOUS 480 ML 30GUAIFENESIN TABLET 12-HOUR VARIOUSGUAIFENESIN TABLETS VARIOUSGUAIFENESIN-CODEINE SYRUP ROBITUSSIN AC 240 ML 12
GUANFACINE HCL TENEX PA Required for ages < 6 yearsGUANFACINE HCL (ADHD) TABLET 12-HOUR GUANFACINE HCL ER Preferred Drug PA Required for ages < 6 years 30 30GUANFACINE HCL (ADHD) TABLET 24-HOUR GUANFACINE ER Preferred Drug PA Required for Ages < 6 years 30 30GUANFACINE HCL TABLETS TENEX PA Required for Ages <6 years
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
HYDROCHLOROTHIAZIDE CAPSULES 12.5MG MICROZIDEHYDROCHLOROTHIAZIDE TABLETS 25MG, 50MG HYDROCHLOROTHIAZIDEHYDROCODONE BITARTRATE ER TABLETS 24-HR ABUSE DETERRANT HYSINGLA ER Brand Only Preferred PA RequiredHYDROCODONE W/ HOMATROPINE SYRUP VARIOUS 240 ML 12HYDROCODONE W/ HOMATROPINE TABLETS VARIOUS
HYDROCORTISONE OINTMENT VARIOUSHYDROCORTISONE SOD SUCCINATE SOLUTION (INJECTABLE) A-HYDROCORT Long Term Care Only
HYDROCORTISONE SOLUTION VARIOUS
Page 22 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
(CONCENTRATED) Preferred Drug PA RequiredINSULIN REGULAR (HUMAN) SOLUTION HUMULIN R Preferred Drug
INSULIN REGULAR (HUMAN) SOLUTION
HUMULIN R U-500
(CONCENTRATED) Preferred Drug PA Required
INSULIN SYRINGE VARIOUSINTERFERON ALFA-2B SOLUTION INTRON A PA RequiredINTERFERON ALFA-2B SOLUTION INTRON A PA RequiredINTERFERON ALFA-N3 SOLUTION ALFERON N PA RequiredINTERFERON BETA-1A KIT AVONEX PA RequiredINTERFERON BETA-1A SOLUTION REBIF REBIDOSE PA RequiredINTERFERON BETA-1B KIT BETASERON PA RequiredINTERFERON GAMMA-1B SOLUTION ACTIMMUNE PA Required
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
LIDOCAINE HCL GEL XYLOCAINELIDOCAINE HCL LOCAL INJECTION XYLOCAINE PA Required (FOR ESRD ONLY)
LIDOCAINE HCl LOCAL INJECTION PRESERVATIVE FREE XYLOCAINE-MPF PA Required (FOR ESRD ONLY)
Page 26 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
LIDOCAINE HCL SOLUTION VARIOUSLIDOCAINE OINTMENT 5% VARIOUS PA Required 50 GM 30LIDOCAINE PATCH LIDODERM PA RequiredLIDOCAINE-PRILOCAINE CREAM EMLALINACLOTIDE CAPSULES LINZESS PA RequiredLINAGLIPTIN TABLET TRADJENTA Preferred Drug PA RequiredLINAGLIPTIN/METFORMIN TABLETS JENTADUETO Preferred Drug PA RequiredLINDANE LOTION KWELL
LINDANE SHAMPOO KWELLLINEZOLID SUSPENSION ZYVOX PA RequiredLINEZOLID TABLETS ZYVOX PA RequiredLIOTHYRONINE SODIUM TABLETS CYTOMELLIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE ZENPEP Brand Only Preferred Drug 500 30LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE 5000 U PANCRELIPASE 5000 U Brand Only Preferred Drug 500 30LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE CREON Brand Only Preferred Drug 500 30LIRAGLUTIDE SOLUTION VICTOZA Preferred Drug PA Required
LISDEXAMFETAMINE DIMESYLATE CAPSULES VYVANSE Brand Only Preferred Drug PA Required for Ages < 6 years 30 30LISINOPRIL & HYDROCHLOROTHIAZIDE TABLETS ZESTORETICLISINOPRIL TABLETS ZESTRIL
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
for additional medicationsLUBIPROSTONE CAPSULES AMITIZA PA Required
LURASIDONE HCL TABS LATUDA Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 30 30MAGNESIOUN CITRATE SOLUTION MAG CITRATEMAGNESIUM HYDROXIDE SUSPENSION MILK OF MAGNESIAMAGNESIUM HYDROXIDE SUSPENSION CONCENTRATE MILK OF MAGNESIA
MAGNESIUM OXIDE CAPSULES VARIOUSMAGNESIUM OXIDE TABLETS VARIOUSMAPROTILINE HCL TABLETS LUDIOMIL PA Required for ages < 6 yearsMARAVIROC TABLETS SELZENTRY PA RequiredMECASERMIN SOLUTION INCRELEX PA RequiredMECLIZINE HCL CHEWABLE TABLETS BONINEMECLIZINE HCL TABLETS BONINEMECLOFENAMATE SODIUM CAPSUL MECLOFENAMATE
MEDROXYPROGESTERONE ACETATE SUSPENSION
DEPO-PROVERA
CONTRACEPTIVE
MEDROXYPROGESTERONE ACETATE TABLETS PROVERA
Page 28 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
METHOTREXATE SODIUM TABLETS METHOTREXATEMETHSCOPOLAMINE BROMIDE TABLETS PAMINEMETHYCLOTHIAZIDE TABLETS AQUATENSENMETHYLDOPA TABLETS METHYLDOPAMETHYLERGONOVINE MALEATE TABLETS METHERGINEMETHYLNALTREXONE BROMICE INJECTION RELISTOR PA RequiredMETHYLPHENIDATE HCL CAPSULE 24-HOUR RITALIN LA 10MG Brand Only Preferred Drug PA Required for Ages < 6 years 30 30METHYLPHENIDATE HCL CAPSULE 24-HOUR APTENSIO XR Brand Only Preferred Drug PA Required for Ages < 6 years 30 30
METHYLPHENIDATE HCL CAPSULE 24-HOUR VARIOUS Preferred Drug PA Required for Ages < 6 years 30 30METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE METADATE CD Preferred Drug PA Required for Ages < 6 years 30 30METHYLPHENIDATE HCL CHEWABLE TABLETS METHYLIN Preferred Drug PA Required for Ages < 6 years 90 30
Page 29 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
METHYLPHENIDATE HCL CHEWABLE TABLETS EXTENDED RELEASE QUILLICHEW ER Brand Only Preferred Drug PA Required for Ages < 6 years 30 30METHYLPHENIDATE HCL SOLUTION METHYLIN Brand Only Preferred Drug PA Required for ages < 6 years 300ML 30METHYLPHENIDATE HCL SUSPENSION QUILLIVANT XR Brand Only Preferred Drug PA Required for ages < 6 years 150ML 30METHYLPHENIDATE HCL TABLET 24-HOUR METHYLPHENIDATE HCL ER Preferred Drug PA Required for Ages < 6 years 60 30METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE METHYLPHENIDATE HCL ER Preferred Drug PA Required for Ages < 6 years 60 30METHYLPHENIDATE HCL TABLET SUSTAINED RELEASE RITALIN SR PA Required for ages < 6 years 60 30METHYLPHENIDATE HCL TABLETS VARIOUS Preferred Drug PA Required for Ages < 6 years 90 30METHYLPHENIDATE HCL TD PATCH DAYTRANA Brand Only Preferred Drug PA Required for ages < 6 years 30 30
METHYLPREDNISOLONE ACETATE SUSPENSION (INJECTABLE) DEPO-MEDROL Long Term Care OnlyMETHYLPREDNISOLONE SOD SUCC SOLUTION (INJECTABLE) A-METHAPRED Long Term Care OnlyMETHYLPREDNISOLONE TABLETS MEDROLMETIPRANOLOL SOLUTION METIPRANOLOLMETOCLOPRAMIDE HCL ORALLY DISINTEGRATING TABLETS VARIOUSMETOCLOPRAMIDE HCL SOLUTION VARIOUSMETOCLOPRAMIDE HCL TABLETS VARIOUSMETOLAZONE TABLETS ZAROXOLYN
METOPROLOL - HYDROCHLOROTHIAZIDE TABLETS LOPRESSOR HCTMETOPROLOL SUCCINATE TABLET 24-HOUR TOPROL XLMETOPROLOL TARTRATE TABLETS METOPROLOL TARTRATEMETRONIDAZOLE CAPSULE FLAGYLMETRONIDAZOLE CREAM METROCREAMMETRONIDAZOLE GEL METROGELMETRONIDAZOLE LOTION METROLOTIONMETRONIDAZOLE TABLET SR FLAGYL ER
METRONIDAZOLE TABLETS FLAGYLMETRONIDAZOLE VAGINAL GEL 0.75% METROGELMEXILETINE HCL CAPSULES MEXILETINE HCLMICONAZOLE NITRATE LIQUID VARIOUSMICONAZOLE NITRATE CREAM VARIOUSMICONAZOLE NITRATE POWDER VARIOUS
MICONAZOLE NITRATE VAGINAL
MONISTAT 3 COMBINATION
PACKETS
MICONAZOLE NITRATE VAGINAL SUPPOSITORY MICONAZOLE 3MIDODRINE HCL TABLETS MIDODRINEMILNACIPRAN HCL TABLETS SAVELLA 60 30MINOCYCLINE HCL CAPSULES MINOCINMINOXIDIL TABLETS MINOXIDILMIRTAZAPINE ORALLY DISINTEGRATING TABLETS 15MG REMERON SOLTAB PA Required for Ages < 6 years 30 30MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 30MG REMERON SOLTAB PA Required for Ages < 6 years 30 30MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG REMERON SOLTAB PA Required for Ages < 6 years 30 30
MIRTAZAPINE TABLETS 30MG MIRTAZAPINE PA Required for Ages < 6 years 30 30MIRTAZAPINE TABLETS 45MG MIRTAZAPINE PA Required for Ages < 6 years 30 30
MIRTAZAPINE TABLETS 7.5MG, 15MG MIRTAZAPINE PA Required for Ages < 6 years 30 30
Page 30 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
NORTRIPTYLINE HCL CAPSULES PAMELOR PA Required for ages < 6 yearsNORTRYIPTYLINE HCL SOLUTION PAMELOR PA Required for ages < 6 yearsNYSTATIN CREAM VARIOUSNYSTATIN POWDER NYAMYCNYSTATIN CAPSULES BIO-STATINNYSTATIN OINTMENT VARIOUSNYSTATIN POWDER NYSTATINNYSTATIN SUSPENSION MYCOSTATIN
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
OXAZEPAM CAP 10 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30
OXAZEPAM CAP 15 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30
OXAZEPAM CAP 30 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30OXCARBAZEPINE SUSPENSION TRILEPTALOXCARBAZEPINE TABLETS TRILEPTAL
OXCARBAZEPINE TABLETS SUSTAINED RELEASE OXTELLAR XR PA Required OXYBUTYNIN CHLORIDE SYRUP VARIOUSOXYBUTYNIN CHLORIDE TABLET 24-HOUR DITROPAN XLOXYBUTYNIN CHLORIDE TABLETS VARIOUS
OXYCODONE HCL CAPSULES OXYCODONE HCL
PA Required for > 2 Short Acting
Narcotics Fill
OXYCODONE HCL CONCENTRATE OXYCODONE HCL
PA Required for > 2 Short Acting
Narcotics
OXYCODONE HCL SOLUTION OXYCODONE HCL
PA Required for > 2 Short Acting
Narcotics FillOXYCODONE HCL TABLET 12-HOUR ABUSE DETERRANT OXYCONTIN Brand Only Preferred PA Required
OXYCODONE HCL TABLETS ROXICODONE
PA Required for > 2 Short Acting
Narcotics Fill
OXYCODONE W/ ACETAMINOPHEN CAPSULES
OXYCODONE/
ACETAMINOPHEN
PA Required for > 2 Short Acting
Narcotics Fill
OXYCODONE W/ ACETAMINOPHEN SOLUTION ROXICET
PA Required for > 2 Short Acting
Narcotics Fill
OXYCODONE W/ ACETAMINOPHEN TABLETS ENDOCET
PA Required for > 2 Short Acting
Narcotics Fill
OXYCODONE W/ASPIRIN TABLETS PERCODAN
PA Required for > 2 Short Acting
Narcotics Fill
OXYCODONE-IBUPROFEN TABLETS OXYCODONE/IBUPROFEN
PA Required for > 2 Short Acting
Narcotics OYSTER SHELL CALCIUM TABLETS VARIOUS
PALIPERIDONE PALMITATE SUSPENSION INVEGA SUSTENNA Preferred Drug
PA Required for Ages < 18 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 1 30
PALIPERIDONE PALMITATE SUSPENSION INVEGA TRINZA Preferred Drug
PA Required for Ages < 18 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 1 90
Page 35 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
PALIVIZUMAB SOLUTION INJECTION SYNAGIS
PA Required - if approved the
prescriber may be required to buy and
bill a medical claim for the drugPANTOPRAZOLE SODIUM SUSPENSION PACKET DELAYED RELEASE PROTONIXPANTOPRAZOLE SODIUM TABLET ENTERIC COATED PROTONIXPAROXETINE HCL ER TABLETS 12.5 MG PAXIL CR PA Required for Ages < 6 years 90 30PAROXETINE HCL ER TABLETS 25 MG PAXIL CR PA Required for Ages < 6 years 60 30
PAROXETINE HCL ER TABLETS 37.5 MG PAXIL CR PA Required for Ages < 6 years 30 30PAROXETINE HCL SUSPENSION PAXIL Brand Only PA Required for Ages < 6 years 900 ML 30
PAROXETINE HCL TABLETS PAXIL PA Required for Ages < 6 years
10mg: 30
20mg: 30
30mg: 30
40mg: 45
30
30
30
30PAROXETINE MESYLATE TABLETS PEXEVA PA RequiredPAZOPANIB HCL TABLETS VOTRIENT PA Required
PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE SOLUTION COLYTEPEGFILGRASTIM SOLUTION NEULASTA PA RequiredPEGINTERFERON ALFA-2A SOLUTION PEGASYS Preferred Drug PA RequiredPEGINTERFERON ALFA-2B (ANTINEOPLASTIC) KIT SYLATRON PA RequiredPEGINTERFERON ALFA-2B KIT PEGINTRON Preferred Drug PA RequiredPENICILLAMINE CAPSULES CUPRIMINEPENICILLIN V POTASSIUM SOLUTION PENICILLIN V POTASSIUMPENICILLIN V POTASSIUM TABLETS PENICILLIN V POTASSIUM
for additional medicationsPHENAZOPYRIDINE HCL TABLETS PYRIDIUMPHENELZINE SULFATE TABLET NARDIL PA Required for Ages < 6 yearsPHENOBARBITAL & HYOSCYAMINE SOLUTION LEVSIN-PBPHENOBARBITAL & HYOSCYAMINE TABLET LEVSIN-PBPHENOBARBITAL SOLUTION PHENOBARBITAL
PHENOBARBITAL TABLETS PHENOBARBITALPHENYLEPHRINE HCL SOLUTION NEOFRINPHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN CAPSULES VARIOUS
Page 36 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
COUGH 480 ML 30PHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN SYRUP VARIOUS 480 ML 30PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN DROPS VARIOUS PA Required for < 6 years oldPHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN LIQUID VARIOUS 480 ML 30
PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN SYRUP VARIOUS 480 ML 30
PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN TABLETS VARIOUS
PHENYLEPHRINE-GUAIFENESIN CAPSULES VARIOUS
PHENYLEPHRINE-GUAIFENESIN LIQUID
TRIAMINIC CHEST/ NASAL
CONGESTION 480 ML 30
PHENYLEPHRINE-GUAIFENESIN SYRUP
TRIAMINIC CHEST & NASAL
CONGESTION 480 ML 30PHENYLEPHRINE-GUAIFENESIN TABLETS VARIOUSPHENYTOIN CHEWABLE TABLETS DILANTIN INFATABLETS
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
PROGESTERONE MICRONIZED CAPSULES PROMETRIUMPROGESTERONE VAGINAL GEL CRINONEPROGESTERONE VAGINAL SUPPOSITORY PROGESTERONE
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
QUETIAPINE FUMARATE TABLETS SEROQUEL Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 60 30QUINAPRIL - HYDROCHLOROTHIAZIDE TABLETS ACCURETICQUINAPRIL HCL TABLETS ACCUPRILQUINIDINE GLUCONATE TABLET CONTROLLED RELEASE QUINIDINE GLUCONATE CR
RAMIPRIL CAPSULES ALTACERANITIDINE HCL CAPSULES RANITIDINE HCLRANITIDINE HCL SUSPENSION DEPRIZINE FUSEPAQRANITIDINE HCL SYRUP ZANTACRANITIDINE HCL TABLETS ZANTAC 75RANOLAZINE TABLET 12-HOUR RANEXA PA RequiredREPAGLINIDE TABLETS PRANDINRIBAVIRIN (HEPATITIS C) CAPSULES VARIOUS Preferred Drug PA Required
RIBAVIRIN (HEPATITIS C) TABLETS VARIOUS Preferred Drug PA RequiredRIFABUTIN CAPSULE MYCOBUTINRIFAMPIN CAPSULES RIFADINRILPIVIRINE HCL TABLETS EDURANTRILUZOLE TABLET RILUTEKRIMANTADINE HYDROCHLORIDE TABLETS FLUMADINE
RISPERIDONE MICROSPHERES SUSPENSION RISPERDAL CONSTA Preferred Drug
PA Required for Ages < 18 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 2 30
RISPERIDONE ORAL SOLUTION RISPERDAL Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 240 ML 30
Page 40 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
RISPERIDONE ORALLY DISPERSABLE TABLET RISPERIDONE ODT Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 60 30
RISPERIDONE TABLETS RISPERDAL Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 60 30RITONAVIR CAPSULES NORVIRRITONAVIR SOLUTION NORVIRRITONAVIR TABLETS NORVIRRIVAROXABAN DOSE PACK XARELTO DOSE PACK Preferred Drug 51 30RIVAROXABAN TABLETS XARELTO Preferred Drug 60 30RIVASTIGMINE PATCH EXELON PA Required
RIVASTIGMINE TARTRATE CAPSULES EXELON PA RequiredRIVASTIGMINE TARTRATE SOLUTION EXELON PA RequiredRIZATRIPTAN BENZOATE ORALLY DISINTEGRATING TABLETS9 MAXALT-MLT 9 30RIZATRIPTAN BENZOATE TABLETS MAXALT 9 30ROPINIROLE HYDROCHLORIDE TABLETS REQUIPROPINIROLE HYDROCHLORIDE TABLETS SR 24 HR REQUIP XLRUFINAMIDE SUSPENSION BANZEL PA RequiredRUFINAMIDE TABLETS BANZEL PA Required
RUXOLITINIB PHOSPHATE TABLETS JAKAFI PA RequiredSACROSIDASE SOLUTION SUCRAID PA RequiredSACUBITRIL / VALSARTAN ENTRESTO PA RequiredSALICYLIC ACID CREAM SALACYNSALICYLIC ACID FOAM SALVAXSALICYLIC ACID GEL KERALYTSALICYLIC ACID LIQUID VIRASALSALICYLIC ACID LOTION SALACYN
SAXAGLIPTIN/METFORMIN ER TABLETS KOMBLIGLYZE XR Preferred Drug PA RequiredSCOPOLAMINE HBR SOLUTION ISOPTO HYASINE
SELEGILINE HCL CAPSULES ELDEPRYL
Page 41 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
SOMATROPIN NORDITROPIN Preferred Drug PA RequiredSOMATROPIN NUTROPIN AQ Preferred Drug PA RequiredSOMATROPIN GENOTROPIN Preferred Drug PA RequiredSORAFENIB TOSYLATE TABLETS NEXAVAR PA RequiredSOTALOL HCL SOLUTION SOTYLIZE
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
TAMOXIFEN CITRATE TABLETS TAMOXIFEN CITRATETAMSULOSIN HCL CAPSULES FLOMAXTELBIVUDINE TABLETS TYZEKA PA RequiredTELBIVUDINE TABLETS TYZEKA PA Required
TEMAZEPAM CAPSULES 15MG, 30MG RESTORIL
PA Required for Ages <6 years
PA Required for > 1 Hypnotic Drug 30 30TENOFOVIR DISOPROXIL FUMARATE ORAL POWDER VIREADTENOFOVIR DISOPROXIL FUMARATE TABLETS VIREAD
TERAZOSIN HCL CAPSULES TERAZOSIN HCLTERBINAFINE HCl CREAM LAMISIL AFTERBINAFINE HCL PACKETS LAMISIL 90 365TERBINAFINE HCL TABLETS LAMISIL 90 365TERCONALZOLE BAGINAL CREAM TERAZOLTESTOSTERONE CYPIONATE SOLUTION DEPO-TESTOSTERONE PA RequiredTESTOSTERONE ENANTHATE SOLUTION TESTOSTERONE ENANTHATE PA RequiredTESTOSTERONE GEL ANDROGEL PA Required
TESTOSTERONE PATCH ANDRODERM PA RequiredTESTOSTERONE SOLUTION AXIRON PA RequiredTHALIDOMIDE CAPSULES THALOMID PA Required
THEOPHYLINE TABLETS SR 12 HR THEOPHYLLINETHEOPHYLLINE CAPSULE CONTROLLED RELEASE THEOPHYLLINETHEOPHYLLINE CAPSULES SR 12 HR THEOPHYLLINETHEOPHYLLINE CAPSULES SR 24 HR THEOPHYLLINETHIAMINE HCL TABLETS VITAMIN B1
THIAMINE MONONITRATE TABLETS VITAMIN B1
THIORIDAZINE HCL TABLETS VARIOUS
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medications
THIOTHIXENE CAPSULES VARIOUS
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medicationsTHYROID TABLETS ARMOUR THYROIDTIAGABINE HCL TABLETS GABITRIL PA RequiredTICAGRELOR TABLETS BRILINTA PA RequiredTIMOLOL MALEATE SOLUTION TIMOPTIC-XETIMOLOL MALEATE SOLUTION TIMOPTIC
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
TIZANIDINE HCL TABLETS TIZANIDINE HCLTOBRAMYCIN NEBULIZED BETHKIS Preferred Drug PA RequiredTOBRAMYCIN NEBULIZED KITABIS Preferred Drug PA RequiredTOBRAMYCIN OINTMENT TOBREX 3.5GM 7TOBRAMYCIN SOLUTION TOBREXTOBRAMYCIN-DEXAMETHASONE OINTMENT 0.3-0.1% TOBRADEXTOBRAMYCIN-DEXAMETHASONE SUSPENSION TOBRADEX STTOLAZAMIDE TABLETS TOLINASE
TOREMIFENE CITRATE TABLETS FARESTON PA RequiredTORSEMIDE TABLETS DEMADEX
TRAMADOL HCL TABLETS ULTRAM
PA Required for > 2 Short Acting
Narcotics Fill
TRAMADOL-ACETAMINOPHEN TABLETS ULTRACET
PA Required for > 2 Short Acting
Narcotics FillTRANDOLAPRIL TABLETS MAVIKTRANYLCYPROMINE SULFATE TABLET PARNATE PA Required for Ages < 6 yearsTRAVOPROST SOLUTION TRAVATAN Z
TRAZODONE HCL TABLETS TRAZODONE HCL PA Required for Ages < 6 years
50mg:90
100mg:120
150mg: 60
300mg 30
30
30
30
30
TREPROSTINIL SODIUM SOLUTION REMODULIN PA RequiredTREPROSTINIL SOLUTION TYVASO PA RequiredTRETINOIN (CHEMOTHERAPY) CAPSULES TRETINOIN PA Required For > 26 Years of AgeTRETINOIN CREAM RETIN-A PA Required FOR > 26 Years of AgeTRETINOIN GEL RETIN-A PA Required FOR > 26 Years of AgeTRIAMCINOLONE ACETONIDE (TOPICAL) AEROSOL VARIOUSTRIAMCINOLONE ACETONIDE (TOPICAL) CREAM VARIOUSTRIAMCINOLONE ACETONIDE (TOPICAL) LOTION VARIOUS
TRIAMCINOLONE ACETONIDE (TOPICAL) OINTMENT VARIOUSTRIAMCINOLONE ACETONIDE DENTAL PASTE VARIOUS
TRIAMCINOLONE ACETONIDE NASAL NASACORT AQ
Page 45 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
TRIAMCINOLONE ACETONIDE ORAL PASTE ORALONETRIAMCINOLONE ACETONIDE SUSPENSION (INJECTABLE) KENALOG-10 Long Term Care OnlyTRIAMCINOLONE DIACETATE SUSPENSION (INJECTABLE) TRIAMCINOLONE Long Term Care Only
INTRA-ARTICULAR Long Term Care OnlyTRIAMTERENE & HYDROCHLOROTHIAZIDE CAPSULES DYAZIDETRIAMTERENE & HYDROCHLOROTHIAZIDE TABLETS MAXZIDE-25TRIAMTERENE CAPSULES DYRENIUM
TRIAZOLAM TABLETS HALCION
PA Required for Ages <6 years
PA Required for > 1 Hypnotic Drug 30 30
TRIFLUOPERAZINE HCL TABLETS VARIOUS
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medicationsTRIFLURIDINE SOLUTION VIROPTIC
compounding pharmacy PA RequiredVANDETANIB TABLETS CAPRELSA PA Required
VARENICLINE TARTRATE TABLETS CHANTIX
84-day
supply 180
VEMURAFENIB TABLETS ZELBORAF PA Required
Page 46 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
VENLAFAXINE HCL ER CAPSULES EFFEXOR XR PA Required for Ages < 6 years
37.5mg: 90
75mg: 90
150mg: 30
30
30
30VENLAFAXINE HCL ER CAPSULES 37.5 MG VENLAFAXINE PA Required for Ages < 6 years 120 30
VENLAFAXINE HCL TABLETS (IMMEDIATE RELEASE ONLY) VENLAFAXINE PA Required for Ages < 6 years
25mg: 120
37.5mg: 90
50mg: 90
75mg: 150
100mg: 90
30
30
30
30
30VERAPAMIL HCL CAPSULE CONTROLLED RELEASE VERELAN PM 30 30VERAPAMIL HCL TABLET CONTROLLED RELEASE CALAN SR 30 30VERAPAMIL HCL TABLETS VERAPAMIL HCLVILAZODONE HCL STARTER KIT VIIBRYD PA RequiredVILAZODONE HCL TABLETS VIIBRYD PA RequiredVITAMIN E CAPSULES VITAMIN EVITAMIN E TABLETS VITAMIN E
VORICONAZOLE SUSPENSION VFEND PA RequiredVORICONAZOLE TABLETS VFEND PA RequiredVORINOSTAT CAPSULES ZOLINZA PA Required
List for additional medications 60 30ZOLMITRIPTAN ORALLY DISINTEGRATING TABLETS ZOMIG ZMT 12 28ZOLMITRIPTAN TABLETS ZOMIG 12 28ZOLPIDEM TARTRATE SOLUTION ZOLPIMIST PA Required
ZOLPIDEM TARTRATE TABLETS AMBIEN
PA Required for Ages <6 years
PA Required for > 1 Hypnotic Drug
60: 5MG
30: 10MG
30
30
ZOLPIDEM TARTRATE TABLETS CONTROLLED RELEASE AMBIEN CR PA Required ZOLPIDEM TARTRATE TABLETS SUBLINGUAL INTERMEZZO PA Required
ZOLPIDEM TARTRATE TABLETS SUBLINGUAL EDLUAR PA Required
Page 47 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1