Pharmacy

IMPORTANT: Read this notice regarding pharmacy network changes

Preferred drug lists

Mercy Care RBHA uses three 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 (CMDP, DES/DDD, or ACC Opt-Out) or as Non-Title 19/21 determined to have a serious mental illness (SMI), 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.

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

 

Afinitor - Afinitor Disperz

Ampyra

Armodafinil - Modafinil

Botulinum Toxins 

Capecitabine (Xeloda)

Colony Stimulating Factors    (ex: Neulasta, Neupogen)

Concomitant Antidepressant Therapy 

Concomitant Antipsychotic Treatment  

Cytokine and CAM Antagonist (ex:Enbrel, Humira)  Updated 10.01.2019

Daraprim Updated 10.01.2019

Dose Optimization

DPP-4 Inhibitors 

Eligard-Trelstar-Vantas

Erythropoiesis Stimulating Agents 

Eucrisa

Forteo

Growth Hormone 

Hemophilia  NEW 10.01.2019

Hepatitis C Agents   Updated 10.01.2019

Hereditary Angioedema

HP Acthar

Hyaluronic Acid Derivatives

Hyperlipidemia Medications

Idiopathic Pulmonary Fibrosis Agents  Updated 12.02.2019

Increlex NEW 12.02.2019

Inhaled Antibiotics for Cystic Fibrosis 

Inlyta 

Interferons  NEW 10.01.2019

Interleukin-5 Antagonists  Updated 12.02.2019

Jakafi

Kalydeco

Leuprolide

Lupron Depot 

Lucemyra

Multiple Sclerosis Agents 

Nexavar 

Oncology - General

Opioids  NEW 10.01.2019

Orkambi 

Platelet Inhibitors  Updated 12.02.2019

Premarin Vaginal Cream

Prolia 

Pulmonary Arterial Hypertension   

Pulmozyme

Quantity Limit Exceptions 

Revlimid 

Savella

Second-Third Generation TKIs for CML

Serostim 

Somatostatin Analogs  Updated 12.02.2019

Spinraza 

Supprelin LA 

Sutent

Sylatron 

Symdeko

Synarel

Tarceva

Testosterone  Updated 12.02.2019

Thrombopoiesis Stimulating Products (Promacta, Nplate, Tavalisse) Updated 12.02.2019

Toujeo 

Triptodur

Tykerb 

Tymlos 

Votrient 

Xolair   Updated 12.02.2019

Xyrem NEW 12.02.2019

Zoladex

Zoladronic acid

Zorbtive 

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 (effective 12.02.2019)

GMH/SA and Non-Title 19/21 SMI Members (effective 10.01.2019)

Botulinum Toxins (effective 12.02.2019)

Colony Stimulating Factors (effective 08.01.2019)

Cytokine and CAM Antagonists (effective 10.01.2019)

Growth Hormone (effective 12.01.2018)

Hemophilia (effective 02.04.2019)

Hepatitis C (effective 12.02.2019)

Hereditary Angioedema (effective 02.04.2019)

Immune Globulins (effective 12.02.2019)

Injectable Osteoporosis Agents (effective 10.01.2018)

Multiple Sclerosis Agents (effective 12.02.2019)

Opioids (effective 12.02.2019)

Smoking cessation 

Step Therapy

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.

December 2019

Title 19/21 SMI Drug List Updates:

Additions:

  • Synagis Inj 100mg/ml (Age Limit, Quantity Level Limit)
  • Synagis Inj 50mg/0.5ml (Age Limit, Quantity Level Limit)

Removals:

  • Benzoyl Peroxide Liq 7%

Other Updates:

  • None

 

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

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

November 2019

Title 19/21 SMI Drug List Updates:

Additions:

  • Aminocaproic Acid Sol 0.25gm/ml

Removals:

  • Amicar Sol 0.25gm/ml

Other Updates:

  • None

 

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

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

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

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

October 2019

Title 19/21 SMI Drug List Updates:

Additions:

  • Aimovig Inj 70mg/ml (Prior Authorization Required)
  • Aquadeks Chw
  • Aquadeks Dro
  • Budesonide Sus 1mg/2ml (Age Limit)
  • Bupren/Nalox Sub 2-0.5mg Tab
  • Bupren/Nalox Sub 8-2mg Tab
  • Dekas Cap Essential
  • Dekas Liq Essential
  • Dekas Plus Chw
  • Dekas Plus Liq
  • Dexmethylph Tab 10mg (Age Limit, Quantity Level Limit)
  • Dexmethylph Tab 2.5mg (Age Limit, Quantity Level Limit)
  • Dexmethylph Tab 5mg (Age Limit, Quantity Level Limit)
  • Dyanavel XR Sus 2.5mg/ml (Age Limit, Quantity Level Limit)
  • Emgality Inj 120mg/ml (Prior Authorization Required)
  • Emgality Inj 120mg/ml (Prior Authorization Required)
  • Multivitamin Chw Children
  • Mvw Complete Chw
  • Mvw Complete Chw
  • Otezla Tab 10/20/30 (Prior Authorization Required)
  • Otezla Tab 30mg (Prior Authorization Required)
  • Pifeltro Tab 100mg
  • Sofos/Velpat Tab 400-100 (Prior Authorization Required)
  • Sublocade Inj 100/0.5 (Prior Authorization Required)
  • Sublocade Inj 300/1.5 (Prior Authorization Required)
  • Symjepi Inj 0.15mg (Quantity Level Limit)
  • Symjepi Inj 0.3mg (Quantity Level Limit)
  • Tudorza Pres Aer 400/Act (Quantity Level Limit)
  • Vitamax Chw
  • Vitamax Ped Dro
  • Xarelto Tab 2.5mg (Quantity Level Limit)
  • Xeljanz Tab 10mg (Prior Authorization Required)
  • Xeljanz Tab 5mg (Prior Authorization Required)

Removals:

  • Advair Disku Aer 100/50
  • Advair Disku Aer 250/50
  • Advair Disku Aer 500/50
  • Aripiprazole Sol 1mg/ml
  • Aripiprazole Tab 10mg ODT
  • Aripiprazole Tab 15mg ODT
  • Dextroamphet Cap 10mg ER
  • Dextroamphet Cap 15mg ER
  • Dextroamphet Cap 5mg ER
  • Epinephrine Inj 0.15mg (Generic Adrenaclick)
  • Focalin Tab 10mg
  • Focalin Tab 2.5mg
  • Focalin Tab 5mg
  • Pulmicort Sus 1mg/2ml
  • Saphris Sub 10mg
  • Saphris Sub 2.5mg
  • Saphris Sub 5mg

Other Updates:

  • None

 

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

Additions:

  • Dexmethylph Tab 5mg (Age Limit, Quantity Level Limit)
  • Dexmethylph Tab 10mg (Age Limit, Quantity Level Limit)
  • Bupren/Nalox Sub 2-0.5mg Tab
  • Bupren/Nalox Sub 8-2mg Tab
  • Sublocade Inj 100/0.5 (Prior Authorization Required)
  • Sublocade Inj 300/1.5 (Prior Authorization Required)
  • Dyanavel XR Sus 2.5mg/ml (Age Limit)
  • Dexmethylph Tab 2.5mg (Age Limit, Quantity Level Limit)

Removals:

  • Aripiprazole Sol 1mg/ml
  • Aripiprazole Tab 10mg ODT
  • Aripiprazole Tab 15mg ODT
  • Dextroamphet Cap 10mg ER
  • Dextroamphet Cap 15mg ER
  • Dextroamphet Cap 5mg ER
  • Focalin Tab 10mg
  • Focalin Tab 2.5mg
  • Focalin Tab 5mg
  • Saphris Sub 10mg
  • Saphris Sub 2.5mg
  • Saphris Sub 5mg

Other Updates:

  • None

 

September 2019

Title 19/21 SMI Drug List Updates:

Additions:

  • Febuxostat Tab (Quantity Level Limit, Step Therapy)
  • Multiple Vitamin
  • Pediatric Multiple Vitamin
  • Pregabalin Cap (Prior Authorization Required)
  • Pregabalin Sol (Prior Authorization Required)

Removals:

  • Uloric Tab
  • Lyrica Cap
  • Lyrica Sol

 

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

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

August 2019

Title 19/21 SMI Drug List Updates:

Additions:

  • Adcirca – Brand only (Prior Authorization Required)
  • Alendronate Sodium Soln
  • Bicillin L-A 1200000 Unit/2ml
  • Bicillin L-A 2400000 Unit/4ml
  • Bicillin L-A 600000 Unit/ml
  • Bivigam (Prior Authorization Required)
  • Carimune NF Nanofiltered (Prior Authorization Required)
  • Cerdelga (Prior Authorization Required)
  • Elelyso (Prior Authorization Required)
  • Farxiga (Prior Authorization Required)
  • Flebogamma Dif (Prior Authorization Required)
  • Fulphila (Prior Authorization Required)
  • Gamastan S-D (Prior Authorization Required)
  • Gammagard S-D (Prior Authorization Required)
  • Gleevec – Brand only (Prior Authorization Required)
  • Hizentra (Prior Authorization Required)
  • Imbruvica Tablets (Prior Authorization Required)
  • Invokana (Prior Authorization Required)
  • Letairis – Brand only (Prior Authorization Required)
  • Leukeran (Prior Authorization Required)
  • Lidocaine Patch 4% (Quantity Level Limit)
  • Lorcaserin HCl Tab ER 24hr 20mg (Prior Authorization Required, Quantity Level Limit)
  • Miglustat (Prior Authorization Required)
  • Nplate (Prior Authorization Required)
  • ProAir – Brand only
  • Retacrit (Prior Authorization Required)
  • Revatio solution – Brand only (Prior Authorization Required for age > 12)
  • Tracleer – Brand only (Prior Authorization Required)
  • Udenyca (Prior Authorization Required)
  • Vpriv (Prior Authorization Required)

Removals:

  • Arcapta Neohaler
  • Bupropion HCl Tab ER 24hr 450mg
  • Butalbital-Acetaminophen-Caffeine Cap 50-300-40mg
  • Butalbital-Acetaminophen-Caffeine Cap 50-325-40mg
  • Desvenlafaxine Succinate ER
  • Emsam
  • Epinastine HCl Ophth Soln 0.05%
  • Epogen
  • Erythromycin Ethylsuccinate For Susp
  • Escitalopram Oxalate Soln
  • Prefest
  • Etidronate Disodium
  • Etodolac Tab ER 24hr
  • Fluoxetine DR
  • Fluvoxamine Maleate ER
  • Glipizide-Metformin
  • Iclusig
  • Imatinib
  • Isocaboxazid
  • Jakafi
  • Marplan
  • Melphalan
  • Nefazodone HCl
  • Neulasta
  • Ofloxacin Otic
  • Olopatadine HCl Ophth Soln 0.2%
  • Opsumit
  • Paroxetine ER
  • Paxil Sus 10mg/5ml
  • Pexeva
  • Phenelzine Sulfate
  • Procrit
  • Purixan Solution
  • Riomet
  • Segluromet
  • Steglatro
  • Striverdi Respimat
  • Tasigna
  • Thalomid
  • Tranylcypromine Sulfate
  • Tymlos
  • Tyvaso
  • Ventavis
  • Ventolin HFA
  • Viibryd
  • Zolinza

Other Updates:

  • Azelastine Ophth Soln 0.2% (Added Quantity Level Limit)
  • Baraclude Oral Soln 0.05 mg/ml (Prior Authorization Required)
  • Butalbital-Acetaminophen-Caffeine Tab 50-325-40mg (Added Quantity Level Limit)
  • Calcipotriene Soln 0.005%, Calcipotriene cream 0.005%, Calcipotriene Oint 0.005% (Prior Authorization Required)
  • Citalopram Hydrobromide Oral Soln 10mg/5ml (Added Age Limit)
  • Evotaz Tablet 300-150mg (Added Quantity Level Limit)
  • Fluoxetine HCl Solution 20mg/5ml (Added Age Limit)
  • Sertraline HCl Oral Concentrate For Solution 20mg/ml (Added Age Limit)

 

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

Additions:

  • None

Removals:

  • Desvenlafaxine Succinate ER
  • Emsam
  • Escitalopram Oxalate Soln 5 Mg/5ml
  • Fluoxetine DR
  • Fluvoxamine Maleate ER
  • Marplan
  • Nefazodone HCl
  • Paroxetine ER
  • Paxil Sus 10mg/5ml
  • Pexeva
  • Phenelzine Sulfate
  • Tranylcypromine Sulfate
  • Viibryd

Other Updates:

  • Citalopram Hydrobromide Oral Soln 10mg/5ml (Added Age Limit)
  • Fluoxetine HCl Solution 20mg/5ml (Added Age Limit)
  • Sertraline HCl Oral Concentrate for Solution 20mg/ml (Added Age Limit)

 

July 2019

Title 19/21 SMI Drug List Updates:

Additions:

  • Avastin Inj
  • Cefixime Cap 400mg (Quantity Level Limit)
  • Erlotinib Tab 150mg (Prior Authorization Required)
  • Herceptin Inj
  • Mesalamine Cap 400mg DR (Quantity Level Limit)
  • Penicillamine Capsule
  • Sildenafil Sus 10mg/ml (Prior Authorization Required)

Removals:

  • Benziq Wash Liq 5.25%
  • Bio-Statin Cap 1000000
  • Bio-Statin Cap 500000 U
  • Bio-Statin Pow
  • Bocasal Pow
  • Calcium Carb Pow Ppt/Heav
  • Cuprimine Capsule
  • Delzicol Cap 400mg DR
  • Ergocal Cap 2500unit
  • Fluorabon Dro
  • Fluoroplex Cre 1%
  • Flura-Drops Dro 4drp=1mg
  • Gentamicin Pow Sulfate
  • Homatropine Sol 5% Op
  • Nature-Throi Tab 2gr
  • Revatio Sus 10mg/ml
  • Sod Fluoride Tab 0.5mg F
  • Sod Fluoride Tab 1mg F
  • Suprax Cap 400mg
  • Tarceva Tab 150mg

Other Updates:

  • None

 

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

Additions:

  • None

Removals:

  • None

Other Updates:

  • None

 

June 2019

Title 19/21 SMI Drug List Updates:

Additions:

  • Docosanol Cream 10%
  • Melatonin Tab 1 Mg
  • Melatonin Tab 3 Mg
  • Melatonin Tab 5 Mg

Removals:s

  • Abreva Cream 10%

Other Updates:

  • None

 

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

Additions:

  • Melatonin Tab 1 Mg
  • Melatonin Tab 3 Mg
  • Melatonin Tab 5 Mg

Removals:

  • None

Other Updates:

  • None

 

May 2019

Title 19/21 SMI Drug List Updates:

Additions:

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

Removals:

  • EryPed 400 Sus 400/5ml
  • Methylphenidate Tab ER
  • Methylphenidate Tab ER
  • Prochlorperazine Maleate Tab 10 Mg (Base Equivalent)
  • Prochlorperazine Maleate Tab 5 Mg (Base Equivalent)
  • Prochlorperazine Suppos 25 Mg
  • Ranexa Tab 1000mg ER
  • Rapamune Sol 1mg/ml

Other Updates:

  • None

 

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

Additions:

  • Concerta Tab ER

Removals:

  • Methylphenidate Tab ER

Other Updates:

  • None

 

April 2019

Title 19/21 SMI Drug List Updates:

Additions:

  • 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)

Removals:

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

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

Additions:

  • Ritalin LA Cap 20mg, 30mg, 40mg (Age Limit, Quantity Level Limit)

Removals:

  • None

 

 

March 2019

Title 19/21 SMI Drug List Updates:

Additions:

  • Cinacalcet tablet added with PA
  • Aminocaproic acid tablet
  • Carbidopa 25mg tablet
  • Toremifene tablet added with PA
  • Mesalamine 1000mg Suppositories added with QLL (30/30days)
  • Clonidine 0.1mg ER tablet added with QLL (120/30 days) and PA < 6 years of age

Removals:

  • Sensipar
  • Amicar
  • Fareston
  • Canasa Suppositories
  • Norethindrone- ethinyl estradiol- ferrous fumarate 1-20 mg-mcg (24) tablets
  • Kapvay

 

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

Additions:

  • Clonidine 0.1mg ER tablet added with QLL (120/30 days) and PA < 6 years of age

Removals:

  • Kapvay

 

February 2019

Title 19/21 SMI Drug List Updates:

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)
  • Clonidine HCL ER 0.1mg Tab
  • Flebogamma added with PA (must be filled at Contracted Home Infusion Pharmacy)
  • Gammagard added with PA (must be filled at Contracted Home Infusion Pharmacy)
  • Gammaked added with PA (must be filled at Contracted Home Infusion Pharmacy)
  • Gamunex-C added with PA (must be filled at Contracted Home Infusion Pharmacy)
  • 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
  • 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

 

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

Additions:

  • None

Removals:

  • None

 

January 2019

Title 19/21 SMI Drug List Updates:

Additions:

  • Celecoxib 50mg and 100mg QLL added (60/30 days)

Removals:

  • None

Title 19/21 Non-SMI & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • None

 

December 2018

Title 19/21 SMI Drug List Updates:

Additions:

  • Donepezil, donepezil ODT PA added
  • Memantine PA added
  • Mesalamine enema QLL (120ml/day)
  • Pentasa QLL (270 /30days)
  • Sildenafil citrate suspension 10 mg/mL with PA
  • Sulfasalazine QLL (240/30)
  • Tretinoin cream/gel age limitation of 26

Removals:

  • Benazepril & hydrochlorothiazide tab 5-6.25 mg
  • Interferon alfa-2b for inj 50000000 unit
  • Methotrexate sodium inj pf 100 mg/4ml (25 mg/ml)
  • Methotrexate sodium inj pf 200 mg/8ml (25 mg/ml)
  • Peginterferon alfa-2b for inj kit 80 mcg/0.5ml
  • Sodium fluoride-xylitol chew tab 1.1 (0.5 mg f)-236.79
  • Sodium sulfacetamide/ sulfur 10-5% emulsion
  • Telbivudine tab 600 mg
  • Tretinoin cream/gel age limitation of 35

 

Title 19/21 Non-SMI & Non-Title 19/21 Drug List Updates:

Additions:

  • None

Removals:

  • None