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

 

Preferred drug lists

Mercy Care RBHA uses four preferred drug lists, depending on your member’s eligibility.

The Integrated Preferred Drug List and the Behavioral Health Preferred Drug List are updated quarterly. For monthly changes, you can review the Preferred Drug List Updates below.

The lists are based on the Arizona Health Care Cost Containment System (AHCCCS)-approved drug list. Drugs on these lists are generally covered under the plan as long as they are medically necessary. Members must fill their prescriptions at a network pharmacy.

For more detailed information about the Mercy Care RBHA prescription drug coverage, please review the Provider Handbook and other plan materials. If you have questions please call Provider Relations at 602-263-3000 or 1-800-564-5465 (TTY/TDD 711).

Please review these preferred drug lists for any restrictions or recommendations before prescribing a medication to a Mercy Care RBHA member.

  • Behavioral Health Preferred Drug List: For members who qualify under Title 19/21 Non-SMI or as Non-Title 19/21 determined to have a serious mental illness (SMI), or Non-Title 19/21 children with a serious emotional disturbance (SED), Mercy Care RBHA fills only behavioral health medications.
  • Integrated Preferred Drug List: For Title 19/21 SMI members, Mercy Care RBHA fills physical health and behavioral health medications.
  • Crisis Medication List: For adults or children who are Non-Title 19/21 and Non-SMI who present in crisis at any of the facility-based psychiatric urgent care centers, detox facilities and/or access point in Maricopa County. The medications on this list will help stabilize an individual in crisis and bridge them to a follow-up outpatient appointment.
  • Substance Abuse Block Grant Medication List: For Non-Title 19/21 members with SUDs and primary substance use and misuse.

You can use the Integrated Preferred Drug List Search Tool and Behavioral Health Preferred Drug List Search Tool to find out whether a medication is on the preferred drug list. 

Prior authorization request forms and quantity limits for drugs

Mercy Care RBHA requires prior authorization for certain drugs on the preferred drug lists and for all drugs not on the preferred drug lists. You may request prior authorization for most drugs via phone by calling the Mercy Care RBHA Pharmacy Prior Authorization team at 1‑800‑564-5465.

You can also print the required prior authorization form and fax it, along with supporting clinical notes, to 1-855-247-3677 for Title 19/21 SMI members or 1-855-246-7736 for GMH/SA and Non-Title 19/21 SMI members. If a drug that is not on this list is needed in an emergency, a limited supply may be given.

You can call Mercy Care RBHA Member Services 24 hours a day, 7 days a week at 602-586-1841 or (toll free) 1‑800‑564-5465; (TTY/TDD) 711.

 

Physical and behavioral health medication fax forms

Universal Pharmacy Prior Authorization Request Form

 

Botulinum Toxins   (Botox, Dysport, Myobloc, Xeomin)

Calcitonin Gene-Related Peptide Receptor Antagonists  (Ajovy, Emgality, Aimovig, Nurtec, Ubrelvy, Vyepti)

Colony Stimulating Factors  (Neupogen, Fulphila, Udencya, etc)  

Concomitant Antidepressant Therapy 

Concomitant Antipsychotic Treatment  

Corlanor  

Cystic Fibrosis  (Bethkis, Kitabis, Cayston, Kalydeco, Pulmozyme, etc)

Cytokine and CAM Antagonist (Enbrel, Humira, etc)  

Dalfampridine (Ampyra)  

Dupixent  

Egrifta  

Emflaza  

Entresto  

Epidiolex  

Erythropoiesis Stimulating Agents  (Aranesp, Epogen, Procrit, Retacrit, etc)

Gonadotropin Releasing Hormone Analogs (Lupron, Orilissa, Supprelin LA)

Growth Hormone  (Genotropin, Norditropin)  

Hemophilia  (Factor VIIa, Factor VIII, Factor IX, Novoseven, Hemlibra, etc)

Hepatitis C Agents    

Hyaluronic Acid Derivatives (Gel-One, Visco-3)

Idiopathic Pulmonary Fibrosis Agents  (Esbriet, Ofev)

Injectable Osteoporosis Agents (Tymlos, Evenity, Forteo, Prolia, zoledronic acid) 

Interferons  (Actimmune, Intron-A, Pegasys, etc)

Interleukin-5 Antagonists  (Cinquir, Fasenra, Nucala)

Janus Associated Kinase Inhibitors (Inrebic, Jakafi)  

Krystexxa

Monoamine Depletors (Austedo, Ingrezza, tetrabenazine)  

Multiple Sclerosis Agents   (Avonex, Betaseron, Copaxone, Gilenya, Glatopa 40mg, Rebif/Rebidose, etc)

Opioids  

Pulmonary Arterial Hypertension  Tracleer, Letairis, Adcirca, Sildenafil, Revatio susp) 

Pyrimethamine (Daraprim)

Somatostatin Analogs and Somavert (Sandostatin, Sandostatin LAR Depot, Signifor, Signifor LAR, Somatulane Depot, Octreotide) 

Spinraza 

Spravato  

Sublocade 

Tepezza

Testosterone  

Thrombopoiesis Stimulating Products (Promacta, Nplate, Tavalisse) 

Xolair

Xyrem 

Requests for medications requiring Prior Authorization (PA) will be reviewed based on the PA Guidelines/Criteria for that medication. Medications that don't have a specific PA guideline will follow the Non-Formulary Medication Guideline. Additional information may be required on a case-by-case basis to allow for adequate review. 

Here are the guidelines for:

Title 19/21 SMI Members 

GMH/SU and Non-Title 19/21 SMI Members 

Botulinum Toxins

Colony Stimulating Factors 

Cytokine and CAM Antagonists 

Growth Hormone 

Hemophilia 

Hepatitis C 

Hereditary Angioedema 

Immune Globulins 

Injectable Osteoporosis Agents 

Multiple Sclerosis Agents 

Opioids 

Opioids 5-Day Supply Limit

Smoking cessation 

Step Therapy Prior Authorization Guidelines (PDF)

Spravato 

Sublocade 

We are committed to making sure our providers receive the best possible information, and the latest technology and tools available.

We have partnered with CoverMyMeds® and SureScripts to provide you a new way to request a pharmacy prior authorization through the implementation of Electronic Prior Authorization (ePA) program.

With Electronic Prior Authorization (ePA), you can look forward to:

  • Time saving
    • Decreasing paperwork, phone calls and faxes for requests for prior authorization
  • Quicker Determinations
    • Reduces average wait times, resolution often within minutes
  • Accommodating & Secure
    • HIPAA compliant via electronically submitted requests Getting started is easy. Choose ways to enroll:
    • No cost required! Let us help get you started!

Billing Information:

BIN: 610591

PCN: ADV

Group: RX8822

CVS Caremark Specialty Pharmacy is a pharmacy that offers medications for a variety of conditions, such as cancer, hemophilia, immune deficiency, multiple sclerosis and rheumatoid arthritis, which aren't often available at local pharmacies. Specialty medications require prior authorization before they can be filled and delivered. Providers can call 1‑800‑564-5465 (toll-free) to request prior authorization, or complete the applicable Prior Authorization Request Form and fax to 1-855-247-3677 for Title 19/21 SMI members or 1-855-246-7736 for GMH/SA and Non-Title 19/21 SMI members.

Specialty medications can be delivered to the provider’s office, member’s home or another requested location.

For providers who prefer to purchase the specialty drug and bill through the member’s medical insurance:

Call 602-586-1841 or 1-800-564-5465 (toll free)  to initiate prior authorization for the requested specialty medication.

For providers who prefer to bill through the member’s pharmacy insurance directly:

Call 1-800-564-5465 (toll-free) to request prior authorization. Or, complete the applicable Prior Authorization Request Form and fax to 1-855-247-3677 for Title 19/21 SMI members or 1-855-246-7736 for GMH/SA and Non-Title 19/21 SMI members.

Click here for the Specialty Drug List

CVS/Coram pharmacy enrollment form

July 2021

Title 19/21 SMI Drug List Updates:

Additions:

  • None

Removals:

  • BP Foam Aer 9.8%

Other Updates:

  • None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

June 2021

Title 19/21 SMI Drug List Updates:

Additions:

  • Renflexis 100 Mg Vial (Prior Authorization Required)

Removals:

  • Tretinoin Cream 0.025%
  • Tretinoin Cream 0.05%
  • Tretinoin Cream 0.1%
  • Tretinoin Gel 0.01%
  • Tretinoin Gel 0.025%

Other Updates:

  • Sumatriptan Succinate Inj 6 Mg/0.5ml (Quantity Level Limit)
  • Sumatriptan Succinate Solution Auto-Injector 4 Mg/0.5ml (Quantity Level Limit)
  • Sumatriptan Succinate Solution Auto-Injector 6 Mg/0.5ml (Quantity Level Limit)
  • Sumatriptan Succinate Solution Cartridge 4 Mg/0.5ml (Quantity Level Limit)
  • Sumatriptan Succinate Solution Cartridge 6 Mg/0.5ml (Quantity Level Limit)

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

May 2021

Title 19/21 SMI Drug List Updates:

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

April 2021

Title 19/21 SMI Drug List Updates:

Additions:

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

Removals:

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

Other Updates:

  • None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

March 2021

Title 19/21 SMI Drug List Updates:

Additions:

  • Esbriet Cap 267mg (Prior Authorization Required)
  • Esbriet Tab 267mg (Prior Authorization Required)
  • Esbriet Tab 801mg (Prior Authorization Required)
  • Myleran Tab 2mg
  • Ocrevus Inj 300/10ml (Prior Authorization Required, Quantity Level Limit)
  • Pot & Sod Citrates W/ Cit Ac Soln 550-500-334mg/5ml
  • Tukysa Tab 150mg (Prior Authorization Required)
  • Tukysa Tab 50mg (Prior Authorization Required)
  • Valtoco Liq 15mg (Quantity Level Limit)
  • Valtoco Liq 20mg (Quantity Level Limit)
  • Valtoco Spr 10mg (Quantity Level Limit)
  • Valtoco Spr 5mg (Quantity Level Limit)
  • Visco-3 Inj 25/2.5ml (Prior Authorization Required)

Removals:

  • Doxycycline Monohydrate Tab 100mg
  • Hyalgan Inj 20mg/2ml
  • Hyoscyamine Dro 0.125/ml
  • Ofev Cap 100mg
  • Ofev Cap 150mg

Other Updates:

  • Ondansetron Tablet Dispersible 4mg Oral (Changed Quantity Level Limit)
  • Phenylephrine HCl Ophth Soln 2.5% (Added Quantity Level Limit)
  • Extavia Inj 0.3mg (Added Quantity Level Limit)
  • Santyl Oin 250 Unit/Gm (Added Quantity Level Limit)
  • Juluca Tab 50-25mg (Added Prior Authorization)

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

February 2021

Title 19/21 SMI Drug List Updates:

Additions:

  • Calamine-Zinc Oxide Lotion
  • Calcium Carbonate-Cholecalciferol Chew Tab 500 Mg-400 Unit
  • Diaper Rash Products - Ointment (Age Limit)
  • Dimethicone-Zinc Oxide-Vitamin A-Vitamin D Cream 1-10% (Age Limit)
  • Glycerin Liquid Suppos 2.8 Gm (2.7 Ml)
  • Glycerin Suppos 1 Gm
  • Glycerin Suppos 1.2 Gm
  • Glycerin Suppos 2 Gm
  • Lubiprostone Cap 24mcg (Quantity Level Limit)
  • Lubiprostone Cap 8mcg (Quantity Level Limit)
  • Mineral Oil
  • Pediatric Multiple Vitamin W/ C & Fa Chew Tab
  • Pediatric Multiple Vitamin W/ Extra C & Fa Chew Tab
  • Pediatric Multiple Vitamins W/ Iron Chew Tab 18 Mg
  • Sodium Fluoride Cream 1.1%
  • Sodium Fluoride Paste 1.1%
  • Sucralfate Susp 1 Gm/10ml (Age Limit)
  • Tretinoin Cream 0.025% (Age Limit)
  • Tretinoin Cream 0.05% (Age Limit)
  • Tretinoin Cream 0.1% (Age Limit)
  • Tretinoin Gel 0.01% (Age Limit)
  • Tretinoin Gel 0.025% (Age Limit)
  • Zinc Oxide Cream 13% (Age Limit)

Removals:

  • Amitiza Cap 24mcg
  • Amitiza Cap 8mcg

Other Updates:

  • None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

January 2021

Title 19/21 SMI Drug List Updates:

Additions:

  • Levonorgest-Eth Estrad 91-Day TABLET 0.15-0.03 &0.01 MG
  • Norethin Ace-Eth Estrad-FE Tablet 1-20 MG-MCG(24)
  • Benzoyl Peroxide 6% Cleanser
  • Clind Ph-Benzoyl Perox 1.2-5%
  • Detrol 1 MG Tablet
  • Detrol 2 MG Tablet
  • Detrol LA 2 MG Capsule
  • Detrol LA 4 MG Capsule
  • Esomeprazole DR 10 Mg Packet (Age Limit)
  • Esomeprazole DR 20 Mg Packet (Age Limit)
  • Esomeprazole DR 40 Mg Packet (Age Limit)
  • Esomeprazole Mag DR 40 Mg Cap
  • Fish Oil EC 1,000 Mg Softgel
  • Krill Oil 300 Mg Softgel
  • Kyleena 19.5 Mg System
  • Norethin Ace-Eth Estrad-FE Tablet Chewable 1-20 MG-MCG(24)
  • Mirena 52 Mg System
  • Nadolol 20 Mg Tablet (Age Limit)
  • Nadolol 40 Mg Tablet (Age Limit)
  • Nadolol 80 Mg Tablet (Age Limit)
  • Nuvaring Vaginal Ring
  • Plan B One-Step Tablet 1.5mg
  • Pantoprazole Sodium Packet 40 MG Oral (Age Limit)
  • Protonix 40 Mg Suspension (Age Limit)
  • Retacrit Inj 20000uni (Prior Authorization Required)
  • Retin-A 0.025% Cream
  • Retin-A 0.05% Cream
  • Retin-A 0.1% Cream
  • Retin-A 0.025% Gel
  • Retin-A 0.01% Gel
  • Rufinamide Sus 40mg/ml (Prior Authorization Required)
  • Skyla 13.5 Mg System
  • SM Omega 3-6-9 Softgel
  • Toviaz ER 4 Mg Tablet
  • Toviaz ER 8 Mg Tablet

Removals:

  • Adapalene 0.1% Cream
  • Amantadine 100 Mg Tablet
  • Carbidopa 25 Mg Tablet
  • Carbidopa-Levo 25-100 Mg ODT
  • Carbidopa-Levo 25-250 Mg ODT
  • Carbidopa-Levodopa 100 Mg-Enta
  • Carbidopa-Levodopa 125 Mg-Enta
  • Carbidopa-Levodopa 150 Mg-Enta
  • Carbidopa-Levodopa 200 Mg-Enta
  • Carbidopa-Levodopa 50 Mg-Enta
  • Carbidopa-Levodopa 75 Mg-Enta
  • Ciclopirox 0.77% Topical Susp
  • Colestipol HCl Granules
  • Colestipol HCl Granules Packet
  • Ella 30 Mg Tablet
  • Erythromycin 2% Pads
  • Erythromycin 2% Gel
  • Etonogestrel-Ethinyl Estradiol Ring 0.12-0.015 MG/24HR Vaginal
  • Flavoxate HCl 100 Mg Tablet
  • Fluvastatin ER 80 Mg Tablet
  • Fluvastatin Sodium 20 Mg Cap
  • Fluvastatin Sodium 40 Mg Cap
  • Niacin 500 Mg Tablet
  • Omeprazole Dr 20 Mg Tablet
  • Omeprazole Mag Dr 20.6 Mg Cap
  • Banzel Sus 40mg/ml
  • Selegiline HCl 5 Mg Capsule
  • Selegiline HCl 5 Mg Tablet
  • Sod Sulfacetamide 10% Shampoo
  • Sodium Sulfacetamide 10% Wash
  • Solifenacin 10 Mg Tablet
  • Solifenacin 5 Mg Tablet
  • Sulfacetamide Sod 10% Top Susp
  • Tazarotene 0.1% Cream
  • Tolterodine Tartrate Tablet 1 MG Oral
  • Tolterodine Tartrate Tablet 2 MG Oral
  • Tolterodine Tartrate ER Capsule Extended Release 24 Hour 2 MG Oral
  • Tolterodine Tartrate ER Capsule Extended Release 24 Hour 4 MG Oral
  • Tretinoin Cream 0.025 %
  • Tretinoin Cream 0.05 %
  • Tretinoin Cream 0.1 %
  • Tretinoin Gel 0.01 %
  • Tretinoin Gel 0.025 %
  • Trospium Chloride 20 Mg Tablet
  • Trospium Chloride ER 60 Mg Cap
  • Verapamil ER PM 100 Mg Capsule
  • Verapamil ER PM 200 Mg Capsule
  • Verapamil ER PM 300 Mg Capsule

Other Updates:

  • Detrol 1 Mg Tablet (Removed Step Therapy)
  • Detrol 2 Mg Tablet (Removed Step Therapy)
  • Detrol LA 2 Mg Capsule (Removed Step Therapy)
  • Detrol LA 4 Mg Capsule (Removed Step Therapy)
  • Ezetimibe 10 Mg Tablet (Removed Step Therapy)
  • Lansoprazole ODT 15 Mg Tablet (Removed Prior Authorization, Added Age Limit)
  • Lansoprazole ODT 30 Mg Tablet (Removed Prior Authorization, Added Age Limit)
  • Montelukast Sod 4 Mg Granules (Updated Age Limit)
  • Retin-A 0.01% Gel (Removed Step Therapy)
  • Retin-A 0.025% Cream (Removed Step Therapy)
  • Retin-A 0.025% Gel (Removed Step Therapy)
  • Retin-A 0.05% Cream (Removed Step Therapy)
  • Retin-A 0.1% Cream (Removed Step Therapy)
  • Rosuvastatin Calcium 10 Mg Tab (Removed Step Therapy)
  • Rosuvastatin Calcium 20 Mg Tab (Removed Step Therapy)
  • Rosuvastatin Calcium 40 Mg Tab (Removed Step Therapy)
  • Rosuvastatin Calcium 5 Mg Tab (Removed Step Therapy)
  • Sevelamer Carbonate 800 Mg Tab (Removed Prior Authorization)

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

  • Fish Oil EC 1,000 Mg Softgel
  • Krill Oil 300 Mg Softgel
  • SM Omega 3-6-9 Softgel

Removals:

  • Amantadine 100 Mg Tablet
  • Selegiline HCl 5 Mg Capsule
  • Selegiline HCl 5 Mg Tablet

 

December 2020

Title 19/21 SMI Drug List Updates:

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

November 2020

Title 19/21 SMI Drug List Updates:

Additions:

  • Cetirizine Cap 10mg
  • Dimethyl Fum Cap 120mg DR (Quantity Level Limit, Prior Authorization Required)
  • Dimethyl Fum Cap 240mg DR (Quantity Level Limit, Prior Authorization Required)
  • Diphenhydramine Chw 12.5mg
  • Emtricitabin Cap 200mg
  • Guaifenesin Tab 400mg
  • Levocetirizi Sol 2.5mg/5
  • Levocetirizi Tab 5mg
  • Nebulizers
  • Phenylephrine Tab 10mg
  • Saline Gel Nasal

Removals:

  • Emtriva Cap 200mg
  • Tamiflu Cap 30mg
  • Tamiflu Cap 45mg
  • Tamiflu Cap 75mg
  • Tamiflu Susp 6mg/ml
  • Tecfidera Cap DR 120mg
  • Tecfidera Cap DR 240mg

Other Updates:

  • Linaclotide capsules (Step Therapy Updated)

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

October 2020

Title 19/21 SMI Drug List Updates:

Additions:

  • Advair Diskus 100-50 mcg/dose (Step Therapy Required)
  • Advair Diskus 250-50 mcg/dose (Step Therapy Required)
  • Advair Diskus 500-50 mcg/dose (Step Therapy Required)
  • Ajovy Inj 225/1.5 (Prior Authorization Required)
  • Ajovy Syn 225/1.5 (Prior Authorization Required)
  • Efavirenz-Lamivudine-Tenofovir Df Tab 400-300-300 Mg
  • Efavirenz-Lamivudine-Tenofovir Df Tab 600-300-300 Mg
  • Flovent Disk Aer 100mcg
  • Flovent Disk Aer 250mcg
  • Flovent Disk Inh 50mcg
  • Humalog Jr Inj 100/ml
  • Humulin 5's Pen 70/30kwp
  • Humulin N Pen U-100kwp
  • Dulera Aerosol 50-5mcg (Step Therapy Required)

Removals:

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

Other Updates:

  • None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • Dyanavel XR Sus 2.5mg/ml
  • Psyllium Powder 30%
  • Psyllium Powder 33%
  • Psyllium Powder 49%
  • Quillichew Chw 20mg ER
  • Quillichew Chw 30mg ER
  • Quillichew Chw 40mg ER
  • Quillivantxr Sus 25mg/5ml

Other Updates:

  • None

 

September 2020

Title 19/21 SMI Drug List Updates:

Additions:

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

Removals:

  • None

Other Updates:

  • None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

August 2020

Title 19/21 SMI Drug List Updates:

Additions:

  • Diclofenac Sodium Soln 1.5% (Quantity Level Limit, Step Therapy Required)
  • Ibrance Cap 100mg (Prior Authorization Required, Quantity Level Limit)
  • Ibrance Cap 125mg (Prior Authorization Required, Quantity Level Limit)
  • Ibrance Cap 75mg (Prior Authorization Required, Quantity Level Limit)
  • Ibrance Tab 100mg (Prior Authorization Required, Quantity Level Limit)
  • Ibrance Tab 125mg (Prior Authorization Required, Quantity Level Limit)
  • Ibrance Tab 75mg (Prior Authorization Required, Quantity Level Limit)
  • Temixys 300-300 (Quantity Level Limit)
  • Lynparza Tab 100mg (Prior Authorization Required, Quantity Level Limit)
  • Lynparza Tab 150mg (Prior Authorization Required, Quantity Level Limit)
  • Solifenacin Succinate Tab 10 Mg (Quantity Level Limit, Step Therapy Required)
  • Solifenacin Succinate Tab 5 Mg (Quantity Level Limit, Step Therapy Required)
  • Symproic Tab 0.2mg (Prior Authorization Required, Quantity Level Limit)

Removals:

  • Fluorouracil Cream 0.5%
  • Naproxen Sodium Tab 275 Mg
  • Tolmetin Sodium Cap 400
  • Tolmetin Sodium Tab 200
  • Tolmetin Sodium Tab 600

Other Updates:

  • Symtuza Tab (Added Prior Authorization)
  • Testosterone TD Soln 30 Mg/Act (Added Quantity Level Limit)
  • Testosterone Gel 1.62% (Added Quantity Level Limit)
  • Candesartan Cilexetil Tab 4 Mg (Added Step Therapy)
  • Candesartan Cilexetil Tab 8 Mg (Added Step Therapy)
  • Candesartan Cilexetil Tab 16 Mg (Added Step Therapy)
  • Candesartan Cilexetil Tab 32 Mg (Added Step Therapy)
  • Candesartan Cilexetil-Hydrochlorothiazide Tab 16-12.5 Mg (Added Step Therapy)
  • Candesartan Cilexetil-Hydrochlorothiazide Tab 32-12.5 Mg (Added Step Therapy)
  • Candesartan Cilexetil-Hydrochlorothiazide Tab 32-25 Mg (Added Step Therapy)
  • Fluvastatin Sodium Cap 20 Mg (Added Step Therapy)
  • Fluvastatin Sodium Cap 40 Mg (Added Step Therapy)
  • Carbamide Peroxide 6.5% Otic Soln (Added Quantity Level Limit)
  • Betamethasone Dipropionate Augmented Cream 0.05% (Added Quantity Level Limit)
  • Lidocaine Oint 5% (Changed Quantity Level Limit)

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

July 2020

Title 19/21 SMI Drug List Updates:

Additions:

  • None

Removals:

  • Videx EC Cap 125mg
  • Videx Ped Pow 2gm
  • Videx Sol 4gm
  • Zaclir Lot 8%

Other Updates:

  • None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

June 2020

Title 19/21 SMI Drug List Updates:

Additions:

  • Alahist D Tab
  • Dovato Tab 50-300mg (Quantity Level Limit)
  • Gvoke Hypopen Inj (Quantity Level Limit)
  • Phenazopyridine Tab 95 Mg

Removals:

  • None

Other Updates:

  • None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

May 2020

Title 19/21 SMI Drug List Updates:

Additions:

  • Dexameth Pho Inj 20mg/5ml
  • Dexameth Pho Mdv 10mg/ml
  • Dexameth Pho Via 120mg/30
  • Dexamethason Via 10mg/ml
  • Dexamethason Via 4mg/ml
  • Everolimus Tab 0.25mg (Prior Authorization Required)
  • Everolimus Tab 0.5mg (Prior Authorization Required)
  • Everolimus Tab 0.75mg (Prior Authorization Required)
  • Pyrimethamine Tab 25mg (Prior Authorization Required)

Removals:

  • Daraprim Tab 25mg
  • Zortress Tablet 0.25mg
  • Zortress Tablet 0.5mg
  • Zortress Tablet 0.75mg

Other Updates:

  • None

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

April 2020

Title 19/21 SMI Drug List Updates:

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)

 

GMH/SU & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • Konsyl Daily Fiber Packet 100%
  • Sennosides Tab 17.2 Mg

Other Updates:

  • None