AHCCCS DRUG LIST

AHCCCS ACUTE - LONG TERM CARE DRUG LIST EFFECTIVE OCTOBER 1, 2020

? 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

Reference Brand Name

BRAND ONLY / Generic Notes

Preferred Drug Status

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 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

ADDERALL XR ADDERALL VARIOUS

VYVANSE CHEWABLES VYVANSE

FOCALIN XR VARIOUS METHYLIN

RITALIN LA 10MG APTENSIO XR VARIOUS VARIOUS DAYTRANA METHYLIN VARIOUS RITALIN LA CONCERTA

VARIOUS

Catapres Catapres Patches

Clonidine ER GUANFACINE ER

Tenex

BRAND ONLY PREFERRED DRUG Brand & Generic PREFERRED DRUG

PREFERRED DRUG BRAND ONLY PREFERRED DRUG BRAND ONLY PREFERRED DRUG

BRAND ONLY

BRAND ONLY BRAND ONLY

BRAND ONLY BRAND ONLY BRAND ONLY BRAND ONLY

PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG

PREFERRED DRUG

PREFERRED DRUG PREFERRED DRUG

9/29/2020

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 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

60

30

60

30

30

30

4

28

120

30

30

30

1

AHCCCS ACUTE - LONG TERM CARE DRUG LIST EFFECTIVE OCTOBER 1, 2020

? 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 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 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

Reference Brand Name NEOMYCIN SULFATE

BETHKIS KITABIS

RHEUMATREX

CELEBREX VOLTAREN-XR

VOLTAREN VARIOUS VARIOUS 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

BRAND ONLY PREFERRED DRUG BRAND ONLY PREFERRED DRUG

9/29/2020

Prior Authorization Type PA Required PA Required

PA Required

Step Therapy Requirements

Quantity QL Limit (QL) Days

20

30

2

AHCCCS ACUTE - LONG TERM CARE DRUG LIST EFFECTIVE OCTOBER 1, 2020

? 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 LEFLUNOMIDE TABLETS CYTOKINE & CAM ANTAGONIST AGENTS ADALIMUMAB APREMILAST 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 OXYCODONE HCL TABLET 12-HOUR ABUSE DETERRANT TRAMADOL HCL TABLETS ER BUPRENORPHINE PATCH WEEKLY SHORT-ACTING OPIOID AGONISTS

Reference Brand Name ARAVA

HUMIRA OTEZLA ENBREL XELJANZ IMMEDIATE RELEASE ONLY

BRAND ONLY / Generic Notes

Preferred Drug Status

BRAND ONLY BRAND ONLY BRAND ONLY

PREFERRED DRUG PREFERRED DRUG 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 EMBEDA VARIOUS XTAMPZA ER ULTRAM ER BUTRANS

BRAND ONLY BRAND ONLY BRAND ONLY

PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG

9/29/2020

Prior Authorization Type PA Required PA Required PA Required PA Required

PA Required PA Required PA Required PA Required PA Required PA Required

Step Therapy Requirements

Quantity QL Limit (QL) Days

120

30

120

30

3

AHCCCS ACUTE - LONG TERM CARE DRUG LIST EFFECTIVE OCTOBER 1, 2020

? 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

Reference Brand Name

BRAND ONLY / Generic Notes

HYDROMORPHONE HCL LIQUID

DILAUDID

HYDROMORPHONE HCL SUPPOSITORY

HYDROMORPHONE HCL

HYDROMORPHONE HCL TABLETS

DILAUDID

MEPERIDINE HCL TABLETS

DEMEROL

MORPHINE SULFATE SOLUTION

MORPHINE SULFATE

MORPHINE SULFATE SUPPOSITORY

MORPHINE SULFATE

MORPHINE SULFATE TABLETS

MORPHINE SULFATE

OXYCODONE HCL CAPSULES

OXYCODONE HCL

OXYCODONE HCL CONCENTRATE

OXYCODONE HCL

OXYCODONE HCL SOLUTION

OXYCODONE HCL

OXYCODONE HCL TABLETS

ROXICODONE

TRAMADOL HCL TABLETS OPIOID COMBINATIONS

ULTRAM

ACETAMINOPHEN W/ CODEINE SOLUTION

ACETAMINOPHEN/CODEINE

ACETAMINOPHEN W/ CODEINE TABLETS

ACETAMINOPHEN/CODEINE

BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/ CODEINE CAPSULES

FIORICET/CODEINE

BUTALBITAL-ASPIRIN-CAFFEINE W/COD CAPSULES

ASCOMP/CODEINE

HYDROCODONE-ACETAMINOPHEN CAPSULES

HYDROGESIC

Preferred Drug Status

Prior Authorization Type 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. PA Required for > 2 Short Acting Opioid Medications

in a 30-day time period.

Step Therapy Requirements

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.

Quantity QL Limit (QL) Days

9/29/2020

4

AHCCCS ACUTE - LONG TERM CARE DRUG LIST EFFECTIVE OCTOBER 1, 2020

? 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

HYDROCODONE-ACETAMINOPHEN SOLUTION

HYDROCODONE-ACETAMINOPHEN TABLETS

HYDROCODONE-IBUPROFEN TABLETS

OXYCODONE W/ ACETAMINOPHEN CAPSULES

OXYCODONE W/ ACETAMINOPHEN SOLUTION

OXYCODONE W/ ACETAMINOPHEN TABLETS

OXYCODONE-IBUPROFEN TABLETS ANTIDOTES OPIOID ANTAGONISTS NALOXONE HCL SOLUTION + SYRINGE NALOXONE HCL NASAL SPRAY NALTREXONE HCL TABLETS NALTREXONE SUSPENSION OPIOID AGONISTS

Reference Brand Name

HYCET

VERDROCET

REPREXAIN OXYCODONE/ ACETAMINOPHEN

ROXICET

ENDOCET

OXYCODONE/IBUPROFEN

NALOXONE HCL + SYRINGE NARCAN NASAL SPRAY NALTREXONE HCL VIVITROL

BRAND ONLY / Generic Notes

Preferred Drug Status

Prior Authorization Type 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.

PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG PREFERRED DRUG

Step Therapy Requirements

Quantity QL Limit (QL) Days

9/29/2020

5

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