Preferred Drug List Updates

May 2013

P. 33: Taron-C DHA added to formulary
P. 30: Delzicol added to formulary
P. 9: Bactroban cream removed from formulary
P. 9: mupirocin cream added to formulary
P. 15: phenytoin infatabs 50mg chew added to formulary
P. 11: Zovirax 5% ointment removed from formulary, generic acyclovir 5% ointment added to formulary
P. 25: Sklice added to formulary with PA

April 2013

P. 17: trimethobenzamide 250 mg, 300 mg capsules, 200 mg suppositories: added to formulary
P. 23: fenofibrate 45 mg, 145 mg: added to formulary
P. 24: tretinoin: QLL changed to 45 gm/30 days
P. 29: DocuSol enema: added to formulary
P. 29: Enemeez enema: added to formulary
P. 29: Vacuant enema: added to formulary
P. 32: Phos-NaK: added to formulary
P. 32: K-Phos Neutral tablets: added to formulary
P. 30: Hydrocortisone suppositories: removed from formulary due to medication being classified as a DESI drug

March 2013

P. 17: Entacapone: removed QLL (per AHCCCS MRPDL)
P. 13: Stivarga: added to formulary with PA required
P. 22: Sildenafil: added diagnosis and age requirement - COVERED FOR AGE > 17 YEARS OLD FOR DIAGNOSIS OF PAH WHEN PRESCRIBED BY CARDIOLOGISTS AND PULMONOLOGISTS; ALL OTHERS REQUIRE PA

February 2013

P. 12: Isoniazid-rifampin: added to formulary
P. 15: levetiracetam ER: added to formulary
P. 23: Fluocinolone scalp oil: added to formulary
P. 24: Benzoyl peroxide-erythromycin 5%-3% gel: added to formulary
P. 28: Desmopressin: changed to: COVERED FOR DD AND ENDO/NEURO PROVIDERS; ALL OTHERS REQUIRE PA AFTER 4 FILLS WITHIN 130 days

January 2013

P.8: Lidoderm patch: added to formulary
P.12: Albenza, atovaquone-proguanil, Biltricide, Coartem, quinine, Stromectol: added to formulary
P.13: Leuprolide: added to formulary with PA required
P.14: Migergot suppositories: added to formulary, QLL=12/30 days
P.15: Onfi, Banzel, Vimpat: added to formulary with PA required
P.16: Escitalopram: added to formulary, QLL=30/30days
P.17: Gilenya: added to formulary with PA required
P.22: Amiodarone, mexiletine, propafenone: Remove cardiology specialist requirement
P.23: Tikosyn, Ranexa: added to formulary with PA required
P.25: Eurax, Sklice: added to formulary with PA required
P.26: Triamcinolone acetonide nasal (generic Nasacort AQ): added to formulary with PA required
P.28: Lupron Depot-Ped: added to formulary with PA required
P.32: Xarelto: added to the formulary with PA required, QLL=30/30 days
P.32: Brilinta: added to the formulary with PA required, QLL=60/30 days
P.33: Epogen/Procrit, Neupogen, Neulasta, Promacta: added to formulary with PA required
P.34: Lupron Depot: added to formulary with PA required
P.34: AVC vaginal cream: added to formulary
P.35: latanoprost (generic for Xalatan): added to formulary
P.36: Zioptan: added to formulary with PA required
P.36: naphazoline-pheniramine eye drops: added to formulary
P.36: Albuterol: remove QLL
P.37: zafirlukast: remove asthma diagnosis restriction
P.38: fexofenadine-pseudoephedrine: added to formulary, QLL=30/30 days for 24 hr products, QLL=60/30 days for 12 hr products
P.40: Aerochamber/Optichamber, etc: change qLL to 2 spacers/year

December 2012

P.15: Gabitril 2mg, 4mg: removed from formulary. Generic tiagabine 2mg, 4mg added to formulary, QLL=60/30 days
P.17: Comtan: removed from formulary. Generic entacapone added to formulary, QLL=120 tabs/30 days
P.18: Metadate CD: removed from formulary. Generic methylphenidate CD added to formulary, QLL=60/30 days
P.24: Dovonex Cream: removed from formulary. Generic calcipotriene cream added to formulary
P.28: First-lansoprazole, First-omeprazole: removed PA requirement for age >5 years
P.38: Sanctura XR: removed from formulary. Generic trospium XR added to formulary, STEP, QLL=30/30 days

November 2012

P.22: Brand Revatio removed from formulary; generic sildenafil added COVERED FOR CARDIOLOGISTS AND PULMONOLOGISTS; ALL OTHERS REQUIRE PA; QLL=90 tabs/30 days
P.25: Janumet, Janumet XR: added to formulary with STEP (after 1 fill of metformin)
P.39: Accu-check Nano Smartview glucometer: added to formulary

October 2012

P.9 : Cipro oral suspension: added to formulary
P.18: Ritalin LA 10mg: PA removed, QLL=60/30 days
P.36: Sodium Chloride 7% (hypertonic saline) for inhalation: added to formulary
P.36: Singulair granules: removed from formulary; generic montelukast granules added with QLL=30/30 days
P.36: Combivent Respimat: added to formulary (Combivent MDI is being phased out – contains CFCs)

The following mandatory AHCCCS formulary changes are effective October 1, 2012

P.9: Flucytosine, Noxafil oral suspension, voriconazole: added to formulary with PA Required
P.10: Terbinafine topical cream: added to formulary
P.10: Antiretrovirals and Protease inhibitors: ID specialist restriction removed (except for Fuzeon)
P.11: Zyvox, foscarnet injection, Hepsera, Incivek, Victrelis, Intron A, Infergen, Synagis, Vistide injection: added to formulary with PA Required
P.12: Tobi and Actimmune: added to formulary with PA Required
P.13: mycophenolate, Rapamune, tacrolimus: PA requirement removed
P.13: Orencia, Remicaide, Revlimid, Thalomid: added to formulary with PA Required
P.13: Acetaminophen, aspirin, buffered aspirin, enteric-coated aspirin: added to formulary
P.13: Meperidine: added to formulary with QLL=180 tabs/30 days
P.14: Naratriptan: added to formulary with QLL=9 tabs/30 days
P.14: Zolpidem: added to formulary with QLL for 5mg=60 tabs/30 days, 10mg=30 tabs/30 days
P.15: Carbamazepine: removed QLL
P.15: Oxcarbazepine, felbatol, levetiracetam, zonisamide: removed Neurology specialist restriction
P.15: Lyrica: added to formulary with PA Required
P.16: Protriptyline: added to formulary
P.16: Ondansetron, -ODT: 4mg and 8mg tabs added to formulary with QLL=30 tabs/30 days, 24mg added to formulary with PA Required
P.16: Anzemet: added to formulary with PA Required
P.16: Emend: PA requirement removed, added QLL=6 tabs/30 days
P.17: Comtan, pramipexole, ropinirole, selegiline: Neurology specialist restriction removed
P.17: Avonex, Betaseron, Copaxone, Rebif: added to formulary with PA Required
P.17: Clozapine ODT, fluphenazine, olanzapine ODT, perphenazine, risperidone ODT, thiothixene: added to formulary: COVERED FOR MCY ALTCS; MCY ACUTE/DD REQUIRE PA
P.17: Seroquel XR: added to formulary with PA Required, QLL=60 tabs/30 days
P.18: Methylphenidate ER (generic Concerta, Ritalin LA): added to formulary, QLL-60/30 days
P.18: Exelon patch: added to formulary with PA Required
P.20: Eplerenone: added to formulary with PA Required
P.22: Adcirca, epoprostenol, Letairis, Remodulin, Tracleer, Tyvaso, Ventavis: added to formulary with PA Required
P.23: Capex Shampoo, Cordran tape, fluocinolone oil, benzoyl peroxide: added to formulary
P.25: Piperonyl butoxide/pyrethrins OTC shampoo (generic for RID): added to formulary
P.25: Carbamide peroxide, Abreva, Aphthasol, Denavir: added to formulary
P.25: Janumet: added to formulary with PA Required
P.26: Insulin pens, Byetta: added to formulary with PA Required
P.26: Hydrocortisone, methylprednisolone, triamcinolone injections: added to formulary: COVERED FOR MCY ALTCS; MCY ACUTE/DD REQUIRE PA
P.27: Increlex, Serostim, Tev-Tropin: added to formulary with PA Required
P.27: Androderm, Androgel, Testim, testosterone enanthate injection: added to formulary with PA Required
P.28: lansoprazole, -ODT and pantoprazole: specialist restriction/PA requirement removed
P.29: Balsalazide, budesonide, Cortifoam: added to formulary
P.30: UIoric: added to formulary with PA Required
P.32: Pradaxa, Cerezyme, Elaprase, Sucraid: added to formulary with PA Required
P.33: Cenestin, Vivelle Dot: added to formulary
P.35: Natacyn: added to formulary
P.35: Restasis: added to formulary with PA Required
P.35: Foradil: added to formulary with PA Required
P.36: Asmanex, QVAR: added to formulary
P.36: Aralast NP, Prolastin, Pulmozyme, TOBI: added to formulary with PA Required
P.37: Fexofenadine, pseudoephedrine: added to formulary
P.37: Delsym suspension, hydrocodone/homatropine: added to formulary. Other cough and cold products updated based on availability.
P.38: Detrol LA, tolterodine: added to formulary with STEP
P.38: Trospium, tamsulosin: STEP requirement removed

September 2012

P.21: Valsartan-HCT: added to formulary- covered for Cardiologist, STEP for others. Diovan-HCT removed from formulary
P.32: Prenafirst, Prenatab FA, Prenatab RX, Prenatal H, Prenatal U, Ultra-natal: removed from formulary- products are no longer available
P.36: Montelukast, Singulair granules: PA requirement removed
P.40: Accu-Chek Smartview test strips, One Touch Verio monitor and test strips: added to formulary with combined QLL for test strips=204 strips/30 days

August 2012

P.24: Elidel: changed to STEP. Covered for ages 2-10 years.
P.25: Actos: removed from formulary. Generic pioglitazone added to formulary. QLL=30/30 days
P.25: Actoplus Met: removed from formulary. Generic pioglitazone-metformin added to formulary. QLL=90/30 days
P.27: First-lansoprazole: added to formulary
P.27: First-omeprazole: added to formulary
P.35: Singular: removed from formulary. Generic montelukast added to formulary. Removed PA requirement. QLL=30/30 days

July 2012

P.10: Combivir: removed from formulary. Generic lamivudine-zidovudine 150-300mg added to formulary.
P.11: Vancocin pulvules: removed from formulary. Generic vancomycin capsules added to formulary.
P.11: Viramune tablets, oral suspension: removed from formulary. Generic nevirapine added to formulary.
P.11: Ziagen tablets: removed from formulary. Generic abacavir tablets added to formulary.
P.15: mephobarbital: removed from formulary. Product is off market. Phenobarbital and primidone are available on the formulary.
P.17: ziprasidone: changed: QLL= 60 caps/30 days
P.17: Stalevo: removed from formulary. Generic carbidopa/levodopa/entacapone added to formulary.
P.24: Occlusal-HP (salicylic acid 17%): removed from formulary. Product is off market. Wart remover 17% is available on formulary.
P.28: Creon 5, 10, 20 and all Lipram products: removed from formulary. Products are off market. Creon 3,000; 6,000; 12,000; 24,000 units are available and on the formulary.
P.32: Cal-nate, natalcare glosstabs, natatab Rx: removed from formulary. Products are off market. Numerous other prenatal vitamins available on the formulary.
P.33: Activella: removed from formulary. Generic estradiol-norethindrone added to formulary.
P.33: Prometrium: removed from formulary. Generic progesterone capsules added to formulary.
P.36: andehist nr syrup, bromaxefed rf syrup: removed from formulary. Products are off market. Sildec syrup: added to formulary as a replacement.
P.36: Brompheniramine maleate chewable tablets, suspension: removed from formulary. Products are off market. Bromax tabs and Vazol solution added to formulary as replacements.
P.36: Colfed-a capsules, pseudo-chlor capsule: removed from formulary. FDA Unapproved cough, cold, allergy product. No replacement product available.
P.37: Uroxatral: removed from formulary. Generic alfuzosin added to formulary.
P.37: Ceron-DM syrup, Sildec PE-DM syrup: removed from formulary. FDA Unapproved cough, cold, allergy product. NoHist-DM syrup: added to formulary as a replacement.
P.37: C-phen drops, syrup: removed from formulary. Products are off market. Virdec drops added to formulary as a replacement.
P.37: C-phen DM drops, syrup, Sildec PE-DM drops: removed from formulary. Products are off market. Virdec-DM drops and NoHist-DM syrup: added to formulary as replacements.
P.37: Guaifenex PSE: removed from formulary. Product is off market. Mucinex D ER is available on the formulary.

The following products are no longer available and were removed from the formulary: Gantrisin, Kemadrin, hydra-zide, Alupent MDI, Intal MDI, procainamide, p-ephed-cpm 120-8 mg SA, chlor-pseudo sr capsule, rhinacon a liquid, tablet, sildec PE DM, Duradryl syrup, Histade capsule. No replace products are available.

May 2012

P.15: Felbatol: removed from formulary. Generic felbamate added to formulary. COVERED FOR NEUROLOGISTS; ALL OTHERS REQUIRE PA
P.16: Venlafaxine XR/ER tablets, capsules: added to formulary, QLL=30 tabs or caps/30 days
P.17: Geodon: removed from formulary. Generic ziprasidone added to formulary. COVERED FOR MCY ALTCS; MCY ACUTE/DD REQUIRE PA. QLL=30 caps/30 days
P.17: Seroquel: removed from formulary. Generic quetiapine added to formulary. COVERED FOR MCY ALTCS; MCY ACUTE/DD REQUIRE PA. QLL 90 tabs/30 days; 300 mg= 60 tabs/30 days.
P.23: Lescol: removed formulary. Generic fluvastatin added to formulary. QLL= 30 caps/30 days
P.30: Calcium with vitamin D: generics added to formulary
P.30: Vitamin B12 500mcg and 1000mcg: added to formulary
P.31: Plavix: removed from formulary. Generic clopidogrel added to formulary. QLL=30 tabs/30 days

April 2012

P.36: Cetirizine syrup: changed QLL – Under 6 years of age QLL=150
ml/30 days. 6 years and older QLL= 300ml/30Days
P.19: Diltiazem ER/XT products: changed QLL to 60/30 days
P.19: Matzim LA: added to formulary

March 2012

P.27: Omeprazole rx 10mg, 20mg and 40mg: added to formulary
omeprazole 10mg QLL=30 caps/30 days
omeprazole 20mg QLL=120 caps or tabs/30 days
omeprazole 40mg QLL=270 caps/30 days
P.29: Celebrex: added to formulary with STEP

February 2012

P.17: Zyprexa removed from formulary. Olanzapine added to formulary COVERED FOR MCY ALTCS; MCY ACUTE/DD REQUIRE PA

January 2012

P.10: Complera: added to formulary
P.25: Januvia: added to formulary with STEP
P.22: Atorvastatin: added to formulary; QLL=30 tabs/30 days

December 2011

P.13: Acetaminophen Elixir: age restriction removed

November 2011

P.30: OTC Fish Oil: added to formulary
P.14: Buspirone: added QLL=60 tabs/30 days for 30mg tablets
P.10: Edurant: added to formulary

October 2011

P.17: Risperidone tabs: changed QLL=60 tabs/30 days
P.16: Paroxetine tabs: changed QLL=60 tabs/30 days

September 2011

P15:Gabapentin: removed QLL

August 2011

P.8: Clarithromycin extended-release: QLL=28 tabs/30 days
P.24: Natroba: added to the formulary with STEP

July 2011

P.15: topiramate: removed QLL
P.10: Intelence: PA required removed

June 2011

P.9: fluconazole QLL for 150 mg=1 tab/Rx: removed QLL
P.10: Fortovase: no longer available and removed from formulary
P.11: Viramune XR: added to formulary
P.11: Zovirax 5% cream: added to formulary
P.15: fluoxetine 20 mg QLL=60 tabs or caps/30 days: removed QLL
P.16: granisetron QLL=2 tabs/Rx: removed QLL
P.21: losartan/losartan HCTZ: added to formulary
P.22: Nitrostat: added to formulary
P.24: calcipotriene ointment: added to formulary
P.25: OTC oxymetazoline nasal spray: added to formulary
P.28: Pancrease MT 4, 10, 16, 20: no longer available and removed from formulary
P.28: Ultracaps MT 20: no longer available and removed from formulary
P.31: Select-OB, Select-OB + DHA: added to formulary
P.33: levofloxacin 0.5% ophth soln: added to formulary
P.38: OTC Alcohol Prep Pads: added to formulary

March 2011

P.19: nifediac cc: added to formulary
P.19: acetazolamide ER: added to formulary
P.21: ramipril: added to formulary
P.22: Revatio: changed PA requirement to allow for “COVERED FOR CARDIOLOGISTS AND PULMONOLOGISTS; ALL OTHERS REQUIRE PA.”
P.24: pyrethrin 0.33% OTC shampoo: added to formulary
P.27: Senokot OTC (brand and generic OTC dosage forms): added to formulary
P.27: lansoprazole oral disintegrating tablet: replaced Brand Prevacid Solu-Tab with generic; requirements still apply-COVERED FOR PULMONOLOGISTS (INCLUDING PEDIATRIC PULMONOLOGISTS) AND PEDIATRIC GASTROENTEROLOGISTS FOR CHILDREN 17 YEARS OF AGE AND YOUNGER
P.30: cholecalciferol (Vitamin D): added to formulary
P.31-32: added the following prescription prenatals to formulary: natalcare glosstabs, natatab Rx, prenafirst, prenatabs FA, prenatabs rx, vinate II, vinate az , vinate calcium, vinate gt, vinate m, vinate one; requirements still apply-PRENATAL VITAMINS (COVERED FOR FEMALES AGES 11 to 49), QLL=100 tabs/90 days for all legend prenatal vitamins
P.33: Zymaxid: added to formulary
P.36: sildec PE-DM drops, syrup: added to formulary