Pharmacy |

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

October 2019

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

September 2019

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

August 2019

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
Bosentan Tab For Oral Susp 32mg
Bupropion HCl Tab EERr 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
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
Prefest
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)

July 2019

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

June 2019

Additions:

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

Removals:

Abreva Cream 10%

Other Updates:

None

May 2019

Additions:

Concerta Tab ER (Age Limit, Quantity Level 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
Ranexa Tab 1000mg ER
Rapamune Sol 1mg/ml

Other Updates:

None

April 2019

Additions:

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

Removals:

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

March 2019

Additions:

Aminocaproic 500mg, 1000mg Tab
Carbidopa 25mg Tab
Cinacalcet HCL 30mg, 60mg, 90mg Tab added with PA
Mesalamine Supp 1000mg added with QL 30/30 days
Toremifene Citrate 60mg Tab added with PA

Removals:

Amicar 500mg, 1000mg Tab
Canasa 1000mg Supp
Fareston 60mg Tab
Norethin Ace & Estrad-FE (24)
Sensipar 30mg, 60mg, 90mg Tab

February 2019

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
Gammagard added with PA
Gammaked added with PA
Gamunex-C added with PA
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

January 2019

Additions:

Albendazole 200mg tab added with Step

Changes:

Celecoxib 50mg, 100mg caps QL 60/30 days

Removals:

Synagis 50mg/0.5mL solution
Synagis 100mg/mL solution
Albenza 200mg tab

December 2018

Additions:

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

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 Prior Authorization Guidelines (effective 10.01.2019)
Botulinum Toxins (effective 02.04.2019)
Colony Stimulating Factors (effective 08.01.2019)
Cytokine and CAM Antagonists (effective 10.01.2019)
Growth Hormone (effective 12.01.2018)
Hemophilia (effective 02.04.2019)
Hepatitis C (effective 10.01.2019)
Hereditary Angioedema (effective 02.04.2019)
Immune Globulins (effective 08.01.2019)
Injectable Osteoporosis Agents Prior Authorization Guidelines (effective 10.01.2018)
Multiple Sclerosis (effective 02.04.2019)
Opioids (effective 10.01.2019)
Smoking Cessation
Step Therapy Prior Authorization Guidelines

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.

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

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’.