Prescription Drug Benefits

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

Download the Mercy Care formulary PDF Opens In New Window.

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

May 2019


  • Concerta Tab ER (Age Limit, Quantity Limit)
  • Erythrom Eth Sus 400/5ml
  • Ranolazine Tab 1000mg ER (Prior Authorization Required)
  • Sirolimus Sol 1mg/ml


  • EryPed 400 Sus 400/5ml
  • Methylphenidate Tab ER
  • Ranexa Tab 1000mg ER
  • Rapamune Sol 1mg/ml

Other Updates:

  • None


April 2019


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


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


March 2019


  • 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


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


February 2019


  • 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


  • 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


  • Albendazole 200mg tab added with Step


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


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


December 2018


  • 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


  • 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


  • 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


  • Albendazole added with STEP


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


October 2018


  • 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



  • 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



  • 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


  • Eliquis starter pack added with QLL 74/30days
  • Makena 275mg /1.1ml Auto Inj added with PA
  • Phosphorous 250mg powder for solution
  • Symtuza added with QLL #30/30days



  • Eurax PA removed



  • Eliquis starter pack QLL changed to 74/30days


August 2018


  • 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



  • 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



  • 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


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


  • Sevelamer
  • 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


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


  • Biltricide
  • Prevacid Solu Tab


May 2018


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


  • Norvir tablets

Other Updates:

  • Rosuvastatin (Prior Authorization Removed, Step Therapy Added)

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

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

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

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

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

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

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


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.

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’.