AHCCCS ACUTE - LONG TERM CARE DRUG LIST EFFECTIVE …

AHCCCS ACUTE - LONG TERM CARE DRUG LIST EFFECTIVE April 1, 2021

? Generic Drugs Are Preferred Over Brand Name Drugs Unless The Drug Is Specified As BRAND ONLY ? Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List May Be Available Through Prior Authorization

Drug Class/Drug Name ADHD/ANTI-NARCOLEPSY

Amphetamines

AMPHETAMINE-DEXTROAMPHETAMINE CAPSULE 24-HOUR

AMPHETAMINE-DEXTROAMPHETAMINE TABLETS DEXTROAMPHETAMINE SULFATE TABLETS

LISDEXAMFETAMINE DIMESYLATE CAPSULES

LISDEXAMFETAMINE DIMESYLATE CAPSULES Stimulants

DEXMETHYLPHENIDATE HCL CAPSULE 24-HOUR DEXMETHYLPHENIDATE HCL TABLETS METHYLPHENIDATE HCL CHEWABLE TABLETS

METHYLPHENIDATE HCL CAPSULE 24-HOUR

METHYLPHENIDATE HCL CAPSULE 24-HOUR METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE CD METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE

METHYLPHENIDATE PATCH

METHYLPHENIDATE HCL SOLUTION METHYLPHENIDATE HCL TABLETS

Reference Brand Name

BRAND ONLY / Generic Notes

Preferred Drug Status

ADDERALL XR

ADDERALL VARIOUS

VYVANSE CHEWABLES

VYVANSE

FOCALIN XR VARIOUS METHYLIN

RITALIN LA 10MG

APTENSIO XR VARIOUS VARIOUS

DAYTRANA

METHYLIN VARIOUS

BRAND ONLY PREFERRED DRUG

Brand & Generic

PREFERRED DRUG

PREFERRED DRUG

BRAND ONLY PREFERRED DRUG

BRAND ONLY PREFERRED DRUG

BRAND ONLY PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG

BRAND ONLY PREFERRED DRUG

BRAND ONLY PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG

BRAND ONLY PREFERRED DRUG

BRAND ONLY PREFERRED DRUG PREFERRED DRUG

8/20/2021

Prior Authorization Type

PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age

PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age

Step Therapy Requirements

Quantity QL Limit (QL) Days

30

30

60

30

60

30

30

30

30

30

60

30

60

30

90

30

30

30

30

30

30

30

30

30

30

30

300

30

90

30

1

AHCCCS ACUTE - LONG TERM CARE DRUG LIST EFFECTIVE April 1, 2021

? Generic Drugs Are Preferred Over Brand Name Drugs Unless The Drug Is Specified As BRAND ONLY ? Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List May Be Available Through Prior Authorization

Drug Class/Drug Name

METHYLPHENIDATE HCL TABLET EXTENDED RELEASE

METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE Miscellaneous Agents ATOMOXETINE HCL CAPSULES Central Alpha-Agonists clonidine hcl clonidine hcl transdermal patch CLONIDINE HCL (ADHD) TABLET 12-HOUR GUANFACINE HCL (ADHD) TABLET 24-HOUR guanfacine hcl AMINOGLYCOSIDES AMINOGLYCOSIDES NEOMYCIN SULFATE TABLETS INHALED ANTIBIOTICS

TOBRAMYCIN NEBULIZED

TOBRAMYCIN NEBULIZED ANALGESICS - ANTI-INFLAMMATORY ANTIRHEUMATIC ANTIMETABOLITES METHOTREXATE SODIUM TABLETS NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) CELECOXIB CAPSULES DICLOFENAC SODIUM TABLET 24-HOUR DICLOFENAC SODIUM TABLET ENTERIC COATED ETODOLAC CAPSULES ETODOLAC TABLETS

Reference Brand Name

RITALIN LA

CONCERTA

VARIOUS

Catapres Catapres Patches

Clonidine ER GUANFACINE ER

Tenex

BRAND ONLY / Generic Notes

Preferred Drug Status

BRAND ONLY PREFERRED DRUG

BRAND ONLY PREFERRED DRUG

PREFERRED DRUG

PREFERRED DRUG PREFERRED DRUG

NEOMYCIN SULFATE

BETHKIS KITABIS

BRAND ONLY PREFERRED DRUG BRAND ONLY PREFERRED DRUG

RHEUMATREX

CELEBREX VOLTAREN-XR

VOLTAREN VARIOUS VARIOUS

8/20/2021

Prior Authorization Type PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age PA Required for Ages < 6 years of age

PA Required PA Required

PA Required

Step Therapy Requirements

Quantity QL Limit (QL) Days

60

30

60

30

30

30

4

28

120

30

30

30

2

AHCCCS ACUTE - LONG TERM CARE DRUG LIST EFFECTIVE April 1, 2021

? Generic Drugs Are Preferred Over Brand Name Drugs Unless The Drug Is Specified As BRAND ONLY ? Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List May Be Available Through Prior Authorization

Drug Class/Drug Name FENOPROFEN CALCIUM CAPSULES FENOPROFEN CALCIUM TABLETS FLURBIPROFEN TABLETS IBUPROFEN CAPSULES IBUPROFEN CHEWABLE TABLETS IBUPROFEN SUSPENSION IBUPROFEN TABLETS INDOMETHACIN CAPSULES INDOMETHACIN CAPSULE CONTROLLED RELEASE INDOMETHACIN SUPPOSITORY INDOMETHACIN SUSPENSION KETOPROFEN CAPSULES KETOROLAC TROMETHAMINE TABLETS MELOXICAM SUSPENSION MELOXICAM TABLETS NABUMETONE TABLETS NAPROXEN SODIUM TABLETS NAPROXEN SUSPENSION NAPROXEN TABLETS OXAPROZIN TABLETS PIROXICAM CAPSULES SULINDAC TABLETS PYRIMIDINE SYNTHESIS INHIBITORS LEFLUNOMIDE TABLETS CYTOKINE & CAM ANTAGONIST AGENTS

ADALIMUMAB

APREMILAST

Reference Brand Name NALFON

FENOPROFEN CALCIUM FLURBIPROFEN ADVIL

CHILDRENS MOTRIN CHILDRENS MOTRIN

ADVIL VARIOUS INDOMETHACIN CR INDOCIN INDOCIN ORUDIS KETOROLAC TROMETHAMINE MOBIC MOBIC NABUMETONE ALEVE. ANAPROX NAPROSYN NAPROSYN DAYPRO FELDENE SULINDAC

BRAND ONLY / Generic Notes

Preferred Drug Status

ARAVA

HUMIRA OTEZLA

BRAND ONLY PREFERRED DRUG

BRAND ONLY PREFERRED DRUG 8/20/2021

Prior Authorization Type

PA Required PA Required

Step Therapy Requirements

Quantity QL Limit (QL) Days

20

30

3

AHCCCS ACUTE - LONG TERM CARE DRUG LIST EFFECTIVE April 1, 2021

? Generic Drugs Are Preferred Over Brand Name Drugs Unless The Drug Is Specified As BRAND ONLY ? Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List May Be Available Through Prior Authorization

Drug Class/Drug Name

ETANERCEPT

TOFACITINIB CITRATE ANALGESICS - NONNARCOTIC ANALGESIC COMBINATIONS BUTALBITAL-ACETAMINOPHEN-CAFFEINE TABLETS BUTALBITAL-ASPIRIN-CAFFEINE TABLETS ANALGESICS OTHER ACETAMINOPHEN CAPSULES ACETAMINOPHEN CHEWABLE TABLETS ACETAMINOPHEN ELIXIR ACETAMINOPHEN LIQUID ACETAMINOPHEN SUPPOSITORY ACETAMINOPHEN SUSPENSION SALICYLATES ASPIRIN CHEWABLE TABLETS ASPIRIN SUPPOSITORY ASPIRIN TABLETS DIFLUNISAL TABLETS SALSALATE TABLETS ANALGESICS - OPIOID LONG-ACTING OPIOID AGONISTS

FENTANYL PATCH 72-HOUR 12mcg, 25mcg, 50mcg, 75mcg & 100mcg

MORPHINE-NALTREXONE CAPSULE CONTROLLED RELEASE RELEASE MORPHINE SULFATE TABLET CONTROLLED RELEASE

Reference Brand Name

ENBREL XELJANZ IMMEDIATE

RELEASE ONLY

BRAND ONLY / Generic Notes

Preferred Drug Status

BRAND ONLY PREFERRED DRUG

BRAND ONLY PREFERRED DRUG

VARIOUS VARIOUS

VARIOUS VARIOUS VARIOUS VARIOUS FEVERALL INFANTS TYLENOL INFANTS

VARIOUS VARIOUS VARIOUS DIFLUNISAL DISALCID

DURAGESIC 12mcg, 25mcg, 50mcg, 75mcg & 100mcg

PREFERRED DRUG

EMBEDA VARIOUS

BRAND ONLY PREFERRED DRUG PREFERRED DRUG

Prior Authorization Type PA Required PA Required

PA Required PA Required PA Required

8/20/2021

Step Therapy Requirements

Quantity QL Limit (QL) Days

120

30

120

30

4

AHCCCS ACUTE - LONG TERM CARE DRUG LIST EFFECTIVE April 1, 2021

? Generic Drugs Are Preferred Over Brand Name Drugs Unless The Drug Is Specified As BRAND ONLY ? Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List May Be Available Through Prior Authorization

Drug Class/Drug Name OXYCODONE HCL TABLET 12-HOUR ABUSE DETERRANT TRAMADOL HCL TABLETS ER BUPRENORPHINE PATCH WEEKLY SHORT-ACTING OPIOID AGONISTS HYDROMORPHONE HCL LIQUID HYDROMORPHONE HCL SUPPOSITORY HYDROMORPHONE HCL TABLETS MEPERIDINE HCL TABLETS MORPHINE SULFATE SOLUTION MORPHINE SULFATE SUPPOSITORY MORPHINE SULFATE TABLETS OXYCODONE HCL CAPSULES OXYCODONE HCL CONCENTRATE OXYCODONE HCL SOLUTION OXYCODONE HCL TABLETS

Reference Brand Name

XTAMPZA ER ULTRAM ER

BUTRANS

BRAND ONLY / Generic Notes

Preferred Drug Status

BRAND ONLY PREFERRED DRUG PREFERRED DRUG

BRAND ONLY PREFERRED DRUG

DILAUDID HYDROMORPHONE HCL

DILAUDID DEMEROL MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE OXYCODONE HCL OXYCODONE HCL OXYCODONE HCL ROXICODONE

8/20/2021

Prior Authorization Type

PA Required PA Required

PA Required

PA Required for > 2 Short Acting Opioid Medications in a 30-day time period.

PA Required for > 2 Short Acting Opioid Medications in a 30-day time period.

PA Required for > 2 Short Acting Opioid Medications in a 30-day time period.

PA Required for > 2 Short Acting Opioid Medications in a 30-day time period.

PA Required for > 2 Short Acting Opioid Medications in a 30-day time period.

PA Required for > 2 Short Acting Opioid Medications in a 30-day time period.

PA Required for > 2 Short Acting Opioid Medications in a 30-day time period.

PA Required for > 2 Short Acting Opioid Medications in a 30-day time period.

PA Required for > 2 Short Acting Opioid Medications in a 30-day time period.

PA Required for > 2 Short Acting Opioid Medications in a 30-day time period.

PA Required for > 2 Short Acting Opioid Medications in a 30-day time period.

Step Therapy Requirements

Quantity QL Limit (QL) Days

5

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