Pharmacy

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.

Behavioral health medications

Brand Name Drugs

Buprenorphine  

Concomitant Antidepressant Therapy

Concomitant Antipsychotic Treatment  

Nuedexta

Sublocade

 

Physical health medications

Non-Formulary 

Actemra

Actimmune

Afinitor - Afinitor Disperz

Ampyra

Anthelmintics

Aranesp

Arcalyst

Armodafinil - Modafinil

Botulinum Toxins

Brand Name Drugs

Cabometyx-Cometriq

Cambia

Capecitabine (Xeloda)

Caprelsa

Celecoxib (Celebrex)

Cialis for BPH

Cimzia

Colony Stimulating Factors

Compounded Drug Products 

Corlanor

Cosentyx

Daliresp

Daraprim

Diabetic Test Strips 

Diclegis

Direct Renin Inhibitors

Dose Optimization

DPP-4 Inhibitors 

Dupixent

Egrifta

Eligard-Trelstar-Vantas

Elmiron

Emflaza

Enbrel

Entresto

Entyvio

Epogen-Procrit

Erivedge

Eucrisa

Fentanyl Transmucosal IR Agents (TIRF)

Forteo

GLP-1 Agonist

Growth Hormone 

Hepatitis C Agents

HP Acthar

Humira

Hyaluronic Acid Derivatives  

Hyperlipidemia Medications

Idiopathic Pulmonary Fibrosis Agents

Ilaris

Imatinib

Inflectra

Inhaled Antibiotics for Cystic Fibrosis

Inlyta

Interleukin-5 Antagonists

Intravaginal Progesterone Products

Intron-A and Alferon-N 

Jakafi

Juxtapid and Kynamro

Kalydeco

Kevzara

Kineret

Leukine  

Leuprolide  

Lidocaine ointment

Lidocaine patch

Lupron Depot

Lyrica

Makena

Monoamine Depletors

Movantik 

Multaq

Multiple Sclerosis Agents

Nexavar

Nuedexta

Octreotide

Oncology - General Request

Ondansetron Oral Solution

Onychomysosis and Tinea

Opioids - Long-Acting

Opioids - Short-Acting Post Limit

Orencia

Orkambi

Otezla

PCSK9 Inhibitors

Pegasys for Hepatitis B

Platelet Inhibitors

Premarin Vaginal Cream

Prolia 

Promacta

Proton Pump Inhibitors 

Pulmonary Arterial Hypertension 

Pulmozyme

Quantity Limit Exceptions 

Ranexa 

Remicade

Renflexis

Restasis-Xiidra

Revlimid

Savella

Second Generation TKIs for CML

Sensipar 

Serostim 

SGLT2 Inhibitors

Siliq

Simponi - Simponi Aria

Somatostatin Analogs 

Stelara

Sucraid

Supprelin LA

Sutent

Sylatron

Symdeko

Synarel

Taltz

Tarceva

Tavalisse

Testosterone

Thalomid

Toujeo 

Tranexamic acid

Triptodur

Tykerb

Tremfya

Tymlos 

Tysabri for Crohns

Vancomycin Oral

Votrient

Weight Reduction Medications 

Xeljanz

Xifaxan

Xolair 

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 12.01.2018)

GMH/SA and Non-Title 19/21 SMI Member (effective 12.01.2018)

5-day Supply Limit of Prescription Opioid Medications

Botulinum Toxins

Colony Stimulating Factors

Cytokine and CAM Antagonists 

Growth Hormone (effective 12.01.2018)

Hepatitis C

Injectable Osteoporisis Agents (effective 10.01.2018)

Multiple Sclerosis Agents  (effective 10.01.2018)

Oncology - Drug Specific

Smoking cessation

Step Therapy

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.

Specialty Medication Drug List

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 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

 

November 2018

Title 19/21 SMI Drug List Updates:

Additions:

  • Albendazole added with ST

Removals:

  • Cytra-K (all NDCs are DESI)
  • Albenza
  • Clotrimazole ointment (no longer marketed)

 

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

Additions:

  • None

Removals:

  • None

 

October 2018

Title 19/21 SMI Drug List Updates:

Additions:

  • Arcapta Neohaler added with QLL (30 caps/ 30 days)
  • Aristada Initio added with QLL (2/365days)
  • Atomoxetine added with QLL (30/30days)
  • Butenafine cream
  • Cascara sagrada
  • Dutasteride
  • Fiber tablet, powder, capsule
  • Glatopa 40mg
  • Loratadine chew tab added with QLL (60/30days)
  • Magnesium Citrate soln
  • Magnesium Oxide tab
  • Methylcellulose powder, tab
  • Ondansetron 4mg tablet and ODT QLL changed to 90tabs/30days
  • Prasugrel added with QLL (30/30 days)
  • Procrit added with PA
  • Senna syrup, liquid, tab
  • Striverdi Respimat added with QLL (1/30days)
  • Tadalafil (generic Adcirca) added with STEP
  • Tazarotene cream added with QLL (90gm/30days)
  • Tymlos added with PA and QLL (1/30days)
  • Valganciclovir QLL added (60/30days)
  • Vitamin E Chew tab
  • Vyvanse chewable tablet added with QLL (30/30days)

Removals:

  • Acebutolol
  • Aclometasone
  • Adcirca
  • Capex shampoo
  • Cardura XL
  • Copaxone 40mg
  • Desonide
  • Diltiazem 24hr ER tablet
  • Diltiazem IR and ER QLL removed
  • Fluocinolone cream, solution
  • Griseofulvin ultramicrosize
  • Hydrocortisone butyrate
  • Hydrocortisone valerate
  • Isradipine
  • Itraconazole
  • Ketoconazole
  • MatzimLA
  • Methylphenidate chewable tablet
  • Nicardipine
  • Nimodipine
  • Nisoldipine
  • Noxafil suspension
  • Pindolol
  • Sporanox solution
  • Strattera
  • Timolol tablet
  • Voriconazole

 

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

Additions:

  • Aristada Initio added with QLL (2/365 days) and age limit (PA for < 18 years)
  • Atomoxetine added with QLL (30/30 days) and age limit (PA for <6 years)
  • Bisacodyl enema, supp, tab
  • Cascara sagrada capsule
  • Fiber tablet, powder, capsule
  • Lithium age limit added (PA for <6 years)
  • Magnesium Citrate soln
  • Magnesium Oxide tab
  • Methylcellulose powder, tab
  • Niacin tablet, chew tab, and ER tab
  • Pimozide age limit added (PA for <12 years)
  • Senna syrup, liquid, tab
  • Vitamin E Chew tab
  • Vyvanse chewable tablet added with QLL (30/30days ) and age limt (PA for <6 years)

Removals:

  • Methylphenidate chewable tablet
  • Strattera

 

September 2018

Title 19/21 SMI Drug List Updates:

Additions

  • Eliquis starter pack  added with QLL (74/30days)
  • Makena 275mg /1.1ml Auto Inj added with PA
  • Phosphorous 250mg powder for solution
  • Pyrethrins-piperonyl Butoxide Gel
  • Symtuza tablets added with QLL (30/30days)

Removals

  • Eurax PA removed
  • PHOS-NAK

 

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

Additions

  • None

Removals

  • None

 

July 2018

Title 19/21 SMI Drug List Updates

 Additions:

  • Naratriptan tablets added with QLL (9/30 days)
  • Rizatriptan QLL changed (9/30days)
  • Zolmitriptan tablets and ODT added with QLL (9/30days)
  • Rozerem ST and QLL added (30/30 days)
  • Novolog Mix 70/30 Flexpen and Vial
  • Novolog 100Units/Ml Vial, Flexpen, and cartridge
  • Glyxambi added with PA
  • Norvir powder added
  • Phytonadione
  • Renagel PA added
  • Renvela Brand Only added with PA
  • Levalbuterol solution added (no PA required for age <4)
  • Montelukast chewable tabs added with QLL (30/30days)
  • Montelukast granules PA added for age > 4
  • Bevespi Aerosphere added with PA
  • Stiolto Respimat added with PA
  • Alprazolam ER QLL changed (30/30days)
  • Lorazepam 2mg tablet QLL changed (60/30)
  • Lorazepam Intensol QLL changed (60ml/30)
  • Chlordiazepoxide QLL added (60/30days)
  • Clorazepate 3.75mg and 7.5mg QLL added (120/30)
  • Clorazepate 15mg QLL added (60/30)
  • Oxazepam QLL added (60/30days)
  • Xarelto Starter Pack QLL changed to 51/30
  • Servent Diskus PA added

Removals:

  • Meprobamate
  • Estazolam
  • Flurazepam
  • Eszopiclone
  • Triazolam
  • Rozerem PA removed
  • Zaleplon
  • Zolpidem ER
  • Intermezzo SL/ Edular
  • Zolpimist
  • Silenor
  • Mephyton
  • Auryxia
  • Fosrenol
  • Sevelamer generic
  • Levalbuterol HFA
  • Montelukast granules PA removed for age > 2
  • Arcapta Neohaler
  • Foradil
  • Metaproterenol
  • Striverdi Respimat
  • Zafirlukast

 

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

Additions:

  • Rozerem ST and QLL added (30/30)
  • Haloperidol decanoate PA added for age < 18
  • Fluphenazine decanoate PA added for age < 18
  • Alprazolam ER QLL changed (30/30days)
  • Chlordiazepoxide QLL added (60/30days)
  • Clorazepate 3.75mg and 7.5mg QLL added (120/30)
  • Clorazepate 15mg QLL added (60/30)
  • Oxazepam QLL added (60/30days)
  • Lorazepam 2mg tablet QLL changed (60/30)
  • Lorazepam Intensol QLL changed (60ml/30)

Removals:

  • Pexeva QLL removed
  • Silenor
  • Meprobamate
  • Estazolam
  • Flurazepam
  • Eszopiclone
  • Triazolam
  • Rozerem PA removed
  • Zaleplon
  • Zolpidem ER
  • Intermezzo SL/ Edular
  • Zolpimist

 

June 2018

Title 19/21 SMI Drug List Updates

Additions:

  • Symfi added with QLL (30/30 days)
  • Praziquantel
  • Lansoprazole ODT added with PA and QLL (30/30 days)
  • Tasigna 50mg added with PA and QLL (120/30 days)

Removals:

  • Biltricide
  • Sensipar smart edit PA for nephrologists
  • Prevacid ODT

 

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

Additions:

  • None

Removals:

None

 

May 2018

Title 19/21 SMI Drug List Updates

Additions:

  • Colchicine 0.6mg capsule
  • Firvanq solution
  • Jardiance added (Quantity Level Limit, Step Therapy Required)
  • Ritonavir 100mg tablet
  • Symfi Lo (Quantity Level Limit)
  • Synjardy (Quantity Level Limit, Step Therapy Required)
  • Synjardy XR 10/1000mg and 25/1000mg (Quantity Level Limit, Step Therapy Required)
  • Synjardy XR 5/1000mg and 12.5/1000mg (Quantity Level Limit, Step Therapy Required)

Removals:

  • Norvir tablet

Other Updates:

  • Rosuvastatin (Removed Prior Authorization, Added Step Therapy)

 

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

  • No Monthly Updates

 

April 2018

Title 19/21 SMI Drug List Updates

Additions:

  • Biktarvy
  • Pulmicort Flexhaler
  • Tramadol ER tablets (Prior Authorization Required)

Removals:

  • Emend

Other Updates:

  • Aprepitant (Added Quantity Level Limit)

 

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

  • No Monthly Updates

 

March 2018

Title 19/21 SMI Drug List Updates

Additions:

  • Efavirenz
  • Methergine

Removals:

  • Sustiva

 

April 2018

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

  • No Monthly Updates

 

February 2018

Title 19/21 SMI Drug List Updates

Additions:

  • Atazanavir tablets
  • BD Pen Needles
  • Efavirenz
  • Estradiol 0.01% vaginal cream
  • Juluca (Quantity Level Limit)
  • Tenofovir
  • Vancomycin capsules (Prior Authorization Required -use First Vancomycin Solution)

Removals:

  • Albuterol tablets, IR and ER
  • Amcinonide cream/lotion
  • Betopic S ophthalmic
  • Brimonidine 0.15% ophthalmic
  • Cefaclor ER
  • Estrace vaginal cream
  • FML forte ophthalmic
  • Gatifloxacin 0.5% ophthalmic solution
  • Hydromorphone suppositories
  • Neomycin/polymyxin HC ophthalmic
  • One Touch Verio High
  • Oxymorphone IR
  • Pen Needles (any brand other than BD)
  • Pramosone-HC 1%-1% topical cream
  • Prednicarbate topical
  • Reyataz tablets
  • Sustiva
  • Terbutaline tablets
  • Viread

Other Updates:

  • Brimonidine 0.2% ophthalmic (Added Quantity Level Limit)
  • Ciprofloxacin 250mg/5ml (Added Quantity Level Limit)
  • Clobetasol Cream Emollient 0.05% (Added Quantity Level Limit)
  • Combigan (Added Step Therapy)
  • Fentanyl lozenges (Added Prior Authorization)
  • Halobetasol topical (Added Quantity Level Limit)
  • Sprycel (Added Quantity Level Limit)
  • Timolol gel (Added Step Therapy)

 

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

  • No Monthly Updates

 

January 2018

Title 19/21 SMI Drug List Updates

Additions:

  • Armodafinil (Prior Authorization Required, Quantity Level Limit)
  • Carboxymethycellulose sodium ophth soln 0.25%
  • Epinephrine 0.3mg/0.3ml and 0.15mg/0.15ml Pens (Mylan)
  • Opsumit (Prior Authorization Required)
  • Xtampza ER (Prior Authorization Required)

Removals:

  • Epclusa
  • Epinephrine by Impax Labs
  • Epipen, Epipen Jr
  • Harvoni
  • Hysingla
  • Oxycontin
  • Technivie
  • Viekiera Pak
  • Viekiera Pak XR
  • Zepatier

Other Updates:

  • Adcirca (Removed Quantity Level Limit)
  • Benzonatate (Removed Quantity Level Limit)
  • Brilinta (Removed Quantity Level Limit)
  • Brompheniramine-dm-pseudoephedrine (Removed Quantity Level Limit)
  • Budesonide (Removed Quantity Level Limit)
  • Clopidogrel (Removed Quantity Level Limit)
  • Cyclobenzaprine 5mg, 10mg (Removed Quantity Level Limit)
  • Descovy (Removed Quantity Level Limit)
  • Donepezil/ donepezil ODT (Removed Quantity Level Limit)
  • Ella (Removed Quantity Level Limit)
  • Emend (Changed Quantity Level Limit)
  • Fluocinonide 0.05% gel, ointment (Removed Quantity Level Limit)
  • Foradil (Removed Quantity Level Limit)
  • Gabapentin (Removed Quantity Level Limit)
  • Galantamine (Removed Quantity Level Limit)
  • Gemfibrozil (Removed Quantity Level Limit)
  • Genvoya (Removed Quantity Level Limit)
  • Imbruvica (Removed Quantity Level Limit)
  • Isentress tabs, chew tabs, suspension (Removed Quantity Level Limit)
  • Lamivudine (Removed Quantity Level Limit)
  • Lansoprazole (Rx) (Removed Quantity Level Limit)
  • Letairis (Removed Quantity Level Limit)
  • Levonorgestrel 0.75mg (Removed Quantity Level Limit)
  • Lidocaine-prilocaine topical (Removed Quantity Level Limit)
  • Lisinopril (Removed Quantity Level Limit)
  • Methocarbamol (Removed Quantity Level Limit)
  • Nexavar (Removed Quantity Level Limit)
  • Next Choice, Next Choice One Dose (Removed Quantity Level Limit)
  • Nisoldipine (Removed Quantity Level Limit)
  • Omeprazole (Rx) (Removed Quantity Level Limit)
  • Pantoprazole (Removed Quantity Level Limit)
  • Pioglitazine/ pioglitazine-metformin (Removed Quantity Level Limit)
  • Plan B One Step (Removed Quantity Level Limit)
  • Raloxifene (Removed Quantity Level Limit)
  • Revlimid (Removed Quantity Level Limit)
  • Rivastigamine (Removed Quantity Level Limit)
  • Ropinirole (Removed Quantity Level Limit)
  • Sildenafil (Removed Quantity Level Limit)
  • Spiriva (Removed Quantity Level Limit)
  • Stribild (Removed Quantity Level Limit)
  • Sutent (Removed Quantity Level Limit)
  • Tamsulosin (Removed Quantity Level Limit)
  • Tasigna (Removed Quantity Level Limit)
  • Terazosin (Removed Quantity Level Limit)
  • Thalomid (Removed Quantity Level Limit)
  • Tivicay (Removed Quantity Level Limit)
  • Tobradex ointment (Removed Quantity Level Limit)
  • Tracleer (Removed Quantity Level Limit)
  • Trospium (Removed Quantity Level Limit)
  • Tykerb (Removed Quantity Level Limit)
  • Valsartan/ Valsartan HCTZ (Removed Quantity Level Limit)
  • Verapamil IR (Removed Quantity Level Limit)
  • VIread (Removed Quantity Level Limit)
  • Votrient (Removed Quantity Level Limit)
  • Zafirlukast (Removed Quantity Level Limit)
  • Zonisamide (Removed Quantity Level Limit)

 

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

  • No Monthly Updates