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. Patients will ask you to write a prescription for up to a 90-day supply with up to one year of refills. They can start the mail-order process by completing a mail-order request form or signing up online.

By mail
Members can call Mercy Care Member Services at 1-800-624-3879; (TTY 711) to request a mail-order form. Or, download a mail-order service form here: English | Spanish

Online
Members 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
Members must fill their medications at a network pharmacy. Dual-eligible members have different options.

Mercy Care Medicaid 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

If you electronically transmit or call in prescriptions for members, be sure the pharmacy is not a Walgreens pharmacy. Members can contact Mercy Care Member Services for assistance in locating a pharmacy near them.

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. 

 

Use the 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 2022

Additions:

  • Accutane Cap 10mg
  • Accutane Cap 20mg
  • Accutane Cap 30mg
  • Accutane Cap 40mg
  • Amnesteem Cap 10mg
  • Amnesteem Cap 20mg
  • Amnesteem Cap 40mg
  • Flonase Nasal Suspension 50mcg/act
  • Histex PD Liquid 0.938mg/Ml (OTC)

 Removals:

  • N/A

 Other Updates:

  • N/A

 

November 2022

Additions:

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

 Removals:

  • N/A

 Other Updates:

  • N/A

  

October 2022

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)

 

September 2022

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:

  • Avastin Solution 25mg/mL
  • Herceptin Solution 150mg
  • Herceptin Solution 440mg
  • Ontruzant Solution 150mg
  • Ontruzant Solution 420mg
  • Rituxan Solution 10mg/mL

 Other Updates:

  • None

 

August 2022

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:

  • Amcinonide Ointment 0.1%
  • Lidocaine Jelly 2%
  • Memantine Hcl Tablet Titration Pack
  • Metronidazole Capsule 375mg
  • Mometasone Furoate Nasal Spray 50mcg
  • Selenium Sulfide Shampoo 2.25%
  • Vemlidy Tablet 25mg

Other Updates:

  • None

 

July 2022

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

 

June 2022

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

 

May 2022

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

April 2022

Additions:

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

Removals:

  • Acyclovir Oint 5%

Other Updates:

  • None

 

March 2022

Additions:

  • Diclofenac Gel Otc 1% (Quantity Limit)

Removals:

  • None

Other Updates:

  • None

 

February 2022

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)

 

January 2022

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
  • Efavirenz/Lamivudine/Tenofovir
  • 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)

 

December 2021

Additions:

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

Removals:

  • Afinitor 3mg
  • Afinitor 5mg
  • Afinitor 10mg

 Other Updates:

  • None

 

November 2021

Additions:

  • Kloxxado 8mg

 Removals:

  • None

 Other Updates:

  • None

 

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)
  • Avsola 100mg Vial (Prior Authorization Required)
  • Cafergot Tablet 1-100mg (Brand Only)
  • Enbrel 25mg/0.5ml Vial (Prior Authorization Required)
  • Ivermectin 3mg Tablet (Quantity Limit)
  • 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)
  • Ritalin LA 10mg Capsule (Brand Only)
  • Ritalin LA 20mg Capsule (Brand Only)
  • Ritalin LA 30mg Capsule (Brand Only)
  • Ritalin LA 40mg Capsule (Brand Only)
  • Ubrelvy 100mg Tablet (Prior Authorization Required)
  • Ubrelvy 50mg Tablet (Prior Authorization Required)

 Removals:

  • Aptensio XR 10mg Capsule
  • Aptensio XR 15mg Capsule
  • Aptensio XR 20mg Capsule
  • Aptensio XR 30mg Capsule
  • Aptensio XR 40mg Capsule
  • Aptensio XR 50mg Capsule
  • Aptensio XR 60mg Capsule
  • Bevespi Aerosphere Inhaler 9-4.8mcg/act
  • Depo-Provera 400mg/ml Vial
  • Gvoke Hypopen 1mg/0.2ml
  • Humulin N 100Unit/ml Kwikpen
  • Humalog Mix 50-50 Kwikpen
  • Methylphenidate LA 60mg Capsule
  • Norethindrone 5mg Tablet
  • Renflexis 100mg Vial
  • Vyvanse 10mg Chewable Tablet
  • Vyvanse 20mg Chewable Tablet
  • Vyvanse 30mg Chewable Tablet
  • Vyvanse 40mg Chewable Tablet
  • Vyvanse 50mg Chewable Tablet
  • Vyvanse 60mg Chewable Tablet

 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%
  • Vitamax Pediatric Sol oral

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:

  • Alkeran 2mg Tablet (Prior Authorization Required)
  • Androgel 1% (25 Mg/2.5 G) Pkt (Prior Authorization Required)
  • Androgel 1% (50 Mg/5 G) Pkt (Prior Authorization Required)
  • Androgel 1.62% Gel Pump (Prior Authorization Required)
  • Androgel 1.62%(1.25g) Gel Pckt (Prior Authorization Required)
  • Androgel 1.62%(2.5g) Gel Pckt (Prior Authorization Required)
  • Apriso ER 0.375 Gram Capsule
  • Brinzolamide Sus 1% (Step Therapy Required)
  • Canasa 1,000mg Suppository
  • Delzicol Dr 400mg Capsule
  • Gammaked Solution 10 GM/100mL (Prior Authorization Required)
  • Gleevec 100mg Tablet (Prior Authorization Required)
  • Gleevec 400mg Tablet (Prior Authorization Required)
  • Hizentra 1 Gram/5ml Syringe (Prior Authorization Required)
  • Hizentra 2 Gram/10ml Syringe (Prior Authorization Required)
  • Hizentra 4 Gram/10ml Syringe (Prior Authorization Required)
  • Invokamet 150-1,000mg Tablet (Prior Authorization Required)
  • Invokamet 150-500mg Tablet (Prior Authorization Required)
  • Invokamet 50-1,000mg Tablet (Prior Authorization Required)
  • Invokamet 50-500mg Tablet (Prior Authorization Required)
  • Lialda Dr 1.2gm Tablet
  • Nivestym 300mcg/0.5ml Syringe (Prior Authorization Required)
  • Nivestym 480mcg/0.8ml Syringe (Prior Authorization Required)
  • Nyvepria 6mg/0.6ml Syringe (Prior Authorization Required)
  • Ofloxacin 0.3% Ear Drops
  • Privigen 10 GM/100mL Vial (Prior Authorization Required)
  • Privigen 10% Vial (Prior Authorization Required)
  • Privigen 20 GM/200mL Vial (Prior Authorization Required)
  • Privigen 5 GM/50mL Vial (Prior Authorization Required)
  • Sfrowasa 4gm/60ml Enema
  • Synjardy 12.5-1,000mg Tablet (Prior Authorization Required)
  • Synjardy 12.5-500mg Tablet (Prior Authorization Required)
  • Synjardy 5-1,000mg Tablet (Prior Authorization Required)
  • Synjardy 5-500mg Tablet (Prior Authorization Required)
  • Trijardy XR 10-5-1,000mg Tab (Prior Authorization Required)
  • Trijardy XR 12.5-2.5-1,000mg (Prior Authorization Required)
  • Trijardy XR 25-5-1,000mg Tab (Prior Authorization Required)
  • Trijardy XR 5-2.5-1,000mg Tab (Prior Authorization Required)
  • Trulicity 0.75mg/0.5ml Pen (Prior Authorization Required)
  • Trulicity 1.5mg/0.5ml Pen (Prior Authorization Required)
  • Trulicity 3mg/0.5ml Pen (Prior Authorization Required)
  • Trulicity 4.5mg/0.5ml Pen (Prior Authorization Required)
  • Xigduo XR 10mg-1,000mg Tab (Prior Authorization Required)
  • Xigduo XR 10mg-500mg Tablet (Prior Authorization Required)
  • Xigduo XR 2.5mg-1,000mg Tab (Prior Authorization Required)
  • Xigduo XR 5mg-1,000mg Tablet (Prior Authorization Required)
  • Xigduo XR 5mg-500mg Tablet (Prior Authorization Required)

Removals:

  • Azopt Sus 1%
  • Balsalazide Disodium 750mg Cp
  • Bivigam 5 GM/50mL Vial
  • Dipentum 250mg Capsule
  • Gamastan S-D Vial
  • Imatinib Mesylate 100mg Tablet
  • Imatinib Mesylate 400mg Tablet
  • Mesalamine 1,000mg Suppository
  • Mesalamine 4 gm/60ml Enema
  • Mesalamine 800 mg DR Tablet
  • Mesalamine DR 1.2gm Tablet
  • Mesalamine DR 400mg Capsule
  • Mesalamine ER 0.375 Gram Capsule
  • Santyl Oin 250u/gm
  • Testosterone 1% (25 Mg/2.5 G) Pkt
  • Testosterone 1% (50 Mg/5 G) Pkt
  • Testosterone 1.62% Gel Pump
  • Testosterone 1.62%(1.25g) Gel Pckt
  • Testosterone 1.62%(2.5g) Gel Pckt
  • Testosterone 12.5mg/1.25 Gram
  • Testosterone 30mg/1.5ml Pump

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:

  • Aimovig Inj 70mg/ml
  • Aimovig Pen 140mg/ml
  • Artificial Tears 1% Solution
  • Dyanavel XR Sus 2.5mg/ml
  • Insulin Lispro Junior Kwikpen
  • Insulin Lispro Protamine Mix Kwikpen
  • Novolin 70/30 Vial
  • Psyllium Powder 30%
  • Psyllium Powder 33%
  • Psyllium Powder 49%
  • Quillichew Chw 20mg ER
  • Quillichew Chw 30mg ER
  • Quillichew Chw 40mg ER
  • Quillivantxr Sus 25mg/5ml
  • Symfi Lo Tablet 400-300-300mg
  • Symfi Tablet 600-300-300mg
  • Symjepi Inj 0.15mg
  • Symjepi Inj 0.3mg

Other Updates:

  • None

 

September 2020

Additions:

  • Cyclophosph Cap 25mg
  • Cyclophosph Cap 50mg
  • Erivedge Cap 150mg (Prior Authorization Required)
  • Abiraterone Tab 250mg (Prior Authorization Required)
  • Venclexta Tab 10mg (Prior Authorization Required)
  • Venclexta Tab 50mg (Prior Authorization Required)
  • Venclexta Tab 100mg (Prior Authorization Required)
  • Venclexta Tab Start Pk (Prior Authorization Required)
  • Tafinlar Cap 50mg (Prior Authorization Required)
  • Tafinlar Cap 75mg (Prior Authorization Required)
  • Rydapt Cap 25mg (Prior Authorization Required)
  • Mekinist Tab 0.5mg (Prior Authorization Required)
  • Mekinist Tab 2mg (Prior Authorization Required)
  • Gilotrif Tab 20mg (Prior Authorization Required)
  • Gilotrif Tab 30mg (Prior Authorization Required)
  • Gilotrif Tab 40mg (Prior Authorization Required)
  • Alecensa Cap 150mg (Prior Authorization Required)
  • Zykadia Cap 150mg (Prior Authorization Required)
  • Jakafi Tab 5mg (Prior Authorization Required)
  • Jakafi Tab 10mg (Prior Authorization Required)
  • Jakafi Tab 15mg (Prior Authorization Required)
  • Jakafi Tab 20mg (Prior Authorization Required)
  • Jakafi Tab 25mg (Prior Authorization Required)
  • Kalydeco Tab 150mg (Prior Authorization Required)
  • Kalydeco Pak 25mg (Prior Authorization Required)
  • Kalydeco Pak 50mg (Prior Authorization Required)
  • Kalydeco Pak 75mg (Prior Authorization Required)
  • Ofev Cap 100mg (Prior Authorization Required)
  • Ofev Cap 150mg (Prior Authorization Required)
  • Austedo Tab 6mg (Prior Authorization Required)
  • Austedo Tab 9mg (Prior Authorization Required)
  • Austedo Tab 12mg (Prior Authorization Required)
  • Soliris Inj 10mg/Ml (Prior Authorization Required)
  • Lenvima Cap 4mg (Prior Authorization Required)
  • Lenvima Cap 8 Mg (Prior Authorization Required)
  • Lenvima Cap 10 Mg (Prior Authorization Required)
  • Lenvima Cap 12mg (Prior Authorization Required)
  • Lenvima Cap 20 Mg (Prior Authorization Required)
  • Lenvima Cap 14 Mg (Prior Authorization Required)
  • Lenvima Cap 18 Mg (Prior Authorization Required)
  • Lenvima Cap 24 Mg (Prior Authorization Required)
  • Repatha Push Inj 420/3.5 (Prior Authorization Required)
  • Repatha Inj 140mg/ml (Prior Authorization Required)
  • Xolair Inj 75/0.5 (Prior Authorization Required)
  • Xolair Inj 150mg/ml (Prior Authorization Required)
  • Symdeko Tab 50-75mg (Prior Authorization Required)
  • Symdeko Tab 100-150 (Prior Authorization Required)

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)

 

March 2020

Additions:

  • None

Removals:

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

Other Updates:

  • None

 

February 2020

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)

 

January 2020

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:

  • Calc Acetate Tab 668mg
  • Clobetasol Lot 0.05%
  • Fluocinolone Acet Oil 0.01% Body
  • Fluocinolone Acet Oil 0.01% Sc
  • Nadolol Tab 20mg
  • Nadolol Tab 40mg
  • Nadolol Tab 80mg
  • Nadolol/Bend Tab 40-5mg
  • Renagel Tab 800mg
  • Renagel Tab 400mg
  • Renvela Tab 800mg
  • Scalpicin Sol 1%
  • Sumatriptan Inj 6mg/0.5
  • Sumatriptan  Spr 20mg/Act
  • Sumatriptan  Spr 5mg/Act
  • Verapamil Cap 360mg Sr

Other Updates:

  • None

 

December 2019

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

 

November 2019

Additions:

  • Aminocaproic Acid Sol 0.25gm/ml

Removals:

  • Amicar Sol 0.25gm/ml

Other Updates:

  • None

 

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

Other Updates:

  • None

 

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:

  • Benziq Wash Liq 5.25%
  • Bio-Statin Cap 1000000
  • Bio-Statin Cap 500000 U
  • Bio-Statin Pow
  • Bocasal Pow
  • Calcium Carb Pow Ppt/Heav
  • Cuprimine Capsule
  • Delzicol Cap 400mg DR
  • Ergocal Cap 2500unit
  • Fluorabon Dro
  • Fluoroplex Cre 1%
  • Flura-Drops Dro 4drp=1mg
  • Gentamicin Pow Sulfate
  • Homatropine Sol 5% Op
  • Nature-Throi Tab 2gr
  • Revatio Sus 10mg/ml
  • Sod Fluoride Tab 0.5mg F
  • Sod Fluoride Tab 1mg F
  • Suprax Cap 400mg
  • Tarceva Tab 150mg

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:

  • 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

Removals:

  • Sevelamer
  • 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 don't have a specific PA guideline will follow the AHCCCS Fee-For-Service Prior Authorization Criteria for Non-Preferred Drugs. Additional information may be required on a case-by-case basis to allow for adequate review.

Here are the guidelines for:

AHCCCS Fee-For-Service Program Pharmacy Prior Authorization Criteria - Effective December 1, 2022

 

Mercy Care Prior Authorization Guidelines

Advair Diskus

Alphanate-Humate

Anoro Ellipta

Botulinum Toxins

Celecoxib

Cinacalcet

Concomitant Antipsychotic Under Age 18

Diabetic Testing Supplies

Dulera

Erythromycin Ethylsuccinate Suspension

Hemophilia

Imcivree

Injectable Osteoporosis Agents (Prolia, Evenity, Zoledronic Acid)

Krystexxa

Lyrica

OmniPod

Ondansetron Oral Solution

Onychomycosis

Opioids 5-Day Supply Limit

Oral Liquids

Pegasys for Hepatitis B

Savella

Smoking cessation 

Step Therapy Prior Authorization Guidelines (PDF)

Tepezza

Viscosupplements

Xifaxan

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

You can 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. You can get a prior authorization request form faxed to you, just contact the Mercy Care Pharmacy Prior Authorization team at 602-263-3000 or 1-800-624-3879. You can also submit the request via electronic prior authorization (ePA) through CoverMyMeds® and SureScripts. See the Electronic Prior Authorization (ePA) section below for additional information.

These are fax forms for drugs in our prior authorization program. Select the drug name to download the prior authorization request form. If the drug you're requesting is not listed, please use the Universal Pharmacy Prior Authorization Form. Most drugs will require use of the Universal Pharmacy Prior Authorization 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!

Billing Information:

BIN: 610591

PCN: ADV

Group: RX8805

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

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’.

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

These links provide access to our formulary JSON files which can be downloaded by third parties and used to review data. Files meet CMS standards and regulations.

JSON - Mercy Care Formulary