Pharmacy |

You now have the ability to use the new Formulary Search Tool to find out which medications are on the formulary drug lists. You can search by drug name or drug class. The search tool will show formulary status, generic alternatives and if there are any requirements, such as prior authorization, quantity limits or age limits. The formularies can change.

Download the Mercy Care Formulary

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)
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
Levonor/ethi tab estradio
Lidocaine/hc kit 20x7gm
Lidocaine/hc kit 3%-1%
Lo Loestrin tablet
Nitro-bid 2% packets
Prenatal multivitamins & minerals w/ l-methylfolate-fa 0.6-0.4mg chew tab
Prenatal mv & min w/fe polysaccharide complex-fa-dha 29-1mg & 250mg pack
Prenatal vit w/ ferrous fumarate-folic acid 65-1mg tab
Prenatal vit w/ ferrous fumarate-l methylfolate-folic acid 27-0.6-0.4mg tab
Prenatal vit w/ iron carbonyl-fe aspart glyc-fa-omega 3 27-1mg cap
Prenatal vit w/ iron carbonyl-folic acid 50-1.25mg tab
Prenatal vit w/ iron polysaccharide complex-folic acid 29-1 chew tab
Prenatal w/o vit a w/ fe carbonyl-fe asp glyc-methfol-fa-dha 18-0.6-0.4-350mg cap
Prenatal w/o vit a w/ fe carbonyl-fe gluconate-dss-fa-dha 27-1mg & 250mg pack
Prenatal w/o vit a w/ fe fumarate-dss-fa-dha 27-1.25-300mg cap
Prenatal without a w/ fe fumarate-l methylfolate-fa-dha 27-0.6-0.4-300mg cap
Prenatal without a w/ fe fumarate-l methylfolate-fa-omega 3 28-0.6-0.4-340mg cap
Synjardy and Synjardy XR tablet
Terconazole vaginal suppos 80 mg
Trimethobenzamide hcl cap 300 mg

January 2019

Additions:

Albendazole 200mg tab added with Step

Changes:

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

Removals:

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

December 2018

Additions:

Changes:

Famciclovir 125mg, 250mg, 500mg tabs added with PA
Femring 0.05mg/24hr added with PA
Femring 0.1mg/24hr added with PA
Testosterone 40.5mg/2.5gm (1.62%) gel added with PA
Travatan Z 0.0004% opth solution added with PA

Removals:

Advanced Allergy Kit 2.5%
Armour Thyroid 1.5GR Tab
Armour Thyroid 1/2GR Tab
Armour Thyroid 1/4GR Tab
Armour Thyroid 1GR Tab
Armour Thyroid 2GR Tab
Benazepril-HCTZ 5-6.25mg tab
BPO 4% gel
Carafate 1gm/10mL suspension
Lanoxin 0.125mg Tab
Lanoxin 0.25mg Tab
Lotrimin 2% AF Aerosol
Menest 2.5mg tab
MG217 Psoriasis Anti-itch 1% gel
MultiNatal Plus 30-1mg tab
MultiNatal Plus 40-1mg chew
Omeprazole-Sodium Bicarbonate 20-1100mg cap
Sulfacetamide Sodium-Sulfur 10-5% emulsion

November 2018

Additions:

Albendazole added with STEP

Removals:

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

October 2018

Additions:

Arcapta added with QLL 30capsules for inhalation per 30days
Aristada Initio added with QLL 2 per year, age < 18 requires PA
Atomoxetine capsules
Cyanocobalamin injection
Dutasteride 0.5mg
Fluocinonide cream
Glatopa 40mg added with PA
Loratadine chew 5mg added with QLL 60/30days
Lotrimin Ultra cream
Metoprolol 75mg tab
Prasugrel added with QLL 30/30days
Procrit added with PA
Striverdi Respimat added with QLL 1 inhaler per 30days
Tadalafil added with step
Tazarotene 0.1% cream added with QLL 90gm/30days
Tymlos added with PA and QLL 1 pen/30days
Vyvanse chewable tablets added with QLL 30/30days

Removals:

Acebutolol cap
Adcirca
Alclometasone dip cream and ointment
Betamethasone dp Aug lotion, gel and ointment
Betamethasone dp cream, ointment
Cardura XL
Ciclopirox gel and shampoo
Clobetasol foam, lotion, gel, shampoo
Clotrimazole/betamethasone lotion
Copaxone 40mg
Desonide cream, lotion, ointment
Diltiazem 24hr ER tab
Flucytosine
Fluocinolone solution, cream, ointment
Fluocinonide E 0.05% cream
Fluticasone prop lotion
Griseofulvin ultra
Hydrocortisone butyr cream, ointment
Hydrocortisone val cream, ointment
Isradipine
Itraconazole
Ketoconazole tab
Methylphenidate chew tabs
Nicardipine
Nimodipine
Nisoldipine
Noxafil
Nystatin topical powder
Pindolol
Prednicarbate ointment
Strattera
Timolol tab
Triamcinolone spray
Trianex oil
Voriconazole

Changes:

Antipsychotics: PA removed for Acute (ACC), age edits and QL still apply
Ondansetron 4mg QLL changed to 90/30days
Valgancyclovir PA removed, added QLL 60/30days

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:

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:

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

Removals:

Fosrenol
Estazolam
Flurazepam
Triazolam
Eszopiclone
Zaleplon
Zolpidem ER
Zolpidem SL
Zolpimist
Silenor
Meprobamate
Mephyton
Foradil
Arcapta
Albuterol solution (Step Therapy) removed
Metaproterenol
Striverdi
Zafirlukast

Other Updates:

Rizatriptan (Quantity Level Limit) changed from 12/30days to 9/30days
Montelukast granules changed to (Prior Authorization) required for (Age Limit) > 4
Rozerem- must use temazepam and zolpidem first
Sildenafil specialist requirement removed

June 2018

Additions:

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

Removals:

Biltricide
Sensipar removed smart edit for specialist

May 2018

Additions:

Colchicine capsules
Firvanq
Jardiance (Step Thearapy Required)
Ritonavir tablets
Symfilo
Synjardy, Synjardy XR (Step Thearapy 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:

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:

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 Ed

it, 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 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!

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

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’.