Pharmacy

Mail order pharmacy services
Your patients don't have to leave their homes to get their medications. They can get their medications mailed to them. Or, if they prefer, they can get the medications mailed to their provider's office. They can start the mail-order process by completing a mail-order request form or signing up online.

By mail
They can call Mercy Care Member Services at 1-800-564-5465; (TTY/TDD 711) to request a mail-order form. Or, download a mail-order service form here: English | Spanish

Online
They can also register for mail order with CVS Caremark at www.caremark.com. Once they've registered, they can order refills, renew prescriptions and check their orders.

Prescription Drug Benefits Pharmacy Network Changes
Effective February 3, 2020, Mercy Care Medicaid members will be transitioned to a network with CVS Caremark that continues to meet member access requirements but may offer fewer pharmacy providers. As of February 3, 2020, Walgreens Pharmacy will no longer be in Mercy Care’s Medicaid pharmacy network.

Mercy Care network pharmacies include:

Any CVS Pharmacy^® (including those inside Target^® stores), Walmart, Safeway, Fry’s, Albertson’s and Sam’s Club
Most local neighborhood pharmacies
Many hospital pharmacies

Our Medicaid pharmacy network directory is available on our website at mercycareaz.org. Click on “Find a Provider/Pharmacy”. Please be aware that Walgreens pharmacies will still show in the directory until February 2.

Members may also contact Mercy Care Member Services for assistance in locating a pharmacy near them.

What this means to you:

If you electronically transmit or call in prescriptions for members, please be sure the pharmacy is not a Walgreens pharmacy on or after February 3, 2020.

If you have questions or require more information, please contact your Provider Relations representative.

IMPORTANT: Read this notice regarding pharmacy network changes

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.

Formulary (covered medication list)

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

Formulary updates

October 2021

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

September 2021

Additions:

None

Removals:

None

Other Updates:

None

August 2021

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

July 2021

Additions:

None

Removals:

BP Foam Aer 9.8%

Other Updates:

None

June 2021

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)

May 2021

Additions:

None

Removals:

None

Other Updates:

None

April 2021

Additions:

Removals:

Other Updates:

None

March 2021

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)

February 2021

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

January 2021

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)

December 2020

Additions:

None

Removals:

None

Other Updates:

None

November 2020

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)
Dimethyl Fumarate Capsule DR Starter Pack 120 Mg & 240 Mg (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:

Emtriva Cap 200mg
Tamiflu Cap 30mg
Tamiflu Cap 45mg
Tamiflu Cap 75mg
Tamiflu Susp 6mg/ml
Tecfidera Cap DR 120mg
Tecfidera Cap DR 240mg
Tecfidera Capsule DR Starter Pack 120 Mg & 240 Mg

Other Updates:

Linaclotide capsules (Step Therapy Updated)

October 2020

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

September 2020

Additions:

Removals:

None

Other Updates:

None

August 2020

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)

July 2020

Additions:

None

Removals:

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

Other Updates:

None

June 2020

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

May 2020

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

April 2020

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)

Pharmacy prior authorization guidelines

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.

Pharmacy prior authorization forms

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.

Universal Pharmacy Prior Authorization Request Form
Botulinum Toxins (Botox, Dysport, Mybloc, Xeomin)
Calcitonin Gene-Related Peptide Receptor Antagonists (Ajovy, Emgality, Aimovig, Nurtec, Ubrelvy, Vyepti)
Clozapine Under 18 Years Old
Colony Stimulating Factors (Neupogen, Fulphila, Udencya, etc)
Concomitant Antidepressant
Concomitant Antipsychotic
Corlanor
Cystic Fibrosis (Bethkis, Kitabis, Cayston, Kalydeco, Pulmozyme, etc)
Cytokine and CAM Antagonists (Enbrel, Humira, etc)
Dalfampridine (Ampyra)
Dupixent
Egrifta
Emflaza
Erythropoiesis Stimulating Agents (Aranesp, Epogen, Procrit, Retacrit, etc)
Gonadotropin Releasing Hormone Analogs (Lupron, Orilissa, Supprelin LA, etc)
Growth Hormone (Genotropin, Norditropin)
Hemophilia (Factor VIIa, Factor VIII, Factor IX, Novoseven, Hemlibra, etc)
Hepatitis C
Hyaluronic Acid Derivatives (Gel-One, Visco-3)
Idiopathic Pulmonary Fibrosis Agents (Esbriet, Ofev)
Injectable Osteoporosis (Tymlos, Evenity, Forteo, Prolia, zoledronic acid)
Interleukin-5 Antagonists (Cinqair, Fasenra, Nucala)
Interferons (Actimmune, Intron-A, Pegasys, etc)
Janus Associated Kinase Inhibitors (Inrebic, Jakafi)
Krystexxa
Long Acting Antipsychotic Injectables Under 18 Years Old
Monoamine Depletors (Austedo, Ingrezza, tetrabenazine)
Multiple Sclerosis Agents (Avonex, Betaseron, Copaxone, Gilenya, Glatopa 40mg, Rebif/Rebidose, etc)
Opioids
Pulmonary Arterial Hypertension Agents (Tracleer, Letairis, Adcirca, Sildenafil, Revatio susp)
Pyrimethamine (Daraprim)
Somatostatin Analogs and Somavert (Sandostatin, Sandostatin LAR Depot, Signifor, Signifor LAR, Somatuline Depot, Octreotide)
Spinraza
Spravato
Sublocade
Tepezza
Testosterone
Thrombopoiesis Stimulating Products (Promacta, Nplate, Tavalisse)
Xolair
Xyrem

Electronic Prior Authorization (ePA)

We are committed to making sure our providers receive the best possible information, and the latest technology and tools available.

We have partnered with CoverMyMeds® and SureScripts to provide you a new way to request a pharmacy prior authorization through the implementation of Electronic Prior Authorization (ePA) program.

With Electronic Prior Authorization (ePA), you can look forward to:

Time saving
- Decreasing paperwork, phone calls and faxes for requests for prior authorization
Quicker Determinations
- Reduces average wait times, resolution often within minutes
Accommodating & Secure
- HIPAA compliant via electronically submitted requests Getting started is easy. Choose ways to enroll:
- No cost required! Let us help get you started!

Visit the CoverMyMeds® website
Call CoverMyMeds® toll-free at 866-452-5017
Visit the SureScripts website
Call SureScripts toll-free at 866-797-3239

Billing Information:

BIN: 610591

PCN: ADV

Group: RX8805

Over-the-counter product list

Over-the-counter product list

Specialty drugs

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.

Click here for the Specialty Drug List

CVS/Coram pharmacy enrollment form

Adding a new drug to the formulary

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

Controlled Substance Prescription Monitoring Program (CSPMP)

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

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’.

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