Pharmacy

Prescription Drug Benefits

Learn more about member drug benefits, view formularies and formulary updates. Help your patients get the prescription drugs they need in an easy and cost effective way.

 

You now have the ability to use the new Formulary Search Tool to find out which medications are on the formulary drug lists. You can search by drug name or drug class. The search tool will show formulary status, generic alternatives and if there are any requirements, such as prior authorization, quantity limits or age limits. The formularies can change.

Download the Mercy Care Formulary.

December 2018

Additions:

  • Apriso ER 24hr 0.375gm cap
  • Budesonide 32mcg nasal suspension
  • Canasa 1000mg suppository
  • Candesartan Cilexetil HCTZ tabs
  • Candesartan tabs
  • Cetirizine 5mg, 10mg chew tabs
  • Cetirizine 5mg, 10mg tabs
  • Citalopram 20mg, 40mg tab
  • Delzicol DR 400mg cap
  • Diazepam 5mg/5mL solution
  • Dipentum 250mg cap
  • Duloxetine DR 60mg caps
  • Fexofenadine HCL 30mg/5mL suspension
  • Fluoxetine 20mg, 40mg caps
  • Fluoxetine 20mg/5mL solution
  • Fluvoxamine 100mg tab
  • Mesalamine 4gm enema
  • Mesalamine DR 800mg tab
  • Olanzapine 2.5mg, 7.5mg tabs
  • Pentasa caps
  • Sertraline 100mg tab
  • Sulfasalazine 500mg tab
  • Sulfasalazine DR 500mg tab
  • Vyvanse caps

Changes:

  • Famciclovir 125mg, 250mg, 500mg tabs added with PA
  • Femring 0.05mg/24hr added with PA
  • Femring 0.1mg/24hr added with PA
  • Testosterone 40.5mg/2.5gm (1.62%) gel added with PA
  • Travatan Z 0.0004% opth solution added with PA

Removals:

  • Advanced Allergy Kit 2.5%
  • Armour Thyroid 1.5GR Tab
  • Armour Thyroid 1/2GR Tab
  • Armour Thyroid 1/4GR Tab
  • Armour Thyroid 1GR Tab
  • Armour Thyroid 2GR Tab
  • Benazepril-HCTZ 5-6.25mg tab
  • BPO 4% gel
  • Carafate 1gm/10mL suspension
  • Lanoxin 0.125mg Tab
  • Lanoxin 0.25mg Tab
  • Lotrimin 2% AF Aerosol
  • Menest 2.5mg tab
  • MG217 Psoriasis Anti-itch 1% gel
  • MultiNatal Plus 30-1mg tab
  • MultiNatal Plus 40-1mg chew
  • Omeprazole-Sodium Bicarbonate 20-1100mg cap
  • Sulfacetamide Sodium-Sulfur 10-5% emulsion

 

November 2018

Additions:

  • Albendazole added with STEP

Removals:

  • Clotrimazole ointment – no longer marketed
  • Cytra-K all NDCs on market are DESI
  • Albenza

 

October 2018

Additions:

  • Arcapta added with QLL 30capsules for inhalation per 30days
  • Aristada Initio added with QLL 2 per year, age < 18 requires PA
  • Atomoxetine capsules
  • Cyanocobalamin injection
  • Dutasteride 0.5mg
  • Fluocinonide cream
  • Glatopa 40mg added with PA
  • Loratadine chew 5mg added with QLL 60/30days
  • Lotrimin Ultra cream
  • Metoprolol 75mg tab
  • Prasugrel added with QLL 30/30days
  • Procrit added with PA
  • Striverdi Respimat added with QLL 1 inhaler per 30days
  • Tadalafil added with step
  • Tazarotene 0.1% cream added with QLL 90gm/30days
  • Tymlos added with PA and QLL 1 pen/30days
  • Vyvanse chewable tablets added with QLL 30/30days

Removals:

  • Acebutolol cap
  • Adcirca
  • Alclometasone dip cream and ointment
  • Betamethasone dp Aug lotion, gel and ointment
  • Betamethasone dp cream, ointment
  • Cardura XL
  • Ciclopirox gel and shampoo
  • Clobetasol foam, lotion, gel, shampoo
  • Clotrimazole/betamethasone lotion
  • Copaxone 40mg
  • Desonide cream, lotion, ointment
  • Diltiazem 24hr ER tab
  • Flucytosine
  • Fluocinolone solution, cream, ointment
  • Fluocinonide E 0.05% cream
  • Fluticasone prop lotion
  • Griseofulvin ultra
  • Hydrocortisone butyr cream, ointment
  • Hydrocortisone val cream, ointment
  • Isradipine
  • Itraconazole
  • Ketoconazole tab
  • Methylphenidate chew tabs
  • Nicardipine
  • Nimodipine
  • Nisoldipine
  • Noxafil
  • Nystatin topical powder
  • Pindolol
  • Prednicarbate ointment
  • Strattera
  • Timolol tab
  • Triamcinolone spray
  • Trianex oil
  • Voriconazole

Changes: 

  • Antipsychotics: PA removed for Acute (ACC), age edits and QL still apply
  • Ondansetron 4mg QLL changed to 90/30days
  • Valgancyclovir PA removed, added QLL 60/30days

 

September 2018

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 added with QLL #30/30days

Removals:

  • Eurax PA removed

Changes:

  • Eliquis starter pack QLL changed to 74/30days

 

August 2018

Additions:

  • Aripiprazole ODT added for ALTCS, QLL = 30/30days
  • Aripiprazole solution added for ALTCS, QLL = 150ml/30days
  • Baraclude solution added QLL 600ml/30days
  • Diazepam rectal gel added QLL of 2/rx
  • Diclofenac gel 1% added with QLL 200gm/30days
  • Elmiron added PA
  • Hydrocod-homatropin tab age < 18 requires PA
  • Omega-3 (1gram) cap added with Step and QLL 120/30days
  • Premarin Vaginal Cream added PA
  • Telmisartan added with QLL 30/30days
  • Testosterone cypionate added PA
  • Vemlidy added with QLL 30/30days
  • Verzenio added with PA and QLL 60/30days

Removals: 

  • Amlodipine-valsartan-hctz
  • Chlorpropamide
  • Coumadin Brand
  • Duetact
  • Fenofibric acid
  • Lidocaine 3% cream
  • Meclofenamate
  • Methitest
  • Ondansetron solution
  • Premphase
  • Pyrethrin (drug no longer marketed)
  • Tolazamide
  • Tolbutamide
  • Topical lice products removed QLLs

Changes:

  • Amlodipine 2.5mg and 5mg increased QLL to 60/30days
  • Hydrocod-homatropine syrup increased QLL to 900ml/30days
  • Lidocaine 5% ointment changed STEP to PA

 

July 2018

Additions:  

  • Baclofen 5mg
  • Bevespi Aerosphere (Added Prior Authorization)
  • Diphenhydramine liq 6.25mg
  • Glyxambi (Added Prior Authorization)
  • Levalbuterol solution (Prior Authorization) not required for (Age Limit) < 4
  • Naratriptan added with (Quantity Level Limit) 9/30days
  • Norvir powder
  • Pediatric MVI with iron 11mg/ml
  • Phytonadione tab
  • Prescription opioid cough and cold products (Age Limit) < 18 requires (Prior Authorization)
  • Renagel (Added Prior Authorization)
  • Renvela (brand only) (Added with Prior Authorization)
  • Servent Diskus (Added Prior Authorization)
  • Stiolto Respimat (Added Prior Authorization)
  • Zolmitriptan added with (Quantity Level Limit) 9/30days      
  • Sevelamer

Removals:

  • Albuterol solution (Step Therapy) removed
  • Arcapta
  • Estazolam
  • Eszopiclone
  • Flurazepam
  • Foradil
  • Fosrenol
  • Mephyton
  • Meprobamate
  • Metaproterenol
  • Silenor
  • Striverdi
  • Triazolam
  • Zafirlukast
  • Zaleplon
  • Zolpidem ER
  • Zolpidem SL
  • Zolpimist

Other Updates:

  • Montelukast granules changed to (Prior Authorization) required for (Age Limit) > 4
  • Rizatriptan (Quantity Level Limit) changed from 12/30days to 9/30days
  • Rozerem- must use temazepam and zolpidem first
  • Sildenafil specialist requirement removed

 

June 2018 

Additions:  

  • Lansoprazole ODT (Prior Authorization, Quantity Level Limit)
  • Praziquantel
  • Symfi (Quantity Level Limit)

Removals:

  • Biltricide
  • Prevacid Solu Tab

 

May 2018

Additions:

  • Colchicine capsules
  • Firvanq
  • Jardiance (Step Therapy Required)
  • Ritonavir tablets
  • Symfilo
  • Synjardy, Synjardy XR (Step Therapy Required)

Removals:

  • Norvir tablets

Other Updates:

  • Rosuvastatin (Prior Authorization Removed, Step Therapy Added)

 

April 2018

Additions:

  • Aprepitant combo pack
  • Biktarvy
  • Pulmicort Flexhaler
  • Tramadol ER (Prior Authorization Required)

Removals:

  • Emend combo pack

 

March 2018

Additions:

  • Efavirenz Tab
  • Methergine

Removals:

  • Sustiva Tab

 

February 2018

Additions:

  • BD Pen needles
  • Efavirenz
  • Estradiol 0.01% vaginal cream
  • One Touch Verio High
  • Tenofovir
  • Vancomycin capsules (Prior Authorization Required-use First Vancomycin compounding kit)

Removals:

  • Albuterol tabs (Use Syrup)
  • Amcinonide topical
  • Betoptic S ophthalmic
  • Brimonidine 0.15% ophthalmic
  • Cefaclor ER tabs
  • Ciprofloxacin ER tabs
  • Desoximethasone topical
  • Estrace Vaginal cream
  • FML Forte ophthalmic
  • Gatifloxacin ophthalmic solution
  • Modafinil
  • Neomycin/Polymyxin HC ophthalmic
  • Oxymorphone IR
  • Pramasone HC cream 1-1%
  • Prednicarbate topical
  • Sustiva
  • Terbutaline (Use Albuterol Syrup)
  • Viread

Other Updates:

  • Brimonidine 0.2% ophthalmic (Added Quantity Level Limit)
  • Combigan ophthalmic (Added Step Therapy)
  • Fentanyl lozenge (Added Prior Authorization)
  • Halobetasol topical (Added Quantity Level Limit)
  • Sprycel (Added Quantity Level Limit)
  • Timolol ophthalmic gel (Added Step Therapy)

 

January 2018

Additions:

  • Armodafinil (Prior Authorization Required, Quantity Level Limit)
  • Carboxymethycellulose sodium ophth solun 0.25%
  • Cardura XL
  • Epinephrine 0.15 mg and 0.3mg Auto-Inject (Mylan)
  • Opsumit (Prior Authorization Required)
  • Oseltamivir suspension
  • Xtampza ER(Prior Authorization Required)

Removals:

  • Epclusa
  • Epi Pen
  • Epi Pen jr.
  • Harvoni
  • Hysingla ER
  • Oxycontin
  • Tamiflu suspension
  • Technivie
  • Viekira
  • Viekira XR
  • Zepatier

Other Updates:

  • Suboxone Film (Removed Prior Authorization)
  • Vivitrol (Removed Prior Authorization)

 

December 2017

Additions:

  • Abacavir solution
  • Mavyret (Prior Authorization Required per AHCCCS)

Removals:

  • Ziagen Solution

Other Updates:

  • Tretinoin cream/gel (Removed Step Therapy per AHCCCS)

 

November 2017

Additions:

  • Humulin R U-500 added PA per AHCCCS
  • Fosamprenavir

Removals:

  • Lamotrigine IR QLL removed
  • Lexiva

Other Updates:

  • Lamotrigine IR (Removed Quantity Level Limit)

 

October 2017

Additions:

  • Aptensio XR (Age Edit, Quantity Level Limit)
  • Clonidine patch (Age Edit, Quantity Level Limit)
  • Doxepin HCL capsules and concentrate (Quantity Level Limit)
  • Doxylamine succinate 25mg
  • Enoxaparin (Quantity Level Limit)
  • Eszopiclone (Age Edit, Quantity Level Limit)
  • Lamotrogine XR
  • Meprobamate (Age Edit, Quantity Level Limit)
  • Novolog 100 unit/ml Flexpen
  • Novolog 100unit/ml cartridge
  • Novolog 100unit/ml vial
  • Novolog Mix 70/30 Flexpen
  • Novolog Mix 70/30 vial
  • Paroxetine solution (Quantity Level Limit)
  • Paxil suspension (Quantity Level Limit)
  • Pyridoxine 25mg
  • Silenor (Prior Authorization required)
  • Triazolam (Age Edit, Quantity Level Limit)
  • Vitamin B12 SL
  • Xarelto starter pack
  • Zolpidem CR (Prior Authorization Required)
  • Zolpidem SL (Prior Authorization Required)
  • Zolpimist (Prior Authorization Required)
  • Zolpimist (Prior Authorization Required)

Removals:

  • Diclegis
  • Lovenox
  • Metadate CD
  • Somnote (drug no longer marketed)

Other Updates:

  • Anxiolytics (Added Age Edit)
  • Bupropion tablets, XR, SR (Added Quantity Level Limit)
  • Buspirone (Added Age Edit)
  • Estazolam (Added Age Edit)
  • Flurazepam (Added Age Edit)
  • Hydroxyzine hcl tablets (Added Quantity Level Limit)
  • Hydroxyzine pamoate (Added Quantity Level Limit)
  • Hydroxyzine syrup (Added Quantity Level Limit)
  • Mirtazapine tab, ODT (Added Age Edit)
  • Nefazodone (Added Quantity Level Limit)
  • Rozerem (Added Age Edit)
  • Sertraline solution (Added Quantity Level Limit)
  • Temazepam (Added Age Edit)
  • Trazodone (Added Quantity Level Limit)
  • Tybost (Prior Authorization Removed)
  • Venlafaxine ER (Added Quantity Level Limit)
  • Venlafaxine IR (Added Quantity Level Limit)
  • Zaleplon (Added Age Edit)
  • Zolpidem (Added Age Edit)

 

September 2017

Additions:

  • Artificial tears ointment OTC
  • Mesalamine 1.2GM
  • Moxifloxacin 0.5% ophthalmic
  • Sevelamer

Removals:

  • Renvela
  • Vigamox

Other Updates:

  • Ceftriaxone inj. (Removed Quantity Level Limit)

 

August 2017

Additions:

  • Adcirca (Step Therapy Required - use sildenafil)
  • Albenza (Step Therapy Required - use ivermectin or pyrantel)
  • Corlanor (Step Therapy Required - use beta blocker AND ACEI or ARB)
  • Ergocal 2500 Unit cap
  • Extavia (Prior Authorization Required)
  • Isentress HD 600mg tablet
  • Letairis (Quantity Level Limit)
  • Lidocaine Patch (Prior Authorization Required)
  • Malathion (Step Therapy Required - permethrin or pyrethrin)
  • Melphalan 2mg
  • Multaq (Step Therapy Required - use other antiarrhythmics first)
  • Olopatadine 0.1% and 0.2% (Step Thearapy Required - use Ketotifen OTC)
  • Permethrin lotion1% (Quantity Level Limit)
  • Tracleer (Quantity Level Limit)

Removals:

  • Alkeran 2mg
  • Econazole cream
  • Potassium chloride 10%, 20% solution
  • Potassium chloride packet 20meq, 25meq
  • Ulesfia

 

July 2017

Additions:

  • Bydureon pen and vial (Prior Authorization Required)
  • Kombiglyze XR (Prior Authorization Required)
  • Lidocaine 3% (Step Thearapy Required - use Aspercreme OTC)
  • Lidocaine 5% (Step Thearapy Required - use Aspercreme OTC)
  • Onglyza (Prior Authorization Required)

 

June 2017

Additions:

  • Apriso
  • Desvenlafaxine ER (Prior Authorization Required, Age Limit)
  • Dofetilide (Prior Authorization Required

Removals:

  • Meloxicam liquid
  • Pristiq brand
  • Tikosyn brand

Other Updates:

  • Adapalene cream, gel (Added Step Therapy - use Differin Gel OTC)
  • Tretinoin cream, gel (Added Step Therapy - use Differin Gel OTC)

 

May 2017

Additions:

  • Odefsey

Other Updates:

  • Abilify Maintenna (Quantity Level Limit Added)
  • Abreva (Quantity Level Limit Removed)
  • Alendronate (Quantity Level Limit Removed)
  • Arcapta (Quantity Level Limit Removed)
  • Aristada QLL (Quantity Level Limit Added)
  • Desmopressin nasal spray (Quantity Level Limit Removed)
  • Estradiol patches (Quantity Level Limit Removed)
  • Estring (Quantity Level Limit Removed)
  • Fexofenadine (Quantity Level Limit Changed)
  • Medroxyprogesterone IM (Quantity Level Limit Removed)
  • Mupirocin cream (Quantity Level Limit Removed)
  • Paroxetine solution (Quantity Level Limit Removed)
  • Polyethylene glycol 3350 (Quantity Level Limit Removed)
  • Prenatal vitamins (Quantity Level Limit Removed)
  • Pseudoephedrine (Quantity Level Limit Removed)
  • Rimantadine (Quantity Level Limit Removed)
  • Risperidone Consta (Quantity Level Limit Added)
  • Sertraline solution (Quantity Level Limit Removed)
  • Spinosad suspension (Quantity Level Limit Removed)
  • Tretinoin topical (Quantity Level Limit Removed)
  • Vancomycin oral (Quantity Level Limit Removed)
  • Ventolin HFA (Quantity Level Limit Removed)

Some prescriptions require prior authorization from Mercy Care before they can be filled. Requests for medications requiring Prior Authorization (PA) will be reviewed based on the PA Guidelines/Criteria for that medication.

Medications that do not have a specific PA guideline will follow the Non-Formulary Medication Guideline. Additional information may be required on a case-by-case basis to allow for adequate review.

Mercy Care requires prior authorization for certain drugs on the Preferred Drug List and for all non-formulary drug requests.

You may now request prior authorization by calling 602-263-3000 or toll-free 1-800-624-3879, or you may print the required prior authorization form below and fax it along with supporting clinical notes to 1-800-854-7614.

If the drug you are requesting is not listed, please use the Non-Formulary PA request form. Most drugs will require use of the Non-Formulary PA form. If you would like a prior authorization request form faxed to you, please contact the Mercy Care Pharmacy Prior Authorization team at 602-263-3000 or toll free 1-800-624-3879.

These are fax forms for drugs in our prior authorization program. Select the drug name to download the prior authorization request form.

How to order specialty drugs for patients CVS Caremark Specialty Pharmacy offers medications that are not often available at local pharmacies for a variety of conditions, such as cancer, hemophilia, immune deficiency, multiple sclerosis and rheumatoid arthritis.

Specialty medications require prior authorization before they can be filled and delivered. These medications can be delivered to the provider’s office, member’s home or other location as requested.

For providers who prefer to purchase the specialty drug and bill through the member’s Medical Insurance:

  • Call 602-263-3000 or toll-free at 1-800-624-3879 to initiate prior authorization for the requested specialty medication. 

 For providers who prefer to bill through the member’s Pharmacy Insurance directly: 

Complete the applicable Pharmacy Prior Authorization form and fax it to 1-800-854-7614.

You work with patients every day, and there may be times when you believe we should add a drug to the formulary. If you want to ask for a change to Mercy Care’s Preferred Drug List (PDL), include the following information in your request:

  • Basic product information
  • Indications for use
  • Therapeutic advantage
  • Which drug(s) it would replace in the current PDL
  • Any supporting literature from medical journals

The requesting physician may be invited to attend the Pharmacy and Therapeutics Committee meeting to support the PDL addition request and answer questions.

Requests should be sent to: Aetna Corporate Pharmacy Director 4500 E. Cotton Center Blvd. Phoenix, AZ 85040

The Controlled Substance Prescription Monitoring Program (CSPMP) is a program developed to promote public health and welfare by detecting diversion, abuse, and misuse of prescription medications classified as controlled substances.  Every physician who possesses DEA registration is required to also possess a CSPMP registration.

  • Step 1: Register
    • Register for CSPMP.  Click on ‘Register now’ and fill out the ‘New Registration’ information.
  • Step 2: Verify
    • After you submit the registration form, you will receive a verification email with your CSPMP ID number and verification code.
    • Follow the email link to verify your email address.
  • Step 3: Login
    • Once you login, you will then be able to complete your registration profile with your CSPMP ID and DEA number.

Fill out the ‘Registration Details’ and certify that the application is complete and accurate, then ‘Print Certificate’.