Mercy Care home

Pharmacy benefits

We cover a wide range of prescription and over-the-counter (OTC) medications to help keep our members as healthy as they can be. Members can fill prescriptions at any network pharmacy.

Covered medications

Covered medications

Prescription medications

We cover the prescription medications on our formulary/preferred drug list or PDL (PDF) and ACC-RBHA with SMI preferred drug lists. If your patient needs medication, you’ll want to check the right list for:

Covered medications
Step therapy requirements
Prior authorization (PA) requirements

Quantity or age limits
Updates

These lists can change, so check them regularly. If a medication isn’t on the formulary, you can:

Prescribe a similar one that’s on the list

Get PA for coverage

Check the information that follows to learn about drug lists for each plan. Still not sure if we cover a specific medication? Just contact us. We can check it for you.

You can download the formulary/preferred drug list or PDL (PDF) or check it online with the formulary search tool. 

You can also see a list of over-the-counter products (PDF) we cover.

In emergencies, we may be able to provide a limited supply for medications that aren’t on these lists.

These lists are based on the Arizona Health Care Cost Containment System (AHCCCS)-approved drug list. The medications are generally covered under the plan when medically necessary. Members can fill their prescriptions at any network pharmacy.

You’ll want to review these preferred drug lists for any restrictions or recommendations before prescribing medication to members of Mercy Care ACC-RBHA with SMI.

Behavioral Health Preferred Drug List (PDF) (updated quarterly): behavioral health medications for members who qualify under:
- Non-Title 19/21 determined to have a serious mental illness (SMI)
- Non-Title 19/21 children with a serious emotional disturbance (SED)

Use the Behavioral Health Preferred Drug List Search Tool to find out if a certain medication is on the list.

Integrated Preferred Drug List (PDF) (updated quarterly): behavioral and physical health medications for Title 19/21 SMI members

Use the Integrated Preferred Drug List Search Tool to find out if a certain medication is on the list.

Crisis Medication List (PDF): medications that help stabilize members in crisis and bridge them to a follow-up outpatient appointment. We cover up to a 7-day supply of drugs on this list with 1 refill. This list is for adults or children who are Non-Title 19/21 and Non-SMI who present in crisis at any Maricopa County:
- Facility-based psychiatric urgent care centers
- Detox facilities
- Access point
Substance Abuse Block Grant Medication List (PDF): For Non-Title 19/21 members with SUDs and primary substance use and misuse.

In emergencies, we may be able to provide a limited supply for medications that aren’t on these lists.

Need to learn more about pharmacy benefits? Check your provider manual and other plan materials. Or call 602-586-1841 or 1-800-564-5465 (TTY 711). We’re here for you 24 hours a day, 7 days a week.

Specialty medications

Not all pharmacies carry specialty medications. CVS Specialty® offers medications for a variety of conditions, like:

Cancer
Hemophilia
Immune deficiency
Multiple sclerosis

Rheumatoid arthritis

Members can choose delivery to their home, provider’s office or other convenient location. They can also call CVS Specialty pharmacy at 1-800-237-2767 (TTY 711) with questions.

If you bill through members’ medical insurance (your practice purchases the specialty medications): Contact us by plan to start PA for the requested specialty medication. 
If you bill through members’ pharmacy benefit directly: Complete the right PA form. You can find PA forms in the next section. Then, fax the form to the number on the form.

You can also check the specialty drug list (PDF). Or find the CVS Specialty and Coram® pharmacy enrollment forms.

Pharmacy PA

Some prescriptions require PA from Mercy Care before members can fill them. We’ll review requests for medications requiring PA based on the PA guidelines and criteria for that medication.

AHCCCS Fee-For-Service Prior Authorization Criteria for Non-Preferred Drugs (PDF): For medications not on the fomulary and don't have a specific PA guideline
AHCCCS Fee-For-Service Prior Authorization Criteria for Preferred Drugs (PDF): For medications on the formulary but don't have a specific PA guideline

We may need more information on a case-by-case basis to allow for adequate review.

We can also fax you the right form. Just contact us by plan.

By phone: Just contact us by plan.

By fax: Print the right PA form and fax it to the number at the top of each form. Be sure to include your supporting clinical notes.

Online with electronic PA (ePA): You need the right tools and technology to help our members. That’s why we’ve partnered with CoverMyMeds® and Surescripts to provide electronic pharmacy PA requests.

Billing for Mercy Care ACC-RBHA, DCS CHP, Long Term Care and Developmental Disabilities

There is no cost for ePA and getting started is easy. You’ll need this information to enroll:

BIN: 610591
PCN: ADV
Group: RX8805

Billing for Mercy Care ACC-RBHA with SMI

BIN: 610591
PCN: ADV
Group: RX8822

Choose ways to enroll:

Visit CoverMyMeds or call 1-866-452-5017

Visit SureScripts or call 1-866-797-3239

Here are the guidelines for: AHCCCS Fee-For-Service Program Pharmacy Prior Authorization Criteria (PDF), effective November 1, 2023.

Mercy Care PA guidelines (* also applies to Non-Title 19/21 Non-SMI members) for:

These PA forms are for Mercy Care ACC-RBHA. Choose the right form by finding the drug name. Then, you can download the form, print, complete and fax it back to us.

These PA forms are for Mercy Care ACC-RBHA with SMI. Choose the right form by finding the drug name. Then, you can download the form, print, complete and fax it back to us.

Title 19/21 serious mental illness (SMI) PA forms

Physical and behavioral health

Non-Title 19/21 SMI or Non-Title 19/21 SED PA request forms

Behavioral health

These PA forms are for Mercy Care DCS CHP. Choose the right form by finding the drug name. Then, you can download the form, print, complete and fax it back to us.

These PA forms are for Mercy Care Long Term Care. Choose the right form by finding the drug name. Then, you can download the form, print, complete and fax it back to us.

These PA forms are for Mercy Care Developmental Disabilities. Choose the right form by finding the drug name. Then, you can download the form, print, complete and fax it back to us.

More pharmacy info

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

When members take maintenance medication for an ongoing health condition, they can get it by mail. We work with CVS Caremark® to provide this service at no extra cost. Each order is checked for safety. And members can speak with a pharmacist anytime on the phone. 

To get started, members will need their:

Plan member ID card
Mailing address, including ZIP code

Provider’s first and last name and phone number
List of allergies and other health conditions
Original prescription from their provider (if they have it)

Mail service makes it easy

Members can sign up for mail service:

Online

Members can visit CVS Caremark and sign in or register (for new users). Then, they can order refills, renew prescriptions and check their orders.

By mail

Members will ask you to write a prescription for a 90-day supply with up to one year of refills. Then, they can fill out a mail service order form English (PDF) | Español (PDF). Or, they can contact us and we’ll send them a form. Members can mail the completed form, along with their prescription, to the address on the form.

Mercy Care network pharmacies include:

Any CVS Pharmacy® (including those inside Target® stores), Walmart®, Safeway®, Fry’s®, Albertsons® and Sam’s Club®
Most local neighborhood pharmacies
Many hospital pharmacies

Walgreens® is no longer in our Medicaid pharmacy network (since February 2020). If you electronically transmit or call in prescriptions for members, be sure the pharmacy is NOT Walgreens.

Find a pharmacy

You can see our Medicaid pharmacy network directory. Just go to the top of this page. Then, choose “Find a provider.” Members can also contact us for help finding a pharmacy near them.

E-Prescribing (PDF)

Drugs with QT Prolonging Effects (PDF)

Lab Monitoring (PDF)

Informed Consent (PDF)

CSPMP promotes public health and welfare by detecting diversion, abuse and misuse of prescription medications classified as controlled substances. If you have a DEA registration, you’re also required to have a CSPMP registration.

Register: Go to CSPMP. 
Verify. After you submit the registration form, you’ll receive a verification email with your CSPMP ID number and verification code. Follow the email link to verify your email address.
Log in. Then, you’ll 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.

You can ask for a change or addition to our formulary. Be sure to include this information in your request:

Basic product information

Indications for use
Therapeutic advantage
Which medication it would replace in the current formulary, if any
Any supporting literature from medical journals

Send your request in writing to:

Aetna Corporate Pharmacy Director

4500 E. Cotton Center Blvd.

Phoenix, AZ 85040

December 2023

Additions:

None

Removals:

None

Other Updates:

None

November 2023

Additions:

Omnitrope 5.8 mg solution (Prior Authorization)
Omnitrope cartridge 10 mg per 1.5mL solution (Prior Authorization)
Omnitrope cartridge 5 mg per 1.5mL solution (Prior Authorization)
Zomactron 10 mg solution (Prior Authorization)
Zomactron 5 mg solution (Prior Authorization)

Removals

Proctofoam HC 1% to 1% rectal foam

Other updates

Haloperidol 0.5 mg tablet (age limit updated)
Haloperidol 1 mg tablet (age limit updated)
Haloperidol 10 mg tablet (age limit updated)
Haloperidol 2 mg tablet (age limit updated)

Haloperidol 20 mg tablet (age limit updated)
Haloperidol 5 mg tablet (age limit updated)
Haloperidol lactate 2 mg per mL oral concentrate (age limit updated)
Haloperidol lactate 5 mg per mL solution injection (age limit updated)
Loxapine succinate 10 mg capsule (age limit updated)

Loxapine succinate 25 mg capsule (age limit updated)
Loxapine succinate 5 mg capsule (age limit updated)
Loxapine succinate 50 mg capsule (age limit updated)
Nayzilam 5mg per 0.1 mL nasal spray (quantity limit updated, age limit added)
Perphenazine 16 mg tablet (age limit updated)

Perphenazine 2 mg tablet (age limit updated)
Perphenazine 4 mg tablet (age limit updated)
Perphenazine 8 mg tablet (age limit updated)
Pimozide 1 mg tablet (age limit updated)
Pimozide 2 mg tablet (age limit updated)

Thioridazine HCl 10 mg tablet (age limit updated)
Thioridazine HCl 100 mg tablet (age limit updated)
Thioridazine HCl 25 mg tablet (age limit updated)
Thioridazine HCl 50 mg tablet (age limit updated)
Thiothixene 1 mg capsule (age limit updated)

Thiothixene 10 mg capsule (age limit updated)
Thiothixene 2 mg capsule (age limit updated)
Thiothixene 5 mg capsule (age limit updated)
Trifluoperazine HCl 1 mg tablet (age limit updated)
Trifluoperazine HCl 10 mg tablet (age limit updated)

Trifluoperazine HCl 2 mg tablet (age limit updated)
Trifluoperazine HCl 5 mg tablet (age limit updated)
Valtoco 10 mg nasal spray (quantity limit updated, age limit added)
Valtoco 15 mg nasal spray (quantity limit updated, age limit added)
Valtoco 20 mg nasal spray (quantity limit updated, age limit added)

Valtoco 5 mg nasal spray (quantity limit updated, age limit added)

October 2023

Additions

Dexmethylphenidate extended release 10 mg capsule (quantity limit, age limit)
Dexmethylphenidate extended release 15 mg capsule (quantity limit, age limit)
Dexmethylphenidate extended release 20 mg capsule (quantity limit, age limit)

Dexmethylphenidate extended release 25 mg capsule (quantity limit, age limit)
Dexmethylphenidate extended release 30 mg capsule (quantity limit, age limit)
Dexmethylphenidate extended release 35 mg capsule (quantity limit, age limit)
Dexmethylphenidate extended release 40 mg capsule (quantity limit, age limit)
Dexmethylphenidate extended release 5 mg capsule (quantity limit, age limit)

Gvoke Kit 1 mg per 0.2 mL solution (quantity limit)
Gvoke prefilled syringe 0.5 mg per 0.1 mL solution (quantity limit)
Gvoke prefilled syringe 1 mg per 0.2 mL solution (quantity limit)
Infliximab 100 mg intravenous solution (prior authorization)
Lintera 10% wash

Naloxone 4 mg per 0.1 mL nasal liquid (OTC)
Octagam 25 gm per 500 mL (5%) intravenous solution (prior authorization)
Spiriva Respimat 1.25 mcg per inhalation solution
Spiriva Respimat 2.5 mcg per inhalation solution
Zegalogue auto-injector 0.6 mg per 0.6 mL solution (quantity limit)

Removals

Aimovig auto-injector 140 mg per mL solution
Aimovig auto-injector 70 mg per mL solution
Avsola 100 mg reconstituted solution

Ergotamine tartrate 2 mg and caffeine 100 mg suppository
Focalin XR 10 mg capsule
Focalin XR 15 mg capsule
Focalin XR 20 mg capsule
Focalin XR 25 mg capsule

Focalin XR 30 mg capsule
Focalin XR 35 mg capsule
Focalin XR 40 mg capsule
Focalin XR 5 mg capsule
Makena 250 mg per mL oil

Makena auto-injector 275 mg per 1.1 mL solution
Pradaxa 100 mg packet
Pradaxa 150 mg packet
Pradaxa 20 mg packet
Pradaxa 30 mg packet

Pradaxa 40 mg packet
Pradaxa 50 mg packet

Other updates

Levocarnitine 330 mg tablet (prior authorization removed)

September 2023

Additions: None

Removals: None

Other updates: None

August 2023

Additions

Tranexamic acid 650 mg tablet (prior authorization)

Removals

Imbruvica 140 mg tablet (prior authorization)
Tranexamic acid 650 mg tablet (prior authorization)
Vogelxo 50 mg per 5 gram gel packet (prior authorization)

Other updates: None

July 2023

Additions

Gefitinib 250 mg tablet (prior authorization)
Kalydeco 13.4 mg packet (prior authorization)
Lurasidone 120 mg tablet (quantity limit, age limit)
Lurasidone 20 mg tablet (quantity limit, age limit)
Lurasidone 40 mg tablet (quantity limit, age limit)

Lurasidone 60 mg tablet (quantity limit, age limit)
Lurasidone 80 mg tablet (quantity limit, age limit)
Mekinist 0.05 mg per mL solution (prior authorization)
Tafinlar 10 mg tablet (prior authorization)
Trikafta 100 mg/50 mg/75 mg/75 mg therapy pack (prior authorization)

Trikafta 80 mg/40 mg/60 mg/59.5 mg therapy pack (prior authorization)

Removals

Esomeprazole magnesium delayed release 40 mg capsule
Iressa 250 mg tablet

Latuda 120 mg tablet
Latuda 20 mg tablet
Latuda 40 mg tablet
Latuda 60 mg tablet
Latuda 80 mg tablet

Omega-3 ethyl esters 1 gm capsule
Sucraid 8500 unit per mL solution

Other updates: None

June 2023

Additions

First-metronidazole 50 mg/mL suspension (age limit)

Tinidazole 250 mg tablet
Tinidazole 500 mg tablet
Vancomycin 25 mg per mL oral solution
Vancomycin 50 mg per mL oral solution

Removals

Firvanq 25 mg per mL oral solution
Firvanq 50 mg per mL oral solution
Repatha prefilled syringe 140 mg per mL solution
Repatha Pushtronex cartridge 420 mg per 3.5mL solution

Repatha SureClick auto-injector 140 mg per mL solution

Other updates: None

May 2023

Additions

Gilenya 0.25 mg capsule (prior authorization, quantity limit)
Trikafta 100 mg/50 mg/75 mg/150 mg tablet (prior authorization)

Trikafta 50 mg/25 mg/37.5 mg/75 mg tablet (prior authorization)

Removals

Capsaicin 0.1% cream
Lidocaine 4% cream

Triamcinolone acetonide powder

Other updates

Fexofenadine 30 mg per 5 mL (changed quantity limit)
Fingolimod 0.5 mg capsule (added quantity limit)

Freestyle Libre 14 Day Sensor (changed quantity limit)
Freestyle Libre 2 Sensor (changed quantity limit)
Freestyle Libre 3 Sensor (changed quantity limit)

April 2023

Additions

Ambrisentan 10 mg tablet (prior authorization)
Ambrisentan 5 mg tablet (prior authorization)

Aranesp 10 mcg per 0.4 mL prefilled syringe solution (prior authorization)
Aranesp 100 mcg per 0.5 mL prefilled syringe solution (prior authorization)
Aranesp 150 mcg per 0.3 mL prefilled syringe solution (prior authorization)
Aranesp 200 mcg per 0.4 mL prefilled syringe solution (prior authorization)
Aranesp 25 mcg per 0.42 mL prefilled syringe solution (prior authorization)

Aranesp 300 mcg per 0.6 mL prefilled syringe solution (prior authorization)
Aranesp 40 mcg per 0.4 mL prefilled syringe solution (prior authorization)
Aranesp 500 mcg per 1 mL prefilled syringe solution (prior authorization)
Aranesp 60 mcg per 0.3 mL prefilled syringe solution (prior authorization)
Armour Thyroid 120 mg tablet

Armour Thyroid 15 mg tablet
Armour Thyroid 30 mg tablet
Armour Thyroid 60 mg tablet
Armour Thyroid 90 mg tablet
Bivigam 5 gm per 50 mL intravenous solution (prior authorization)

Bosentan 125 mg tablet (prior authorization)
Bosentan 62.5 mg tablet (prior authorization)
Fylnetra 6 mg per 0.6 mL prefilled syringe (prior authorization)
Nivestym 300 mcg per mL solution (prior authorization)
Nivestym 480 mcg per 1.6 mL solution (prior authorization)

Octagam 1 gm per 200 mL (5%) intravenous solution (prior authorization)
Octagam 10 gm per 100 mL (10%) intravenous solution (prior authorization)
Octagam 10 gm per 200 mL (5%) intravenous solution (prior authorization)
Octagam 2 gm per 20 mL (10%) intravenous solution (prior authorization)
Octagam 20 gm per 200 mL (10%) intravenous solution (prior authorization)

Octagam 30 gm per 300 mL (10%) intravenous solution (prior authorization)
Octagam 5 gm per 100 mL (5%) intravenous solution (prior authorization)
Octagam 5 gm per 50 mL (10%) intravenous solution (prior authorization)
Pradaxa 110 mg pellet packet (quantity limit)
Pradaxa 150 mg pellet packet (quantity limit)

Pradaxa 20 mg pellet packet (quantity limit)
Pradaxa 30 mg pellet packet (quantity limit)
Pradaxa 40 mg pellet packet (quantity limit)
Pradaxa 50 mg pellet packet (quantity limit)
Testosterone 50 mg per 5 gm (1%) gel (prior authorization) (limited to one NDC)

Xembify 1 gm per 5mL (20%) solution vial (prior authorization)
Xembify 10 gm per 50mL (20%) solution vial (prior authorization)
Xembify 2 gm per 10mL (20%) solution vial (prior authorization)
Xembify 4 gm per 20mL (20%) solution vial (prior authorization)
Ziextenzo 6 mg per 0.6 mL prefilled syringe (prior authorization)

Zovirax 5% ointment (quantity limit)

Removals

Acyclovir 5% ointment
Aubagio 14 mg tablet

Aubagio 7 mg tablet
Fulphila 6 mg per 0.6 mL prefilled syringe
Imbruvica 140 mg capsule
Imbruvica 140 mg tablet
Imbruvica 280 mg tablet

Imbruvica 420 mg tablet
Imbruvica 560 mg tablet
Imbruvica 70 mg capsule
Imbruvica 70 mg per mL suspension
Jakafi 10 mg tablet

Jakafi 15 mg tablet
Jakafi 20 mg tablet
Jakafi 25 mg tablet
Jakafi 5 mg tablet
Lenalidomide 10 mg capsule

Lenalidomide 15 mg capsule
Lenalidomide 20 mg capsule
Lenalidomide 25 mg capsule
Lenalidomide 5 mg capsule
Letairis 10 mg tablet

Letairis 5 mg tablet
Leukeran 2 mg tablet
Myleran 2 mg tablet
Neupogen 300 mcg per 0.5 mL prefilled syringe
Neupogen 300 mcg per 0.5 mL vial

Neupogen 480 mcg per 0.8 mL prefilled syringe
Neupogen 480 mcg per 1.6 mL vial
Nyvepria 6 mg per 0.6 mL prefilled syringe
Provida OB 20 mg/20 mg/1.5 mg capsule
Revlimid 10 mg capsule

Revlimid 15 mg capsule
Revlimid 2.5 mg capsule
Revlimid 20 mg capsule
Revlimid 25 mg capsule
Revlimid 5 mg capsule

Rydapt 25 mg capsule
Salicylic acid 6% cream
Salicylic acid 6% shampoo
Sprycel 100 mg tablet
Sprycel 140 mg tablet

Sprycel 20 mg tablet
Sprycel 50 mg tablet
Sprycel 70 mg tablet
Sprycel 80 mg tablet
Tabloid 40 mg tablet

Tamiflu 30 mg capsule
Tamiflu 45 mg capsule
Tamiflu 6 mg per mL suspension
Tamiflu 75 mg capsule
Tracleer 125 mg tablet

Tracleer 62.5 mg tablet
Udenyca 6 mg per 0.6 mL prefilled syringe
Venclexta 10 mg tablet
Venclexta 100 mg tablet
Venclexta 50 mg tablet

Venclexta starting pack
Xofluza 40 mg therapy pack
Xofluza 80 mg therapy pack

Other updates

None

March 2023

Additions

Guaifenesin 100 mg/codeine 6.33 mg per 5 mL solution (quantity limit, age limit, OTC)

Removals: None

Other updates

Advair Diskus 100 mcg/50 mcg per actuation (removed step therapy)
Advair Diskus 250 mcg/50 mcg per actuation (removed step therapy)
Advair Diskus 500 mcg/50 mcg per actuation (removed step therapy)
Advair HFA 115 mcg/21 mcg per actuation (removed step therapy)

Advair HFA 230 mcg/21 mcg per actuation (removed step therapy)
Advair HFA 45 mcg/21 mcg per actuation (removed step therapy)
Dulera 100 mcg/5 mcg per actuation (removed step therapy)
Dulera 200 mcg/5 mcg per actuation (removed step therapy)
Dulera 50 mcg/5 mcg per actuation (removed step therapy)

Pregabalin 100 mg capsule (removed prior authorization, updated quantity limit)
Pregabalin 150 mg capsule (removed prior authorization, updated quantity limit)
Pregabalin 20 mg per mL solution (removed prior authorization, updated quantity limit)
Pregabalin 200 mg capsule (removed prior authorization, updated quantity limit)
Pregabalin 225 mg capsule (removed prior authorization, updated quantity limit)

Pregabalin 25 mg capsule (removed prior authorization, updated quantity limit)
Pregabalin 300 mg capsule (removed prior authorization, updated quantity limit)
Pregabalin 50 mg capsule (removed prior authorization, updated quantity limit)
Pregabalin 75 mg capsule (removed prior authorization, updated quantity limit)
Symbicort 160 mcg/4.5 mcg per actuation (removed step therapy)

Symbicort 80 mcg/4.5 mcg per actuation (removed step therapy)

February 2023

Additions

Dificid 200 mg tablet (prior authorization)
Dificid 40 mg/mL suspension (prior authorization)
Ethacrynic acid 25 mg tablet
Fluocinolone acetonide 0.01% otic oil (quantity limit, OTC)

Lactobacillus extra strength capsule (OTC)
Miconazole nitrate vaginal suppository 1200 mg and 2% cream kit (OTC)
Phenylephrine 10 mg/dextromethorphan 18 mg/guaifenesin 200 mg per 15 mL liquid (quantity limit, OTC)
Pramoxine hydrochloride (perianal) 1% foam (quantity limit, OTC)
Probiotic capsule (OTC)

Pseudoephedrine 30 mg/dexchlorpheniramine 1 mg/chlophedianol 5 mg per 5 mL liquid (quantity limit, OTC)
Refresh Relieva 0.5/1% preservative free ophthalmic solution (OTC)
Sodium fluoride 1.1%/5% gel
Xifaxan 550 mg tablet (prior authorization)

Removals

Benzocaine 20 mg/docusate sodium 283 mg rectal enema
Bisacodyl 10 mg/30 mL enema (OTC)
Brimonidine tartrate 0.2%/timolol 0.5% ophthalmic solution
Celontin 300 mg capsule

Colchicine 0.6 mg capsule
Ibrance 100 mg tablet
Ibrance 125 mg tablet
Ibrance 75 mg tablet
Levofloxacin 0.5% ophthalmic solution

Magnesium hydroxide concentrate 2400 mg/10 mL
Naproxen delayed release, enteric coated 500 mg tablet
Pirfenidone 267 mg capsule
Potassium citrate 550 mg/sodium citrates 500 mg/citric acid 334 mg per 5 mL solution

Other updates

Azelastine HCl 0.05% ophthalmic solution (removed step therapy)
Celecoxib 100 mg capsule (removed step therapy)
Celecoxib 200 mg capsule (removed step therapy)
Celecoxib 400 mg capsule (removed step therapy)

Celecoxib 50 mg capsule (removed step therapy)
Vancomycin HCl 125 mg capsule (removed prior authorization, added quantity limit)
Vancomycin HCl 250 mg capsule (removed prior authorization, added quantity limit)

January 2023

Additions

Dupixent pen-injector 200 mg/1.14 mL solution (prior authorization)
Dupixent pen-injector 300 mg/2 mL solution (prior authorization)

Dupixent prefilled syringe 100 mg/0.67 mL solution (prior authorization)
Dupixent prefilled syringe 200 mg/1.14 mL solution (prior authorization)
Dupixent prefilled syringe 300 mg/2 mL solution (prior authorization)
Eucrisa 2% ointment (prior authorization)
Pimecrolimus 1% cream (prior authorization)

Berinert kit 500 unit (prior authorization)
Cinryze vial 500 unit (prior authorization)
Firazyr syringe 30 mg/3 mL (prior authorization)
Kalbitor vial 10 mg/mL (prior authorization)
Orladeyo 110 mg capsule (prior authorization)

Orladeyo 150 mg capsule (prior authorization)
Symfi Lo 400 mg/300 mg/300 mg tablet
Symfi 600 mg/300 mg/300 mg tablet
Triumeq PD 60 mg/5 mg/30 mg soluble tablet
Vfend 40 mg/mL suspension

Ella 30 mg tablet (quantity limit)
Tafluprost (PF) ophthalmic 0.0015% suspension

Removals

Invirase 200 mg capsule

Invirase 500 mg tablet
Stavudine 15 mg capsule
Stavudine 20 mg capsule
Stavudine 30 mg capsule
Stavudine 40 mg capsule

Viracept 250 mg tablet
Viracept 625 mg tablet
Zioptan ophthalmic 0.0015% solution
All Non-OneTouch Delica and Delica Plus Lancets and Lancet Devices

Other updates: None

December 2022

Additions

Accutane 10 mg capsule
Accutane 20 mg capsule
Accutane 30 mg capsule
Accutane 40 mg capsule

Amnesteem 10 mg capsule
Amnesteem 20 mg capsule
Amnesteem 40 mg capsule
Flonase nasal suspension 50 mcg/act
Histex PD 0.938 mg/mL liquid (OTC)

Removals: None

Other updates: None

November 2022

Additions

Imbruvica Susp 70 mg/mL (prior authorization, quantity limit)

Orkambi Granule 75 to 94 mg (prior authorization)

Removals: None

Other updates: None

December 2023

Title 19/21 SMI Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

Non-Title 19/21 Drug List Updates:

Additions:

None

Removals:

None

Other Updates:

None

November 2023

Title 19/21 SMI Drug List Updates:

Additions:

Omnitrope 5.8 mg solution (Prior Authorization)
Omnitrope cartridge 10 mg per 1.5mL solution (Prior Authorization)
Omnitrope cartridge 5 mg per 1.5mL solution (Prior Authorization)
Zomactron 10 mg solution (Prior Authorization)
Zomactron 5 mg solution (Prior Authorization)

Removals

Proctofoam HC 1% to 1% rectal foam

Other updates

Haloperidol 0.5 mg tablet (age limit updated)
Haloperidol 1 mg tablet (age limit updated)
Haloperidol 10 mg tablet (age limit updated)

Haloperidol 2 mg tablet (age limit updated)
Haloperidol 20 mg tablet (age limit updated)
Haloperidol 5 mg tablet (age limit updated)
Haloperidol lactate 2 mg per mL oral concentrate (age limit updated)
Haloperidol lactate 5 mg per mL solution injection (age limit updated)

Loxapine succinate 10 mg capsule (age limit updated)
Loxapine succinate 25 mg capsule (age limit updated)
Loxapine succinate 5 mg capsule (age limit updated)
Loxapine succinate 50 mg capsule (age limit updated)
Nayzilam 5mg per 0.1 mL nasal spray (quantity limit updated, age limit added)

Perphenazine 16 mg tablet (age limit updated)
Perphenazine 2 mg tablet (age limit updated)
Perphenazine 4 mg tablet (age limit updated)
Perphenazine 8 mg tablet (age limit updated)
Pimozide 1 mg tablet (age limit updated)

Pimozide 2 mg tablet (age limit updated)
Thioridazine HCl 10 mg tablet (age limit updated)
Thioridazine HCl 100 mg tablet (age limit updated)
Thioridazine HCl 25 mg tablet (age limit updated)
Thioridazine HCl 50 mg tablet (age limit updated)

Thiothixene 1 mg capsule (age limit updated)
Thiothixene 10 mg capsule (age limit updated)
Thiothixene 2 mg capsule (age limit updated)
Thiothixene 5 mg capsule (age limit updated)
Trifluoperazine HCl 1 mg tablet (age limit updated)

Trifluoperazine HCl 10 mg tablet (age limit updated)
Trifluoperazine HCl 2 mg tablet (age limit updated)
Trifluoperazine HCl 5 mg tablet (age limit updated)
Valtoco 10 mg nasal spray (quantity limit updated, age limit added)
Valtoco 15 mg nasal spray (quantity limit updated, age limit added)

Valtoco 20 mg nasal spray (quantity limit updated, age limit added)
Valtoco 5 mg nasal spray (quantity limit updated, age limit added)

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates

Haloperidol 0.5 mg tablet (age limit updated)
Haloperidol 1 mg tablet (age limit updated)
Haloperidol 10 mg tablet (age limit updated)
Haloperidol 2 mg tablet (age limit updated)
Haloperidol 20 mg tablet (age limit updated)
Haloperidol 5 mg tablet (age limit updated)
Haloperidol lactate 2 mg per mL oral concentrate (age limit updated)
Haloperidol lactate 5 mg per mL solution injection (age limit updated)
Loxapine succinate 10 mg capsule (age limit updated)
Loxapine succinate 25 mg capsule (age limit updated)
Loxapine succinate 5 mg capsule (age limit updated)
Loxapine succinate 50 mg capsule (age limit updated)
Perphenazine 16 mg tablet (age limit updated)
Perphenazine 2 mg tablet (age limit updated)
Perphenazine 4 mg tablet (age limit updated)
Perphenazine 8 mg tablet (age limit updated)
Pimozide 1 mg tablet (age limit updated)
Pimozide 2 mg tablet (age limit updated)
Thioridazine HCl 10 mg tablet (age limit updated)

October 2023

Title 19/21 SMI drug list updates

Additions

Dexmethylphenidate extended release 10 mg capsule (quantity limit, age limit)
Dexmethylphenidate extended release 15 mg capsule (quantity limit, age limit)

Dexmethylphenidate extended release 20 mg capsule (quantity limit, age limit)
Dexmethylphenidate extended release 25 mg capsule (quantity limit, age limit)
Dexmethylphenidate extended release 30 mg capsule (quantity limit, age limit)
Dexmethylphenidate extended release 35 mg capsule (quantity limit, age limit)
Dexmethylphenidate extended release 40 mg capsule (quantity limit, age limit)

Dexmethylphenidate extended release 5 mg capsule (quantity limit, age limit)
Gvoke Kit 1 mg per 0.2 mL solution (quantity limit)
Gvoke prefilled syringe 0.5 mg per 0.1 mL solution (quantity limit)
Gvoke prefilled syringe 1 mg per 0.2 mL solution (quantity limit)
Infliximab 100 mg intravenous solution (prior authorization)

Lintera 10% wash
Naloxone 4 mg per 0.1 mL nasal liquid (OTC)
Octagam 25 gm per 500 mL (5%) intravenous solution (prior authorization)
Spiriva Respimat 1.25 mcg per inhalation solution
Spiriva Respimat 2.5 mcg per inhalation solution

Zegalogue auto-injector 0.6 mg per 0.6 mL solution (quantity limit)

Removals

Aimovig auto-injector 140 mg per mL solution
Aimovig auto-injector 70 mg per mL solution

Avsola 100 mg reconstituted solution
Ergotamine tartrate 2 mg and caffeine 100 mg suppository
Focalin XR 10 mg capsule
Focalin XR 15 mg capsule
Focalin XR 20 mg capsule

Focalin XR 25 mg capsule
Focalin XR 30 mg capsule
Focalin XR 35 mg capsule
Focalin XR 40 mg capsule
Focalin XR 5 mg capsule

Makena 250 mg per mL oil
Makena auto-injector 275 mg per 1.1 mL solution
Pradaxa 100 mg packet
Pradaxa 150 mg packet
Pradaxa 20 mg packet

Pradaxa 30 mg packet
Pradaxa 40 mg packet
Pradaxa 50 mg packet

Other updates

Levocarnitine 330 mg tablet (prior authorization removed)

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates: None

September 2023

Title 19/21 SMI drug list updates

Additions: None

Removals: None

Other updates: None

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates: None

August 2023

Title 19/21 SMI drug list updates

Additions

Imbruvica 140 mg tablet (prior authorization)
Tranexamic acid 650 mg tablet (prior authorization)

Vogelxo 50 mg per 5 gram gel packet (prior authorization)

Removals

Telmisartan 20 mg tablet
Telmisartan 40 mg tablet

Telmisartan 80 mg tablet

Other updates: None

Non-Title 19/21 drug list updates

Additions:

Naloxone 4 mg nasal spray (OTC)

Removals: None

Other updates: None

July 2023

Title 19/21 SMI drug list updates

Additions

Gefitinib 250 mg tablet (prior authorization)
Kalydeco 13.4 mg packet (prior authorization)

Lurasidone 120 mg tablet (quantity limit, age limit)
Lurasidone 20 mg tablet (quantity limit, age limit)
Lurasidone 40 mg tablet (quantity limit, age limit)
Lurasidone 60 mg tablet (quantity limit, age limit)
Lurasidone 80 mg tablet (quantity limit, age limit)

Mekinist 0.05 mg per mL solution (prior authorization)
Tafinlar 10 mg tablet (prior authorization)
Trikafta 100 mg/50 mg/75 mg/75 mg therapy pack (prior authorization)
Trikafta 80 mg/40 mg/60 mg/59.5 mg therapy pack (prior authorization)

Removals

Esomeprazole magnesium delayed release 40 mg capsule
Iressa 250 mg tablet
Latuda 120 mg tablet
Latuda 20 mg tablet

Latuda 40 mg tablet
Latuda 60 mg tablet
Latuda 80 mg tablet
Omega-3 ethyl esters 1 gm capsule
Sucraid 8500 unit per mL solution

Other updates: None

Non-Title 19/21 drug list updates

Additions: None

 Removals: None

 Other updates: None

June 2023

Title 19/21 SMI drug list updates

Additions

First-metronidazole 50 mg/mL suspension (age limit)
Tinidazole 250 mg tablet
Tinidazole 500 mg tablet
Vancomycin 25 mg per mL oral solution

Vancomycin 50 mg per mL oral solution

Removals

Firvanq 25 mg per mL oral solution
Firvanq 50 mg per mL oral solution

Repatha prefilled syringe 140 mg per mL solution
Repatha Pushtronex cartridge 420 mg per 3.5mL solution
Repatha SureClick auto-injector 140 mg per mL solution

Other updates: None

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates: None

May 2023

Title 19/21 SMI drug list updates

Additions

Gilenya 0.25 mg capsule (prior authorization, quantity limit)

Trikafta 100 mg/50 mg/75 mg/150 mg tablet (prior authorization)
Trikafta 50 mg/25 mg/37.5 mg/75 mg tablet (prior authorization)

Removals

Capsaicin 0.1% cream

Lidocaine 4% cream
Triamcinolone acetonide powder

Other updates

Fexofenadine 30 mg per 5 mL (changed quantity limit)

Fingolimod 0.5 mg capsule (added quantity limit)
Freestyle Libre 14 Day Sensor (changed quantity limit)
Freestyle Libre 2 Sensor (changed quantity limit)
Freestyle Libre 3 Sensor (changed quantity limit)

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates: None

April 2023

Title 19/21 SMI drug list updates

Additions

Ambrisentan 10 mg tablet (prior authorization)
Ambrisentan 5 mg tablet (prior authorization)

Aranesp 10 mcg per 0.4 mL prefilled syringe solution (prior authorization)
Aranesp 100 mcg per 0.5 mL prefilled syringe solution (prior authorization)
Aranesp 150 mcg per 0.3 mL prefilled syringe solution (prior authorization)
Aranesp 200 mcg per 0.4 mL prefilled syringe solution (prior authorization)
Aranesp 25 mcg per 0.42 mL prefilled syringe solution (prior authorization)

Aranesp 300 mcg per 0.6 mL prefilled syringe solution (prior authorization)
Aranesp 40 mcg per 0.4 mL prefilled syringe solution (prior authorization)
Aranesp 500 mcg per 1 mL prefilled syringe solution (prior authorization)
Aranesp 60 mcg per 0.3 mL prefilled syringe solution (prior authorization)
Armour Thyroid 120 mg tablet

Armour Thyroid 15 mg tablet
Armour Thyroid 30 mg tablet
Armour Thyroid 60 mg tablet
Armour Thyroid 90 mg tablet
Bivigam 5 gm per 50 mL intravenous solution (prior authorization)

Bosentan 125 mg tablet (prior authorization)
Bosentan 62.5 mg tablet (prior authorization)
Fylnetra 6 mg per 0.6 mL prefilled syringe (prior authorization)
Nivestym 300 mcg per mL solution (prior authorization)
Nivestym 480 mcg per 1.6 mL solution (prior authorization)

Octagam 1 gm per 200 mL (5%) intravenous solution (prior authorization)
Octagam 10 gm per 100 mL (10%) intravenous solution (prior authorization)
Octagam 10 gm per 200 mL (5%) intravenous solution (prior authorization)
Octagam 2 gm per 20 mL (10%) intravenous solution (prior authorization)
Octagam 20 gm per 200 mL (10%) intravenous solution (prior authorization)

Octagam 30 gm per 300 mL (10%) intravenous solution (prior authorization)
Octagam 5 gm per 100 mL (5%) intravenous solution (prior authorization)
Octagam 5 gm per 50 mL (10%) intravenous solution (prior authorization)
Pradaxa 110 mg pellet packet (quantity limit)
Pradaxa 150 mg pellet packet (quantity limit)

Pradaxa 20 mg pellet packet (quantity limit)
Pradaxa 30 mg pellet packet (quantity limit)
Pradaxa 40 mg pellet packet (quantity limit)
Pradaxa 50 mg pellet packet (quantity limit)
Testosterone 50 mg per 5 gm (1%) gel (prior authorization) (limited to one NDC)

Xembify 1 gm per 5 mL (20%) solution vial (prior authorization)
Xembify 10 gm per 50 mL (20%) solution vial (prior authorization)
Xembify 2 gm per 10 mL (20%) solution vial (prior authorization)
Xembify 4 gm per 20 mL (20%) solution vial (prior authorization)
Ziextenzo 6 mg per 0.6 mL prefilled syringe (prior authorization)

Zovirax 5% ointment (quantity limit)

Removals

Acyclovir 5% ointment
Aubagio 14 mg tablet

Aubagio 7 mg tablet
Fulphila 6 mg per 0.6 mL prefilled syringe
Imbruvica 140 mg tablet
Imbruvica 280 mg tablet
Imbruvica 420 mg tablet

Imbruvica 560 mg tablet
Lenalidomide 10 mg capsule
Lenalidomide 15 mg capsule
Lenalidomide 20 mg capsule
Lenalidomide 25 mg capsule

Lenalidomide 5 mg capsule
Letairis 10 mg tablet
Letairis 5 mg tablet
Leukeran 2 mg tablet
Myleran 2 mg tablet

Neupogen 300 mcg per 0.5 mL prefilled syringe
Neupogen 300 mcg per 0.5 mL vial
Neupogen 480 mcg per 0.8 mL prefilled syringe
Neupogen 480 mcg per 1.6 mL vial
Nyvepria 6 mg per 0.6 mL prefilled syringe

Provida OB 20 mg/ 20 mg/1.5 mg capsule
Rydapt 25 mg capsule
Salicylic acid 6% cream
Salicylic acid 6% shampoo
Tabloid 40 mg tablet

Tamiflu 30 mg capsule
Tamiflu 45 mg capsule
Tamiflu 6 mg per mL suspension
Tamiflu 75 mg capsule
Tracleer 125 mg tablet

Tracleer 62.5 mg tablet
Udenyca 6 mg per 0.6 mL prefilled syringe
Venclexta 10 mg tablet
Venclexta 100 mg tablet
Venclexta 50 mg tablet

Venclexta starting pack
Xofluza 40 mg therapy pack
Xofluza 80 mg therapy pack

Other updates: None

Non-Title 19/21 drug list updates

Additions

Lurasidone 120 mg tablet (quantity limit, age limit)
Lurasidone 20 mg tablet (quantity limit, age limit)
Lurasidone 40 mg tablet (quantity limit, age limit)
Lurasidone 60 mg tablet (quantity limit, age limit)

Lurasidone 80 mg tablet (quantity limit, age limit)

Removals

Latuda 120 mg tablet
Latuda 20 mg tablet

Latuda 40 mg tablet
Latuda 60 mg tablet
Latuda 80 mg tablet

Other updates: None

March 2023

Title 19/21 SMI drug list updates

Additions

Guaifenesin 100 mg/codeine 6.33 mg per 5 mL solution (quantity limit, age limit, OTC)

Removals: None

Other updates

Advair Diskus 100 mcg/50 mcg per actuation (removed step therapy)

Advair Diskus 250 mcg/50 mcg per actuation (removed step therapy)
Advair Diskus 500 mcg/50 mcg per actuation (removed step therapy)
Advair HFA 115 mcg/21 mcg per actuation (removed step therapy)
Advair HFA 230 mcg/21 mcg per actuation (removed step therapy)
Advair HFA 45 mcg/21 mcg per actuation (removed step therapy)

Dulera 100 mcg/5 mcg per actuation (removed step therapy)
Dulera 200 mcg/5 mcg per actuation (removed step therapy)
Dulera 50 mcg/5 mcg per actuation (removed step therapy)
Pregabalin 100 mg capsule (removed prior authorization, updated quantity limit)
Pregabalin 150 mg capsule (removed prior authorization, updated quantity limit)

Pregabalin 20 mg per mL solution (removed prior authorization, updated quantity limit)
Pregabalin 200 mg capsule (removed prior authorization, updated quantity limit)
Pregabalin 225 mg capsule (removed prior authorization, updated quantity limit)
Pregabalin 25 mg capsule (removed prior authorization, updated quantity limit)
Pregabalin 300 mg capsule (removed prior authorization, updated quantity limit)

Pregabalin 50 mg capsule (removed prior authorization, updated quantity limit)
Pregabalin 75 mg capsule (removed prior authorization, updated quantity limit)
Symbicort 160 mcg/4.5 mcg per actuation (removed step therapy)
Symbicort 80 mcg/4.5 mcg per actuation (removed step therapy)

Non-Title 19/21 drug list updates

Additions: None

Removals: None

Other updates: None

February 2023

Title 19/21 SMI drug list updates

Additions

Dificid 200 mg tablet (prior authorization)

Dificid 40 mg/mL suspension (prior authorization)
Ethacrynic acid 25 mg tablet
Fluocinolone acetonide 0.01% otic oil (quantity limit, OTC)
Lactobacillus extra strength capsule (OTC)
Miconazole nitrate vaginal suppository 1200 mg and 2% cream kit (OTC)

Phenylephrine 10 mg/dextromethorphan 18 mg/guaifenesin 200 mg per 15 mL liquid (quantity limit, OTC)
Pramoxine hydrochloride (perianal) 1% foam (quantity limit, OTC)
Probiotic capsule (OTC)
Pseudoephedrine 30 mg/dexchlorpheniramine 1 mg/chlophedianol 5 mg per 5 mL liquid (quantity limit, OTC)
Refresh Relieva 0.5/1% preservative free ophthalmic solution (OTC)

Sodium fluoride 1.1%/5% gel
Xifaxan 550 mg tablet (prior authorization)

Removals

Benzocaine 20 mg/docusate sodium 283 mg rectal enema

Bisacodyl 10 mg/30mL enema (OTC)
Brimonidine tartrate 0.2%/timolol 0.5% ophthalmic solution
Celontin 300 mg capsule
Colchicine 0.6 mg capsule
Ibrance 100 mg tablet

Ibrance 125 mg tablet
Ibrance 75 mg tablet
Levofloxacin 0.5% ophthalmic solution
Magnesium hydroxide concentrate 2400 mg/10 mL
Naproxen delayed release, enteric coated 500 mg tablet

Pirfenidone 267 mg capsule
Potassium citrate 550 mg/sodium citrates 500 mg/citric acid 334 mg per 5 mL solution

Other updates

Azelastine HCl 0.05% ophthalmic solution (removed step therapy)

Celecoxib 100 mg capsule (removed step therapy)
Celecoxib 200 mg capsule (removed step therapy)
Celecoxib 400 mg capsule (removed step therapy)
Celecoxib 50 mg capsule (removed step therapy)
Vancomycin HCl 125 mg capsule (removed prior authorization, added quantity limit)