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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
ADHD/ANTI-NARCOLEPSY								
							
Amphetamines							

AMPHETAMINE-DEXTROAMPHETAMINE CAPSULE 24-HOUR	
ADDERALL XR	
BRAND ONLY	PREFERRED DRUG	PA Required for Ages < 6 years of age		
30	
30	

AMPHETAMINE-DEXTROAMPHETAMINE TABLETS	
ADDERALL	Brand &
Generic	PREFERRED DRUG	PA Required for Ages < 6 years of age		
60	
30	
DEXTROAMPHETAMINE SULFATE TABLETS	VARIOUS		PREFERRED DRUG	PA Required for Ages < 6 years of age		60	30	

LISDEXAMFETAMINE DIMESYLATE CAPSULES	
VYVANSE CHEWABLES	
BRAND ONLY	PREFERRED DRUG	PA Required for Ages < 6 years of age		
30	
30	

LISDEXAMFETAMINE DIMESYLATE CAPSULES	
VYVANSE	
BRAND ONLY	PREFERRED DRUG	PA Required for Ages < 6 years of age		
30	
30	
Stimulants							

DEXMETHYLPHENIDATE HCL CAPSULE 24-HOUR	
FOCALIN XR	
BRAND ONLY	PREFERRED DRUG	PA Required for Ages < 6 years of age		
60	
30	
DEXMETHYLPHENIDATE HCL TABLETS	VARIOUS		PREFERRED DRUG	PA Required for Ages < 6 years of age		60	30	
METHYLPHENIDATE HCL CHEWABLE TABLETS	METHYLIN		PREFERRED DRUG	PA Required for Ages < 6 years of age		90	30	

METHYLPHENIDATE HCL CAPSULE 24-HOUR	
RITALIN LA 10MG	
BRAND ONLY	PREFERRED DRUG	PA Required for Ages < 6 years of age		
30	
30	

METHYLPHENIDATE HCL CAPSULE 24-HOUR	
APTENSIO XR	
BRAND ONLY	PREFERRED DRUG	PA Required for Ages < 6 years of age		
30	
30	
METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE CD	VARIOUS		PREFERRED DRUG	PA Required for Ages < 6 years of age		30	30	
METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE	VARIOUS		PREFERRED DRUG	PA Required for Ages < 6 years of age		30	30	

METHYLPHENIDATE PATCH	
DAYTRANA	
BRAND ONLY	PREFERRED DRUG	PA Required for Ages < 6 years of age		
30	
30	

METHYLPHENIDATE HCL SOLUTION	
METHYLIN	
BRAND ONLY	PREFERRED DRUG	PA Required for Ages < 6 years of age		
300	
30	
METHYLPHENIDATE HCL TABLETS	VARIOUS		PREFERRED DRUG	PA Required for Ages < 6 years of age		90	30	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

METHYLPHENIDATE HCL TABLET EXTENDED RELEASE	
RITALIN LA	
BRAND ONLY	PREFERRED DRUG	PA Required for Ages < 6 years of age		
60	
30	

METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE	
CONCERTA	
BRAND ONLY	PREFERRED DRUG	PA Required for Ages < 6 years of age		
60	
30	
Miscellaneous Agents							
ATOMOXETINE HCL CAPSULES	VARIOUS		PREFERRED DRUG	PA Required for Ages < 6 years of age		30	30	
Central Alpha-Agonists							
clonidine hcl	Catapres			PA Required for Ages < 6 years of age				
clonidine hcl transdermal patch	Catapres Patches			PA Required for Ages < 6 years of age		4	28	
CLONIDINE HCL (ADHD) TABLET 12-HOUR	Clonidine ER		PREFERRED DRUG	PA Required for Ages < 6 years of age		120	30	
GUANFACINE HCL (ADHD) TABLET 24-HOUR	GUANFACINE ER		PREFERRED DRUG	PA Required for Ages < 6 years of age		30	30	
guanfacine hcl	Tenex			PA Required for Ages < 6 years of age				
AMINOGLYCOSIDES								
AMINOGLYCOSIDES								
NEOMYCIN SULFATE TABLETS	NEOMYCIN SULFATE							
INHALED ANTIBIOTICS								

TOBRAMYCIN NEBULIZED	
BETHKIS	
BRAND ONLY	PREFERRED DRUG	
PA Required				

TOBRAMYCIN NEBULIZED	
KITABIS	
BRAND ONLY	PREFERRED DRUG	
PA Required				
ANALGESICS - ANTI-INFLAMMATORY								
ANTIRHEUMATIC ANTIMETABOLITES								
METHOTREXATE SODIUM TABLETS	RHEUMATREX							
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)								
CELECOXIB CAPSULES	CELEBREX			PA Required				
DICLOFENAC SODIUM TABLET 24-HOUR	VOLTAREN-XR							
DICLOFENAC SODIUM TABLET ENTERIC COATED	VOLTAREN							
ETODOLAC CAPSULES	VARIOUS							
ETODOLAC TABLETS	VARIOUS							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
FENOPROFEN CALCIUM CAPSULES	NALFON							
FENOPROFEN CALCIUM TABLETS	FENOPROFEN CALCIUM							
FLURBIPROFEN TABLETS	FLURBIPROFEN							
IBUPROFEN CAPSULES	ADVIL							
IBUPROFEN CHEWABLE TABLETS	CHILDRENS MOTRIN							
IBUPROFEN SUSPENSION	CHILDRENS MOTRIN							
IBUPROFEN TABLETS	ADVIL							
INDOMETHACIN CAPSULES	VARIOUS							
INDOMETHACIN CAPSULE CONTROLLED RELEASE	INDOMETHACIN CR							
INDOMETHACIN SUPPOSITORY	INDOCIN							
INDOMETHACIN SUSPENSION	INDOCIN							
KETOPROFEN CAPSULES	ORUDIS							
KETOROLAC TROMETHAMINE TABLETS	KETOROLAC TROMETHAMINE					20	30	
MELOXICAM SUSPENSION	MOBIC							
MELOXICAM TABLETS	MOBIC							
NABUMETONE TABLETS	NABUMETONE							
NAPROXEN SODIUM TABLETS	ALEVE. ANAPROX							
NAPROXEN SUSPENSION	NAPROSYN							
NAPROXEN TABLETS	NAPROSYN							
OXAPROZIN TABLETS	DAYPRO							
PIROXICAM CAPSULES	FELDENE							
SULINDAC TABLETS	SULINDAC							
PYRIMIDINE SYNTHESIS INHIBITORS								
LEFLUNOMIDE TABLETS	ARAVA							
CYTOKINE & CAM ANTAGONIST AGENTS								

ADALIMUMAB	
HUMIRA	
BRAND ONLY	
PREFERRED DRUG	
PA Required				

APREMILAST	
OTEZLA	
BRAND ONLY	
PREFERRED DRUG	
PA Required				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

ETANERCEPT	
ENBREL	
BRAND ONLY	
PREFERRED DRUG	
PA Required				

TOFACITINIB CITRATE	XELJANZ IMMEDIATE RELEASE ONLY	
BRAND ONLY	
PREFERRED DRUG	
PA Required				
ANALGESICS - NONNARCOTIC								
ANALGESIC COMBINATIONS								
BUTALBITAL-ACETAMINOPHEN-CAFFEINE TABLETS	VARIOUS					120	30	
BUTALBITAL-ASPIRIN-CAFFEINE TABLETS	VARIOUS					120	30	
ANALGESICS OTHER								
ACETAMINOPHEN CAPSULES	VARIOUS							
ACETAMINOPHEN CHEWABLE TABLETS	VARIOUS							
ACETAMINOPHEN ELIXIR	VARIOUS							
ACETAMINOPHEN LIQUID	VARIOUS							
ACETAMINOPHEN SUPPOSITORY	FEVERALL INFANTS							
ACETAMINOPHEN SUSPENSION	TYLENOL INFANTS							
SALICYLATES								
ASPIRIN CHEWABLE TABLETS	VARIOUS							
ASPIRIN SUPPOSITORY	VARIOUS							
ASPIRIN TABLETS	VARIOUS							
DIFLUNISAL TABLETS	DIFLUNISAL							
SALSALATE TABLETS	DISALCID							
ANALGESICS - OPIOID								
LONG-ACTING OPIOID AGONISTS								

FENTANYL PATCH 72-HOUR 12mcg, 25mcg, 50mcg, 75mcg & 100mcg	DURAGESIC 12mcg, 25mcg, 50mcg,
75mcg & 100mcg		
PREFERRED DRUG	
PA Required				

MORPHINE-NALTREXONE CAPSULE CONTROLLED RELEASE RELEASE	
EMBEDA	
BRAND ONLY	PREFERRED DRUG	
PA Required				
MORPHINE SULFATE TABLET CONTROLLED RELEASE	VARIOUS		PREFERRED DRUG	PA Required				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

OXYCODONE HCL TABLET 12-HOUR ABUSE DETERRANT	
XTAMPZA ER	
BRAND ONLY	PREFERRED DRUG	
PA Required				
TRAMADOL HCL TABLETS ER	ULTRAM ER		PREFERRED DRUG	PA Required				

BUPRENORPHINE PATCH WEEKLY	
BUTRANS	
BRAND ONLY	PREFERRED DRUG	
PA Required				
SHORT-ACTING OPIOID AGONISTS								

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

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

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

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

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

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

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

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

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

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

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

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

TRAMADOL HCL TABLETS	
ULTRAM			PA Required for > 2 Short Acting Opioid
Medications in a 30-day time period.				
OPIOID COMBINATIONS								

ACETAMINOPHEN W/ CODEINE SOLUTION	
ACETAMINOPHEN/CODEINE			PA Required for > 2 Short Acting Opioid
Medications in a 30-day time period.				

ACETAMINOPHEN W/ CODEINE TABLETS	
ACETAMINOPHEN/CODEINE			PA Required for > 2 Short Acting Opioid
Medications in a 30-day time period.				

BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/ CODEINE CAPSULES	
FIORICET/CODEINE			PA Required for > 2 Short Acting Opioid
Medications in a 30-day time period.				

BUTALBITAL-ASPIRIN-CAFFEINE W/COD CAPSULES	
ASCOMP/CODEINE			PA Required for > 2 Short Acting Opioid
Medications in a 30-day time period.				

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

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

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

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

OXYCODONE W/ ACETAMINOPHEN CAPSULES	OXYCODONE/ ACETAMINOPHEN			PA Required for > 2 Short Acting Opioid
Medications in a 30-day time period.				

OXYCODONE W/ ACETAMINOPHEN SOLUTION	
ROXICET			PA Required for > 2 Short Acting Opioid
Medications in a 30-day time period.				

OXYCODONE W/ ACETAMINOPHEN TABLETS	
ENDOCET			PA Required for > 2 Short Acting Opioid
Medications in a 30-day time period.				

OXYCODONE-IBUPROFEN TABLETS	
OXYCODONE/IBUPROFEN			PA Required for > 2 Short Acting Opioid
Medications in a 30-day time period.				
ANTIDOTES								
OPIOID ANTAGONISTS								

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
NALOXONE HCL SOLUTION + SYRINGE	NALOXONE HCL + SYRINGE		PREFERRED DRUG					
NALOXONE HCL NASAL SPRAY	NARCAN NASAL SPRAY		PREFERRED DRUG					
NALTREXONE HCL TABLETS	NALTREXONE HCL		PREFERRED DRUG					
NALTREXONE SUSPENSION	VIVITROL		PREFERRED DRUG					
OPIOID AGONISTS								

BUPRENORPHINE	

VARIOUS			PA Required unless the member is pregnant or nursing.
The prescriber must note the following ICD-10 codes on the prescription:
O09.91- Supervision of high risk pregnancy, 1st Trimester.
O09.92- Supervision of high risk pregnancy, 2nd Trimester.
O09.93- Supervision of high risk pregnancy, 3rd Trimester.
O09.91- Supervision of high risk pregnancy- use for Postpartum Nursing Mothers.
The first digit of the diagnosis code is the Letter - O and the second is a Zero - 0				
BUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE FILM	SUBOXONE FILM	BRAND ONLY	PREFERRED DRUG					

BUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE ORALLY DISINTEGRATING TABLETS	

VARIOUS	GENERIC FORMULATIO
NS ONLY	
PREFERRED DRUG					

BUPRENORPHINE EXTENDED RELEASE INJECTION	
SUBLOCADE	
BRAND ONLY	PREFERRED DRUG	
PA Required				

METHADONE	
VARIOUS			Only avaliable at an Opioid Treatment
Program (OTP) provider.				
MISCELLANEOUS AGENTS								

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
ACAMPROSATE	VARIOUS							
DISULFIRAM	ANTABUSE							
ANDROGENS-ANABOLIC								
ANDROGENS								
DANAZOL CAPSULES	DANAZOL							
TESTOSTERONE CYPIONATE SOLUTION	DEPO-TESTOSTERONE			PA Required				
TESTOSTERONE ENANTHATE SOLUTION	TESTOSTERONE ENANTHATE			PA Required				

TESTOSTERONE GEL	
ANDROGEL	
BRAND ONLY	PREFERRED DRUG	
PA Required				
TESTOSTERONE PATCH	ANDRODERM			PA Required				
ANORECTAL AGENTS								
INTRARECTAL STEROIDS								
HYDROCORTISONE (INTRARECTAL) ENEMA	COLOCORT							
HYDROCORTISONE ACETATE (INTRARECTAL) FOAM	CORTIFOAM							
RECTAL STEROIDS								
HYDROCORTISONE (RECTAL) CREAM	PROCTOCORT							
ANTHELMINTICS								
ANTHELMINTICS								
ALBENDAZOLE TABLETS	ALBENZA			PA Required				
IVERMECTIN TABLETS	STROMECTOL			PA Required				
PRAZIQUANTEL TABLETS	BILTRICIDE							
ANTIANGINAL AGENTS								
ANTIANGINALS-OTHER								
RANOLAZINE TABLET 12-HOUR	RANEXA			PA Required				
NITRATES								
ISOSORBIDE DINITRATE CAPSULE CONTROLLED RELEASE	DILATRATE SR							
ISOSORBIDE DINITRATE SUBLINGUAL	ISOSORBIDE DINITRATE							
ISOSORBIDE DINITRATE TABLETS	ISORDIL TITRADOSE							
ISOSORBIDE DINITRATE TABLET CONTROLLED RELEASE	ISOSORBIDE DINITRATE ER							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
ISOSORBIDE MONONITRATE TABLETS	ISOSORBIDE MONONITRATE							
ISOSORBIDE MONONITRATE TABLET 24-HOUR	IMDUR							
NITROGLYCERIN CAPSULE CONTROLLED RELEASE	NITRO-TIME							
NITROGLYCERIN OINTMENT	NITRO-BID							
NITROGLYCERIN PATCH 24-HOUR	NITRO-DUR							
NITROGLYCERIN SUBLINGUAL	NITROSTAT							
ANTIANXIETY AGENTS								
ANTIANXIETY AGENTS - MISC.								

BUSPIRONE HCL TAB 5 MG	

BUSPIRONE HCL			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

BUSPIRONE HCL TAB 7.5 MG	

BUSPIRONE HCL			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

BUSPIRONE HCL TAB 10 MG	

BUSPIRONE HCL			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

BUSPIRONE HCL TAB 15 MG	

BUSPIRONE HCL			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a
30-day time period.		

120	

30	

BUSPIRONE HCL TAB 30 MG	

BUSPIRONE HCL			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

60	

30	
HYDROXYZINE HCL SYRUP	HYDROXYZINE SYRUP					300	30	
HYDROXYZINE HCL TABLETS	HYDROXYZINE TABLETS					240	30	
HYDROXYZINE PAMOATE CAPSULES	VISTARIL					120	30	
BENZODIAZEPINES								

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

ALPRAZOLAM CONC 1 MG/ML	

ALPRAZOLAM INTENSOL			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

60	

15	

ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.25 MG	
VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a		
120	
30	

ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

ALPRAZOLAM ORALLY DISINTEGRATING TAB 1 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

ALPRAZOLAM ORALLY DISINTEGRATING TAB 2 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

60	

30	

ALPRAZOLAM TAB 0.25 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

ALPRAZOLAM TAB 0.5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a
30-day time period.		

120	

30	

ALPRAZOLAM TAB 1 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

ALPRAZOLAM TAB 2 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

60	

30	

ALPRAZOLAM TAB SR 24HR 0.5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

30	

30	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

ALPRAZOLAM TAB SR 24HR 1 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

30	

30	

ALPRAZOLAM TAB SR 24HR 2 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

30	

30	

ALPRAZOLAM TAB SR 24HR 3 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

30	

30	

CHLORDIAZEPOXIDE HCL CAP 10 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a
30-day time period.		

60	

30	

CHLORDIAZEPOXIDE HCL CAP 25 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

60	

30	

CHLORDIAZEPOXIDE HCL CAP 5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

60	

30	

CLONAZEPAM 0.5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		
120	
30	

CLONAZEPAM 1.0 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		
120	
30	

CLONAZEPAM 2 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		
60	
30	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

CLONAZEPAM ODT 0.125MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		
120	
30	

CLONAZEPAM ODT 0.25MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		
120	
30	

CLONAZEPAM ODT 0.5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		
120	
30	

CLONAZEPAM ODT 1MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a
30-day time period.		
120	
30	

CLONAZEPAM ODT 2MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		
60	
30	

CLORAZEPATE DIPOTASSIUM TAB 15 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

60	

30	

CLORAZEPATE DIPOTASSIUM TAB 3.75 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

CLORAZEPATE DIPOTASSIUM TAB 7.5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

DIAZEPAM CONC 5 MG/ML	

DIAZEPAM INTENSOL			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

60	

30	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

DIAZEPAM SOLN 1 MG/ML	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

300	

30	

DIAZEPAM TAB 10 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

DIAZEPAM TAB 2 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

DIAZEPAM TAB 5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a
30-day time period.		

120	

30	

LORAZEPAM CONC 2 MG/ML	

LORAZEPAM INTENSOL			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

60	

30	

LORAZEPAM TAB 0.5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

LORAZEPAM TAB 1 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

LORAZEPAM TAB 2 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

60	

30	

OXAZEPAM CAP 10 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

60	

30	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

OXAZEPAM CAP 15 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

60	

30	

OXAZEPAM CAP 30 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

60	

30	
ANTIARRHYTHMICS								
ANTIARRHYTHMICS TYPE I-A								
DISOPYRAMIDE PHOSPHATE CAPSULES	NORPACE							
DISOPYRAMIDE PHOSPHATE CAPSULE 12-HOUR	NORPACE CR							
QUINIDINE GLUCONATE TABLET CONTROLLED RELEASE	QUINIDINE GLUCONATE CR							
QUINIDINE SULFATE TABLETS	QUINIDINE SULFATE							
QUINIDINE SULFATE TABLET CONTROLLED RELEASE	QUINIDINE SULFATE ER							
ANTIARRHYTHMICS TYPE I-B								
MEXILETINE HCL CAPSULES	MEXILETINE HCL							
ANTIARRHYTHMICS TYPE I-C								
FLECAINIDE ACETATE TABLETS	TAMBOCOR							
PROPAFENONE HCL CAPSULE 12-HOUR	RYTHMOL SR							
PROPAFENONE HCL TABLETS	RYTHMOL							
ANTIARRHYTHMICS TYPE III								
AMIODARONE HCL TABLETS 100MG & 200MG	PACERONE							
DOFETILIDE CAPSULES	TIKOSYN			PA Required				
DRONEDARONE HCL TABLETS	MULTAQ			PA Required				
ANTIASTHMATIC AND BRONCHODILATOR AGENTS								
ANTI-INFLAMMATORY AGENTS								
CROMOLYN SODIUM NEBULIZER	CROMOLYN SODIUM							
BRONCHODILATORS - ANTICHOLINERGICS								
ACLIDINIUM BROMIDE	TUDORZA PRESSAIR		PREFERRED DRUG					
IPRATROPIUM BROMIDE HFA AEROSOL	ATROVENT HFA		PREFERRED DRUG					

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
IPRATROPIUM BROMIDE SOLUTION	IPRATROPIUM BROMIDE		PREFERRED DRUG					
TIOTROPIUM BROMIDE MONOHYDRATE CAPSULES	SPIRIVA HANDIHALER		PREFERRED DRUG					
LEUKOTRIENE MODULATORS								
MONTELUKAST SODIUM CHEWABLE TABLETS	SINGULAIR		PREFERRED DRUG			30	30	
MONTELUKAST SODIUM GRANULES	SINGULAIR			PA IS NOT Required for < 4 Years of Age		30	30	
MONTELUKAST SODIUM TABLETS	SINGULAIR		PREFERRED DRUG			30	30	
STEROID INHALANTS								
BUDESONIDE (INHALATION) SUSPENSION 0.25MG, 0.50MG & 1.0MG	PULMICORT	VARIOUS	PREFERRED DRUG	PA IS NOT Required for < 4 Years of Age				

BUDESONIDE INHALATION POWDER	
PULMICORT FLEXHALER	
BRAND ONLY	PREFERRED DRUG					

FLUTICASONE PROPIONATE HFA AERO	
FLOVENT HFA	
BRAND ONLY	PREFERRED DRUG					
FLUTICASONE PROPIONATE ORAL INHALATION	FLOVENT DISKUS	Brand Only	PREFERRED DRUG					
MOMETASONE FUROATE (INHALATION) AEPB	ASMANEX TWISTHALER		PREFERRED DRUG					
SYMPATHOMIMETICS								

ALBUTEROL SULFATE AEROSOL	
PROAIR HFA- BRAND ONLY	
BRAND Only	
PREFERRED DRUG	PROAIR IS THE ONLY PREFERRED ALBUTEROL
INHALER ON THE AHCCCS DRUG LIST.				
ALBUTEROL SULFATE NEBULIZED	ALBUTEROL SULFATE		PREFERRED DRUG					
ALBUTEROL SULFATE SYRUP	ALBUTEROL SULFATE		PREFERRED DRUG					

BUDESONIDE-FORMOTEROL FUMARATE DIHYDRATE AEROSOL	

SYMBICORT	

BRAND ONLY	

PREFERRED DRUG	

Step Therapy	Patient must have
tried one steroid inhaler: Beclomethasone Dipropionate, Budesonide, Fluticasone Propionate, or Mometasone			

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

FLUTICASONE-SALMETEROL ORAL INHALATION	

ADVAIR DISKUS	

Brand Only	

Preferred Drug	

Step Therapy	Patient must have tried one steriod inhaler: Beclomethasone Dipropionate, Budesonide, Fluticasone Propionate, or
Mometasone			

FLUTICASONE-SALMETEROL AEROSOL	

ADVAIR HFA	

BRAND ONLY	

PREFERRED DRUG	

Step Therapy	Patient must have
tried one steroid inhaler: Beclomethasone Dipropionate, Budesonide, Fluticasone Propionate, or
Mometasone			

MOMETASONE FUROATE-FORMOTEROL FUMARATE DIHYDRATE AEROSOL	

DULERA	

BRAND ONLY	

PREFERRED DRUG	

Step Therapy	Patient must have
tried one steroid inhaler: Beclomethasone Dipropionate, Budesonide, Fluticasone Propionate, or
Mometasone			
IPRATROPIUM-ALBUTEROL AEROSOL	COMBIVENT RESPIMAT		PREFERRED DRUG					
IPRATROPIUM-ALBUTEROL SOLUTION	DUONEB		PREFERRED DRUG					
SALMETEROL XINAFOATE AEROSOL POWDER BREATH ACTIVATED	SEREVENT DISKUS		PREFERRED DRUG	PA Required				
GLYCOPYRROLATE-FORMOTEROL FUMARATE AEROSOL SOLUTION	BEVESPI AEROSPHERE		PREFERRED DRUG	PA Required				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
TIOTROPIUM BROMIDE-OLODATEROL HCL AEROSOL SOLUTION	STIOLTO RESPIMAT		PREFERRED DRUG	PA Required				
SALMETEROL XINAFOATE AEROSOL POWDER BREATH ACTIVATED	SEREVENT DISKUS		PREFERRED DRUG	PA Required				
ANTICOAGULANTS								
COUMARIN ANTICOAGULANTS								
WARFARIN SODIUM TABLETS	VARIOUS		PREFERRED DRUG					
DIRECT FACTOR XA INHIBITORS								

APIXABAN TABLETS	
ELIQUIS	
BRAND ONLY	PREFERRED DRUG			
60	
30	

APIXABAN TABLETS STARTER PACK	
ELIQUIS STARTER PACK	
BRAND ONLY	PREFERRED DRUG			
74	
365	

RIVAROXABAN TABLETS	
XARELTO	
BRAND ONLY	PREFERRED DRUG			
60	
30	

RIVAROXABAN TABLETS	
XARELTO DOSE PACK	
BRAND ONLY	PREFERRED DRUG			
51	
30	
HEPARINS AND HEPARINOID-LIKE AGENTS								
ENOXAPARIN SODIUM INJ 100 MG/ML	VARIOUS VIAL OR SYRINGE		PREFERRED DRUG			60	30	
ENOXAPARIN SODIUM INJ 120 MG/0.8ML	VARIOUS VIAL OR SYRINGE		PREFERRED DRUG			60	30	
ENOXAPARIN SODIUM INJ 150 MG/ML	VARIOUS VIAL OR SYRINGE		PREFERRED DRUG			60	30	
ENOXAPARIN SODIUM INJ 30 MG/0.3ML	VARIOUS VIAL OR SYRINGE		PREFERRED DRUG			60	30	
ENOXAPARIN SODIUM INJ 300 MG/3ML	VARIOUS VIAL OR SYRINGE		PREFERRED DRUG			60	30	
ENOXAPARIN SODIUM INJ 40 MG/0.4ML	VARIOUS VIAL OR SYRINGE		PREFERRED DRUG			60	30	
ENOXAPARIN SODIUM INJ 60 MG/0.6ML	VARIOUS VIAL OR SYRINGE		PREFERRED DRUG			60	30	
ENOXAPARIN SODIUM INJ 80 MG/0.8ML	VARIOUS VIAL OR SYRINGE		PREFERRED DRUG			60	30	
HEPARIN (PORCINE) IN SODIUM CHLORIDE SOLUTION	HEPARIN SODIUM/NACL 0.9%							
HEPARIN SOD (PORCINE) IN D5W SOLUTION	HEPARIN SODIUM/D5W							
HEPARIN SODIUM (PORCINE) LOCK FLUSH & NACL LOCK FLUSH KIT	HEPARIN SODIUM LOCK FLUSH							
HEPARIN SODIUM (PORCINE) LOCK FLUSH SOLUTION	HEPARIN LOCK FLUSH							
THROMBIN INHIBITORS								

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

DABIGATRAN ETEXILATE MESYLATE CAPSULES	
PRADAXA	
BRAND ONLY	PREFERRED DRUG			
60	
30	
ANTICONVULSANTS								
ANTICONVULSANTS - BENZODIAZEPINES								
CLOBAZAM SUSPENSION	ONFI			PA Required				
CLOBAZAM TABLETS	ONFI			PA Required				

CLONAZEPAM TAB 0.5 MG	

KLONOPIN			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

CLONAZEPAM TAB 1 MG	

KLONOPIN			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a
30-day time period.		

120	

30	

CLONAZEPAM TAB 2 MG	

KLONOPIN			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

60	

30	

CLONAZEPAM ORALLY DISINTEGRATING TAB 0.125 MG	

CLONAZEPAM ODT			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

CLONAZEPAM ORALLY DISINTEGRATING TAB 0.25 MG	

CLONAZEPAM ODT			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

CLONAZEPAM ORALLY DISINTEGRATING TAB 0.5 MG	

CLONAZEPAM ODT			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

CLONAZEPAM ORALLY DISINTEGRATING TAB 1 MG	

CLONAZEPAM ODT			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

120	

30	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

CLONAZEPAM ORALLY DISINTEGRATING TAB 2 MG	

CLONAZEPAM ODT			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.		

60	

30	
DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG	DIASTAT					2	30	
DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG	DIASTAT					2	30	
DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG	DIASTAT					2	30	
ANTICONVULSANTS - MISC.								
CARBAMAZEPINE CHEWABLE TABLETS	CARBAMAZEPINE							
CARBAMAZEPINE CAPSULE 12-HOUR	CARBATROL							
CARBAMAZEPINE SUSPENSION	TEGRETOL							
CARBAMAZEPINE TABLETS	EPITOL							
CARBAMAZEPINE CAPSULE 12-HOUR	EQUETRO							
CARBAMAZEPINE TABLET 12-HOUR	TEGRETOL-XR							
GABAPENTIN CAPSULES	NEURONTIN							
GABAPENTIN SOLUTION	NEURONTIN							
GABAPENTIN	GRALISE			PA Required				
GABAPENTIN TABLETS	NEURONTIN							
GABAPENTIN	HORIZANT			PA Required				
LACOSAMIDE SOLUTION	VIMPAT			PA Required				
LACOSAMIDE TABLETS	VIMPAT			PA Required				
LAMOTRIGINE CHEWABLE TABLETS	LAMICTAL CHEWABLE							
LAMOTRIGINE TABLETS	LAMICTAL							
LAMOTRIGINE TABLET 24-HOUR	LAMICTAL XR							
LAMOTRIGINE ORALLY DISINTEGRATING TABLETS	LAMICTAL ODT							
LEVETIRACETAM SOLUTION	KEPPRA							
LEVETIRACETAM TABLETS	KEPPRA							
LEVETIRACETAM TABLET 24-HOUR	KEPPRA XR							
OXCARBAZEPINE SUSPENSION	TRILEPTAL							
OXCARBAZEPINE TABLETS	TRILEPTAL							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
PREGABALIN CAPSULES	LYRICA			PA Required				
PREGABALIN SOLUTION	LYRICA			PA Required				
PRIMIDONE TABLETS	MYSOLINE							
RUFINAMIDE SUSPENSION	BANZEL			PA Required				
RUFINAMIDE TABLETS	BANZEL			PA Required				
TOPIRAMATE SPRINKLE CAPSULES	TOPAMAX SPRINKLES							
TOPIRAMATE TABLETS	TOPAMAX							
ZONISAMIDE CAPSULES	ZONEGRAN							
CARBAMATES								
FELBAMATE SUSPENSION	FELBATOL							
FELBAMATE TABLETS	FELBATOL							
GABA MODULATORS								
TIAGABINE HCL TABLETS	GABITRIL			PA Required				
HYDANTOINS								
PHENYTOIN CHEWABLE TABLETS	DILANTIN INFATABLETS							
PHENYTOIN SODIUM EXTENDED CAPSULES	DILANTIN							
PHENYTOIN SUSPENSION	DILANTIN-125							
SUCCINIMIDES								
ETHOSUXIMIDE CAPSULES	ZARONTIN							
ETHOSUXIMIDE SOLUTION	ZARONTIN							
VALPROIC ACID								
DIVALPROEX SODIUM SPRINKLE CAPSULES	DEPAKOTE SPRINKLES							
DIVALPROEX SODIUM TABLET 24-HOUR	DEPAKOTE ER							
DIVALPROEX SODIUM TABLET ENTERIC COATED	DEPAKOTE							
VALPROATE SODIUM SYRUP	DEPAKENE+B252							
VALPROIC ACID CAPSULES	DEPAKENE							
ANTIDEPRESSANTS								
ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)								

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

MIRTAZAPINE TABLETS	
MIRTAZAPINE			
PA Required for Ages < 6 years of age		
30	
30	
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS	REMERON SOLTAB			PA Required for Ages < 6 years of age		30	30	
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST							
ESKETAMINE HYDROCHLORIDE	SPRAVATO			PA Required				
Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs)							
BUPROPION HCL TABLETS	WELLBUTRIN			PA Required for Ages < 6 years of age		120	30	
BUPROPION HCL TABLET 12-HOUR	BUDEPRION SR			PA Required for Ages < 6 years of age		60	30	
BUPROPION HCL TABLET 24-HOUR (150MG & 300MG)	WELLBUTRIN XL			PA Required for Ages < 6 years of age		30	30	
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)								

CITALOPRAM HYDROBROMIDE SOLUTION	
CELEXA			PA Required for Ages < 6 years of age and
greater than 12 years of age		
600	
30	

CITALOPRAM HYDROBROMIDE TABLETS	

CELEXA			
PA Required for Ages < 6 years of age		10mg: 60
20mg: 30
40mg: 30	30
30
30	

ESCITALOPRAM OXALATE TABLETS	

LEXAPRO			
PA Required for Ages < 6 years of age		5mg: 60
10mg: 30
20mg: 30	30
30
30	

FLUOXETINE HCL CAPSULES ONLY	

PROZAC			
PA Required for Ages < 6 years of age		10mg: 60
20mg: 120
40mg: 60	30
30
30	

FLUOXETINE HCL SOLUTION	
PROZAC			PA Required for Ages < 6 years of age and
greater than 12 years of age		
600	
30	
FLUOXETINE HCL TABLETS - WEEKLY	PROZAC WEEKLY			PA Required				

FLUVOXAMINE MALEATE TABLETS	

LUVOX			
PA Required for Ages < 6 years of age		25mg: 60
50mg: 180
100mg: 90	30
30
30	

PAROXETINE HCL TABLETS	

PAXIL			

PA Required for Ages < 6 years of age		10mg: 30
20mg: 30
30mg: 30
40mg: 45	30
30
30
30	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

SERTRALINE HCL CONCENTRATE	
ZOLOFT			PA Required for Ages < 6 years of age and
greater than 12 years of age		
300	
30	

SERTRALINE HCL TABLETS	

ZOLOFT			
PA Required for Ages < 6 years of age		25mg: 90
50mg: 120
100mg: 60	30
30
30	
SEROTONIN MODULATORS								

TRAZODONE HCL TABLETS	

TRAZODONE HCL			

PA Required for Ages < 6 years of age		50mg:90
100mg:120
150mg: 60
300mg 30	30
30
30
30	
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRI)								

DULOXETINE HCL CAPSULE DELAYED RELEASE 20MG, 30MG & 60MG	CYMBALTA
20MG, 30MG & 60MG			
PA Required for Ages < 6 years of age		20mg: 120
30mg: 120
60mg: 60	30
30
30	

VENLAFAXINE HCL CAPSULE CONTROLLED RELEASE	

EFFEXOR XR			
PA Required for Ages < 6 years of age		37.5mg: 90
75mg: 90
150mg: 30	30
30
30	

VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY	

VENLAFAXINE HCL			

PA Required for Ages < 6 years of age		25mg: 120
37.5mg: 90
50mg: 90
75mg: 150
100mg: 90	30
30
30
30
30	
TRICYCLIC AGENTS								
AMITRIPTYLINE HCL TABLETS	AMITRIPTYLINE HCL			PA Required for Ages < 6 years of age				
AMOXAPINE TABLETS	VARIOUS			PA Required for Ages < 6 years of age				
CLOMIPRAMINE HCL CAPSULES	ANAFRANIL			PA Required for Ages < 6 years of age				
DESIPRAMINE HCL TABLETS	NORPRAMIN			PA Required for Ages < 6 years of age				
DOXEPIN HCL CAPSULES	DOXEPIN HCL			PA Required for Ages < 6 years of age		90	30	
DOXEPIN HCL CONCENTRATE	DOXEPIN HCL			PA Required for Ages < 6 years of age		180	30	
IMIPRAMINE PAMOATE CAPSULES	TORFRANIL-PM			PA Required for Ages < 6 years of age		30	30	
IMIPRAMINE HCL TABLETS	TOFRANIL			PA Required for Ages < 6 years of age				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
MAPROTILINE HCL	VARIOUS			PA Required for Ages < 6 years of age				
NORTRIPTYLINE HCL CAPSULES	PAMELOR			PA Required for Ages < 6 years of age				
NORTRIPTYLINE HCL SOLUTION	NORTRIPTYLINE HCL			PA Required for Ages < 6 years of age				
PROTRIPTYLINE HCL TABLETS	VIVACTIL			PA Required for Ages < 6 years of age				
TRIMIPRAMINE MALEATE	SURMONTIL			PA Required for Ages < 6 years of age				
ANTIDIABETICS								
ALPHA-GLUCOSIDASE INHIBITORS								
ACARBOSE TABLETS	PRECOSE							
ANTIDIABETIC - AMLYN ANALOGS								
PRAMLINTIDE ACETATE SOLUTION PEN INJECTION	SYMLINPEN 60		PREFERRED DRUG	PA Required				
ANTIDIABETIC COMBINATIONS								

CANAGLIFLOZIN-METFORMIN HCL	
INVOKAMET	
BRAND ONLY	
Preferred Drug	
PA Required				

DAPAGLIFLOZIN - METFORMIN	
XIDUO XR	
BRAND ONLY	PREFERRED DRUG	
PA Required				

EMPAGLIFLOZIN-LINAGLIPTIN TABLETS	
GLYXAMBI	
BRAND ONLY	
Preferred Drug	
PA Required				

EMPAGLIFLOZIN-LINAGLIPTIN-METFORMIN	
TRIJARDY XR	
BRAND ONLY	
Preferred Drug	
PA Required				

EMPAGLIFLOZIN-METFORMIN HCL	
SYNJARDY	
BRAND ONLY	
Preferred Drug	
PA Required				
GLYBURIDE-METFORMIN HCL TABLETS	GLYBURIDE/METFORMIN HCL							

LINAGLIPTIN-METFORMIN HCL TABLETS	
JENTADUETO	
bRAND ONLY	
Preferred Drug	
PA Required				
PIOGLITAZONE HCL-METFORMIN HCL TABLETS	ACTOPLUS MET							
PIOGLITAZONE HCL-METFORMIN HCL TABLET 24-HOUR	ACTOPLUS MET XR							

SAXAGLIPTIN-METFORMIN HCL TABLETS	
KOMBIGLYZE XR	
BRAND ONLY	
Preferred Drug	
PA Required				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

SITAGLIPTIN-METFORMIN HCL TABLETS	
JANUMET	
BRAND ONLY	
Preferred Drug	
PA Required				

SITAGLIPTIN-METFORMIN HCL TABLET 24-HOUR	
JANUMET XR	
BRAND ONLY	
Preferred Drug	
PA Required				
BIGUANIDES								
METFORMIN HCL TABLETS	GLUCOPHAGE							
METFORMIN HCL TABLET 24-HOUR (GENERIC OF GLUCOPHAGE XR ONLY- 500MG & 750MG)	
Various			PA Required for Osmotic and Modified Release
Products				
DIABETIC OTHER								
GLUCAGON (RDNA) KIT	GLUCAGON EMERGENCY KIT					1	30	
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS								

LINAGLIPTIN TABLETS	
TRADJENTA	
BRAND ONLY	PREFERRED DRUG	
PA Required				

SAXAGLIPTIN HCL TABLETS	
ONGLYZA	
BRAND ONLY	PREFERRED DRUG	
PA Required				

SAXAGLIPTIN-METFORMIN HCL TABLETS	
KOMBIGLYZE XR	
BRAND ONLY	PREFERRED DRUG	
PA Required				

SITAGLIPTIN PHOSPHATE TABLETS	
JANUVIA	
BRAND ONLY	PREFERRED DRUG	
PA Required				
INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)								
DULAGLUTIDE SOLUTION PEN-INJECTION	TRULICITY		PREFERRED DRUG	PA Required				
EXENATIDE SOLUTION PEN INJECTION	BYETTA		PREFERRED DRUG	PA Required				
EXENATIDE PEN	BYDUREON		PREFERRED DRUG	PA Required				
LIRAGLUTIDE SOLUTION PEN INJECTION	VICTOZA		PREFERRED DRUG	PA Required				
DIABETIC MISCELLANEOUS AGENT								
PRAMLINTIDE	SYMLIN PEN		PREFERRED DRUG	PA Required				
INSULIN SENSITIZING AGENTS								
PIOGLITAZONE HCL TABLETS	ACTOS							
INSULIN								

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

INSULIN ASPART	
NOVOLOG	
BRAND ONLY	
PREFERRED DRUG					

INSULIN ASPART	
NOVOLOG PENFILL	
BRAND ONLY	
PREFERRED DRUG					

INSULIN ASPART	
NOVOLOG FLEXPEN	
BRAND ONLY	
PREFERRED DRUG					

INSULIN ASPART PROTAMINE SUSPENSION & INSULIN ASPART	
NOVOLOG MIX 70/30	
BRAND ONLY	
PREFERRED DRUG					

INSULIN ASPART PROTAMINE SUSPENSION & INSULIN ASPART	
NOVOLOG MIX 70/30 FLEXPEN	
BRAND ONLY	
PREFERRED DRUG					

INSULIN DETEMIR SOLUTION	
LEVEMIR	
BRAND ONLY	
PREFERRED DRUG					

INSULIN DETEMIR SUSPENSION	
LEVEMIR FLEXPEN	
BRAND ONLY	
PREFERRED DRUG					

INSULIN GLARGINE SOLUTION	
LANTUS	
BRAND ONLY	
PREFERRED DRUG					

INSULIN GLARGINE SUSPENSION	
LANTUS SOLOSTAR	
BRAND ONLY	
PREFERRED DRUG					

INSULIN LISPRO (HUMAN) SOLUTION	
HUMALOG	
BRAND ONLY	
PREFERRED DRUG					

INSULIN LISPRO (HUMAN) SUSPENSION	
HUMALOG KWIKPEN	
BRAND ONLY	
PREFERRED DRUG					

INSULIN LISPRO (HUMAN) SOLUTION PEN INJECTION 100/ML	
HUMALOG JUNIOR KWIKPEN	
BRAND ONLY	
PREFERRED DRUG					

INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION	
HUMALOG MIX 50/50	
BRAND ONLY	
PREFERRED DRUG					

INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION	
HUMALOG MIX 50/50 KWIKPEN	
BRAND ONLY	
PREFERRED DRUG					

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION	
HUMALOG MIX 75/25	
BRAND ONLY	
PREFERRED DRUG					

INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION	
HUMALOG MIX 75/25 KWIKPEN	
BRAND ONLY	
PREFERRED DRUG					

INSULIN NPH (HUMAN) (ISOPHANE) SUSPENSION	
HUMULIN N	
BRAND ONLY	
PREFERRED DRUG					

INSULIN REGULAR (HUMAN) SOLUTION PEN INJECTION	
HUMULIN N KWIKPEN	
BRAND ONLY	
PREFERRED DRUG					

INSULIN NPH (HUMAN) (ISOPHANE) SUSPENSION	
NOVOLIN N	
BRAND ONLY	
PREFERRED DRUG					

INSULIN NPH ISOPHANE & REG (HUMAN) SUSPENSION	
HUMULIN 70/30	
BRAND ONLY	
PREFERRED DRUG					

INSULIN NPH ISOPHANE & REG (HUMAN) SUSPENSION	
HUMULIN 70/30 KWIKPEN	
BRAND ONLY	
PREFERRED DRUG					

INSULIN REGULAR (HUMAN) SOLUTION	
HUMULIN R U-100	
BRAND ONLY	
PREFERRED DRUG					

INSULIN REGULAR (HUMAN) SOLUTION	
NOVOLIN R	
BRAND ONLY	
PREFERRED DRUG					

INSULIN REGULAR (HUMAN) SOLUTION	HUMULIN R U-500 (CONCENTRATED)	
BRAND ONLY	
PREFERRED DRUG	
PA REQUIRED				

INSULIN REGULAR (HUMAN) PEN	HUMULIN R U-500 PEN (CONCENTRATED)	
BRAND ONLY	
PREFERRED DRUG	
PA REQUIRED				
MEGLITINIDE ANALOGUES								
NATEGLINIDE TABLETS	STARLIX							
REPAGLINIDE TABLETS	PRANDIN							
SGLT2S								
DAPAGLIFLOZIN PROPANEDIOL	FARXIGA		PREFERRED DRUG	PA Required				
CANAGLIFLOZIN	INVOKANA		PREFERRED DRUG	PA Required				
EMPAGLIFLOZIN	JARDIANCE		PREFERRED DRUG	PA Required				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
SULFONYLUREAS								
GLIMEPIRIDE TABLETS	AMARYL							
GLIPIZIDE TABLETS	GLUCOTROL							
GLIPIZIDE TABLET 24-HOUR	GLUCATROL XL							
GLYBURIDE MICRONIZED TABLETS	GLYNASE							
GLYBURIDE TABLETS	DIABETA							
ANTIDIARRHEALS								
ANTIPERISTALTIC AGENTS								
DIPHENOXYLATE W/ ATROPINE LIQUID	DIPHENOXYLATE/ATROPINE							
DIPHENOXYLATE W/ ATROPINE TABLETS	LOMOTIL							
LOPERAMIDE HCL CAPSULES	LOPERAMIDE HCL							
LOPERAMIDE HCL CHEWABLE TABLETS	IMODIUM A-D							
LOPERAMIDE HCL LIQUID	LOPERAMIDE HCL							
LOPERAMIDE HCL SUSPENSION	IMODIUM A-D							
LOPERAMIDE HCL TABLETS	IMODIUM A-D							
ANTIDOTES								
OPIOID ANTAGONISTS								
NALOXONE HCL SOLUTION + SYRINGE	NALOXONE HCL + SYRINGE		PREFERRED DRUG					
NALOXONE HCL NASAL SPRAY	NARCAN NASAL SPRAY		PREFERRED DRUG					
ANTIEMETICS								
5-HT3 RECEPTOR ANTAGONISTS								
DOLASETRON MESYLATE TABLETS	ANZEMET			PA Required				
GRANISETRON HCL SOLUTION	VARIOUS			PA Required				
GRANISETRON HCL TABLETS	VARIOUS			PA Required				
ONDANSETRON HCL TABLETS	ZOFRAN			PA Required for tablets > 8mg		30	30	
ANTIEMETICS MISC.								
PROCHLORPERAZINE MALEATE TABLETS	COMPAZINE							
PROCHLORPERAZINE SUPPOSITORY	COMPAZINE							
SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONIST								

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
APREPITANT CAPSULES	EMEND					6	21	
ANTIFUNGALS								
ANTIFUNGAL ORAL AGENTS								
CLOTRIMAZOLE TROCHE	VARIOUS							
GRISEOFULVIN SUSPENSION	VARIOUS							
GRISEOFULVIN MICROSIZE TABLETS	GRIFULVIN V							
NYSTATIN SUSPENSION	NYSTATIN							
NYSTATIN TABLETS	NYSTATIN							
TERBINAFINE HCL TABLETS	LAMISIL					90	365	
IMIDAZOLE-RELATED ANTIFUNGALS								
FLUCONAZOLE SUSPENSION	DIFLUCAN					600	30	
FLUCONAZOLE TABLETS	DIFLUCAN					60	30	
ANTIHISTAMINES								
ANTIHISTAMINES - ALKYLAMINES								
BROMPHENIRAMINE MALEATE	J-TAN PD							
CHLORPHINERAMINE MALEATE	CHLORPHENIRAMINE MALEATE							
DEXCHLORPHENIRAMINE MALEATE SYRUP	DEXCHLORPHENIRAMINE MALEATE							
ANTIHISTAMINES - ETHANOLAMINES								
CLEMASTINE FUMARATE SYRUP	CLEMASTINE FUMARATE							
CLEMASTINE FUMARATE TABLETS	CLEMASTINE FUMARATE							
DIPHENHYDRAMINE HCL CAPSULES	VARIOUS							
DIPHENHYDRAMINE HCL CHEWABLE TABLETS	VARIOUS							
DIPHENHYDRAMINE HCL ELIXIR	VARIOUS							
DIPHENHYDRAMINE HCL LIQUID	VARIOUS							
DIPHENHYDRAMINE HCL SOLUTION	VARIOUS							
DIPHENHYDRAMINE HCL SUSPENSION	VARIOUS							
DIPHENHYDRAMINE HCL SYRUP	VARIOUS							
DIPHENHYDRAMINE HCL TABLETS	VARIOUS							
ANTIHISTAMINES - NON-SEDATING								

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
CETIRIZINE HCL CAPSULES	ZYRTEC ALLERGY					30	30	
CETIRIZINE HCL CHEWABLE TABLETS	VARIOUS					30	30	
CETIRIZINE HCL SYRUP	VARIOUS					150	30	
CETIRIZINE HCL TABLETS	VARIOUS					30	30	
CETIRIZINE HCL ORALLY DISINTEGRATING TABLETS	ZYRTEC ALLERGY					30	30	
FEXOFENADINE HCL SUSPENSION	ALLEGRA ALLERGY CHILDRENS					150	30	
FEXOFENADINE HCL TABLETS	ALLEGRA ALLERGY CHILDRENS					30	30	
FEXOFENADINE HCL ORALLY DISINTEGRATING TABLETS	ALLEGRA ALLERGY CHILDRENS					30	30	
LORATADINE CAPSULES	CLARITIN					30	30	
LORATADINE CHEWABLE TABLETS	CLARITIN					30	30	
LORATADINE SYRUP	CLARITIN					150	30	
LORATADINE TABLETS	ALAVERT					30	30	
LORATADINE ORALLY DISINTEGRATING TABLETS	CLARITIN REDITABS					30	30	
ANTIHISTAMINES - PHENOTHIAZINES								
PROMETHAZINE HCL SUPPOSITORY	PHENERGAN							
PROMETHAZINE HCL TABLETS	PROMETHAZINE HCL							
ANTIHISTAMINES - PIPERIDINES								
CYPROHEPTADINE HCL SYRUP	CYPROHEPTADINE HCL							
CYPROHEPTADINE HCL TABLETS	CYPROHEPTADINE HCL							
ANTIHYPERLIPIDEMICS								
BILE ACID SEQUESTRANTS								
CHOLESTYRAMINE LIGHT PACKETS	PREVALITE							
CHOLESTYRAMINE LIGHT POWDER	PREVALITE							
CHOLESTYRAMINE PACKETS	QUESTRAN							
CHOLESTYRAMINE POWDER	QUESTRAN							
COLESTIPOL HCL TABLETS	COLESTID							
FIBRIC ACID DERIVATIVES								
FENOFIBRATE MICRONIZED CAPSULES 67MG, 134MG & 200MG	VARIOUS							
FENOFIBRATE TABLETS 48MG, 54MG, 145MG & 160MG	VARIOUS							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
FENOFIBRIC ACID TABLETS	FIBRICOR							
GEMFIBROZIL TABLETS	LOPID							
HMG COA REDUCTASE INHIBITORS								
ATORVASTATIN CALCIUM TABLETS	LIPITOR		PREFERRED DRUG			30	30	
LOVASTATIN TABLETS	MEVACOR		PREFERRED DRUG			30	30	
PRAVASTATIN SODIUM TABLETS	PRAVACOL		PREFERRED DRUG			30	30	
ROUVASTATIN TABLETS	CRESTOR		PREFERRED DRUG			30	30	
SIMVASTATIN TABLETS	ZOCOR		PREFERRED DRUG			30	30	
INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS								
EZETIMIBE TABLETS	ZETIA		PREFERRED DRUG	PA Required				
NICOTINIC ACID DERIVATIVES								
NIACIN CAPSULE CONTROLLED RELEASE	VARIOUS							
NIACIN TABLET CONTROLLED RELEASE	VARIOUS							
MISC. NUTRITIONAL SUBSTANCES								
OMEGA-3 FATTY ACIDS CAPSULES	FISH OIL							
OMEGA-3 FATTY ACIDS CAPSULE DELAYED RELEASE	FISH OIL							
ANTIHYPERTENSIVES								
ACE INHIBITORS								
BENAZEPRIL HCL TABLETS	BENAZEPRIL HCL							
CAPTOPRIL TABLETS	CAPTOPRIL							
ENALAPRIL MALEATE SOLUTION	EPANED							
ENALAPRIL MALEATE TABLETS	VASOTEC							
FOSINOPRIL SODIUM TABLETS	FOSINOPRIL SODIUM							
LISINOPRIL TABLETS	ZESTRIL							
MOEXIPRIL HCL TABLETS	UNIVASC							
PERINDOPRIL ERBUMINE TABLETS	ACEON							
QUINAPRIL HCL TABLETS	ACCUPRIL							
RAMIPRIL CAPSULES	ALTACE							
TRANDOLAPRIL TABLETS	MAVIK							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
ANGIOTENSIN II RECEPTOR ANTAGONISTS								
IRBESARTAN TABLETS	AVAPRO							
LOSARTAN POTASSIUM TABLETS	COZAAR							
VALSARTAN TABLETS	DIOVAN							
ANTIADRENERGIC ANTIHYPERTENSIVES								
CLONIDINE HCL PATCH-WEEKLY	CATAPRES-TTS-1			PA Required for Ages < 6 years of age		4	28	
CLONIDINE HCL TABLETS	CATAPRES							
CLONIDINE HCL (ADHD) TABLET 12-HOUR	CLONIDINE ER			PA Required for Ages < 6 years of age		120	30	
DOXAZOSIN MESYLATE TABLETS	CARDURA							
GUANFACINE HCL TABLETS	TENEX							
GUANFACINE HCL (ADHD) TABLET 24-HOUR	GUANFACINE ER		PREFERRED DRUG	PA Required for Ages < 6 years of age		30	30	
METHYLDOPA TABLETS	METHYLDOPA							
PRAZOSIN HCL CAPSULES	MINIPRESS							
TERAZOSIN HCL CAPSULES	TERAZOSIN HCL							
ANTIHYPERTENSIVE COMBINATIONS								
ATENOLOL & CHLORTHALIDONE TABLETS	VARIOUS							

CAPTOPRIL & HYDROCHLOROTHIAZIDE TABLETS	CAPTOPRIL/
HYDROCHLOROTHIAZIDE							

ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TABLETS	ENALAPRIL MALEATE/
HYDROCHLOROTHIAZIDE							

FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TABLETS	FOSINOPRIL SODIUM/
HYDROCHLOROTHIAZIDE							
LISINOPRIL & HYDROCHLOROTHIAZIDE TABLETS	ZESTORETIC							
LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TABLETS	HYZAAR							
MOEXIPRIL - HYDROCHLOROTHIAZIDE TABLETS	UNIRETIC							
QUINAPRIL - HYDROCHLOROTHIAZIDE TABLETS	ACCURETIC							
VALSARTAN - HYDROCHLOROTHIAZIDE TABLETS	DIOVAN HCT							
SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)								
EPLERENONE TABLETS	INSPRA			PA Required				
VASODILATORS								

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
HYDRALAZINE HCL TABLETS	HYDRALAZINE HCL							
MINOXIDIL TABLETS	MINOXIDIL							
ANTI-INFECTIVE AGENTS - MISCELLANEOUS								
ANTI-INFECTIVE AGENTS - MISC.								
VANCOMYCIN HCL CAPSULES	VANCOCIN HCL			PA Required				

VANCOMYCIN HCL SOLUTION	Available through a compounding
pharmacy			
PA Required				
ANTI-INFECTIVE MISC. - COMBINATIONS								
ERYTHROMYCIN-SULFISOXAZOLE SUSPENSION	E.S.P.							
SULFAMETHOXAZOLE-TRIMETHOPRIM SUSPENSION	SULFATRIM PEDIATRIC							
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLETS	BACTRIM							
LEPROSTATICS								
DAPSONE TABLETS	DAPSONE							
OXAZOLIDINONES								
LINEZOLID SUSPENSION	ZYVOX			PA Required				
LINEZOLID TABLETS	ZYVOX			PA Required				
ANTIMALARIALS								
ANTIMALARIAL COMBINATIONS								
ARTEMETHER-LUMEFANTRINE TABLETS	COARTEM							
ATOVAQUONE-PROGUANIL HCL TABLETS	MALARONE							
ANTIMALARIALS								
CHLOROQUINE PHOSPHATE TABLETS	CHLOROQUINE PHOSPHATE							
HYDROXYCHLOROQUINE SULFATE TABLETS	PLAQUENIL							
PRIMAQUINE PHOSPHATE TABLETS	PRIMAQUINE PHOSPHATE							
QUININE SULFATE CAPSULES	QUALAQUIN							
ANTIMYCOBACTERIAL AGENTS								
ETHAMBUTOL HCL TABLETS	MYAMBUTOL							
ISONIAZID SYRUP	ISONIAZID							
ISONIAZID TABLETS	ISONIAZID							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
PYRAZINAMIDE TABLETS	PYRAZINAMIDE							
RIFAMPIN CAPSULES	RIFADIN							
ONCOLOGY -FEDERALLY REIMBURSABLE ANTINEOPLASTIC AGENTS,NOT LISTED
BELOW, ARE AVAILABLE THROUGH PRIOR AUTHORIZATION								
ALKYLATING AGENTS								
MELPHALAN TABLETS	ALKERAN	Brand Only		PA Required				
ANTIMETABOLITES								
MERCAPTOPURINE TABLETS	PURINETHOL							
METHOTREXATE SODIUM TABLETS	METHOTREXATE							
ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS								
ANASTROZOLE TABLETS	ARIMIDEX			PA Required				
EXEMESTANE TABLETS	AROMASIN			PA Required				
FLUTAMIDE CAPSULES	FLUTAMIDE							
LEUPROLIDE ACETATE (3 MONTH) KIT	LUPRON DEPOT			PA Required				
LEUPROLIDE ACETATE (4 MONTH) KIT	LUPRON DEPOT			PA Required				
LEUPROLIDE ACETATE KIT	LUPRON DEPOT			PA Required				
TAMOXIFEN CITRATE TABLETS	TAMOXIFEN CITRATE							
TOREMIFENE CITRATE TABLETS	FARESTON			PA Required				
ANTINEOPLASTIC ENZYME INHIBITORS								
AXITINIB TABLETS	INLYTA			PA Required				
CRIZOTINIB CAPSULES	XALKORI			PA Required				
ERLOTINIB HCL TABLETS	TARCEVA			PA Required				
EVEROLIMUS TABLETS	AFINITOR			PA Required				
EVEROLIMUS SOLUBLE TABLET	AFINITOR DISPERZ			PA Required				
GEFITINIB TABLETS	IRESSA			PA Required				
IBRUTINIB CAPSULES	IMBRUVICA			PA Required				

IMATINIB MESYLATE TABLETS	
GLEEVEC	
BRAND ONLY		
PA Required				
LAPATINIB DITOSYLATE TABLETS	TYKERB			PA Required				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
NILOTINIB HCL CAPSULES	TASIGNA			PA Required				
PAZOPANIB HCL TABLETS	VOTRIENT			PA Required				
PONATINIB HCL TABLETS	ICLUSIG			PA Required				
RUXOLITINIB PHOSPHATE TABLETS	JAKAFI			PA Required				
SORAFENIB TOSYLATE TABLETS	NEXAVAR			PA Required				
SUNITINIB MALATE CAPSULES	SUTENT			PA Required				
VANDETANIB TABLETS	CAPRELSA			PA Required				
VEMURAFENIB TABLETS	ZELBORAF			PA Required				
VORINOSTAT CAPSULES	ZOLINZA			PA Required				
ANTINEOPLASTICS - MISC.								
BEXAROTENE CAPSULES	TARGRETIN			PA Required				
HYDROXYUREA CAPSULES	HYDREA							
INTERFERON ALFA-2B SOLUTION	INTRON A			PA Required				
INTERFERON ALFA-2B SOLUTION	INTRON A			PA Required				
INTERFERON ALFA-N3 SOLUTION	ALFERON N			PA Required				
INTERFERON GAMMA-1B SOLUTION	ACTIMMUNE			PA Required				
PEGINTERFERON ALFA-2B (ANTINEOPLASTIC) KIT	SYLATRON			PA Required				
PROCARBAZINE HCL CAPSULES	MATULANE							
TRETINOIN (CHEMOTHERAPY) CAPSULES	TRETINOIN			PA Required For > 26 Years of Age				
CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS								
LEUCOVORIN CALCIUM TABLETS	LEUCOVORIN CALCIUM			PA Required				
MITOTIC INHIBITORS								
ETOPOSIDE CAPSULES	ETOPOSIDE			PA Required				
ANTIPARKINSON AGENTS								
ANTIPARKINSON ANTICHOLINERGICS								
BENZTROPINE MESYLATE TABLETS	BENZTROPINE MESYLATE							
TRIHEXYPHENIDYL HCL ELIXIR	TRIHEXYPHENIDYL HCL							
TRIHEXYPHENIDYL HCL TABLETS	TRIHEXYPHENIDYL HCL							
ANTIPARKINSON COMT INHIBITORS								

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
ENTACAPONE TABLETS	COMTAN							
ANTIPARKINSON DOPAMINERGICS								
AMANTADINE HCL CAPSULES	AMANTADINE HCL							
AMANTADINE HCL SYRUP	AMANTADINE HCL							
BROMOCRIPTINE MESYLATE CAPSULES	PARLODEL							
BROMOCRIPTINE MESYLATE TABLETS	PARLODEL							
CARBIDOPA-LEVODOPA TABLETS	SINEMET							
CARBIDOPA-LEVODOPA ER TABLETS	VARIOUS							
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS	MIRAPEX							
ROPINIROLE HYDROCHLORIDE TABLETS	REQUIP							
ANTIPSYCHOTICS/ANTIMANIC AGENTS								
ANTIMANIC AGENTS								

LITHIUM CARBONATE CAPSULES	

LITHIUM CARBONATE			PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.				

LITHIUM CARBONATE TABLETS	

LITHIUM CARBONATE			PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

LITHIUM CARBONATE TABLET CONTROLLED RELEASE	

LITHOBID			PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.				

LITHIUM SOLUTION	

LITHIUM			PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.				
ANTIPSYCHOTICS							
ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL ORAL AGENTS								

ARIPIPRAZOLE TABLETS	

ABILIFY		

PREFERRED DRUG	PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.		

30	

30	

CLOZAPINE ORALLY DISPERSABLE TABLET	

FAZACLO		

PREFERRED DRUG	PA Required for Ages < 18 years
Prior Authorization is not required for ages 18 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.		

150	

30	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

CLOZAPINE TABLETS	

CLOZARIL		

PREFERRED DRUG	PA Required for Ages < 18 years
Prior Authorization is not required for ages 18 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.		

150	

30	

LURASIDONE HCL TABS	

LATUDA		

PREFERRED DRUG	PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.		

30	

30	

OLANZAPINE ORALLY DISPERSABLE TABLET	

ZYPREXA ZYDIS		

PREFERRED DRUG	PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.		

5mg: 60
10mg: 60
15MG: 30
20mg: 30	

30
30
30
30	

OLANZAPINE TABLETS	

ZYPREXA		

PREFERRED DRUG	PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.		

30	

30	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

QUETIAPINE FUMARATE TABLETS	

SEROQUEL		

PREFERRED DRUG	PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.		

60	

30	

RISPERIDONE ORALLY DISPERSABLE TABLET	

RISPERIDONE ODT		

PREFERRED DRUG	PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.		

60	

30	

RISPERIDONE ORAL SOLUTION	

RISPERDAL		

PREFERRED DRUG	PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.		

240	

30	

RISPERIDONE TABLETS	

RISPERDAL		

PREFERRED DRUG	PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.		

60	

30	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

ZIPRASIDONE HCL CAPSULES	

GEODON		

PREFERRED DRUG	PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.		

60	

30	
ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL LONG ACTING INJECTABLES							

ARIPIPRAZOLE LAUROXIL	

ARISTADA INITIO		

PREFERRED DRUG	PA Required for Ages < 18 years
Prior Authorization is not required for ages 18 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.		

2	

365	

ARIPIPRAZOLE LAUROXIL	

ARISTADA		

PREFERRED DRUG	PA Required for Ages < 18 years
Prior Authorization is not required for ages 18 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.		

1	

30	

ARIPIPRAZOLE SUSPENSION	

ABILIFY MAINTENA		

PREFERRED DRUG	PA Required for Ages < 18 years
Prior Authorization is not required for ages 18 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.		

1	

30	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

PALIPERIDONE PALMITATE SUSPENSION	

INVEGA SUSTENNA		

PREFERRED DRUG	PA Required for Ages < 18 years
Prior Authorization is not required for ages 18 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.		

1	

30	

PALIPERIDONE PALMITATE SUSPENSION	

INVEGA TRINZA		

PREFERRED DRUG	PA Required for Ages < 18 years
Prior Authorization is not required for ages 18 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.		

1	

90	

RISPERIDONE MICROSPHERES SUSPENSION	

RISPERDAL CONSTA		

PREFERRED DRUG	PA Required for Ages < 18 years
Prior Authorization is not required for ages 18 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.		

2	

30	
ANTIPSYCHOTICS - FIRST GENERATION -TYPICAL ORAL AGENTS								

CHLORPROMAZINE HCL SOLUTION	

VARIOUS			PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

CHLORPROMAZINE HCL TABLETS	

VARIOUS			PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.				

FLUPHENAZINE HCL CONCENTRATE	

VARIOUS			PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.				

FLUPHENAZINE HCL ELIXIR	

VARIOUS			PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.				

FLUPHENAZINE HCL TABLETS	

VARIOUS			PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

HALOPERIDOL LACTATE CONCENTRATE	

VARIOUS			PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.				

HALOPERIDOL TABLETS	

VARIOUS			PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.				

LOXAPINE SUCCINATE CAPSULES	

LOXITANE			PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.				

PERPHENAZINE TABLETS	

VARIOUS			PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

PIMOZIDE	

ORAP			PA Required for Ages < 12 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.				

THIORIDAZINE HCL TABLETS	

VARIOUS			PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.				

THIOTHIXENE CAPSULES	

VARIOUS			PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.				

TRIFLUOPERAZINE HCL TABLETS	

VARIOUS			PA Required for Ages < 6 years
Prior Authorization is not required for ages 6 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.				
ANTIPSYCHOTICS - FIRST GENERATION -TYPICAL -LONG ACTING INJECTIONS								

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

FLUPHENAZINE DECANOATE SOLUTION	

FLUPHENAZINE DECANOATE			PA Required for Ages < 18 years
Prior Authorization is not required for ages 18 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO
Contractors.				

HALOPERIDOL DECANOATE SOLUTION	

HALDOL DECANOATE 50			PA Required for Ages < 18 years
Prior Authorization is not required for ages 18 and greater when prescribed by a psychiatric clinician, a developmental pediatrician or other prescribers as approved by the MCO Contractors.				
ANTIVIRALS								
ANTIRETROVIRALS								
ABACAVIR SULFATE SOLUTION	ZIAGEN							
ABACAVIR SULFATE TABLETS	ZIAGEN							
ABACAVIR SULFATE-LAMIVUDINE TABLETS	EPZICOM							
ABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE TABLETS	TRIZIVIR							
ABACAVIR-DOLUTEGRAVIR-LAMIVUDINE TABLETS	TRIUMEQ							
ATAZANAVIR SULFATE CAPSULES	REYATAZ							
ATAZANAVIR SULFATE PACK	REYATAZ							
ATAZANAVIR SULFATE-COBICISTAT TABLETS	EVOTAZ							
BICTEGRAVIR-EMTRICITABINE-TENOFOVIR ALAFENAMIDE FUMARATE TABLETS	BIKTARVY					30	30	
COBICISTAT TABLETS	TYBOST					30	30	
DARUNAVIR ETHANOLATE SUSPENSION	PREZISTA							
DARUNAVIR ETHANOLATE TABLETS	PREZISTA							
DARUNAVIR-COBICISTAT TABLETS	PREZCOBIX							
DELAVIRDINE MESYLATE TABLETS	RESCRIPTOR							
DIDANOSINE CAPSULE DELAYED RELEASE	VIDEX EC							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
DIDANOSINE SOLUTION	VIDEX PEDIATRIC							
DOLUTEGRAVIR SODIUM TABLETS	TIVICAY							
DORAVIRINE TABLETS	PIFELTRO							
EFAVIRENZ CAPSULES	SUSTIVA							
EFAVIRENZ TABLETS	SUSTIVA							
EFAVIRENZ-EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS	ATRIPLA	BRAND ONLY						
ELVITEGRAVIR TABLETS	VITEKTA							
ELVITEGRAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR TABLETS	STRIBILD							
ELVITEGRAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR ALAFENAMIDE TABLETS	GENVOYA							
EMTRICITABINE CAPSULES	EMTRIVA							
EMTRICITABINE SOLUTION	EMTRIVA							
EMTRICITABINE-RILPIVIRINE-TENOFOVIR ALAFENAMIDE FUMARATE TABLETS	ODEFSEY							
EMTRICITABINE-RILPIVIRINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS	COMPLERA							
EMTRICITABINE-TENOFOVIR ALAFENAMIDE FUMARATE TABLETS	DESCOVY							
EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS	TRUVADA	BRAND ONLY						
ENFUVIRTIDE SOLUTION	FUZEON			PA Required		1	30	
ETRAVIRINE TABLETS	INTELENCE							
FOSAMPRENAVIR CALCIUM SUSPENSION	LEXIVA							
FOSAMPRENAVIR CALCIUM TABLETS	LEXIVA							
INDINAVIR SULFATE CAPSULES	CRIXIVAN							
LAMIVUDINE SOLUTION	EPIVIR							
LAMIVUDINE TABLETS	EPIVIR							
LAMIVUDINE-ZIDOVUDINE TABLETS	COMBIVIR							
LOPINAVIR-RITONAVIR SOLUTION	KALETRA							
LOPINAVIR-RITONAVIR TABLETS	KALETRA							
MARAVIROC TABLETS	SELZENTRY			PA Required				
NELFINAVIR MESYLATE TABLETS	VIRACEPT							
NEVIRAPINE SUSPENSION	VIRAMUNE							
NEVIRAPINE TABLETS	VIRAMUNE							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
NEVIRAPINE TABLET 24-HOUR	VIRAMUNE XR							
RALTEGRAVIR POTASSIUM CHEWABLE TABLETS	ISENTRESS							
RALTEGRAVIR POTASSIUM PACK	ISENTRESS							
RALTEGRAVIR POTASSIUM TABLETS	ISENTRESS							
RILPIVIRINE HCL TABLETS	EDURANT							
RITONAVIR CAPSULES	NORVIR							
RITONAVIR SOLUTION	NORVIR							
RITONAVIR TABLETS	NORVIR							
SAQUINAVIR MESYLATE CAPSULES	INVIRASE							
SAQUINAVIR MESYLATE TABLETS	INVIRASE							
STAVUDINE CAPSULES	ZERIT							
STAVUDINE SOLUTION	ZERIT							
TENOFOVIR DISOPROXIL FUMARATE POWDER	VIREAD							
TENOFOVIR DISOPROXIL FUMARATE TABLETS	VIREAD							
TIPRANAVIR CAPSULES	APTIVUS							
TIPRANAVIR SOLUTION	APTIVUS							
ZIDOVUDINE CAPSULES	RETROVIR							
ZIDOVUDINE SYRUP	RETROVIR							
ZIDOVUDINE TABLETS	ZIDOVUDINE							
CMV AGENTS								
CIDOFOVIR IV	VISTIDE			PA Required				
FOSCARENT SODIUM	FOSCAVIR			PA Required				
GANCICLOVIR SODIUM	CYTOVENE			PA Required				
VALGANCICLOVIR HCL SOLUTION	VALCYTE			PA Required				
VALGANCICLOVIR HCL TABLETS	VALCYTE			PA Required				
HEPATITIS B AGENTS								
ADEFOVIR DIPIVOXIL TABLETS	HEPSERA			PA Required				
ENTECAVIR SOLUTION	BARACLUDE			PA Required				
ENTECAVIR TABLETS	BARACLUDE			PA Required				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
LAMIVUDINE (HBV) SOLUTION	EPIVIR HBV							
LAMIVUDINE (HBV) TABLETS	EPIVIR HBV							
TELBIVUDINE TABLETS	TYZEKA			PA Required				
HEPATITIS C AGENTS								
GLECAPREVIR-PIBRENTASVIR TABLETS	MAVYRET		PREFERRED DRUG	PA Required				
PEGINTERFERON ALFA-2A SOLUTION	PEGASYS		PREFERRED DRUG	PA Required				
PEGINTERFERON ALFA-2B KIT	PEGINTRON		PREFERRED DRUG	PA Required				
RIBAVIRIN (HEPATITIS C) CAPSULES	VARIOUS		PREFERRED DRUG	PA Required				
RIBAVIRIN (HEPATITIS C) TABLETS	VARIOUS		PREFERRED DRUG	PA Required				

SOFOSBUVIR/VELPATASVIR	

EPCLUSA	
AUTHORIZED
GENERIC BRAND ONLY	

PREFERRED DRUG	

PA Required				
HERPES AGENTS								
ACYCLOVIR SUSPENSION	ZOVIRAX							
ACYCLOVIR TABLETS	ZOVIRAX							
FAMCICLOVIR TABLETS	FAMVIR			PA Required				
VALACYCLOVIR HCL TABLETS	VALTREX			PA Required				
INFLUENZA AGENTS								
OSELTAMIVIR PHOSPHATE CAPSULES	TAMIFLU					20	270	
OSELTAMIVIR PHOSPHATE SUSPENSION	TAMIFLU							
RIMANTADINE HYDROCHLORIDE TABLETS	FLUMADINE							
ZANAMIVIR AEROSOL POWDER BREATH ACTIVATED	RELENZA DISKHALER					40	270	
ASSORTED CLASSES								
BLOOD PRODUCTS - IMMUNE GLOBULINS								
IMMUNE GLOBULIN	BIVIGAM (IV)	BRAND ONLY	PREFERRED DRUG	PA REQUIRED				
IMMUNE GLOBULIN	FLEBOGFAMMA DIF (IV)	BRAND ONLY	PREFERRED DRUG	PA REQUIRED				
IMMUNE GLOBULIN	GAMMAGARD LIQUID (INJ)	BRAND ONLY	PREFERRED DRUG	PA REQUIRED				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

IMMUNE GLOBULIN	
GAMMAKED (INJ)	
BRAND ONLY	
Preferred Drug	
PA Required				

IMMUNE GLOBULIN	
GAMUNEX-C (INJ)	
BRAND ONLY	
Preferred Drug	
PA REQUIRED				

IMMUNE GLOBULIN	
HIZENTRA (SUBQ)	
BRAND ONLY	
Preferred Drug	
PA REQUIRED				

IMMUNE GLOBULIN	
PRIVIGEN (IV)	
BRAND ONLY	
Preferred Drug	
PA Required				
CHELATING AGENTS								
PENICILLAMINE CAPSULES	CUPRIMINE							
IMMUNOMODULATORS								
LENALIDOMIDE CAPSULES	REVLIMID			PA Required				
THALIDOMIDE CAPSULES	THALOMID			PA Required				
IMMUNOSUPPRESSIVE AGENTS								
AZATHIOPRINE TABLETS	IMURAN							
CYCLOSPORINE CAPSULES	SANDIMMUNE							
CYCLOSPORINE MODIFIED (FOR MICROEMULSION) CAPSULES	GENGRAF							
CYCLOSPORINE MODIFIED (FOR MICROEMULSION) SOLUTION	GENGRAF							
CYCLOSPORINE SOLUTION	SANDIMMUNE							
EVEROLIMUS (IMMUNOSUPRESSANT) TABLETS	ZORTRESS			PA Required				
MYCOPHENOLATE MOFETIL CAPSULES	CELLCEPT							
MYCOPHENOLATE MOFETIL SUSPENSION	CELLCEPT							
MYCOPHENOLATE MOFETIL TABLETS	CELLCEPT							
SIROLIMUS SOLUTION	RAPAMUNE							
SIROLIMUS TABLETS	RAPAMUNE							
TACROLIMUS CAPSULES	HECORIA							
TACROLIMUS CAPSULE CONTROLLED RELEASE	ASTAGRAF XL							
POTASSIUM REMOVING RESINS								
SODIUM POLYSTYRENE SULFONATE POWDER	KAYEXALATE							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
SODIUM POLYSTYRENE SULFONATE SUSPENSION	KIONEX							
BETA BLOCKERS								
ALPHA-BETA BLOCKERS								
CARVEDILOL TABLETS	COREG							
LABETALOL HCL TABLETS	TRANDATE							
BETA BLOCKERS CARDIO-SELECTIVE								
ATENOLOL TABLETS	TENORMIN							
ATENOLOL/CHLORTHALIDONE	VARIOUS							
BISOPRODOL	VARIOUS							
BISOPRODOL/HCTZ	VARIOUS							
METOPROLOL TARTRATE TABLETS	VARIOUS							
METOPROLOL SUCCINATE TABLET XL 24-HOUR	VARIOUS							
METOPROLOL TARTRATE/HCTZ	VARIOUS							
BETA BLOCKERS NON-SELECTIVE								

NADOLOL	
VARIOUS			PA NOT REQUIRED FOR CHILDREN AND
ADOLESCENTS UNDER 19 YEARS OF AGE				
PROPRANOLOL HCL CAPSULE ER CONTROLLED RELEASE	VARIOUS							
PROPRANOLOL HCL SOLUTION	VARIOUS							
PROPRANOLOL HCL TABLETS	VARIOUS							
PROPRANOLOL / HCTZ	VARIOUS							
SOTALOL HCL TABLETS	BETAPACE							
CALCIUM CHANNEL BLOCKERS								
CALCIUM CHANNEL BLOCKERS								
AMLODIPINE BESYLATE	VARIOUS					30	30	
DILTIAZEM CAPSULE ER	VARIOUS							
DILTIAZEM TABLETS	VARIOUS							
FELODIPINE TABLET ER 24-HOUR	VARIOUS					30	30	
NIFEDIPINE IR CAPSULES	VARIOUS							
NIFEDIPINE TABLET ER 24-HOUR	VARIOUS					30	30	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
VERAPAMIL HCL CAPSULE SR	VARIOUS					30	30	
VERAPAMIL HCL TABLETS	VARIOUS							
VERAPAMIL HCL TABLET CONTROLLED RELEASE	VARIOUS					30	30	
CARDIOTONICS								
CARDIAC GLYCOSIDES								
DIGOXIN SOLUTION	DIGOXIN							
DIGOXIN TABLETS	LANOXIN							
CARDIOVASCULAR AGENTS - MISC.								
ANGIOTENSTIN RECEPTOR NEPRILYSIN INHIBITOR								
SACUBITRIL / VALSARTAN	ENTRESTO			PA Required				
PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAG								

AMBRISENTAN TABLETS	
LETAIRIS	
BRAND ONLY	
PREFERRED DRUG	
PA Required				

BOSENTAN TABLETS	
TRACLEER	
BRAND ONLY	
PREFERRED DRUG	
PA Required				
PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBIT								

SILDENAFIL CITRATE (PULMONARY HYPERTENSION) SUSPENSION	
REVATIO	
BRAND ONLY	
PREFERRED DRUG	
PA Required FOR > 12 YEARS OF AGE				
SILDENAFIL CITRATE (PULMONARY HYPERTENSION) TABLETS	VARIOUS		PREFERRED DRUG	PA Required				

TADALAFIL (PULMONARY HYPERTENSION) TABLETS	
ADCIRCA	
BRAND ONLY	
PREFERRED DRUG	
PA Required				
CEPHALOSPORINS								
CEPHALOSPORINS - 1ST GENERATION								
CEFADROXIL CAPSULES	CEFADROXIL							
CEFADROXIL SUSPENSION	CEFADROXIL							
CEFADROXIL TABLETS	CEFADROXIL							
CEPHALEXIN CAPSULES	KEFLEX							
CEPHALEXIN SUSPENSION	CEPHALEXIN							
CEPHALEXIN TABLETS	CEPHALEXIN							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
CEPHALOSPORINS - 2ND GENERATION								
CEFACLOR CAPSULES	CEFACLOR							
CEFACLOR SUSPENSION	CEFACLOR							
CEFPROZIL SUSPENSION	CEFPROZIL							
CEFPROZIL TABLETS	CEFPROZIL							
CEFUROXIME AXETIL SUSPENSION	CEFTIN							
CEFUROXIME AXETIL TABLETS	CEFTIN							
CEPHALOSPORINS - 3RD GENERATION								
CEFDINIR CAPSULES	CEFDINIR							
CEFDINIR SUSPENSION	CEFDINIR							
CEFIXIME CAPSULES	SUPRAX					1	30	
CEFIXIME CHEWABLE TABLETS	SUPRAX					1	30	
CEFIXIME SUSPENSION	SUPRAX					1	30	
CEFIXIME TABLETS	SUPRAX					1	30	
CEFPODOXIME PROXETIL SUSPENSION	CEFPODOXIME PROXETIL							
CEFPODOXIME PROXETIL TABLETS	CEFPODOXIME PROXETIL							
CONTRACEPTION								
COMBINATION CONTRACEPTIVES - ORAL								
DESOGESTREL & ETHINYL ESTRADIOL TABLETS	APRI							
DESOGESTREL-ETHINYL ESTRADIOL (BIPHASIC) TABLETS	AZURETTE							
DESOGESTREL-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS	CAZIANT							
DROSPIRENONE-ETHINYL ESTRADIOL TABLETS	OCELLA							
ETHYNODIOL DIACET & ETHINYL ESTRADIOL TABLETS	KELNOR 1/35							
LEVONORGESTREL & ETHINYL ESTRADIOL TABLETS	AUBRA							
LEVONORGESTREL-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS	ENPRESSE-28							
LEVONORGESTREL-ETHINYL ESTRADIOL (91-DAY) TABLETS	AMETHIA LO							
LEVONORGESTREL & ETHINYL ESTRADIOL (CONTINUOUS) TABLETS	AMETHYST							
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TABLETS	JUNEL FE							
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE CHEWABLES	MELODETTA 24 FE							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
NORETHINDRONE & ETH ESTRADIOL TABLETS	BALZIVA							
NORETHINDRONE & MESTRANOL TABLETS	NECON 1/50-28							
NORETHINDRONE ACET & ETH ESTRA TABLETS	GILDESS 1/20							
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL-FE TABLETS	ESTROSTEP FE							
NORETHIN ACET & ESTRAD-FE TABLETS	LOESTRIN FE TAB 1/20							
NORETHINDRONE-ETH ESTRADIOL (BIPHASIC) TABLETS	NECON 10/11-28							
NORETHINDRONE-ETH ESTRADIOL (TRIPHASIC) TABLETS	CYCLAFEM 7/7/7							
NORETHINDRONE & ETHINYL ESTRADIOL-FE CHEWABLES	KAITLIB FE							
NORGESTIMATE-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS	ORTHO TRI-CYCLEN							
NORGESTIMATE-ETHINYL ESTRADIOL TABLETS	ESTARYLLA							
NORGESTREL & ETHINYL ESTRADIOL TABLETS	CRYSELLE-28							
COMBINATION CONTRACEPTIVES - VAGINAL								

ETONOGESTREL-ETHINYL ESTRADIOL RING	
NUVARING	
BRAND ONLY						
COPPER CONTRACEPTIVES - IUD								
COPPER (IUD)	PARAGARD			Buy and Bill Under Medical Benefit				
EMERGENCY CONTRACEPTIVES								

LEVONORGESTREL (EMERGENCY OC) TABLETS	

PLAN B ONE-STEP OTC		

PREFERRED DRUG					

LEVONORGESTREL (EMERGENCY OC) TABLETS	

AFTERA OTC		

PREFERRED DRUG					

LEVONORGESTREL (EMERGENCY OC) TABLETS	

LEVONORGESTREL OTC		

PREFERRED DRUG					

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

LEVONORGESTREL (EMERGENCY OC) TABLETS	

MY CHOICE OTC		

PREFERRED DRUG					

LEVONORGESTREL (EMERGENCY OC) TABLETS	

MY WAY OTC		

PREFERRED DRUG					

LEVONORGESTREL (EMERGENCY OC) TABLETS	

NEW DAY OTC		

PREFERRED DRUG					

LEVONORGESTREL (EMERGENCY OC) TABLETS	

OPTION 2 OTC		

PREFERRED DRUG					

LEVONORGESTREL (EMERGENCY OC) TABLETS	

TAKE ACTION OTC		

PREFERRED DRUG					
PROGESTIN CONTRACEPTIVES - IMPLANTS								

ETONOGESTREL IMPLANT	
NEXPLANON		
PREFERRED DRUG					
PROGESTIN CONTRACEPTIVES - INJECTABLE								
MEDROXYPROGESTERONE ACETATE (CONTRACEPTIVE) SUSPENSION	CONTRACEPTIVE							
PROGESTIN CONTRACEPTIVES - IUD								
LEVONORGESTREL (IUD)	LILETTA			Buy and Bill Under Medical Benefit				
LEVONORGESTREL (IUD)	SKYLA			Buy and Bill Under Medical Benefit				
LEVONORGESTREL (IUD)	MIRENA			Buy and Bill Under Medical Benefit				
LEVONORGESTREL (IUD)	KYLEENA			Buy and Bill Under Medical Benefit				
PROGESTIN CONTRACEPTIVES - ORAL								
NORETHINDRONE (CONTRACEPTIVE) TABLETS	CAMILA							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
PROGESTIN CONTRACEPTIVES - TRANSDERMAL								
NORELGESTROMIN-ETHINYL ESTRADIOL PATCH WEEKLY	XULANE							
CORTICOSTEROIDS								
GLUCOCORTICOSTEROIDS								
DEXAMETHASONE CONCENTRATE	DEXAMETHASONE INTENSOL							
DEXAMETHASONE ELIXIR	VARIOUS							
DEXAMETHASONE SOLUTION	DEXAMETHASONE							
DEXAMETHASONE TABLETS	DEXAMETHASONE							
HYDROCORTISONE SOD SUCCINATE SOLUTION (INJECTABLE)	A-HYDROCORT			PA Required				
METHYLPREDNISOLONE ACETATE SUSPENSION (INJECTABLE)	DEPO-MEDROL			PA Required				
METHYLPREDNISOLONE SOD SUCC SOLUTION (INJECTABLE)	A-METHAPRED			PA Required				
METHYLPREDNISOLONE TABLETS	MEDROL							
PREDNISOLONE SODIUM PHOSPHATE SOLUTION	ORAPRED							
PREDNISOLONE SODIUM PHOSPHATE ORALLY DISINTEGRATING TABLETS	ORAPRED ODT							
PREDNISOLONE SYRUP	PRELONE							
PREDNISOLONE TABLETS	VARIOUS							
PREDNISONE CONCENTRATE	PREDNISONE INTENSOL							
PREDNISONE SOLUTION	PREDNISONE							
PREDNISONE TABLETS	PREDNISONE							
TRIAMCINOLONE ACETONIDE SUSPENSION (INJECTABLE)	KENALOG-10			PA Required				
TRIAMCINOLONE DIACETATE SUSPENSION (INJECTABLE)	TRIAMCINOLONE			PA Required				

TRIAMCINOLONE HEXACETONIDE SUSPENSION (INJECTABLE)	ARISTOSPAN INTRALESIONAL &
INTRA-ARTICULAR			
PA Required				
MINERALOCORTICOIDS								
FLUDROCORTISONE ACETATE TABLETS	FLORINEF							
COUGH/COLD/ALLERGY								
ANTITUSSIVES								
BENZONATATE CAPSULES	TESSALON PERLES							
HYDROCODONE W/ HOMATROPINE SYRUP	VARIOUS			PA Required for < 18 years of age		240	12	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
HYDROCODONE W/ HOMATROPINE TABLETS	VARIOUS			PA Required for < 18 years of age				
COUGH/COLD/ALLERGY COMBINATIONS								
BROMPHENIRAMINE & PSEUDOEPHEDRINE LIQUID	VARIOUS							
BROMPHENIRAMINE &PSEUDOEPHEDRINE TABLET 12-HOUR	VARIOUS							
BROMPHENIRAMINE-DEXTROMETHORPHAN-PHENYLEPHRINE   LIQUID/TABLETS	VARIOUS							
CETIRIZINE-PSEUDOEPHEDRINE TABLET 12-HOUR	VARIOUS					30	30	
CHLORPHENIRAMINE &PSEUDOEPHEDRINE CHEWABLE TABLETS	VARIOUS							
CHLORPHENIRAMINE &PSEUDOEPHEDRINE LIQUID	VARIOUS					480	30	
CHLORPHENIRAMINE &PSEUDOEPHEDRINE SOLUTION	VARIOUS					480	30	
CHLORPHENIRAMINE &PSEUDOEPHEDRINE SYRUP	VARIOUS					480	30	
CHLORPHENIRAMINE &PSEUDOEPHEDRINE TABLETS	VARIOUS							
DEXTROMETHORPHAN-GUAIFENESIN TABLET	VARIOUS							
DEXTROMETHORPHAN-GUAIFENESIN LIQUID	VARIOUS					480	30	
DEXTROMETHORPHAN-GUAIFENESIN TABLET 12-HOUR	MUCINEX DM							
FEXOFENADINE-PSEUDOEPHEDRINE TABLET 12-HOUR	VARIOUS					30	30	
FEXOFENADINE-PSEUDOEPHEDRINE TABLET 24-HOUR	VARIOUS					30	30	
GUAIFENESIN-CODEINE SYRUP	ROBITUSSIN AC			PA Required for < 18 years of age		240	12	
LORATADINE & PSEUDOEPHEDRINE TABLET 12-HOUR	ALAVERT ALLERGY/SINUS					30	30	
LORATADINE & PSEUDOEPHEDRINE TABLET 24-HOUR	CLARITIN-D 24 HOUR					30	30	
PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN CAPSULES	VARIOUS							

PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN LIQUID	ROBITUSSIN CHILDRENS COUGH &
COLD CF					
480	
30	
PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN SYRUP	VARIOUS					480	30	
PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN TABLETS	VARIOUS							
PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN TABLET 12-HOUR	VARIOUS							
PHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN ELIXIR	VARIOUS					480	30	

PHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN LIQUID	DIMETAPP DEXTROMETHORPHAN
COLD & COUGH					
480	
30	
PHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN SYRUP	VARIOUS					480	30	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN LIQUID	VARIOUS					480	30	
PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN DROPS	VARIOUS			PA Required for < 6 years age				
PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN SYRUP	VARIOUS					480	30	
PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN TABLETS	VARIOUS							
PHENYLEPHRINE-GUAIFENESIN CAPSULES	VARIOUS							

PHENYLEPHRINE-GUAIFENESIN LIQUID	TRIAMINIC CHEST/
NASAL CONGESTION					
480	
30	

PHENYLEPHRINE-GUAIFENESIN SYRUP	TRIAMINIC CHEST & NASAL
CONGESTION					
480	
30	
PHENYLEPHRINE-GUAIFENESIN TABLETS	VARIOUS							
PROMETHAZINE & PHENYLEPHRINE SYRUP	PROMETHAZINE/ PHENYLEPHRINE					480	30	
PROMETHAZINE W/CODEINE SYRUP	PROMETHAZINE/CODEINE			PA Required for < 18 years of age		240	12	

PROMETHAZINE-DEXTROMETHORPHAN SYRUP	PROMETHAZINE/
DEXTROMETHORPHAN					
480	
30	
PSEUDOEPHEDRINE W/ CODEINE-GUAIFENESIN SYRUP	VARIOUS			PA Required for < 18 years of age		240	12	
EXPECTORANTS								
GUAIFENESIN LIQUID	VARIOUS					480	30	
GUAIFENESIN SYRUP	VARIOUS					480	30	
GUAIFENESIN TABLETS	VARIOUS							
GUAIFENESIN TABLET 12-HOUR	VARIOUS							
DERMATOLOGICALS								
ACNE PRODUCTS								
BENZOYL PEROXIDE WASH 5% & 10%	VARIOUS							

BENZOYL PEROXIDE CLEANSER 6%	NEUTROGENA ON-THE-SPOT
ACNE TREATMENT							
BENZOYL PEROXIDE GEL	BENZOYL PEROXIDE							
BENZOYL PEROXIDE LIQUID	PANOXYL							
BENZOYL PEROXIDE LOTION	BP CLEANSING LOTION							
BENZOYL PEROXIDE-ERYTHROMYCIN PACK	BENZAMYCINPAK							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
CLINDAMYCIN PHOSPHATE (TOPICAL) GEL	CLEOCIN-T							
CLINDAMYCIN PHOSPHATE (TOPICAL) LOTION	CLEOCIN-T							
CLINDAMYCIN PHOSPHATE (TOPICAL) SOLUTION	CLEOCIN-T							
CLINDAMYCIN PHOSPHATE (TOPICAL) SWAB	CLEOCIN-T							
CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE (REFRIGERATE)	CLINDAMY/BEN							
ERYTHROMYCIN (ACNE AID) SOLUTION	ERYTHROMYCIN							
ISOTRETINOIN CAPSULES	ABSORICA			PA Required				
TRETINOIN CREAM	RETIN-A	Brand Only		PA Required For > 26 Years of Age				
TRETINOIN GEL	RETIN-A	Brand Only		PA Required For > 26 Years of Age				
ANTIBIOTICS - TOPICAL								
BACITRACIN OINTMENT	BACIGUENT							
BACITRACIN ZINC OINTMENT	BACITRACIN							
BACITRACIN-POLYMYXIN B OINTMENT	POLYSPORIN							
BACITRACIN-POLYMYXIN-NEOMYCIN HC OINTMENT	CORTISPORIN							
GENTAMICIN SULFATE CREAM	GENTAMICIN SULFATE							
GENTAMICIN SULFATE OINTMENT	GENTAMICIN SULFATE							
MUPIROCIN CALCIUM CREAM	BACTROBAN							
MUPIROCIN OINTMENT	BACTROBAN							
NEOMYCIN-BACITRACIN-POLYMYXIN OINTMENT	NEOSPORIN							
ANTIFUNGALS - TOPICAL								
BUTENAFINE	LOTRIMIN ULTRA							
CICLOPROX CREAM	VARIOUS							
CICLOPROX SOLUTION	VARIOUS							
CLOTRIMAZOLE CREAM (RX & OTC)	LOTRIMIN							
CLOTRIMAZOLE OINTMENT	LOTRIMIN							
CLOTRIMAZOLE SOLUTION (OTC)	VARIOUS							
CLOTRIMAZOLE W/ BETAMETHASONE CREAM	LOTRISONE							
KETOCONAZOLE CREAM	VARIOUS							
KETOCONAZOLE SHAMPOO	VARIOUS							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
MICONAZOLE NITRATE CREAM	VARIOUS							
MICONAZOLE NITRATE POWDER	VARIOUS							
NYSTATIN CREAM	VARIOUS							
NYSTATIN OINTMENT	VARIOUS							
NYSTATIN POWDER	VARIOUS							
TOLNAFTATE AERO POWDER	VARIOUS							
TOLNAFTATE CREAM	VARIOUS							
TOLNAFTATE POWDER	VARIOUS							
TERBINAFINE CREAM	VARIOUS							
ANTIHISTAMINES-TOPICAL								
DIPHENHYDRAMINE HCL CREAM	ANTI-ITCH MAXIMUM STRENGTH							
DIPHENHYDRAMINE HCL GEL	BENADRYL ITCH STOPPING							
DIPHENHYDRAMINE HCL SOLUTION	BENADRYL MAXIMUM STRENGTH							
ANTISEBORRHEIC TOPICAL PRODUCTS								
SELENIUM SULFIDE LOTION	SELSUN SHAMPOO							
ANTIVIRALS - TOPICAL								
DOCOSANOL 10% CREAM	ABREVA		PREFERRED AGENT			15GM	30	
ACYCLOVIR OINTMENT	ZOVIRAX		PREFERRED AGENT					
BURN PRODUCTS								
SILVER SULFADIAZINE CREAM	SILVADENE							
CORTICOSTEROIDS - TOPICAL LOW POTENCY								

FLUOCINOLONE ACETONIDE	
DERMA-SMOOTH FS	
BRAND ONLY						
HYDROCORTISONE CREAM	VARIOUS							
HYDROCORTISONE GEL	VARIOUS							
HYDROCORTISONE LOTION	VARIOUS							
HYDROCORTISONE OINTMENT	VARIOUS							
FLUOCINOLONE 0.01% OIL	VARIOUS							
CORTICOSTEROIDS - TOPICAL MEDIUM POTENCY								

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
FLUTICASONE PROPIONATE CREAM	VARIOUS							
FLUTICASONE PROPIONATE OINTMENT	VARIOUS							
MOMETASONE FUROATE CREAM	VARIOUS							
MOMETASONE FUROATE OINTMENT	VARIOUS							
MOMETASONE FUROATE SOLUTION	VARIOUS							
CORTICOSTEROIDS - TOPICAL HIGH POTENCY								
BETAMETHASONE DIPROPIONATE LOTION	VARIOUS							
BETAMETHASONE DIPROPIONATE/PROPYLENE GLYC. CREAM	VARIOUS							
BETAMETHASONE VALERATE CREAM	VARIOUS							
BETAMETHASONE VALERATE LOTION	VARIOUS							
BETAMETHASONE VALERATE SOLUTION	VARIOUS							
FLUOCINONIDE CREAM	VARIOUS							
FLUOCINONIDE OINTMENT	VARIOUS							
FLUOCINONIDE SOLUTION	VARIOUS							
TRIAMCINOLONE ACETONIDE CREAM	VARIOUS							
TRIAMCINOLONE ACETONIDE LOTION	VARIOUS							
TRIAMCINOLONE ACETONIDE OINTMENT	VARIOUS							
CORTICOSTEROIDS - TOPICAL VERY HIGH POTENCY								
CLOBETASOL PROPIONATE CREAM	VARIOUS					100	30	
CLOBETASOL PROPIONATE EMOLLIENT	VARIOUS					100	30	
CLOBETASOL PROPIONATE GEL	VARIOUS					118	30	
CLOBETASOL PROPIONATE OINTMENT	VARIOUS					100	30	
CLOBETASOL PROPIONATE SOLUTION	VARIOUS					100	30	
HALOBETASOL PROPIONATE CREAM	VARIOUS					100	30	
HALOBETASOL PROPIONATE OINTMENT	VARIOUS					100	30	
KERATOLYTIC/ANTIMITOTIC AGENTS								
SALICYLIC ACID CREAM	SALACYN							
SALICYLIC ACID FOAM	SALVAX							
SALICYLIC ACID GEL	KERALYT							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
SALICYLIC ACID LIQUID	VIRASAL							
SALICYLIC ACID LOTION	SALACYN							
SALICYLIC ACID SHAMPOO	SALEX							
SALICYLIC ACID SOLUTION	VARIOUS							
LOCAL ANESTHETICS - TOPICAL								
LIDOCAINE CREAM 4%	ASPERCREME W/LIDOCAINE							
LIDOCAINE HCL GEL 2%	GLYDO							
LIDOCAINE HCL LOTION	LIDOCAINE HCL			PA Required				
LIDOCAINE OINTMENT	LIDOCAINE			PA Required				
LIDOCAINE PATCH	LIDODERM			PA Required				
LIDOCAINE HCL SOLUTION	VARIOUS							
LIDOCAINE-PRILOCAINE CREAM	EMLA							
TOPICAL - MISC.								
ALUMINUM CHLORIDE SOLUTION	DRYSOL							
ROSACEA TOPICAL AGENTS								
METRONIDAZOLE CREAM 0.75%	METROCREAM							
METRONIDAZOLE GEL 0.75%	METROGEL							
METRONIDAZOLE LOTION	METROLOTION							
SCABICIDES & PEDICULICIDES TOPICAl AGENTS+A1106								
CROTAMITON CREAM	EURAX							
CROTAMITON LOTION	EURAX							
IVERMECTIN LOTION	SKLICE			PA Required				
PERMETHRIN CREAM	ACTICIN							
PERMETHRIN 1%, 5%	NIX, ELIMITE							
PERMETHRIN LIQUID	NIX CREME RINSE							
PYRETHRINS-PIPERONYL BUTOXIDE GEL	A-200							
PYRETHRINS-PIPERONYL BUTOXIDE LIQUID	BARC							
PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO	LICIDE							
SPINOSAD SUSPENSION	NATROBA			PA Required				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
DIAGNOSTIC PRODUCTS								
DIAGNOSTIC TESTS								
BLOOD GLUCOSE MONITORS & STRIPS	VARIOUS							
DIGESTIVE AIDS								
DIGESTIVE ENZYMES								

LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE	
CREON	
BRAND ONLY	
PREFERRED DRUG			
500	
30	

LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE	
ZENPEP	
BRAND ONLY	
PREFERRED DRUG			
500	
30	
LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE 5000 UNITS	PANCRELIPASE 5000 UNITS		PREFERRED DRUG			300	30	
DIURETICS								
CARBONIC ANHYDRASE INHIBITORS								
ACETAZOLAMIDE CAPSULE 12-HOUR	DIAMOX							
ACETAZOLAMIDE TABLETS	ACETAZOLAMIDE							
METHAZOLAMIDE TABLETS	NEPTAZANE							
DIURETIC COMBINATIONS								
SPIRONOLACTONE & HYDROCHLOROTHIAZIDE TABLETS	ALDACTAZIDE							
TRIAMTERENE & HYDROCHLOROTHIAZIDE CAPSULES	DYAZIDE							
TRIAMTERENE & HYDROCHLOROTHIAZIDE TABLETS	MAXZIDE-25							
LOOP DIURETICS								
BUMETANIDE TABLETS	BUMETANIDE							
FUROSEMIDE SOLUTION	FUROSEMIDE							
FUROSEMIDE TABLETS	LASIX							
TORSEMIDE TABLETS	DEMADEX							
POTASSIUM SPARING DIURETICS								
SPIRONOLACTONE TABLETS	ALDACTONE							
THIAZIDES AND THIAZIDE-LIKE DIURETICS								
CHLOROTHIAZIDE SUSPENSION	DIURIL							
CHLOROTHIAZIDE TABLETS	CHLOROTHIAZIDE							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
CHLORTHALIDONE TABLETS	CHLORTHALIDONE							
HYDROCHLOROTHIAZIDE CAPSULES 12.5MG	VARIOUS							
HYDROCHLOROTHIAZIDE TABLETS 25MG & 50MG	HYDROCHLOROTHIAZIDE							
INDAPAMIDE TABLETS	INDAPAMIDE							
METOLAZONE TABLETS	ZAROXOLYN							
ENDOCRINE AND METABOLIC AGENTS - MISC.								
BONE DENSITY REGULATORS								
ALENDRONATE SODIUM SOLUTION	ALENDRONATE SODIUM							
ALENDRONATE SODIUM TABLETS	ALENDRONATE SODIUM							
CALCITONIN (SALMON) SOLUTION	FORTICAL							
DENOSUMAB	PROLIA			PA Required				
IBANDRONATE SODIUM	BONIVA							
RALOXIFENE TABLETS	VARIOUS							
TERIPARATIDE (RECOMBINANT)	FORTEO			PA Required				
GROWTH HORMONES								

SOMATROPIN SOLUTION	
NORDITROPIN	
BRAND ONLY	
PREFERRED DRUG	
PA Required				

SOMATROPIN SOLUTION	
GENOTROPIN	
BRAND ONLY	
PREFERRED DRUG	
PA Required				
HORMONE RECEPTOR MODULATORS								
RALOXIFENE HCL TABLETS	EVISTA							
INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)								
MECASERMIN SOLUTION	INCRELEX			PA Required				
LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS								
LEUPROLIDE ACETATE (CPP) (3 MONTH) KIT	LUPRON DEPOT-PED			PA Required				
LEUPROLIDE ACETATE (CPP) KIT	LUPRON DEPOT-PED			PA Required				
METABOLIC MODIFIERS								
CINACALCET HCL TABLETS	SENSIPAR			PA Required				
IDURSULFASE SOLUTION	ELAPRASE			PA Required				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
POSTERIOR PITUITARY HORMONES								
DESMOPRESSIN ACETATE REFRIGERATED SOLUTION	VARIOUS							
DESMOPRESSIN ACETATE SOLUTION	VARIOUS							
DESMOPRESSIN ACETATE SPRAY REFRIGERATED SOLUTION	VARIOUS							
DESMOPRESSIN ACETATE SPRAY SOLUTION	VARIOUS							
DESMOPRESSIN ACETATE TABLETS	VARIOUS			PA Required				
ESTROGENS								
ESTROGEN COMBINATIONS								
CONJUGATED ESTROGENS-MEDROXYPROGESTERONE ACETATE TABLETS	PREMPRO							
ESTRADIOL-LEVONORGESTREL PATCH-WEEKLY	CLIMARA PATCH							
ESTROGENS								
ESTERIFIED ESTROGENS TABLETS	MENEST							
ESTRADIOL PATCH-TWICE WEEKLY	ALORA							
ESTRADIOL PATCH-WEEKLY	MENOSTAR							
ESTRADIOL TABLETS	ESTRACE							
ESTROGENS, CONJUGATED SYNTHETIC A TABLETS	CENESTIN							
ESTROGENS, CONJUGATED TABLETS	PREMARIN							
ESTROPIPATE TABLETS	ORTHO-EST							
FLUOROQUINOLONES								
FLUOROQUINOLONES								
CIPROFLOXACIN HCL TABLETS	CIPROFLOXACIN HCL							
LEVOFLOXACIN SOLUTION	LEVAQUIN							
LEVOFLOXACIN TABLETS	LEVAQUIN							
OFLOXACIN TABLETS	OFLOXACIN							
GASTROINTMENTESTINAL AGENTS - MISC.								
GALLSTONE SOLUBILIZING AGENTS								
URSODIOL CAPSULES	ACTIGALL							
URSODIOL TABLETS	URSO 250							
GASTROINTMENTESTINAL CHLORIDE CHANNEL ACTIVATORS								

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
LUBIPROSTONE CAPSULES	AMITIZA			PA Required				
GASTROINTMENTESTINAL STIMULANTS								
METOCLOPRAMIDE HCL SOLUTION	VARIOUS							
METOCLOPRAMIDE HCL TABLETS	VARIOUS							
METOCLOPRAMIDE HCL ORALLY DISINTEGRATING TABLETS	VARIOUS							
INFLAMMATORY BOWEL AGENTS								
BALSALAZIDE DISODIUM TABLETS	GIAZO					270	30	
INFLIXIMAB-ABDA	RENFLEXIS			PA Required				
BUDESONIDE CAPSULES	ENTOCORT EC							
MESALAMINE CAPSULE CONTROLLED RELEASE	PENTASA					270	30	
MESALAMINE CAPSULE DELAYED RELEASE	DELZICOL	Brand Only				180	30	
MESALAMINE CAPSULE 24-HOUR	APRISO	Brand Only				120	30	
MESALAMINE ENEMA	SFROWASA	Brand Only				30	30	
MESALAMINE TABLET ENTERIC COATED	LIALDA	Brand Only				120	30	
MESALAMINE SUPPOSITORY	CANASA	Brand Only				30	30	
SULFASALAZINE TABLETS	AZULFIDINE					240	30	
SULFASALAZINE TABLET ENTERIC COATED	AZULFIDINE EN-TABLETS					240	30	
IRRITABLE BOWEL SYNDROME (IBS) AGENTS								
LINACLOTIDE CAPSULES	LINZESS			PA Required				
PHOSPHATE BINDER AGENTS								
CALCIUM ACETATE TABLETS	VARIOUS		PREFERRED DRUG					
CALCIUM ACETATE CAPSULES	VARIOUS		PREFERRED DRUG					
SEVELAMER CARBONATE	RENVELA	VARIOUS	PREFERRED DRUG					
GENITOURINARY AGENTS - MISC.								
INTERSTITIAL CYSTITIS AGENTS								
PENTOSAN POLYSULFATE SODIUM CAPSULES	ELMIRON			PA Required				
PROSTATIC HYPERTROPHY AGENTS								
ALFUZOSIN ER	VARIOUS							
DOXAZOSIN MESYLATE	VARIOUS							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
DUTASTERIDE	VARIOUS							
FINASTERIDE	PROSCAR							
TAMSULOSIN HCL	FLOMAX							
TERAZOSIN	VARIOUS							
URINARY ANALGESICS								
PHENAZOPYRIDINE HCL TABLETS	PYRIDIUM							
GOUT AGENTS								
GOUT AGENTS								
ALLOPURINOL TABLETS	ZYLOPRIM							
COLCHICINE TABLETS	VARIOUS							
FEBUXOSTAT TABLETS	ULORIC			PA Required				
URICOSURICS								
PROBENECID TABLETS	PROBENECID							
HEMATOLOGICAL AGENTS - MISC.								
PLATELET AGGREGATION INHIBITORS								
CILOSTAZOL TABLETS	PLETAL							
CLOPIDOGREL BISULFATE TABLETS	PLAVIX							
DIPYRIDAMOLE TABLETS	PERSANTINE							
TICAGRELOR TABLETS	BRILINTA			PA Required				
HEMATOPOIETIC AGENTS								
AGENTS FOR GAUCHER DISEASE								
ELIGLUSTAT TARTRATE	CERDELGA (oral)	BRAND ONLY		PA Required				
IMIGLUCERASE SOLUTION	CEREZYME 400 IU (IV)	BRAND ONLY		PA Required				
TALIGLUCERASE ALFA	ELELYSO (IV)	BRAND ONLY		PA Required				
MIGLUSTAT	MIGLUSTAT (AG) (oral)	BRAND ONLY		PA Required				
VELAGLUCERASE ALFA	VPRIV 400 IU	BRAND ONLY		PA Required				
HEMATOPOIETIC GROWTH FACTORS								

ELTROMBOPAG OLAMINE TABLETS	
PROMACTA	
BRAND ONLY	
PREFERRED DRUG	
PA Required				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
EPOETIN ALFA SOLUTION	RETACRIT	BRAND ONLY	PREFERRED DRUG	PA Required				

FILGRASTIM DISPOSABLE SYRINGE	
NEUPOGEN	
BRAND ONLY	
PREFERRED DRUG	
PA Required				

FILGRASTIM SOLUTION	
NEUPOGEN	
BRAND ONLY	
PREFERRED DRUG	
PA Required				

FILGRASTIM-AAF SOLUTION PREFILLED SYRINGE	
NIVESTYM	
BRAND ONLY	
PREFERRED DRUG	
PA Required				

PEGFILGRASTIM -JMDB PREFILLED SYRINGE	
FULPHILA	
BRAND ONLY	
PREFERRED DRUG	
PA Required				

PEGFILGRASTIM-APGF SOLUTION PREFILLED SYRINGE	
NYVEPRIA	
BRAND ONLY	
PREFERRED DRUG	
PA Required				

PEGFILGRASTIM PREFILLED SYRINGE	
UNDENYCA	
BRAND ONLY	
PREFERRED DRUG	
PA Required				

ROMIPLOSTIM	
NPLATE	
BRAND ONLY	
PREFERRED DRUG	
PA Required				
HEMOSTATICS								
HEMOSTATICS - SYSTEMIC								
AMINOCAPROIC ACID SYRUP	AMICAR							
AMINOCAPROIC ACID TABLETS	AMICAR							
HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENT								
BARBITURATE HYPNOTICS								
PHENOBARBITAL SOLUTION	PHENOBARBITAL							
PHENOBARBITAL TABLETS	PHENOBARBITAL							

NON-BARBITURATE HYPNOTICS								

ESZOPICLONE	

LUNESTA	
VARIOUS	

PREFERRED DRUG	PA Required for Ages <6 years PA Required for > 1 Hypnotic Drug		

30	

30	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

TEMAZEPAM CAPSULES 15MG & 30MG	
RESTORIL		
PREFERRED DRUG	PA Required for Ages <6 years
PA Required for > 1 Hypnotic Drug		
30	
30	

ZOLPIDEM TARTRATE TABLETS 5MG	
AMBIEN		
PREFERRED DRUG	PA Required for Ages <6 years
PA Required for > 1 Hypnotic Drug		
60	
30	

ZOLPIDEM TARTRATE TABLETS 10MG	
AMBIEN		
PREFERRED DRUG	PA Required for Ages <6 years
PA Required for > 1 Hypnotic Drug		
30	
30	
SELECTIVE MELATONIN RECEPTOR AGONISTS								

RAMELTEON TABLETS	

ROZEREM	
BRAND ONLY	

PREFERRED DRUG	

PA Required for < 6 years of age	Patient must have
tried two preferred agents.	

30	

30	
LAXATIVES								
LAXATIVE COMBINATIONS								
PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE SOLUTION	COLYTE							
LAXATIVES - MISC.								
LACTULOSE SOLUTION	LACTULOSE							
MACROLIDES								
AZITHROMYCIN								
AZITHROMYCIN PACKETS	ZITHROMAX							
AZITHROMYCIN SUSPENSION	ZITHROMAX							
AZITHROMYCIN TABLETS	ZITHROMAX							
CLARITHROMYCIN								
CLARITHROMYCIN SUSPENSION	CLARITHROMYCIN							
CLARITHROMYCIN TABLETS	BIAXIN							
CLARITHROMYCIN TABLET 24-HOUR	BIAXIN XL							
MEDICAL DEVICES								
CONTRACEPTIVES								
CONDOMS - FEMALE MISC.	FC FEMALE CONDOM							
CONDOMS - MALE MISC.	LIFESTYLES ASSORTED COLORS							
DIAPHRAGM ARC-SPRING DPRH	CAYA							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

DIAPHRAGM COIL SPRING KIT	ORTHO DIAPHRAGM COIL SPRING
KIT 50							

DIAPHRAGM FLAT SPRING KIT	ORTHO DIAPHRAGM FLAT SPRING
KIT 55							

DIAPHRAGM WIDE SEAL DPRH	WIDE-SEAL SILICONE DIAPHRAGM
KIT 60							
DIAPHRAGMS - OTHER+A1294	OMNIFLEX DIAPHRAGM							
DIABETIC SUPPLIES								
BLOOD GLUCOSE MONITORING KIT W/ DEVICE	VARIOUS							
BLOOD GLUCOSE MONITORING DEVICES	VARIOUS							
LANCET DEVICES MISC.	VARIOUS							
LANCETS MISC.	VARIOUS							
DEVICES - MISC.								
ALCOHOL SWABS PADS	ALCOH-GLOVE CONTOURED WIPE							
RESPIRATORY THERAPY SUPPLIES								

SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MASKS	MASK VORTEX/
BABY WHIRL DUCKLING					
2	
365	

SPACER/AEROSOL-HOLDING CHAMBERS DEVICE	AEROCHAMBER
MINI AEROCHAMBER					
2	
365	
MIGRAINE PRODUCTS								
MIGRAINE COMBINATIONS								
ERGOTAMINE W/ CAFFEINE SUPPOSITORY	MIGERGOT					12	30	
ERGOTAMINE W/ CAFFEINE TABLETS	CAFERGOT							
MIGRAINE PRODUCTS - MONOCLONAL ANTIBODIES								
FREMANEZUMAB-VFRM SOLUTION AUTOINJECTOR	AJOVY		Preferred Drug	PA Required		1.00	30.00	
GALCANEZUMAB-GNLM SOLUTION AUTOINJECTOR / PREFILLED SYRINGE
/ PEN	
EMGALITY		
Preferred Drug	
PA Required				

SEROTONIN AGONISTS								
NARATRIPTAN HCL TABLETS	AMERGE		PREFERRED DRUG			9	30	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
RIZATRIPTAN BENZOATE ORALLY DISPERSABLE TABLET	MAXALT-MLT		PREFERRED DRUG			9	30	
RIZATRIPTAN BENZOATE TABLETS	MAXALT		PREFERRED DRUG			9	30	

SUMATRIPTAN NASAL SPRAY	
IMITREX	
BRAND ONLY	
PREFERRED DRUG			
6	
30	
SUMATRIPTAN SUCCINATE SUBCUTANEOUS SOLUTION AUTO INJECTION	IMITREX		PREFERRED DRUG			2	30	
SUMATRIPTAN SUCCINATE SUBCUTANEOUS SOLUTION CARTRIDGE	IMITREX		PREFERRED DRUG			2	30	

SUMATRIPTAN SUCCINATE TABLETS	
IMITREX		
PREFERRED DRUG			
9	
30	

ZOLMITRIPTAN NASAL SPRAY	
ZOMIG	
BRAND ONLY	
PREFERRED DRUG			
6	
30	

ZOLMITRIPTAN ORALLY DISPERSABLE TABLET	
ZOMIG ZMT		
PREFERRED DRUG			
9	
30	
ZOLMITRIPTAN TABLETS	ZOMIG		PREFERRED DRUG			9	30	
MINERALS & ELECTROLYTES								
SODIUM FLUORIDE CHEWABLE TABLETS	LUDENT							
SODIUM FLUORIDE LOZG	LOZI-FLUR							
SODIUM FLUORIDE SOLUTION	FLUOR-A-DAY							
SODIUM FLUORIDE TABLETS	SODIUM FLUORIDE							
MOUTH/THROAT/DENTAL AGENTS								
ANTI-INFECTIVES - THROAT								
CLOTRIMAZOLE TROC	CLOTRIMAZOLE							
STEROIDS - MOUTH/THROAT								
TRIAMCINOLONE ACETONIDE ORAL PASTE	ORALONE							
MULTIVITAMINS								
PRENATAL VITAMINS								
PRENATAL MULTIVITAMINS WITH OR WITHOUT MINERALS W/ FOLATE	VARIOUS							
PRENATAL MULTIVITAMINES WITH MINERAL W/FE-FA	VARIOUS							
MUSCULOSKELETAL THERAPY AGENTS								
CENTRAL MUSCLE RELAXANTS								

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
BACLOFEN TABLETS	BACLOFEN							

CYCLOBENZAPRINE HCL TABLETS 5MG & 10MG	
FLEXERIL			PA Required for dosages other than 5mg and
10mg tablets				
METHOCARBAMOL TABLETS	ROBAXIN							
TIZANIDINE HCL TABLETS - 2MG & 4MG ONLY	TIZANIDINE HCL							
DIRECT MUSCLE RELAXANTS								
DANTROLENE SODIUM CAPSULES	DANTRIUM							
NASAL AGENTS - SYSTEMIC AND TOPICAL								
NASAL ANTIALLERGY								
AZELASTINE HCL SOLUTION 0.10%	ASTELIN							
NASAL ANTICHOLINERGICS								
IPRATROPIUM BROMIDE SOLUTION	ATROVENT							
NASAL STEROIDS								
FLUNISOLIDE SOLUTION	FLUNISOLIDE							
FLUTICASONE PROPIONATE SUSPENSION	FLONASE							
TRIAMCINOLONE ACETONIDE	NASACORT AQ							
SYMPATHOMIMETIC DECONGESTANTS								
PSEUDOEPHEDRINE HCL LIQUID	SUDAFED CHILDRENS							
PSEUDOEPHEDRINE HCL SYRUP	PSEUDOEPHEDRINE							
PSEUDOEPHEDRINE HCL TABLETS	SUDAFED							
PSEUDOEPHEDRINE HCL TABLET 12-HOUR	NASAL DECONGESTANT							
PSEUDOEPHEDRINE HCL TABLET 24-HOUR	SUDAFED 24 HOUR							
OPHTHALMIC AGENTS								
OPHTHALMIC - BETA-BLOCKERS								
BETAXOLOL HCL SOLUTION	BETAXOLOL HCL							
BETAXOLOL HCL SUSPENSION	BETOPTIC-S							
CARTEOLOL HCL SOLUTION	CARTEOLOL HCL							
DORZOLAMIDE HCL-TIMOLOL MALEATE SOLUTION	COSOPT							
LEVOBUNOLOL HCL SOLUTION	LEVOBUNOLOL HCL							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
METIPRANOLOL SOLUTION	METIPRANOLOL							
TIMOLOL MALEATE SOLUTION	TIMOPTIC-XE							
TIMOLOL MALEATE SOLUTION	TIMOPTIC							
OPHTHALMIC - CYCLOPLEGIC MYDRIATICS								
ATROPINE SULFATE OINTMENT	ATROPINE SULFATE							
ATROPINE SULFATE SOLUTION	ISOPTO ATROPINE							
CYCLOPENTOLATE HCL SOLUTION	CYCLOGYL							
HOMATROPINE HBR SOLUTION	ISOPTO HOMATROPINE							
OPHTHALMIC - MIOTICS								
PILOCARPINE HCL GEL	PILOPINE HS							
PILOCARPINE HCL SOLUTION	ISOPTO CARPINE							
OPHTHALMIC - ANTI-INFECTIVES								
BACITRACIN OINTMENT	BACITRACIN					3.5GM	7	
BACITRACIN-POLYMYXIN B OINTMENT	POLYCIN							
CIPROFLOXACIN HCL OINTMENT	CILOXAN							
CIPROFLOXACIN HCL SOLUTION	CILOXAN							
ERYTHROMYCIN OINTMENT	ILOTYCIN							
GENTAMICIN SULFATE OINTMENT	GARAMYCIN							
GENTAMICIN SULFATE SOLUTION	GARAMYCIN							
MOXIFLOXACIN HCL SOLUTION	VIGAMOX							
NATAMYCIN SUSPENSION	NATACYN							
NEOMYCIN-BACITRACIN ZN-POLYMYXIN OINTMENT	NEO-POLYCIN							
NEOMYCIN-POLYMYXIN-GRAMICIDIN SOLUTION	NEOSPORIN							
OFLOXACIN SOLUTION	OCUFLOX							
POLYMYXIN B-TRIMETHOPRIM SOLUTION	POLYTRIM							
SULFACETAMIDE SODIUM OINTMENT	SULFACETAMIDE SODIUM							
SULFACETAMIDE SODIUM SOLUTION	BLEPH-10							
TOBRAMYCIN OINTMENT	TOBREX					3.5GM	7	
TOBRAMYCIN SOLUTION	TOBREX							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
TRIFLURIDINE SOLUTION	VIROPTIC							
OPHTHALMIC - DECONGESTANTS								
NAPHAZOLINE HCL SOLUTION	VASOCLEAR							
NAPHAZOLINE W/ PHENIRAMINE SOLUTION	NAPHCON-A							
OPHTHALMIC - IMMUNOMODULATORS								
CYCLOSPORINE EMULSION	RESTASIS			PA Required				
OPHTHALMIC - STEROIDS								
BACITRACIN-POLY-NEOMYCIN-HC OINTMENT	NEO-POLYCIN HC							
DEXAMETHASONE SUSPENSION	MAXIDEX							

DEXAMETHASONE SODIUM PHOSPHATE SOLUTION	DEXAMETHASONE SODIUM
PHOSPHATE							
FLUOROMETHOLONE OINTMENT	FML							
FLUOROMETHOLONE SUSPENSION	FML LIQUIFILM							
GENTAMICIN-PREDNISOLONE ACETATE OINTMENT	PRED-G S.O.P.							
GENTAMICIN-PREDNISOLONE ACETATE SUSPENSION	PRED-G							
NEOMYCIN-POLYMY-DEXAMETH OINTMENT	MAXITROL							
NEOMYCIN-POLYMY-DEXAMETH SUSPENSION	MAXITROL							
PREDNISOLONE ACETATE SUSPENSION	PRED MILD							

PREDNISOLONE SODIUM PHOSPHATE SOLUTION	PREDNISOLONE SODIUM
PHOSPHATE							
SULFACETAMIDE SOD-PREDNISOLONE OINTMENT	BLEPHAMIDE S.O.P.							

SULFACETAMIDE SOD-PREDNISOLONE SOLUTION	SULFACETAMIDE
SODIUM/PREDNISOLONE SODIUM PHOSPHATE							
SULFACETAMIDE SOD-PREDNISOLONE SUSPENSION	BLEPHAMIDE							
TOBRAMYCIN-DEXAMETHASONE OINTMENT	TOBRADEX							
TOBRAMYCIN-DEXAMETHASONE SUSPENSION	TOBRADEX ST							
OPHTHALMICS - MISC.								
BRINZOLAMIDE SUSPENSION	AZOPT			PA Required				
CROMOLYN SODIUM SOLUTION	CROMOLYN SODIUM							

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
DICLOFENAC SODIUM SOLUTION	DICLOFENAC SODIUM							
DORZOLAMIDE HCL SOLUTION	TRUSOPT							
FLURBIPROFEN SODIUM SOLUTION	OCUFEN							
KETOROLAC TROMETHAMINE SOLUTION	ACULAR LS							
KETOTIFEN FUMARATE SOLUTION	ALAWAY							
OPHTHALMIC - PROSTAGLANDINS								
LATANOPROST SOLUTION	XALATAN					2.5	30	
TAFLUPROST SOLUTION	ZIOPTAN			PA Required				
TRAVOPROST SOLUTION	TRAVATAN Z			PA Required				
OTIC AGENTS								
OTIC AGENTS - MISCELLANEOUS								
ACETIC ACID SOLUTION	ACETIC ACID							
OTIC ANTI-INFECTIVES								
CIPROFLOXACIN SOLUTION	VARIOUS							
OFLOXACIN (OTIC) SOLUTION	VARIOIUS							
OTIC COMBINATIONS								
ANTIPYRINE-BENZOCAINE SOLUTION	AURODEX							
ANTIPYRINE-BENZOCAINE-POLYCOSANOL SOLUTION	OTIC CARE							

CIPROFLOXACIN-DEXAMETHASONE	
CIPRODEX	
BRAND ONLY	
PREFERRED DRUG					
NEOMYCIN-POLYMYXIN-HC SOLUTION	CORTISPORIN		PREFERRED DRUG					
NEOMYCIN-POLYMYXIN-HC SUSPENSION	NEO/POLYMYXIN/HC 5-10000-1		PREFERRED DRUG					
OTIC STEROIDS								
HYDROCORTISONE W/ACETIC ACID SOLUTION	ACETASOL HC							
OXYTOCICS								
OXYTOCICS								
METHYLERGONOVINE MALEATE TABLETS	METHERGINE							
PASSIVE IMMUNIZING AGENTS								
MONOCLONAL ANTIBODIES								

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

PALIVIZUMAB SOLUTION	

SYNAGIS			PA Required - if approved the prescriber may be required to buy and bill a medical claim for the drug				
PENICILLINS								
AMINOPENICILLINS								
AMOXICILLIN CAPSULES	AMOXICILLIN							
AMOXICILLIN CHEWABLE TABLETS	AMOXICILLIN							
AMOXICILLIN SUSPENSION	AMOXICILLIN							
AMOXICILLIN TABLETS	AMOXICILLIN							
AMPICILLIN CAPSULES	AMPICILLIN							
AMPICILLIN SUSPENSION	AMPICILLIN							
NATURAL PENICILLINS								
PENICILLIN V POTASSIUM SOLUTION	PENICILLIN V POTASSIUM							
PENICILLIN V POTASSIUM TABLETS	PENICILLIN V POTASSIUM							
PENICILLIN COMBINATIONS								
AMOXICILLIN & POT CLAVULANATE CHEWABLE TABLETS	AUGMENTIN							
AMOXICILLIN & POT CLAVULANATE SUSPENSION	AUGMENTIN							
AMOXICILLIN & POT CLAVULANATE TABLET 12-HOUR	AUGMENTIN XR							
PENICILLINASE-RESISTANT PENICILLINS								
DICLOXACILLIN SODIUM CAPSULES	DICLOXACILLIN SODIUM							
PROGESTINS								
PROGESTINS								
MEDROXYPROGESTERONE ACETATE TABLETS	PROVERA							
NORETHINDRONE ACETATE TABLETS	AYGESTIN							
PROGESTERONE MICRONIZED CAPSULES	PROMETRIUM							
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENT								
ANTIDEMENTIA AGENTS								
DONEPEZIL HYDROCHLORIDE TABLETS	ARICEPT			PA Required				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
DONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TABLETS	ARICEPT ODT			PA Required				
GALANTAMINE HYDROBROMIDE CAPSULE CONTROLLED RELEASE	RAZADYNE ER			PA Required				
GALANTAMINE HYDROBROMIDE SOLUTION	RAZADYNE			PA Required				
GALANTAMINE HYDROBROMIDE TABLETS	RAZADYNE			PA Required				
MEMANTINE HCL SOLUTION	NAMENDA			PA Required				
MEMANTINE HCL TABLETS	NAMENDA			PA Required				
RIVASTIGMINE PATCH	EXELON			PA Required				
RIVASTIGMINE TARTRATE CAPSULES	EXELON			PA Required				
RIVASTIGMINE TARTRATE SOLUTION	EXELON			PA Required				
MULTIPLE SCLEROSIS AGENTS								
FINGOLIMOD HCL CAPSULES	GILENYA			PA Required				

GLATIRAMER ACETATE 20MG	
COPAXONE 20mg	
BRAND ONLY	
PREFERRED DRUG	
PA Required				

GLATIRAMER ACETATE 40MG	
GLATOPA 40MG	
BRAND ONLY	
PREFERRED DRUG	
PA Required				
INTERFERON BETA-1A KIT	AVONEX			PA Required				
INTERFERON BETA-1A SOLUTION	REBIF REBIDOSE			PA Required				
INTERFERON BETA-1B KIT	BETASERON			PA Required				
SMOKING DETERRENTS								

BUPROPION HCL (SMOKING DETERRENT) TABLET 12-HOUR	
BUPROBAN					
84-day supply	
180	

NICOTINE INHA	
NICOTROL INHALER					
84-day supply	
180	

NICOTINE POLACRILEX GUM	
NICORETTE GUM					
84-day supply	
180	

NICOTINE POLACRILEX LOZENGE	
COMMIT					
84-day supply	
180	

NICOTINE PATCH	
NICODERM CQ					
84-day supply	
180	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	

NICOTINE SOLUTION	
NICOTROL NS					
84-day supply	
180	

VARENICLINE TARTRATE TABLETS	
CHANTIX					
84-day supply	
180	
RESPIRATORY AGENTS - MISC.								
ALPHA-PROTEINASE INHIBITOR (HUMAN)								
ALPHA1-PROTEINASE INHIBITOR (HUMAN) SOLUTION	ARALAST NP			PA Required				
CYSTIC FIBROSIS AGENTS								
DORNASE ALFA SOLUTION	PULMOZYME			PA Required				
SULFONAMIDES								
SULFONAMIDES								
SULFADIAZINE TABLETS	SULFADIAZINE							
TETRACYCLINES								
TETRACYCLINES								
DEMECLOCYCLINE HCL TABLETS	DEMECLOCYCLINE HCL			PA Required				
DOXYCYCLINE HYCLATE CAPSULES - 50MG AND 100MG CAPSULES ONLY	VARIOUS							
DOXYCYCLINE HYCLATE TABLETS - 20MG AND 100MG TABLETS ONLY	VARIOUS							
DOXYCYCLINE MONOHYDRATE - CAPSULES 50MG & 100MG ONLY	VARIOUS							
MINOCYCLINE HCL - 50MG, 75MG & 100MG CAPSULES ONLY	MINOCIN							
THYROID AGENTS								
ANTITHYROID AGENTS								
METHIMAZOLE TABLETS	TAPAZOLE							
PROPYLTHIOURACIL TABLETS	PROPYLTHIOURACIL							
THYROID HORMONES								
LEVOTHYROXINE SODIUM TABLETS	LEVO-T							
LIOTHYRONINE SODIUM TABLETS	CYTOMEL							
THYROID TABLETS	ARMOUR THYROID							
ULCER DRUGS								
ANTISPASMODICS								

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
DICYCLOMINE HCL CAPSULES	VARIOUS							
DICYCLOMINE HCL SOLUTION	VARIOUS							
DICYCLOMINE HCL TABLETS	VARIOUS							
GLYCOPYRROLATE SOLUTION	VARIOUS							
GLYCOPYRROLATE TABLETS	VARIOUS							
HYOSCYAMINE SULFATE ELIXIR	VARIOUS							
HYOSCYAMINE SULFATE SOLUTION	VARIOUS							
HYOSCYAMINE SULFATE SUBLINGUAL	VARIOUS							
HYOSCYAMINE SULFATE TABLETS	VARIOUS							
HYOSCYAMINE SULFATE TABLET 12-HOUR	VARIOUS							
HYOSCYAMINE SULFATE CONTROLLED RELEASE TABLET	VARIOUS							
HYOSCYAMINE SULFATE ORALLY DISINTEGRATING TABLETS	VARIOUS							
PROPANTHELINE BROMIDE TABLETS	VARIOUS							
H-2 ANTAGONISTS								
FAMOTIDINE CHEWABLE TABLETS	PEPCID AC							
FAMOTIDINE SUSPENSION	PEPCID							
FAMOTIDINE TABLETS	PEPCID AC							
RANITIDINE HCL CAPSULES	RANITIDINE HCL							
RANITIDINE HCL SUSPENSION	DEPRIZINE FUSEPAQ							
RANITIDINE HCL SYRUP	ZANTAC							
RANITIDINE HCL TABLETS	ZANTAC 75							
ANTI-ULCER - MISC.								
SUCRALFATE TABLETS	CARAFATE							
PROTON PUMP INHIBITORS								
ESOMEPRAZOLE MAGNESIUM PACKETS	NEXIUM		PREFERRED DRUG	PA Required for > 18 Years of Age		30.00	30.00	
ESOMEPRAZOLE MAGNESIUM CAPSULE DELAYED RELEASE	NEXIUM		PREFERRED DRUG			60.00	30.00	
LANSOPRAZOLE CAPSULE DELAYED RELEASE	VARIOUS		PREFERRED DRUG			60.00	30.00	
LANSOPRAZOLE ORALLY DISPERSABLE TABLET (ODT)	PREVACID SOLUTAB		PREFERRED DRUG	PA Required for > 18 Years of Age		60.00	30.00	
OMEPRAZOLE ORAL CAPSULES	VARIOUS		PREFERRED DRUG			60.00	30.00	

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
PANTOPRAZOLE SODIUM PACKETS	PROTONIX		PREFERRED DRUG	PA Required for > 18 Years of Age		30.00	30.00	
URINARY ANTISPASMODICS								
URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLI)								
FESOTERODINE FUMARATE	TOVIAZ	BRAND ONLY	PREFERRED DRUG					
OXYBUTYNIN CHLORIDE SYRUP	VARIOUS		PREFERRED DRUG					
OXYBUTYNIN CHLORIDE TABLETS	VARIOUS		PREFERRED DRUG					
OXYBUTYNIN CHLORIDE TABLET 24-HOUR	DITROPAN XL		PREFERRED DRUG					
TOLTERODINE TARTRATE CAPSULE CONTROLLED RELEASE	DETROL LA	BRAND ONLY	PREFERRED DRUG					
TOLTERODINE TARTRATE TABLETS	DETROL	BRAND ONLY	PREFERRED DRUG					
VAGINAL PRODUCTS								
SPERMICIDES								

NONOXYNOL-9 FOAM	VCF VAGINAL CONTRACEPTIVE
FOAM							
NONOXYNOL-9 GEL	SHUR-SEAL							
VAGINAL ANTI-INFECTIVES								
CLINDAMYCIN PHOSPHATE VAGINAL CREAM	CLEOCIN							
CLINDAMYCIN PHOSPHATE VAGINAL SUPPOSITORY	CLEOCIN							
CLOTRIMAZOLE VAGINAL CREAM	GYNE-LOTRIMIN							
METRONIDAZOLE VAGINAL GEL	METROGEL-VAGINAL							

MICONAZOLE NITRATE VAGINAL	MONISTAT 3 COMBINATION
PACKETS							
MICONAZOLE NITRATE VAGINAL SUPPOSITORY	MICONAZOLE 3							
SULFANILAMIDE VAGINAL CREAM	AVC							
VAGINAL ESTROGENS								
ESTRADIOL ACETATE VAGINAL RING	FEMRING			PA Required				
ESTRADIOL VAGINAL RING	ESTRING							
ESTRADIOL VAGINAL TABLETS	VAGIFEM							
ESTRADIOL VAGINAL CREAM 0.01%	ESTRACE CREAM							
ESTROGENS, CONJUGATED VAGINAL CREAM	PREMARIN VAGINAL CREAM			PA Required				

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	

Preferred Drug Status	

Prior Authorization Type	

Step Therapy Requirements	

Quantity Limit (QL)	

QL
Days	
VASOPRESSORS								
ANAPHYLAXIS THERAPY AGENTS								

EPINEPHRINE SELF-INJECTABLE 0.15MG AND 0.30MG	EPINEPHRINE SELF-INJECTABLE (By
Mylan)	
Mylan Generic	
PREFERRED DRUG	
PA Required for > 2 Per Month		
2.00	
30.00