Pharmacy

Mercy Care ACC-RBHA covers prescription medication when:

You get your prescriptions filled at a network pharmacy. (Find a network pharmacy)
Your prescriptions are on our preferred drug lists. These are lists of covered drugs.

Preferred drug lists updates - The Integrated Preferred Drug List is updated four times a year. These drug lists can change as new drugs are added and other drugs are removed. For monthly changes, you can review the Preferred Drug List Updates below. You can find the entire and most recent drug lists below.

Searching the drug lists You can now use our search tools to find out if your medication is on the preferred drug list. You can search by the drug name or drug class. These are lists of drugs that are generally covered as long as they are medically necessary.

Mercy Care ACC-RBHA approved-drug lists:
If you're a Non-Title 19/21 member determined to have a serious mental illness (SMI), a Title 19/21 Non-SMI member, or a Non-Title 19/21 child with a serious emotional disturbance (SED) then Mercy Care only fills prescriptions for your behavioral health medications. This is your Behavioral Health Drug List | Search the Behavioral Health Drug List

If you are a Title 19/21 member determined to have a SMI, then Mercy Care RBHA fills your physical health and behavioral health medications. This is your Integrated Drug List | Search the Integrated Drug List

The Crisis Medication List is for adults or children who are Non-Title 19/21 and Non-SMI who present in crisis at any of the facility-based psychiatric urgent care centers, detox facilities and/or Access Points in Maricopa County, Gila and Pinal Counties. The medications on this list will help stabilize an individual in crisis and bridge them to a follow-up outpatient appointment.

If you are a Non-Title 19/21 member determined to need substance use or misuse treatment, then Mercy Care fills your prescriptions for medications you need to assist you with your treatment. This is your Substance Abuse Block Grant Medication List.

Mercy Care may also cover your over-the-counter medications if they are on your approved-drug list. Some of these may have rules about coverage. If the rules for that medication are met, Mercy Care will cover it. Like other medications, over-the-counter drugs must have a prescription from a provider to be covered at no cost to you.

For detailed information about the Mercy Care RBHA prescription drug coverage, you can review the Member Handbook and other plan materials.

Mail-order prescriptions

If you take medicine for an ongoing health condition, you may be able to have those medicines mailed to your home. These may be medications for conditions such as high blood pressure or arthritis. You can start the mail-order process by completing a mail-order request form.

By mail

Call Mercy Care ACC-RBHA Member Services at 1-800-564-5465; (TTY/TDD 711) to request a mail-order form. Or, you can download a mail-order service form here:

Mail-order service form - English | Mail-order service form - Spanish

Online

You can register for mail order online with CVS Caremark at www.caremark.com. Once you're registered, you can order refills, renew your prescription and check on your order.

Preferred drug list updates

December 2022

Title 19/21 SMI Drug List Updates:

Additions:

Removals:

None

Other Updates:

None

Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

November 2022

Title 19/21 SMI Drug List Updates:

Additions:

Imbruvica Susp 70mg/mL (Prior Authorization, Quantity Limit)
Orkambi Granule 75-94mg (Prior Authorization)

Removals:

None

Other Updates:

None

Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

October 2022

Title 19/21 SMI Drug List Updates:

Additions:

Albuterol HFA Inhaler
Gvoke Hypopen 1 Pack 0.5mg/0.1mL (Quantity Limit)
Gvoke Hypopen 2 Pack 1mg/0.2mL (Quantity Limit)
Invega Hafyera 1092mg/3.5mL (Quantity Limit, Age Restriction)
Invega Hafyera 1560mg/3.5mL (Quantity Limit, Age Restriction)
Orencia Clickject 125mg/mL (Prior Authorization)
Orencia Syringe 125mg/mL (Prior Authorization)
Orencia Syringe 50mg/0.4mL (Prior Authorization)
Orencia Syringe5mg/0.7mL (Prior Authorization)
Pancreaze DR Capsule 10500 Unit (Quantity Limit)
Pancreaze DR Capsule 16800 Unit (Quantity Limit)
Pancreaze DR Capsule 21000 Unit (Quantity Limit)
Pancreaze DR Capsule 2600 Unit (Quantity Limit)
Pancreaze DR Capsule 37000 Unit (Quantity Limit)
Pancreaze DR Capsule 4200 Unit (Quantity Limit)

Removals:

Glyxambi Tablet 10-5mg
Glyxambi Tablet 25-5mg
Humulin N Vial 100 Unit/mL
Humulin R Vial 100 Unit/mL
Proair HFA Inhaler

Other Updates:

Mavyret Packet 50-20mg (Prior Authorization Removed, Quantity Level Limit 280 Packets Per Lifetime Added)
Mavyret Tab 100-40mg (Prior Authorization Removed, Quantity Level Limit 168 Tablets Per Lifetime Added)
Sofosbuvir-Velpatasvir Tab 400-100mg (Prior Authorization Removed, Quantity Level Limit 168 Tablets Per Lifetime Added)

Non-Title 19/21 Drug List Updates:

Additions:

Invega Hafyera 1092mg/3.5mL (Quantity Limit, Age Restriction)
Invega Hafyera 1560mg/3.5mL (Quantity Limit, Age Restriction)

Removals:

None

Other Updates:

None

September 2022

Title 19/21 SMI Drug List Updates:

Additions:

Herzuma Solution 150mg (Prior Authorization)
Herzuma Solution 420mg (Prior Authorization)
Kanjinti Solution 150mg (Prior Authorization)
Kanjinti Solution 420mg (Prior Authorization)
Mvasi Solution 100mg/4mL (Prior Authorization)
Mvasi Solution 400mg/16mL (Prior Authorization)
Ogivri Solution 150mg (Prior Authorization)
Ogivri Solution 420mg (Prior Authorization)
Riabni IV Solution 100mg/10mL (Prior Authorization)
Riabni IV Solution 500mg/50mL (Prior Authorization)
Ruxience IV Solution 100mg/10mL (Prior Authorization)
Ruxience IV Solution 500mg/50mL (Prior Authorization)
Trazimera Solution 150mg (Prior Authorization)
Trazimera Solution 420mg (Prior Authorization)
Truxima Solution 100mg/10mL (Prior Authorization)
Truxima Solution 500mg/50mL (Prior Authorization)
Zirabev Solution 100mg/4mL (Prior Authorization)
Zirabev Solution 400mg/16mL (Prior Authorization)

Removals:

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

August 2022

Title 19/21 SMI Drug List Updates:

Additions:

Calamine Lotion
Doxycycline Monohydrate Tablet 100mg
Metronidazole Gel 1% (Step Therapy Required, Quantity Limit)
Olmesartan Tablet 20mg (Quantity Limit)
Olmesartan Tablet 40mg (Quantity Limit)
Olmesartan Tablet 5mg (Quantity Limit)
Selenium Sulfide Shampoo 1%
Triamcinolone Acetonide Ointment 0.05%
Triprolidine Hcl Drops 0.938mg
Triprolidine Hcl Liquid 0.625mg (PediaClear PD Liquid)
Triprolidine Hcl Syrup 2.5mg/5mL (Histex Syrup)

Removals:

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

July 2022

Title 19/21 SMI Drug List Updates:

Additions:

Lacosamide Soln 10mg/mL (Prior Authorization)
Sorafenib 200mg Tab (Prior Authorization)
Omeprazole 20mg ODT (OTC)

Removals:

Lidocaine/Sorb Lotion 3%
Nexavar 200mg Tab
Oxycodone/APAP Soln 5/325mg
Vimpat Soln 10mg/mL

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

June 2022

Title 19/21 SMI Drug List Updates:

Additions:

Novolin R
Novolin N
Novolin 70/30 Mix
Bortezomib For Inj 3.5 Mg (Prior Authorization)
Lacosamide Tab 100 Mg (Prior Authorization)
Lacosamide Tab 150 Mg (Prior Authorization)
Lacosamide Tab 200 Mg (Prior Authorization)
Lacosamide Tab 50 Mg (Prior Authorization)
Short acting opioids and opioid combinations (Quantity Limit)

Removals:

Velcade For Inj 3.5mg
Vimpat Tab 100mg
Vimpat Tab 150mg
Vimpat Tab 200mg
Vimpat Tab 50mg

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

May 2022

Title 19/21 SMI Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

April 2022

Title 19/21 SMI Drug List Updates:

Additions:

Asacol Hd Dr 800 Mg Tablet
Cipro Hc Otic Suspension
Zovirax 5% Cream
Livtencity Tab 200mg (Prior Authorization)
Kerendia Tab 10mg (Prior Authorization)
Kerendia Tab 20mg (Prior Authorization)
Rezurock Tab 200mg (Prior Authorization)
Zovirax Oint 5% (Quantity Limit)
Amphotericin Inj 50mg
Descovy Tab 120-15mg

Removals:

Acyclovir Oint 5%

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

March 2022

Title 19/21 SMI Drug List Updates:

Additions:

Diclofenac Gel Otc 1% (Quantity Limit)

Removals:

None

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

February 2022

Title 19/21 SMI Drug List Updates:

Additions:

Dexcom G5 Mis Receiver (Prior Authorization, Quantity Limit)
Dexcom G5 Mis Transmit (Prior Authorization, Quantity Limit)
Dexcom G6 Mis Receiver (Prior Authorization, Quantity Limit)
Dexcom G6 Mis Sensor (Prior Authorization, Quantity Limit)
Dexcom G6 Mis Transmit (Prior Authorization, Quantity Limit)
Freestyle 10 Reader Libre (Prior Authorization, Quantity Limit)
Freestyle 10 Sen Libre (Prior Authorization, Quantity Limit)
Freestyle 14 Reader Libre (Prior Authorization, Quantity Limit)
Freestyle 14 Reader Libre 2 (Prior Authorization, Quantity Limit)
Freestyle 14 Sen Libre (Prior Authorization, Quantity Limit)
Freestyle 14 Sen Libre 2 (Prior Authorization, Quantity Limit)
G5/G4 Plati Mis Sensor (Prior Authorization, Quantity Limit)
Paxlovid tablet pack (Quantity Limit)
Molnupiravir cap 200mg (Quantity Limit)

Removals:

None

Other Updates:

Levocetirizine 5mg tablets (Quantity Limit Added)
Promethazine syrup (Quantity Limit Added)

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

January 2022

Title 19/21 SMI Drug List Updates:

Additions:

Betamethasone Cream 0.05%
Biktarvy 30-120-15mg
Clobetasol 0.05% Shampoo
Delstrigo 100-300-300mg
Efavirenz/Emtricitabine/Tenofovir DF Tab 600/200/300mg
Ingrezza 40mg (Prior Authorization Required)
Ingrezza 60mg (Prior Authorization Required)
Ingrezza 80mg (Prior Authorization Required)
Tivicay PD Tab for Suspension 5mg

Removals:

Concept OB Cap
Edurant 25mg
Efavirenz/Lamivudine/Tenofovir 400/300/300mg
Efavirenz/Lamivudine/Tenofovir 600/300/300mg
Intelence 25mg
Mynatal Tab
Temixys 300/300mg
Viread 150mg
Viread 200mg
Viread 250mg
Zolmitriptan Nasal Spray 2.5mg
Zolmitriptan Nasal Spray 5mg

Other Updates:

Budesonide 0.25mg (Age Limit Removed)
Budesonide 0.5mg (Age Limit Removed)
Budesonide 1mg (Age Limit Removed)
Clonazepam ODT 0.125mg (Age Limit Removed)
Clonazepam ODT 0.25mg (Age Limit Removed)
Clonazepam ODT 0.5mg (Age Limit Removed)
Clonazepam ODT 1mg (Age Limit Removed)
Clonazepam ODT 2mg (Age Limit Removed)
Juluca 50/25mg (Prior Authorization Removed)
Symtuza 800/150/200/10mg (Prior Authorization Removed)

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

Removals:

Other Updates:

Clonazepam ODT 0.125mg (Age Limit Removed)
Clonazepam ODT 0.25mg (Age Limit Removed)
Clonazepam ODT 0.5mg (Age Limit Removed)
Clonazepam ODT 1mg (Age Limit Removed)
Clonazepam ODT 2mg (Age Limit Removed)

December 2021

Title 19/21 SMI Drug List Updates:

Additions:

Calcium Acetate 668mg OTC
Everolimus 10mg
Everolimus 3mg
Everolimus 5mg
Norethindrone 5mg

Removals:

Afinitor 3mg
Afinitor 5mg
Afinitor 10mg

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

November 2021

Title 19/21 SMI Drug List Updates:

Additions:

Kloxxado 8mg

Removals:

None

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

October 2021

Title 19/21 SMI Drug List Updates:

Additions:

Aimovig 140mg/ml Autoinjector (Prior Authorization Required)
Aimovig 70mg/ml Autoinjector (Prior Authorization Required
Anoro Ellipta 62.5-25mcg Inhaler (Prior Authorization Required)
Cafergot Tablet 1-100mg (Brand Only)
Enbrel 25mg/0.5ml Vial (Prior Authorization Required)
Jentadueto XR 2.5-1000mg (Prior Authorization Required)
Jentadueto XR 5-1000mg (Prior Authorization Required)
Kazano 12.5-1000mg Tablet (Brand Only, Prior Authorization Required)
Kazano 12.5-500mg Tablet (Brand Only, Prior Authorization Required)
Nesina 12.5mg Tablet (Brand Only, Prior Authorization Required)
Nesina 25mg Tablet (Brand Only, Prior Authorization Required)
Nesina 6.25mg Tablet (Brand Only, Prior Authorization Required)
Oseni 12.5-15mg Tablet (Brand Only, Prior Authorization Required)
Oseni 12.5-30mg Tablet (Brand Only, Prior Authorization Required)
Oseni 12.5-45mg Tablet (Brand Only, Prior Authorization Required)
Oseni 25-15mg Tablet (Brand Only, Prior Authorization Required)
Oseni 25-30mg Tablet (Brand Only, Prior Authorization Required)
Oseni 25-45mg Tablet (Brand Only, Prior Authorization Required)
Perseris ER 120mg Syringe (Age Limit)
Perseris ER 90mg Syringe (Age Limit)
Proglycem 50mg/ml (Brand Only)
Ubrelvy 100mg Tablet (Prior Authorization Required)
Ubrelvy 50mg Tablet (Prior Authorization Required)
Ritalin LA 10mg Capsule (Brand Only)
Ritalin LA 20mg Capsule (Brand Only)
Ritalin LA 30mg Capsule (Brand Only)
Ritalin LA 40mg Capsule (Brand Only)
Avsola 100mg Vial (Prior Authorization Required)
Ivermectin 3mg Tablet (Quantity Limit)

Removals:

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

Removals:

September 2021

Title 19/21 SMI Drug List Updates:

Additions:

None

Removals:

None

Other Updates

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals

None

Other Updates

None

August 2021

Title 19/21 SMI Drug List Updates:

Additions:

Endari Powder 5mg (Prior Authorization Required)
Hydrochlorothiazide tablet 12.5mg
Insulin Aspart 100u/ml Cartridge
Insulin Aspart 100u/ml Pen
Insulin Aspart 100u/ml Vial
Insulin Aspart Mix 70/30 Pen
Insulin Aspart Mix 70/30 Vial
Insulin Lispro 100u/ml Pen
Insulin Lispro 100u/ml Vial
Insulin Lispro Jr 100u/ml Pen
Insulin Lispro Jr 100u/ml Vial
Insulin Lispro Mix 75/25 Pen
Insulin Lispro Mix 75/25 Vial
Nayzilam (Prior Authorization Required, Quantity Level Limit)

Removals:

Caffeine Powder Citrated
Humalog 100u/ml Kwikpen
Humalog 100u/ml Vial
Humalog Jr 100u/ml Kwikpen
Ibrance 100mg Cap
Ibrance 125mg Cap
Ibrance 75mg Cap
Lidocaine- Hydrocortisone Cream Rectal 3-0.5%
Methoxsalen Cap 10mg
Novolog 100u/ml Flexpen
Novolog 100u/ml Penfill
Novolog 100u/ml Vial
Novolog Mix 70/30 Vial

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

July 2021

Title 19/21 SMI Drug List Updates:

Additions:

None

Removals:

BP Foam Aer 9.8%
Vitamax Pediatric Sol oral

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

Gralise 300mg
Gralise 600mg
Gralise 300mg & 600mg Package
Horizant ER 300mg
Horizant ER 600mg

Other Updates:

None

June 2021

Title 19/21 SMI Drug List Updates:

Additions:

Renflexis 100 Mg Vial (Prior Authorization Required)

Removals:

Tretinoin Cream 0.025%
Tretinoin Cream 0.05%
Tretinoin Cream 0.1%
Tretinoin Gel 0.01%
Tretinoin Gel 0.025%

Other Updates:

Sumatriptan Succinate Inj 6 Mg/0.5ml (Quantity Level Limit)
Sumatriptan Succinate Solution Auto-Injector 4 Mg/0.5ml (Quantity Level Limit)
Sumatriptan Succinate Solution Auto-Injector 6 Mg/0.5ml (Quantity Level Limit)
Sumatriptan Succinate Solution Cartridge 4 Mg/0.5ml (Quantity Level Limit)
Sumatriptan Succinate Solution Cartridge 6 Mg/0.5ml (Quantity Level Limit)

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

May 2021

Title 19/21 SMI Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

April 2021

Title 19/21 SMI Drug List Updates:

Additions:

Removals:

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

March 2021

Title 19/21 SMI Drug List Updates:

Additions:

Esbriet Cap 267mg (Prior Authorization Required)
Esbriet Tab 267mg (Prior Authorization Required)
Esbriet Tab 801mg (Prior Authorization Required)
Myleran Tab 2mg
Ocrevus Inj 300/10ml (Prior Authorization Required, Quantity Level Limit)
Pot & Sod Citrates W/ Cit Ac Soln 550-500-334mg/5ml
Tukysa Tab 150mg (Prior Authorization Required)
Tukysa Tab 50mg (Prior Authorization Required)
Valtoco Liq 15mg (Quantity Level Limit)
Valtoco Liq 20mg (Quantity Level Limit)
Valtoco Spr 10mg (Quantity Level Limit)
Valtoco Spr 5mg (Quantity Level Limit)
Visco-3 Inj 25/2.5ml (Prior Authorization Required)

Removals:

Doxycycline Monohydrate Tab 100mg
Hyalgan Inj 20mg/2ml
Hyoscyamine Dro 0.125/ml
Ofev Cap 100mg
Ofev Cap 150mg

Other Updates:

Ondansetron Tablet Dispersible 4mg Oral (Changed Quantity Level Limit)
Phenylephrine HCl Ophth Soln 2.5% (Added Quantity Level Limit)
Extavia Inj 0.3mg (Added Quantity Level Limit)
Santyl Oin 250 Unit/Gm (Added Quantity Level Limit)
Juluca Tab 50-25mg (Added Prior Authorization)

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

February 2021

Title 19/21 SMI Drug List Updates:

Additions:

Calamine-Zinc Oxide Lotion
Calcium Carbonate-Cholecalciferol Chew Tab 500 Mg-400 Unit
Diaper Rash Products - Ointment (Age Limit)
Dimethicone-Zinc Oxide-Vitamin A-Vitamin D Cream 1-10% (Age Limit)
Glycerin Liquid Suppos 2.8 Gm (2.7 Ml)
Glycerin Suppos 1 Gm
Glycerin Suppos 1.2 Gm
Glycerin Suppos 2 Gm
Lubiprostone Cap 24mcg (Quantity Level Limit)
Lubiprostone Cap 8mcg (Quantity Level Limit)
Mineral Oil
Pediatric Multiple Vitamin W/ C & Fa Chew Tab
Pediatric Multiple Vitamin W/ Extra C & Fa Chew Tab
Pediatric Multiple Vitamins W/ Iron Chew Tab 18 Mg
Sodium Fluoride Cream 1.1%
Sodium Fluoride Paste 1.1%
Sucralfate Susp 1 Gm/10ml (Age Limit)
Tretinoin Cream 0.025% (Age Limit)
Tretinoin Cream 0.05% (Age Limit)
Tretinoin Cream 0.1% (Age Limit)
Tretinoin Gel 0.01% (Age Limit)
Tretinoin Gel 0.025% (Age Limit)
Zinc Oxide Cream 13% (Age Limit)

Removals:

Amitiza Cap 24mcg
Amitiza Cap 8mcg

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

January 2021

Title 19/21 SMI Drug List Updates:

Additions:

Levonorgest-Eth Estrad 91-Day TABLET 0.15-0.03 &0.01 MG
Norethin Ace-Eth Estrad-FE Tablet 1-20 MG-MCG(24)
Benzoyl Peroxide 6% Cleanser
Clind Ph-Benzoyl Perox 1.2-5%
Detrol 1 MG Tablet
Detrol 2 MG Tablet
Detrol LA 2 MG Capsule
Detrol LA 4 MG Capsule
Esomeprazole DR 10 Mg Packet (Age Limit)
Esomeprazole DR 20 Mg Packet (Age Limit)
Esomeprazole DR 40 Mg Packet (Age Limit)
Esomeprazole Mag DR 40 Mg Cap
Fish Oil EC 1,000 Mg Softgel
Krill Oil 300 Mg Softgel
Kyleena 19.5 Mg System
Norethin Ace-Eth Estrad-FE Tablet Chewable 1-20 MG-MCG(24)
Mirena 52 Mg System
Nadolol 20 Mg Tablet (Age Limit)
Nadolol 40 Mg Tablet (Age Limit)
Nadolol 80 Mg Tablet (Age Limit)
Nuvaring Vaginal Ring
Plan B One-Step Tablet 1.5mg
Pantoprazole Sodium Packet 40 MG Oral (Age Limit)
Protonix 40 Mg Suspension (Age Limit)
Retacrit Inj 20000uni (Prior Authorization Required)
Retin-A 0.025% Cream
Retin-A 0.05% Cream
Retin-A 0.1% Cream
Retin-A 0.025% Gel
Retin-A 0.01% Gel
Rufinamide Sus 40mg/ml (Prior Authorization Required)
Skyla 13.5 Mg System
SM Omega 3-6-9 Softgel
Toviaz ER 4 Mg Tablet
Toviaz ER 8 Mg Tablet

Removals:

Adapalene 0.1% Cream
Amantadine 100 Mg Tablet
Carbidopa 25 Mg Tablet
Carbidopa-Levo 25-100 Mg ODT
Carbidopa-Levo 25-250 Mg ODT
Carbidopa-Levodopa 100 Mg-Enta
Carbidopa-Levodopa 125 Mg-Enta
Carbidopa-Levodopa 150 Mg-Enta
Carbidopa-Levodopa 200 Mg-Enta
Carbidopa-Levodopa 50 Mg-Enta
Carbidopa-Levodopa 75 Mg-Enta
Ciclopirox 0.77% Topical Susp
Colestipol HCl Granules
Colestipol HCl Granules Packet
Ella 30 Mg Tablet
Erythromycin 2% Pads
Erythromycin 2% Gel
Etonogestrel-Ethinyl Estradiol Ring 0.12-0.015 MG/24HR Vaginal
Flavoxate HCl 100 Mg Tablet
Fluvastatin ER 80 Mg Tablet
Fluvastatin Sodium 20 Mg Cap
Fluvastatin Sodium 40 Mg Cap
Niacin 500 Mg Tablet
Omeprazole Dr 20 Mg Tablet
Omeprazole Mag Dr 20.6 Mg Cap
Banzel Sus 40mg/ml
Selegiline HCl 5 Mg Capsule
Selegiline HCl 5 Mg Tablet
Sod Sulfacetamide 10% Shampoo
Sodium Sulfacetamide 10% Wash
Solifenacin 10 Mg Tablet
Solifenacin 5 Mg Tablet
Sulfacetamide Sod 10% Top Susp
Tazarotene 0.1% Cream
Tolterodine Tartrate Tablet 1 MG Oral
Tolterodine Tartrate Tablet 2 MG Oral
Tolterodine Tartrate ER Capsule Extended Release 24 Hour 2 MG Oral
Tolterodine Tartrate ER Capsule Extended Release 24 Hour 4 MG Oral
Tretinoin Cream 0.025 %
Tretinoin Cream 0.05 %
Tretinoin Cream 0.1 %
Tretinoin Gel 0.01 %
Tretinoin Gel 0.025 %
Trospium Chloride 20 Mg Tablet
Trospium Chloride ER 60 Mg Cap
Verapamil ER PM 100 Mg Capsule
Verapamil ER PM 200 Mg Capsule
Verapamil ER PM 300 Mg Capsule

Other Updates:

Detrol 1 Mg Tablet (Removed Step Therapy)
Detrol 2 Mg Tablet (Removed Step Therapy)
Detrol LA 2 Mg Capsule (Removed Step Therapy)
Detrol LA 4 Mg Capsule (Removed Step Therapy)
Ezetimibe 10 Mg Tablet (Removed Step Therapy)
Lansoprazole ODT 15 Mg Tablet (Removed Prior Authorization, Added Age Limit)
Lansoprazole ODT 30 Mg Tablet (Removed Prior Authorization, Added Age Limit)
Montelukast Sod 4 Mg Granules (Updated Age Limit)
Retin-A 0.01% Gel (Removed Step Therapy)
Retin-A 0.025% Cream (Removed Step Therapy)
Retin-A 0.025% Gel (Removed Step Therapy)
Retin-A 0.05% Cream (Removed Step Therapy)
Retin-A 0.1% Cream (Removed Step Therapy)
Rosuvastatin Calcium 10 Mg Tab (Removed Step Therapy)
Rosuvastatin Calcium 20 Mg Tab (Removed Step Therapy)
Rosuvastatin Calcium 40 Mg Tab (Removed Step Therapy)
Rosuvastatin Calcium 5 Mg Tab (Removed Step Therapy)
Sevelamer Carbonate 800 Mg Tab (Removed Prior Authorization)

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

Fish Oil EC 1,000 Mg Softgel
Krill Oil 300 Mg Softgel
SM Omega 3-6-9 Softgel

Removals:

Amantadine 100 Mg Tablet
Selegiline HCl 5 Mg Capsule
Selegiline HCl 5 Mg Tablet

December 2020

Title 19/21 SMI Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

November 2020

Title 19/21 SMI Drug List Updates:

Additions:

Cetirizine Cap 10mg
Dimethyl Fum Cap 120mg DR (Quantity Level Limit, Prior Authorization Required)
Dimethyl Fum Cap 240mg DR (Quantity Level Limit, Prior Authorization Required)
Diphenhydramine Chw 12.5mg
Emtricitabin Cap 200mg
Guaifenesin Tab 400mg
Levocetirizi Sol 2.5mg/5
Levocetirizi Tab 5mg
Nebulizers
Phenylephrine Tab 10mg
Saline Gel Nasal

Removals:

Other Updates:

Linaclotide capsules (Step Therapy Updated)

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

October 2020

Title 19/21 SMI Drug List Updates:

Additions:

Advair Diskus 100-50 mcg/dose (Step Therapy Required)
Advair Diskus 250-50 mcg/dose (Step Therapy Required)
Advair Diskus 500-50 mcg/dose (Step Therapy Required)
Ajovy Inj 225/1.5 (Prior Authorization Required)
Ajovy Syn 225/1.5 (Prior Authorization Required)
Efavirenz-Lamivudine-Tenofovir Df Tab 400-300-300 Mg
Efavirenz-Lamivudine-Tenofovir Df Tab 600-300-300 Mg
Flovent Disk Aer 100mcg
Flovent Disk Aer 250mcg
Flovent Disk Inh 50mcg
Humalog Jr Inj 100/ml
Humulin 5's Pen 70/30kwp
Humulin N Pen U-100kwp
Dulera Aerosol 50-5mcg (Step Therapy Required)

Removals:

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

Other Updates:

None

September 2020

Title 19/21 SMI Drug List Updates:

Additions:

Removals:

None

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

August 2020

Title 19/21 SMI Drug List Updates:

Additions:

Diclofenac Sodium Soln 1.5% (Quantity Level Limit, Step Therapy Required)
Ibrance Cap 100mg (Prior Authorization Required, Quantity Level Limit)
Ibrance Cap 125mg (Prior Authorization Required, Quantity Level Limit)
Ibrance Cap 75mg (Prior Authorization Required, Quantity Level Limit)
Ibrance Tab 100mg (Prior Authorization Required, Quantity Level Limit)
Ibrance Tab 125mg (Prior Authorization Required, Quantity Level Limit)
Ibrance Tab 75mg (Prior Authorization Required, Quantity Level Limit)
Temixys 300-300 (Quantity Level Limit)
Lynparza Tab 100mg (Prior Authorization Required, Quantity Level Limit)
Lynparza Tab 150mg (Prior Authorization Required, Quantity Level Limit)
Solifenacin Succinate Tab 10 Mg (Quantity Level Limit, Step Therapy Required)
Solifenacin Succinate Tab 5 Mg (Quantity Level Limit, Step Therapy Required)
Symproic Tab 0.2mg (Prior Authorization Required, Quantity Level Limit)

Removals:

Fluorouracil Cream 0.5%
Naproxen Sodium Tab 275 Mg
Tolmetin Sodium Cap 400
Tolmetin Sodium Tab 200
Tolmetin Sodium Tab 600

Other Updates:

Symtuza Tab (Added Prior Authorization)
Testosterone TD Soln 30 Mg/Act (Added Quantity Level Limit)
Testosterone Gel 1.62% (Added Quantity Level Limit)
Candesartan Cilexetil Tab 4 Mg (Added Step Therapy)
Candesartan Cilexetil Tab 8 Mg (Added Step Therapy)
Candesartan Cilexetil Tab 16 Mg (Added Step Therapy)
Candesartan Cilexetil Tab 32 Mg (Added Step Therapy)
Candesartan Cilexetil-Hydrochlorothiazide Tab 16-12.5 Mg (Added Step Therapy)
Candesartan Cilexetil-Hydrochlorothiazide Tab 32-12.5 Mg (Added Step Therapy)
Candesartan Cilexetil-Hydrochlorothiazide Tab 32-25 Mg (Added Step Therapy)
Fluvastatin Sodium Cap 20 Mg (Added Step Therapy)
Fluvastatin Sodium Cap 40 Mg (Added Step Therapy)
Carbamide Peroxide 6.5% Otic Soln (Added Quantity Level Limit)
Betamethasone Dipropionate Augmented Cream 0.05% (Added Quantity Level Limit)
Lidocaine Oint 5% (Changed Quantity Level Limit)

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

July 2020

Title 19/21 SMI Drug List Updates:

Additions:

None

Removals:

Videx EC Cap 125mg
Videx Ped Pow 2gm
Videx Sol 4gm
Zaclir Lot 8%

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

June 2020

Title 19/21 SMI Drug List Updates:

Additions:

Alahist D Tab
Dovato Tab 50-300mg (Quantity Level Limit)
Gvoke Hypopen Inj (Quantity Level Limit)
Phenazopyridine Tab 95 Mg

Removals:

None

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

May 2020

Title 19/21 SMI Drug List Updates:

Additions:

Dexameth Pho Inj 20mg/5ml
Dexameth Pho Mdv 10mg/ml
Dexameth Pho Via 120mg/30
Dexamethason Via 10mg/ml
Dexamethason Via 4mg/ml
Everolimus Tab 0.25mg (Prior Authorization Required)
Everolimus Tab 0.5mg (Prior Authorization Required)
Everolimus Tab 0.75mg (Prior Authorization Required)
Pyrimethamine Tab 25mg (Prior Authorization Required)

Removals:

Daraprim Tab 25mg
Zortress Tablet 0.25mg
Zortress Tablet 0.5mg
Zortress Tablet 0.75mg

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

April 2020

Title 19/21 SMI Drug List Updates:

Additions:

Erlotinib Hcl Tab 100 Mg (Prior Authorization Required)
Erlotinib Hcl Tab 25 Mg (Prior Authorization Required)
Ferrous Fumarate Tab 325 Mg
Forteo Inj 600 Mcg/2.4ml (Prior Authorization Required)
Glycerin Suppos 2.1 Gm
Ibandronate Sodium 150 Mg Tab
Imatinib Mesylate 100 Mg Tab (Prior Authorization Required)
Imatinib Mesylate 400 Mg Tab (Prior Authorization Required)
Mesalamine Cap ER 24hr 0.375 Gm (Quantity Level Limit)
Nevirapine Susp 50 Mg/5ml
Orkambi Granules 100-125 Mg (Prior Authorization Required)
Orkambi Granules 200-125 Mg (Prior Authorization Required)
Orkambi Tab 100-125 Mg (Prior Authorization Required)
Orkambi Tab 200-125 Mg (Prior Authorization Required)
Omeprazole Tablet Delayed Release Disintegrating 20 Mg (Quantity Level Limit)
Prolia Syringe 60 Mg/Ml (Prior Authorization Required)
Tramadol Hcl Tab 100mg (Quantity Level Limit)
Zinc Oxide Oint 40%

Removals:

Apriso Cap ER 24Hr 0.375GM
Bivigam Solution
Carimune Nf Inj
Diphenhydramine HCl Liquid 6.25 Mg/mL
Ferrous Sulfate Syrup 300 Mg/5ml (60 Mg/5ml Elemental)
Gleevec Tab
Konsyl Daily Fiber Packet 100%
Levalbuterol HCL Sol Nebulizer
Polyethylene Glycol 3350 Oral Packet
Sennosides Tab 17.2 Mg
Sodium Bicarbonate Powder
Tarceva Tab
Viramune Susp 50mg/ml

Other Updates:

Valacyclovir Tab 1gm (Termed Quantity Limit)
Valacyclovir Tab 500mg (Termed Quantity Limit)

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

Konsyl Daily Fiber Packet 100%
Sennosides Tab 17.2 Mg

Other Updates:

None

March 2020

Title 19/21 SMI Drug List Updates:

Additions:

None

Removals:

Fluoritab Dro 0.125mg
Prenatal Without A Vit W/ Fe Fumarate-Folic

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

February 2020

Title 19/21 SMI Drug List Updates:

Additions:

Bimatoprost Sol 0.03% (Step Therapy Required)
Ethinyl Estradiol 0.015mg and Etonogestrel 0.12mg Ring
Everolimus Tab 2.5mg (PA Required)
Everolimus Tab 5mg (PA Required)
Everolimus Tab 7.5mg (PA Required)
Flebogamma Dif 5% Vial (PA Required)
Hydrocortisone 1% Ointment
Travoprost Dro 0.004% (PA Required)
Triamcinolone 0.05% Ointment

Removals:

Afinitor Tab 2.5mg
Afinitor Tab 5mg
Afinitor Tab 7.5mg
First-Vanco Sol 25mg/ml
First-Vanco Sol 50mg/ml
Kyleena
Methyclothiazide Tab 5mg
Mirena
NuvaRing 0.12-0.015mg/24hr
Phospholine (Echothiophate Iodide) Opth Solution 0.125%
Rabeprazole EC 20 Mg Cap
Skyla
Travatan Z Solution 0.004%

Other Updates:

Combigan Sol 0.2/0.5% (Added Quantity Level Limit)
Ibandronate Inj 3mg/3ml (Added Quantity Level Limit)
Levofloxacin Sol 0.5% (Added Quantity Level Limit)
Memantine Tab HCl 10mg (Added Quantity Level Limit)
Memantine Tab HCl 5mg (Added Quantity Level Limit)
Tazarotene Cre 0.1% (Added Step Therapy Required)

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

January 2020

Title 19/21 SMI Drug List Updates:

Additions:

Anusol-HC Cream 2.5%
Calc Acetate Tab 667mg
Clobetasol Gel 0.05% (Quantity Level Limit)
Derma-Smoothe/FS Oil 0.01% Body
Derma-Smoothe/FS Oil 0.01% Scalp
Eszopiclone Tab 1mg (Age Limit, Quantity Level Limit)
Eszopiclone Tab 2mg (Age Limit, Quantity Level Limit)
Eszopiclone Tab 3mg (Age Limit, Quantity Level Limit)
Imitrex Spr 20mg/ACT (Quantity Level Limit)
Imitrex Spr 5mg/ACT (Quantity Level Limit)
Metoprolol Tab 37.5mg
Sevelamer Tab 800mg
Zomig Spr 2.5mg (Quantity Level Limit)
Zomig Spr 5mg (Quantity Level Limit)

Removals:

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

Buprenorphine HCl-Naloxone Hcl SL Tab 2-0.5mg
Buprenorphine HCl-Naloxone Hcl SL Tab 8-2mg
Eszopiclone Tab 1mg (Age Limit, Quantity Level Limit)
Eszopiclone Tab 2mg (Age Limit, Quantity Level Limit)
Eszopiclone Tab 3mg (Age Limit, Quantity Level Limit)

Removals:

Nadolol Tab 20mg
Nadolol Tab 40mg
Nadolol Tab 80mg

Other Updates:

None

December 2019

Title 19/21 SMI Drug List Updates:

Additions:

Synagis Inj 100mg/ml (Age Limit, Quantity Level Limit)
Synagis Inj 50mg/0.5ml (Age Limit, Quantity Level Limit)

Removals:

Benzoyl Peroxide Liq 7%

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

November 2019

Title 19/21 SMI Drug List Updates:

Additions:

Aminocaproic Acid Sol 0.25gm/ml

Removals:

Amicar Sol 0.25gm/ml

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

October 2019

Title 19/21 SMI Drug List Updates:

Additions:

Aimovig Inj 70mg/ml (Prior Authorization Required)
Aquadeks Chw
Aquadeks Dro
Budesonide Sus 1mg/2ml (Age Limit)
Bupren/Nalox Sub 2-0.5mg Tab
Bupren/Nalox Sub 8-2mg Tab
Dekas Cap Essential
Dekas Liq Essential
Dekas Plus Chw
Dekas Plus Liq
Dexmethylph Tab 10mg (Age Limit, Quantity Level Limit)
Dexmethylph Tab 2.5mg (Age Limit, Quantity Level Limit)
Dexmethylph Tab 5mg (Age Limit, Quantity Level Limit)
Dyanavel XR Sus 2.5mg/ml (Age Limit, Quantity Level Limit)
Emgality Inj 120mg/ml (Prior Authorization Required)
Emgality Inj 120mg/ml (Prior Authorization Required)
Multivitamin Chw Children
Mvw Complete Chw
Mvw Complete Chw
Otezla Tab 10/20/30 (Prior Authorization Required)
Otezla Tab 30mg (Prior Authorization Required)
Pifeltro Tab 100mg
Sofos/Velpat Tab 400-100 (Prior Authorization Required)
Sublocade Inj 100/0.5 (Prior Authorization Required)
Sublocade Inj 300/1.5 (Prior Authorization Required)
Symjepi Inj 0.15mg (Quantity Level Limit)
Symjepi Inj 0.3mg (Quantity Level Limit)
Tudorza Pres Aer 400/Act (Quantity Level Limit)
Vitamax Chw
Vitamax Ped Dro
Xarelto Tab 2.5mg (Quantity Level Limit)
Xeljanz Tab 10mg (Prior Authorization Required)
Xeljanz Tab 5mg (Prior Authorization Required)

Removals:

Advair Disku Aer 100/50
Advair Disku Aer 250/50
Advair Disku Aer 500/50
Aripiprazole Sol 1mg/ml
Aripiprazole Tab 10mg ODT
Aripiprazole Tab 15mg ODT
Dextroamphet Cap 10mg ER
Dextroamphet Cap 15mg ER
Dextroamphet Cap 5mg ER
Epinephrine Inj 0.15mg (Generic Adrenaclick)
Focalin Tab 10mg
Focalin Tab 2.5mg
Focalin Tab 5mg
Pulmicort Sus 1mg/2ml
Saphris Sub 10mg
Saphris Sub 2.5mg
Saphris Sub 5mg

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

Dexmethylph Tab 5mg (Age Limit, Quantity Level Limit)
Dexmethylph Tab 10mg (Age Limit, Quantity Level Limit)
Bupren/Nalox Sub 2-0.5mg Tab
Bupren/Nalox Sub 8-2mg Tab
Sublocade Inj 100/0.5 (Prior Authorization Required)
Sublocade Inj 300/1.5 (Prior Authorization Required)
Dyanavel XR Sus 2.5mg/ml (Age Limit)
Dexmethylph Tab 2.5mg (Age Limit, Quantity Level Limit)

Removals:

Other Updates:

None

September 2019

Title 19/21 SMI Drug List Updates:

Additions:

Febuxostat Tab (Quantity Level Limit, Step Therapy)
Multiple Vitamin
Pediatric Multiple Vitamin
Pregabalin Cap (Prior Authorization Required)
Pregabalin Sol (Prior Authorization Required)

Removals:

Uloric Tab
Lyrica Cap
Lyrica Sol

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

August 2019

Title 19/21 SMI Drug List Updates:

Additions:

Adcirca – Brand only (Prior Authorization Required)
Alendronate Sodium Soln
Bicillin L-A 1200000 Unit/2ml
Bicillin L-A 2400000 Unit/4ml
Bicillin L-A 600000 Unit/ml
Bivigam (Prior Authorization Required)
Carimune NF Nanofiltered (Prior Authorization Required)
Cerdelga (Prior Authorization Required)
Elelyso (Prior Authorization Required)
Farxiga (Prior Authorization Required)
Flebogamma Dif (Prior Authorization Required)
Fulphila (Prior Authorization Required)
Gamastan S-D (Prior Authorization Required)
Gammagard S-D (Prior Authorization Required)
Gleevec – Brand only (Prior Authorization Required)
Hizentra (Prior Authorization Required)
Imbruvica Tablets (Prior Authorization Required)
Invokana (Prior Authorization Required)
Letairis – Brand only (Prior Authorization Required)
Leukeran (Prior Authorization Required)
Lidocaine Patch 4% (Quantity Level Limit)
Lorcaserin HCl Tab ER 24hr 20mg (Prior Authorization Required, Quantity Level Limit)
Miglustat (Prior Authorization Required)
Nplate (Prior Authorization Required)
ProAir – Brand only
Retacrit (Prior Authorization Required)
Revatio solution – Brand only (Prior Authorization Required for age > 12)
Tracleer – Brand only (Prior Authorization Required)
Udenyca (Prior Authorization Required)
Vpriv (Prior Authorization Required)

Removals:

Arcapta Neohaler
Bupropion HCl Tab ER 24hr 450mg
Butalbital-Acetaminophen-Caffeine Cap 50-300-40mg
Butalbital-Acetaminophen-Caffeine Cap 50-325-40mg
Desvenlafaxine Succinate ER
Emsam
Epinastine HCl Ophth Soln 0.05%
Epogen
Erythromycin Ethylsuccinate For Susp
Escitalopram Oxalate Soln
Prefest
Etidronate Disodium
Etodolac Tab ER 24hr
Fluoxetine DR
Fluvoxamine Maleate ER
Glipizide-Metformin
Iclusig
Imatinib
Isocaboxazid
Jakafi
Marplan
Melphalan
Nefazodone HCl
Neulasta
Ofloxacin Otic
Olopatadine HCl Ophth Soln 0.2%
Opsumit
Paroxetine ER
Paxil Sus 10mg/5ml
Pexeva
Phenelzine Sulfate
Procrit
Purixan Solution
Riomet
Segluromet
Steglatro
Striverdi Respimat
Tasigna
Thalomid
Tranylcypromine Sulfate
Tymlos
Tyvaso
Ventavis
Ventolin HFA
Viibryd
Zolinza

Other Updates:

Azelastine Ophth Soln 0.2% (Added Quantity Level Limit)
Baraclude Oral Soln 0.05 mg/ml (Prior Authorization Required)
Butalbital-Acetaminophen-Caffeine Tab 50-325-40mg (Added Quantity Level Limit)
Calcipotriene Soln 0.005%, Calcipotriene cream 0.005%, Calcipotriene Oint 0.005% (Prior Authorization Required)
Citalopram Hydrobromide Oral Soln 10mg/5ml (Added Age Limit)
Evotaz Tablet 300-150mg (Added Quantity Level Limit)
Fluoxetine HCl Solution 20mg/5ml (Added Age Limit)
Sertraline HCl Oral Concentrate For Solution 20mg/ml (Added Age Limit)

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

Other Updates:

Citalopram Hydrobromide Oral Soln 10mg/5ml (Added Age Limit)
Fluoxetine HCl Solution 20mg/5ml (Added Age Limit)
Sertraline HCl Oral Concentrate for Solution 20mg/ml (Added Age Limit)

July 2019

Title 19/21 SMI Drug List Updates:

Additions:

Avastin Inj
Cefixime Cap 400mg (Quantity Level Limit)
Erlotinib Tab 150mg (Prior Authorization Required)
Herceptin Inj
Mesalamine Cap 400mg DR (Quantity Level Limit)
Penicillamine Capsule
Sildenafil Sus 10mg/ml (Prior Authorization Required)

Removals:

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

June 2019

Title 19/21 SMI Drug List Updates:

Additions:

Docosanol Cream 10%
Melatonin Tab 1 Mg
Melatonin Tab 3 Mg
Melatonin Tab 5 Mg

Removals:s

Abreva Cream 10%

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

Melatonin Tab 1 Mg
Melatonin Tab 3 Mg
Melatonin Tab 5 Mg

Removals:

None

Other Updates:

None

May 2019

Title 19/21 SMI Drug List Updates:

Additions:

Concerta Tab ER (Age Limit, Quantity Limit)
Erythrom Eth Sus 400/5ml
Ranolazine Tab 1000mg ER (Prior Authorization Required)
Sirolimus Sol 1mg/ml

Removals:

EryPed 400 Sus 400/5ml
Methylphenidate Tab ER
Methylphenidate Tab ER
Prochlorperazine Maleate Tab 10 Mg (Base Equivalent)
Prochlorperazine Maleate Tab 5 Mg (Base Equivalent)
Prochlorperazine Suppos 25 Mg
Ranexa Tab 1000mg ER
Rapamune Sol 1mg/ml

Other Updates:

None

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

Concerta Tab ER

Removals:

Methylphenidate Tab ER

Other Updates:

None

April 2019

Title 19/21 SMI Drug List Updates:

Additions:

Ranolazine Tab ER 500mg (Prior Authorization)
Ritalin LA Cap 20mg, 30mg, 40mg (Age Limit, Quantity Level Limit)
Treprostinil Sol 1mg/mL, 2.5mg/mL, 5mg/mL, 10mg/mL (Prior Authorization)

Removals:

Ranexa Tab ER 500mg
Remodulin Sol 1mg/mL, 2.5mg/mL, 5mg/mL, 10mg/mL

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

Ritalin LA Cap 20mg, 30mg, 40mg (Age Limit, Quantity Level Limit)

Removals:

None

March 2019

Title 19/21 SMI Drug List Updates:

Additions:

Cinacalcet tablet added with PA
Aminocaproic acid tablet
Carbidopa 25mg tablet
Toremifene tablet added with PA
Mesalamine 1000mg Suppositories added with QLL (30/30days)
Clonidine 0.1mg ER tablet added with QLL (120/30 days) and PA < 6 years of age

Removals:

Sensipar
Amicar
Fareston
Canasa Suppositories
Norethindrone- ethinyl estradiol- ferrous fumarate 1-20 mg-mcg (24) tablets
Kapvay

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

Clonidine 0.1mg ER tablet added with QLL (120/30 days) and PA < 6 years of age

Removals:

Kapvay

February 2019

Title 19/21 SMI Drug List Updates:

Additions:

Calcipotriene cre 0.005% QLL added (200gm/30days)
Calcipotriene oint 0.005% QLL added (200gm/30days)
Calcipotriene soln 0.005% (50 mcg/ml) QLL added (200ml/30days)
Clonidine HCL ER 0.1mg Tab
Flebogamma added with PA (must be filled at Contracted Home Infusion Pharmacy)
Gammagard added with PA (must be filled at Contracted Home Infusion Pharmacy)
Gammaked added with PA (must be filled at Contracted Home Infusion Pharmacy)
Gamunex-C added with PA (must be filled at Contracted Home Infusion Pharmacy)
Jardiance PA added
Nitrofurantoin Suspension PA > 12 years added
Prenatal mv & min w/fe fumarate-fa-dha 28-0.8-200mg pack added with QLL (100/90 days)
Prenatal vit w/ docusate-fe fumarate-folic acid 29-1mg tab added with QLL (100/90 days)
Prenatal vit w/ ferrous fumarate-folic acid 27-0.8mg tab added with QLL (100/90 days)
Prenatal vit w/ ferrous fumarate-folic acid 27-1mg tab added with QLL (100/90 days)
Prenatal vit w/ ferrous fumarate-folic acid 28-1mg tab added with QLL (100/90 days)
Prenatal vit w/ ferrous fumarate-folic acid 29-1mg chew tab added with QLL (100/90 days)
Prenatal vit w/ ferrous fumarate-folic acid 29-1mg tab added with QLL (100/90 days)
Prenatal without a vit w/ fe fumarate-folic acid 29-1mg chew tab added with QLL (100/90 days)
Prenatal without a vit w/ fe fum-iron polysacch complex –fa 130-92.4-1mg cap added with QLL (100/90 days)
Prenatal without a vit w/ fe fum-iron polysacch complex –fa 20-20-1.25mg cap added with QLL (100/90 days)
Segluromet added with ST and QLL (60/30 days
Steglatro added with ST and QLL (30/30days)

Removals:

Condolyx gel
Dihydroergotamine Nasal Solution
Elidel Cream 1%
Ergomar SL Tablet
Invokana tablet
Invokanamet tablet
Jardiance ST removed
Kapvay ER 0.1mg Tab
Levonor/ethi tab estradio
Lidocaine/hc kit 20x7gm
Lidocaine/hc kit 3%-1%
Lo Loestrin tablet
Nitro-bid 2% packets
Prenatal multivitamins & minerals w/ l-methylfolate-fa 0.6-0.4mg chew tab
Prenatal mv & min w/fe polysaccharide complex-fa-dha 29-1mg & 250mg pack
Prenatal vit w/ ferrous fumarate-folic acid 65-1mg tab
Prenatal vit w/ ferrous fumarate-l methylfolate-folic acid 27-0.6-0.4mg tab
Prenatal vit w/ iron carbonyl-fe aspart glyc-fa-omega 3 27-1mg cap
Prenatal vit w/ iron carbonyl-folic acid 50-1.25mg tab
Prenatal vit w/ iron polysaccharide complex-folic acid 29-1 chew tab
Prenatal w/o vit a w/ fe carbonyl-fe asp glyc-methfol-fa-dha 18-0.6-0.4-350mg cap
Prenatal w/o vit a w/ fe carbonyl-fe gluconate-dss-fa-dha 27-1mg & 250mg pack
Prenatal w/o vit a w/ fe fumarate-dss-fa-dha 27-1.25-300mg cap
Prenatal without a w/ fe fumarate-l methylfolate-fa-dha 27-0.6-0.4-300mg cap
Prenatal without a w/ fe fumarate-l methylfolate-fa-omega 3 28-0.6-0.4-340mg cap
Synjardy and Synjardy XR tablet
Terconazole vaginal suppos 80 mg
Trimethobenzamide hcl cap 300 mg

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

January 2019

Title 19/21 SMI Drug List Updates:

Additions:

Celecoxib 50mg and 100mg QLL added (60/30 days)

Removals:

None

Title 19/21 Non-SMI & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

December 2018

Title 19/21 SMI Drug List Updates:

Additions:

Donepezil, donepezil ODT PA added
Memantine PA added
Mesalamine enema QLL (120ml/day)
Pentasa QLL (270 /30days)
Sildenafil citrate suspension 10 mg/mL with PA
Sulfasalazine QLL (240/30)
Tretinoin cream/gel age limitation of 26

Removals:

Benazepril & hydrochlorothiazide tab 5-6.25 mg
Interferon alfa-2b for inj 50000000 unit
Methotrexate sodium inj pf 100 mg/4ml (25 mg/ml)
Methotrexate sodium inj pf 200 mg/8ml (25 mg/ml)
Peginterferon alfa-2b for inj kit 80 mcg/0.5ml
Sodium fluoride-xylitol chew tab 1.1 (0.5 mg f)-236.79
Sodium sulfacetamide/ sulfur 10-5% emulsion
Telbivudine tab 600 mg
Tretinoin cream/gel age limitation of 35

Title 19/21 Non-SMI & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

November 2018

Title 19/21 SMI Drug List Updates:

Additions:

Albendazole added with ST

Removals:

Albenza
Clotrimazole ointment (no longer marketed)
Cytra-K (all NDCs are DESI)

Title 19/21 Non-SMI & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

October 2018

Title 19/21 SMI Drug List Updates:

Additions:

Arcapta Neohaler added with QLL (30 caps/ 30 days)
Aristada Initio added with QLL (2/365days)
Atomoxetine added with QLL (30/30days)
Butenafine cream
Cascara sagrada
Dutasteride
Fiber tablet, powder, capsule
Glatopa 40mg
Loratadine chew tab added with QLL (60/30days)
Magnesium Citrate soln
Magnesium Oxide tab
Methylcellulose powder, tab
Ondansetron 4mg tablet and ODT QLL changed to 90tabs/30days
Prasugrel added with QLL (30/30 days)
Procrit added with PA
Senna syrup, liquid, tab
Striverdi Respimat added with QLL (1/30days)
Tadalafil (generic Adcirca) added with STEP
Tazarotene cream added with QLL (90gm/30days)
Tymlos added with PA and QLL (1/30days)
Valganciclovir QLL added (60/30days)
Vitamin E Chew tab
Vyvanse chewable tablet added with QLL (30/30days)

Removals:

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

Aristada Initio added with QLL (2/365 days) and age limit (PA for < 18 years)
Atomoxetine added with QLL (30/30 days) and age limit (PA for <6 years)
Bisacodyl enema, supp, tab
Cascara sagrada capsule
Fiber tablet, powder, capsule
Lithium age limit added (PA for <6 years)
Magnesium Citrate soln
Magnesium Oxide tab
Methylcellulose powder, tab
Niacin tablet, chew tab, and ER tab
Pimozide age limit added (PA for <12 years)
Senna syrup, liquid, tab
Vitamin E Chew tab
Vyvanse chewable tablet added with QLL (30/30days ) and age limt (PA for <6 years)

Removals:

Methylphenidate chewable tablet
Strattera

September 2018

Title 19/21 SMI Drug List Updates:

Additions

Eliquis starter pack added with QLL (74/30days)
Makena 275mg /1.1ml Auto Inj added with PA
Phosphorous 250mg powder for solution
Pyrethrins-piperonyl Butoxide Gel
Symtuza tablets added with QLL (30/30days)

Removals

Eurax PA removed
PHOS-NAK

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions

None

Removals

None

July 2018

Title 19/21 SMI Drug List Updates

Additions:

Naratriptan tablets added with QLL (9/30 days)
Rizatriptan QLL changed (9/30days)
Zolmitriptan tablets and ODT added with QLL (9/30days)
Rozerem ST and QLL added (30/30 days)
Novolog Mix 70/30 Flexpen and Vial
Novolog 100Units/Ml Vial, Flexpen, and cartridge
Glyxambi added with PA
Norvir powder added
Phytonadione
Renagel PA added
Renvela Brand Only added with PA
Levalbuterol solution added (no PA required for age <4)
Montelukast chewable tabs added with QLL (30/30days)
Montelukast granules PA added for age > 4
Bevespi Aerosphere added with PA
Stiolto Respimat added with PA
Alprazolam ER QLL changed (30/30days)
Lorazepam 2mg tablet QLL changed (60/30)
Lorazepam Intensol QLL changed (60ml/30)
Chlordiazepoxide QLL added (60/30days)
Clorazepate 3.75mg and 7.5mg QLL added (120/30)
Clorazepate 15mg QLL added (60/30)
Oxazepam QLL added (60/30days)
Xarelto Starter Pack QLL changed to 51/30
Servent Diskus PA added

Removals:

Meprobamate
Estazolam
Flurazepam
Eszopiclone
Triazolam
Rozerem PA removed
Zaleplon
Zolpidem ER
Intermezzo SL/ Edular
Zolpimist
Silenor
Mephyton
Auryxia
Fosrenol
Sevelamer generic
Levalbuterol HFA
Montelukast granules PA removed for age > 2
Arcapta Neohaler
Foradil
Metaproterenol
Striverdi Respimat
Zafirlukast

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

Rozerem ST and QLL added (30/30)
Haloperidol decanoate PA added for age < 18
Fluphenazine decanoate PA added for age < 18
Alprazolam ER QLL changed (30/30days)
Chlordiazepoxide QLL added (60/30days)
Clorazepate 3.75mg and 7.5mg QLL added (120/30)
Clorazepate 15mg QLL added (60/30)
Oxazepam QLL added (60/30days)
Lorazepam 2mg tablet QLL changed (60/30)
Lorazepam Intensol QLL changed (60ml/30)

Removals:

June 2018

Title 19/21 SMI Drug List Updates

Additions:

Symfi added with QLL (30/30 days)
Praziquantel
Lansoprazole ODT added with PA and QLL (30/30 days)
Tasigna 50mg added with PA and QLL (120/30 days)

Removals:

Biltricide
Sensipar smart edit PA for nephrologists
Prevacid ODT

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

May 2018

Title 19/21 SMI Drug List Updates

Additions:

Colchicine 0.6mg capsule
Firvanq solution
Jardiance added (Quantity Level Limit, Step Therapy Required)
Ritonavir 100mg tablet
Symfi Lo (Quantity Level Limit)
Synjardy (Quantity Level Limit, Step Therapy Required)
Synjardy XR 10/1000mg and 25/1000mg (Quantity Level Limit, Step Therapy Required)
Synjardy XR 5/1000mg and 12.5/1000mg (Quantity Level Limit, Step Therapy Required)

Removals:

Norvir tablet

Other Updates:

Rosuvastatin (Removed Prior Authorization, Added Step Therapy)

GMH/SU & Non-Title 19/21 Drug List Updates

No Monthly Updates

April 2018

Title 19/21 SMI Drug List Updates

Additions:

Biktarvy
Pulmicort Flexhaler
Tramadol ER tablets (Prior Authorization Required)

Removals:

Emend

Other Updates:

Aprepitant (Added Quantity Level Limit)

GMH/SU & Non-Title 19/21 Drug List Updates

No Monthly Updates

March 2018

Title 19/21 SMI Drug List Updates

Additions:

Efavirenz
Methergine

Removals:

Sustiva

April 2018

GMH/SU & Non-Title 19/21 Drug List Updates

No Monthly Updates

February 2018

Title 19/21 SMI Drug List Updates

Additions:

Atazanavir tablets
BD Pen Needles
Efavirenz
Estradiol 0.01% vaginal cream
Juluca (Quantity Level Limit)
Tenofovir
Vancomycin capsules (Prior Authorization Required -use First Vancomycin Solution)

Removals:

Other Updates:

Brimonidine 0.2% ophthalmic (Added Quantity Level Limit)
Ciprofloxacin 250mg/5ml (Added Quantity Level Limit)
Clobetasol Cream Emollient 0.05% (Added Quantity Level Limit)
Combigan (Added Step Therapy)
Fentanyl lozenges (Added Prior Authorization)
Halobetasol topical (Added Quantity Level Limit)
Sprycel (Added Quantity Level Limit)
Timolol gel (Added Step Therapy)

GMH/SU & Non-Title 19/21 Drug List Updates

No Monthly Updates

January 2018

Title 19/21 SMI Drug List Updates

Additions:

Armodafinil (Prior Authorization Required, Quantity Level Limit)
Carboxymethycellulose sodium ophth soln 0.25%
Epinephrine 0.3mg/0.3ml and 0.15mg/0.15ml Pens (Mylan)
Opsumit (Prior Authorization Required)
Xtampza ER (Prior Authorization Required)

Removals:

Other Updates:

GMH/SU & Non-Title 19/21 Drug List Updates

No Monthly Updates

Over-the-counter product list for dual eligible T19/21 SMI members

Over-the-counter product list

How to get your prescriptions

If you need medicine, your provider chooses a medication from our list of preferred drugs. Your provider writes you a prescription. Ask your provider to make sure that the medicine is on the list.

Take the prescription to a network pharmacy to have it filled. (Find a network pharmacy)
Show your Mercy Care member ID card at the pharmacy.

How to find a network pharmacy

You can find a network pharmacy by:

Searching for a pharmacy in your area.
Calling Mercy Care ACC-RBHA Member Services at 602-586-1841 or 1‑800‑564-5465; (TTY/TDD: 711). Ask the representative to help you find a network pharmacy in your area.

All prescriptions must be filled at a network pharmacy. Mercy Care does not cover prescriptions filled at other pharmacies.

Specialty Pharmacy

Mercy Care specialty drugs are filled by CVS Specialty Pharmacy. A specialty pharmacy fills drugs and has other services to help you. The Specialty Drug Program has special services for you:

You can talk to a pharmacist 24 hours a day, 7 days a week
Counseling about your drug and disease
Coordination of care with you and your doctor
Delivery of specialty drugs to your home or doctor’s office at no cost to you
You can drop off your prescription and pick up your drug at any CVS Pharmacy (including those inside Target stores)

You can call CVS Specialty Pharmacy at 1-800-237-2767, TTY 1-800-863-5488. CVS Specialty Pharmacy will help you with filling your specialty drug. The specialty drug list lists all the specialty drugs available.

Medicine not on the approved-drug lists

If your medicine is not on an approved-drug list, you can:

Ask your provider for a similar drug that is on the list.
Ask your provider to ask Mercy Care to cover your drug. Your provider will go through the prior authorization process. Your provider will know how to do this.

Prescription refills

Your medicine bottle label says how many refills you can have. If you think you may need a refill, you must contact your provider at least five days before you run out of medicine. When you call, ask your provider about getting a refill. Your provider may want you to make an appointment before giving you a refill.

Questions to ask about your medicine

Mercy Care wants you to be as healthy as possible. This includes knowing about the different medicines you need to take.

To help, we have included a list of questions you should always ask your provider when about a prescription.

Why am I taking this medicine? What is it supposed to do for me?
How should the medicine be taken? When? For how many days?
Are there any side effects or possible allergic reactions to this medicine?
What should I do if I have a side effect or allergic reaction?
What will happen if I don’t take this medicine?

Carefully read the drug information the pharmacy gives you with your medicine. It will tell you what you should and should not do while taking the medicine. If you have questions after you get your medicine, ask to talk with the pharmacist or call your provider.

It's important you tell all your healthcare providers, including your dentist, about prescriptions you're already taking. Also, tell them about non-prescription medicine, vitamins or herbal supplements you take.

Also, check out Mercy Care's Patient Checklist for more tips to prepare you for a doctor’s visit.

Drug safety alerts

Drug safety alerts can provide important information about the safety of medications, click here for more.