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 RBHA 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 2/3/2020, 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.
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Formulary (covered medication list)
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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.
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Formulary updates
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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
November 2019
Additions:
- Aminocaproic Acid Sol 0.25gm/ml
Removals:
- Amicar Sol 0.25gm/ml
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 2019Additions:
- 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
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Pharmacy prior authorization guidelines
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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 04.01.2020)
- Botulinum Toxins (effective 04.01.2020)
- Colony Stimulating Factors (effective 04.01.2020)
- Cytokine and CAM Antagonists (effective 10.01.2019)
- Growth Hormone(effective 04.01.2020)
- Hemophilia (effective 02.04.2019)
- Hepatitis C (effective 01.30.2020)
- Hereditary Angioedema (effective 04.01.2020)
- Immune Globulins (effective 04.01.2020)
- Injectable Osteoporosis Agents(effective 04.01.2020)
- Multiple Sclerosis (effective 04.01.2020)
- Opioids (effective 12.02.2019)
- Smoking Cessation
- Step Therapy Prior Authorization Guidelines
- Sublocade (effective 04.01.2020)
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Pharmacy prior authorization forms
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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
- Afinitor-Afinitor Disperz
- Botulinum Toxins Updated 04.01.2020
- Calcitonin Gene-Related Peptide Receptor Antagonists New 04.01.2020
- Capecitabine
- Clozapine Under 18 Years Old
- Colony Stimulating Factors (ex: Neupogen, Fulphila, Udencya) Updated 04.01.2020
- Concomitant Antidepressant
- Concomitant Antipsychotic
- Cystic Fibrosis New 04.01.2020
- Cytokine and CAM Antagonists (ex: Enbrel, Humira)
- Dalfampridine (Ampyra) Updated 04.01.2020
- Daraprim
- Dose Optimization
- DPP4-Inhibitors
- Dupixent New 04.01.2020
- Erythropoiesis Stimulating Agents Updated 04.01.2020
- Gonadotropin Releasing Hormone Analogs New 04.01.2020
- Growth Hormone (Genotropin, Norditropin) Updated 04.01.2020
- Hemophilia
- Hepatitis C Updated 04.01.2020
- Hyaluronic Acid Derivatives Updated 04.01.2020
- Hyperlipidemia Medications
- Idiopathic Pulmonary Fibrosis Agents
- Increlex
- Injectable Osteoporosis (Tymlos, Evenity, Forteo, Prolia, zoledronic acid) New 04.01.2020
- Inlyta
- Interleukin-5 Antagonists
- Interferons
- Janus Associated Kinase Inhibitors (Inrebic, Jakafi) Updated 04.01.2020
- Long Acting Antipsychotic Injectables Under 18 Years Old
- Multiple Sclerosis Agents Updated 04.01.2020
- Nexavar
- Oncology - General
- Opioids Updated 04.01.2020
- Platelet Inhibitors (Brilinta and Zontivity)
- Premarin Vaginal Cream
- Pulmonary Arterial Hypertension Agents (Tracleer, Letairis, Adcirca, Sildenafil, Revatio susp) Updated 04.01.2020
- Revlimid
- Savella
- Second-Third Generation TKIs for CML
- Somatostatin Analogs (Sandostatin, Sandostatin LAR Depot, Signifor, Signifor LAR, Somatuline Depot, Octreotide)
- Spinraza
- Spravato
- Sutent
- Sylatron
- Tarceva
- Testosterone
- Thrombopoiesis Stimulating Products (Promacta, Nplate, Tavalisse)
- Tykerb
- Votrient
- Xolair
- Xyrem
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Electronic Prior Authorization (ePA)
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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
- Time saving
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Over-the-counter product list
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Specialty drugs
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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
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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)
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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’.