AHCCCS Fee-For-Service DUAL Eligible Members Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS DUAL Program Drug List Effective Date: 8/1/2019	

Drug Class/Drug Name	
Reference Brand Name	
PA Type	
Quantity Limit	
QL Days	
ANALGESICS - ANTI-INFLAMMATORY					
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)					
IBUPROFEN CAPSULES	ADVIL				
IBUPROFEN CHEWABLE	CHILDRENS MOTRIN				
IBUPROFEN SUSPENSION	CHILDRENS MOTRIN				
IBUPROFEN TABLETS	ADVIL JUNIOR STRENGTH				
ANALGESICS - NONNARCOTIC					
ANALGESICS OTHER					
ACETAMINOPHEN CAPSULES	VARIOUS				
ACETAMINOPHEN CHEWABLE	VARIOUS				
ACETAMINOPHEN ELIXIR	VARIOUS				
ACETAMINOPHEN LIQUID	VARIOUS				
ACETAMINOPHEN PACK	VARIOUS				
ACETAMINOPHEN SOLUTION	VARIOUS				
ACETAMINOPHEN SUPPOSITORY	VARIOUS				
ACETAMINOPHEN SUSPENSION	VARIOUS				
ACETAMINOPHEN SYRUP	VARIOUS				
ACETAMINOPHEN TABLETS	VARIOUS				
ACETAMINOPHEN TABLET CONTROLLED RELEASE	VARIOUS				
ACETAMINOPHEN ORALLY DISPERSABLE TABLET	VARIOUS				
SALICYLATES					
ASPIRIN CHEWABLE	ST JOSEPH ADULT				
ASPIRIN SUPPOSITORY	ASPIRIN				
ASPIRIN TABLETS	ASPIRIN				
ASPIRIN ORALLY DISPERSABLE TABLET	ADULT ASPIRIN LOW STRENGTH				
ASPIRIN TABLET ENTERIC COATED	1/2HALFPRIN				
ASPIRIN TABLET EFFERVESCENT	MEDI-SELTZER				
ANTACIDS					
ANTACIDS - CALCIUM SALTS					
CALCIUM CARBONATE (ANTACID) CHEWABLE	CHILDRENS MYLANTA UPSET STOMACH RELIEF				
CALCIUM CARBONATE (ANTACID) TABLETS	CALCIUM CARBONATE				
ANTACID COMBINATIONS					
ALUM & MAG HYDROX-SIMETHICONE SUSPENSION	ANTACID FAST ACTING				
ANTACIDS - MAGNESIUM SALTS					
MAGNESIUM OXIDE TABLETS	MAGNESIUM OXIDE				

                                    AHCCCS Fee-For-Service DUAL Eligible Members Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS DUAL Program Drug List Effective Date: 8/1/2019	

Drug Class/Drug Name	
Reference Brand Name	
PA Type	
Quantity Limit	
QL Days	
ANTICOAGULANTS					
HEPARINS AND HEPARINOID-LIKE AGENTS					
HEPARIN SODIUM (PORCINE) LOCK FLUSH & NACL LOCK FLUSH KIT	HEPARIN SODIUM LOCK FLUSH				
HEPARIN SODIUM (PORCINE) LOCK FLUSH SOLUTION	HEPARIN LOCK FLUSH				
ANTIDIARRHEALS					
ANTIPERISTALTIC AGENTS					
LOPERAMIDE HCL CAPSULES	LOPERAMIDE HCL				
LOPERAMIDE HCL CHEWABLE	IMODIUM A-D				
LOPERAMIDE HCL LIQUID	LOPERAMIDE HCL				
LOPERAMIDE HCL SUSPENSION	IMODIUM A-D				
LOPERAMIDE HCL TABLETS	IMODIUM A-D				
ANTIEMETICS					
ANTIEMETICS - ANTICHOLINERGIC**					
MECLIZINE HCL CHEWABLE	MECLIZINE HCL				
MECLIZINE HCL TABLETS	MECLIZINE HCL				
ANTIHISTAMINES					
ANTIHISTAMINES - ALKYLAMINES					
CHLORPHENIRAMINE MALEATE TABLETS	CHLORPHENIRAMINE MALEATE				
ANTIHISTAMINES - ETHANOLAMINES					
DIPHENHYDRAMINE HCL CAPSULES	BANOPHEN				
DIPHENHYDRAMINE HCL CHEWABLE	BENADRYL ALLERGY CHILDRENS				
DIPHENHYDRAMINE HCL ELIXIR	MEDI-PHEDRYL				
DIPHENHYDRAMINE HCL LIQUID	BANOPHEN				
DIPHENHYDRAMINE HCL STRP	TRIAMINIC COUGH & RUNNY NOSE				
DIPHENHYDRAMINE HCL SYRUP	ALTARYL				
DIPHENHYDRAMINE HCL TABLETS	ALKA-SELTZER PLUS ALLERGY FAST RELIEF FORMULA				
DIPHENHYDRAMINE HCL ORALLY DISPERSABLE TABLET	WAL-DRYL ALLERGY RELIEF CHILDRENS				
ANTIHISTAMINES - NON-SEDATING					
CETIRIZINE HCL CAPSULES	ZYRTEC ALLERGY		30	30	
CETIRIZINE HCL CHEWABLE	WAL-ZYR CHILDRENS		30	30	
CETIRIZINE HCL SYRUP	ALL DAY ALLERGY CHILDRENS		150	30	
CETIRIZINE HCL TABLETS	CETIRIZINE HCL		30	30	
CETIRIZINE HCL ORALLY DISPERSABLE TABLET	ZYRTEC ALLERGY		30	30	
FEXOFENADINE HCL SUSPENSION	ALLEGRA ALLERGY CHILDRENS		150	30	
FEXOFENADINE HCL TABLETS	ALLEGRA ALLERGY CHILDRENS		30	30	

                                    AHCCCS Fee-For-Service DUAL Eligible Members Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS DUAL Program Drug List Effective Date: 8/1/2019	

Drug Class/Drug Name	
Reference Brand Name	
PA Type	
Quantity Limit	
QL Days	
FEXOFENADINE HCL ORALLY DISPERSABLE TABLET	ALLEGRA ALLERGY CHILDRENS		30	30	
LORATADINE CAPSULES	CLARITIN		30	30	
LORATADINE CHEWABLE	CLARITIN		30	30	
LORATADINE SYRUP	CLARITIN		150	30	
LORATADINE TABLETS	ALAVERT		30	30	
LORATADINE ORALLY DISPERSABLE TABLET	CLARITIN REDITABLETS		30	30	
CONTRACEPTIVES					
EMERGENCY CONTRACEPTIVES**					
LEVONORGESTREL (EMERGENCY OC) TABLETS	AFTERA				
COUGH/COLD/ALLERGY					
COUGH/COLD/ALLERGY COMBINATIONS**					
CETIRIZINE-PSEUDOEPHEDRINE TABLET 12-HOUR	VARIOUS		30	30	
CHLORPHENIRAMINE & PSEUDOEPH CHEWABLE	VARIOUS				
CHLORPHENIRAMINE & PSEUDOEPH LIQUID	VARIOUS				
CHLORPHENIRAMINE & PSEUDOEPH SOLUTION	VARIOUS				
CHLORPHENIRAMINE & PSEUDOEPH SYRUP	VARIOUS				
CHLORPHENIRAMINE & PSEUDOEPH TABLETS	VARIOUS				
DIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN LIQUID	VARIOUS				
DIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN PACK	VARIOUS				
DIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN SUSPENSION	VARIOUS				
DIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN TABLETS	VARIOUS				
FEXOFENADINE-PSEUDOEPHEDRINE TABLET 12-HOUR	VARIOUS		30	30	
FEXOFENADINE-PSEUDOEPHEDRINE TABLET 24-HOUR	VARIOUS		30	30	
LORATADINE & PSEUDOEPHEDRINE TABLET 12-HOUR	VARIOUS		30	30	
LORATADINE & PSEUDOEPHEDRINE TABLET 24-HOUR	VARIOUS		30	30	
PHENYLEPHRINE W/ DM-GG CAPSULES	VARIOUS				
PHENYLEPHRINE W/ DM-GG LIQUID	VARIOUS				
PHENYLEPHRINE W/ DM-GG SUSPENSION	VARIOUS				
PHENYLEPHRINE W/ DM-GG SYRUP	VARIOUS				
PHENYLEPHRINE W/ DM-GG TABLETS	VARIOUS				
PHENYLEPHRINE-BROMPHENIRAMINE-DM ELIXIR	VARIOUS		480	30	
PHENYLEPHRINE-BROMPHENIRAMINE-DM LIQUID	VARIOUS		480	30	
PHENYLEPHRINE-BROMPHENIRAMINE-DM SYRUP	VARIOUS		480	30	
PHENYLEPHRINE-CHLORPHEN-DM LIQUID	VARIOUS	PA Required			
PHENYLEPHRINE-CHLORPHEN-DM SOLUTION	VARIOUS	PA Required			

                                    AHCCCS Fee-For-Service DUAL Eligible Members Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS DUAL Program Drug List Effective Date: 8/1/2019	

Drug Class/Drug Name	
Reference Brand Name	
PA Type	
Quantity Limit	
QL Days	
PHENYLEPHRINE-CHLORPHEN-DM SYRUP	VARIOUS	PA Required			
PHENYLEPHRINE-CHLORPHEN-DM TABLETS	VARIOUS	PA Required			
PHENYLEPHRINE-GUAIFENESIN CAPSULES	VARIOUS				
PHENYLEPHRINE-GUAIFENESIN LIQUID	VARIOUS				
PHENYLEPHRINE-GUAIFENESIN SYRUP	VARIOUS				
PHENYLEPHRINE-GUAIFENESIN TABLETS	VARIOUS				
PSEUDOEPHEDRINE-GUAIFENESIN CAPSULES	VARIOUS				
PSEUDOEPHEDRINE-GUAIFENESIN LIQUID	VARIOUS				
PSEUDOEPHEDRINE-GUAIFENESIN SYRUP	VARIOUS				
PSEUDOEPHEDRINE-GUAIFENESIN TABLETS	VARIOUS				
PSEUDOEPHEDRINE-GUAIFENESIN TABLET 12-HOUR	VARIOUS				
EXPECTORANTS					
GUAIFENESIN LIQUID	HERBAL EXPEC				
GUAIFENESIN PACK	MUCINEX FOR KIDS				
GUAIFENESIN SOLUTION	TRIACTIN CHEST CONGESTION				
GUAIFENESIN SYRUP	DIABETIC TUSSIN EX				
GUAIFENESIN TABLETS	GUAIFENESIN				
GUAIFENESIN TABLET 12-HOUR	EQ MUCUS ER				
DERMATOLOGICALS					
ACNE PRODUCTS					
BENZOYL PEROXIDE BAR	BENZOYL PEROXIDE				
BENZOYL PEROXIDE CREAM	NEUTROGENA ON-THE-SPOT ACNE TREATMENT				
BENZOYL PEROXIDE FOAM	CLEAN & CLEAR CONTINUOUS CONTROL ACNE CLEANSER				
BENZOYL PEROXIDE GEL	PANOXYL				
BENZOYL PEROXIDE LIQUID	ALAWAY				
BENZOYL PEROXIDE LOTION	OC8				
ANTIBIOTICS - TOPICAL					
BACITRACIN (TOPICAL) OINTMENT	BENZOYL PEROXIDE WASH ACNE TREATMENT PACK				
BACITRACIN ZINC OINTMENT	BACIGUENT				
NEOMYCIN SULFATE (TOPICAL) OINTMENT	BACITRACIN				
ANTIFUNGALS - TOPICAL					
CLOTRIMAZOLE (TOPICAL) CREAM	FUNGICURE INTENSIVE WITH NAILGUARD				
CLOTRIMAZOLE (TOPICAL) LOTION	CLOTRIMAZOLE GRX				
MICONAZOLE NITRATE (TOPICAL) SPRAY POWDER	VARIOUS				
MICONAZOLE NITRATE (TOPICAL) CREAM	VARIOUS				

                                    AHCCCS Fee-For-Service DUAL Eligible Members Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS DUAL Program Drug List Effective Date: 8/1/2019	

Drug Class/Drug Name	
Reference Brand Name	
PA Type	
Quantity Limit	
QL Days	
MICONAZOLE NITRATE (TOPICAL) OINTMENT	VARIOUS				
MICONAZOLE NITRATE (TOPICAL) POWDER	VARIOUS				
ANTIHISTAMINES-TOPICAL					
DIPHENHYDRAMINE HCL (TOPICAL) GEL	ANTI-ITCH MAXIMUM STRENGTH				
DIPHENHYDRAMINE HCL (TOPICAL) LOTION	BENADRYL ITCH STOPPING				
DIPHENHYDRAMINE HCL (TOPICAL) SOLUTION	DESENEX SHAKE POWDERER				
CORTICOSTEROIDS - TOPICAL					
HYDROCORTISONE (TOPICAL) CREAM	HYDROCORTISONE				
HYDROCORTISONE (TOPICAL) FOAM	AVEENO ANTI-ITCH MAXIMUM STRENGTH				
HYDROCORTISONE (TOPICAL) OINTMENT	HYDROCORTISONE				
EMOLLIENTS					
LACTIC ACID (AMMONIUM LACTATE) CREAM	CORTIZONE-10				
LACTIC ACID (AMMONIUM LACTATE) FOAM	GERI-HYDROLAC 12				
LACTIC ACID (AMMONIUM LACTATE) LOTION	PRO:12 MOUSSE AL12				
VITAMINS A & D (TOPICAL) OINTMENT	VARIOUS				
MISC. TOPICAL					
ZINC OXIDE (TOPICAL) OINTMENT	LICEMD COMPLETE KIT				
ZINC OXIDE (TOPICAL) PASTE	VARIOUS				
SCABICIDES & PEDICULICIDES					
PYRETHRINS-PIPERONYL BUTOXIDE FOAM	A-200 MAXIMUM STRENGTH				
PYRETHRINS-PIPERONYL BUTOXIDE KIT	VARIOUS				
PYRETHRINS-PIPERONYL BUTOXIDE LIQUID	AL12				
GASTROINTESTINAL AGENTS - MISCELLANEOUS					
ANTIFLATULENTS					
SIMETHICONE SUSPENSION	CVS INFANTS GAS RELIEF				
HEMATOPOIETIC AGENTS					
FOLIC ACID/FOLATES					
FOLIC ACID CAPSULES	FA-8				
FOLIC ACID TABLETS	FOLIC ACID				
IRON					
FERROUS FUMARATE CAPSULES	HIGH POTENCY IRON				
FERROUS FUMARATE TABLETS	FEMIRON				
FERROUS FUMARATE TABLET CONTROLLED RELEASE	IRON				
FERROUS GLUCONATE TABLETS	FERATE				
FERROUS SULFATE DRIED TABLETS	FEOSOL				

                                    AHCCCS Fee-For-Service DUAL Eligible Members Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS DUAL Program Drug List Effective Date: 8/1/2019	

Drug Class/Drug Name	
Reference Brand Name	
PA Type	
Quantity Limit	
QL Days	
FERROUS SULFATE DRIED TABLET CONTROLLED RELEASE	EQ SLOW-RELEASE IRON				
FERROUS SULFATE ELIXIR	FEROSUL				
FERROUS SULFATE LIQUID	SPATONE PUR-ABSORB IRON				
FERROUS SULFATE SOLUTION	BPROTECTED PEDIA IRON				
FERROUS SULFATE SYRUP	FERROUS SULFATE				
FERROUS SULFATE TABLETS	FERROUS SULFATE				
FERROUS SULFATE TABLET CONTROLLED RELEASE	FERROUS SULFATE				
FERROUS SULFATE TABLET ENTERIC COATED	FERROUS SULFATE				
HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENT					
ANTIHISTAMINE HYPNOTICS					
DOXYLAMINE SUCCINATE (SLEEP) TABLETS	RA NIGHT SLEEP AID				
LAXATIVES					
BULK LAXATIVES					
PSYLLIUM CAPSULES	NAT-RUL PSYLLIUM SEED HUSKS				
PSYLLIUM PACK	METAMUCIL SMOOTH TEXTURE				
PSYLLIUM POWDER	KONSYL				
PSYLLIUM WAFR	METAMUCIL				
LAXATIVE COMBINATION					
SENNOSIDES-DOCUSATE SODIUM TABLETS	SENNA-S				
LAXATIVES - MISCELLANEOUS					
POLYETHYLENE GLYCOL 3350 PACK	CLEARLAX				
POLYETHYLENE GLYCOL 3350 POWDER	CLEARLAX				
GLYCERIN (LAXATIVE) SUPPOSITORIES	GLYCERIN CHILDREN				
SALINE LAXATIVES					
SODIUM PHOSPHATES ENEMA	VARIOUS				
STIMULANT LAXATIVES					
BISACODYL ENEMA	VARIOUS				
BISACODYL SUPPOSITORY	VARIOUS				
BISACODYL TABLET ENTERIC COATED	VARIOUS				
SENNOSIDES TABLETS	VARIOUS				
SURFACTANT LAXATIVES					
DOCUSATE SODIUM CAPSULES	VARIOUS				
DOCUSATE SODIUM ENEMA	VARIOUS				
DOCUSATE SODIUM LIQUID	PEDIA-LAX				
DOCUSATE SODIUM SYRUP	DIOCTO				

                                    AHCCCS Fee-For-Service DUAL Eligible Members Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS DUAL Program Drug List Effective Date: 8/1/2019	

Drug Class/Drug Name	
Reference Brand Name	
PA Type	
Quantity Limit	
QL Days	
MEDICAL DEVICES					
CONTRACEPTIVES					
CONDOMS - FEMALE MISC	TROJAN NATURALAMB				
CONDOMS - MALE MISC	ZINC OXIDE				
CONDOMS LATEX LUBRICATED - MALE MISC	LIFESTYLES ASSORTED COLORS				
CONDOMS LATEX NON-LUBRICATED - MALE MISC	ATLAS COLORED LUBRICATED CONDOM				
CONDOMS NON-LATEX NON-LUBRICATED - MALE MISC	ATLAS COLORED CONDOM/SPERMICIDE				
MISC. DEVICES					
ALCOHOL SWABS PADS	ALCOHOL SWABS PADS				
MINERALS & ELECTROLYTES					
CALCIUM					
CALCIUM LACTATE CAPSULES	CAL-LAC				
CALCIUM LACTATE TABLETS	CALCIUM LACTATE				
MAGNESIUM					
MAGNESIUM OXIDE (MG SUPPOSITORYLEMENT) CAPSULES	MAGNESIUM				
MAGNESIUM OXIDE (MG SUPPOSITORYLEMENT) TABLETS	MAG-200				
SODIUM					
SODIUM CHLORIDE FLUSH SOLUTION	NORMAL SALINE FLUSH				
MULTIVITAMINS					
B-COMPLEX W/ C					
B COMPLEX W/ C CAPSULES	B COMPLEX/VITAMIN C				
B COMPLEX W/ C TABLETS	B COMPLEX/C				
B COMPLEX W/ C TABLET CONTROLLED RELEASE	B-COMPLEX +C				
MULTIPLE VITAMINS W/ IRON					
MULTIPLE VITAMINS W/ IRON TABLETS	MULTIPLE VITAMINS/IRON				
MULTIPLE VITAMINS W/ MINERALS					
MULTIPLE VITAMINS W/ MINERALS & FOLIC ACID SYRUP	STROVITE FORTE		30	30	
MULTIPLE VITAMINS W/ MINERALS CAPSULES	AMORYN MOOD BOOSTER		30	30	
MULTIPLE VITAMINS W/ MINERALS CHEWABLE	ADVANCED MULTI EA		30	30	
MULTIPLE VITAMINS W/ MINERALS CAPSULE CONTROLLED RELEASE	ANTIOXIDANT FORMULA SG		30	30	
MULTIPLE VITAMINS W/ MINERALS LIQUID	APATATE FORTE		30	30	
MULTIPLE VITAMINS W/ MINERALS MISC	CONCEPTIONXR MOTILITY SUPPOSITORYORT FORMULA		30	30	
MULTIPLE VITAMINS W/ MINERALS TABLETS	ABC PLUS SENIOR		30	30	
MULTIPLE VITAMINS W/ MINERALS TABLET ENTERIC COATED	VARIOUS		30	30	
PEDIATRIC MULTIPLE VITAMINS					

                                    AHCCCS Fee-For-Service DUAL Eligible Members Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS DUAL Program Drug List Effective Date: 8/1/2019	

Drug Class/Drug Name	
Reference Brand Name	
PA Type	
Quantity Limit	
QL Days	
PEDIATRIC MULTIPLE VITAMIN W/ C SOLUTION	POLY-VITE DROPS				
PED MULTIPLE VITAMINS W/ MINERALS					
PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEWABLES	CHILDRENS CHEWABLE GUMMIES				
PED MV W/ IRON					
PEDIATRIC MULTIPLE VITAMINS W/ IRON SOULTION	POLY-VITE SOL /IRON				
NASAL AGENTS - SYSTEMIC AND TOPICAL					
NASAL AGENTS - MISCELLANEOUS					
SALINE NASAL SPRAY	SALINE NASAL SPRAY				
SYMPATHOMIMETIC DECONGESTANTS					
PSEUDOEPHEDRINE HCL LIQUID	VARIOUS				
PSEUDOEPHEDRINE HCL SYRUP	VARIOUS				
PSEUDOEPHEDRINE HCL TABLETS	VARIOUS				
PSEUDOEPHEDRINE HCL TABLET 12-HOUR	VARIOUS				
PSEUDOEPHEDRINE HCL TABLET 24-HOUR	SUDAFED 24 HOUR				
OPHTHALMIC AGENTS					
ARTIFICIAL TEARS AND LUBRICANTS					
ARTIFICIAL TEAR GEL GEL	VARIOUS				
ARTIFICIAL TEAR OINTMENTMENT OINTMENT	VARIOUS				
ARTIFICIAL TEAR SOLUTION SOLUTION	VARIOUS				
CARBOXYMETHYLCELLULOSE-GLYCERIN SOLUTION	VARIOUS				
CARBOXYMETHYLCELLULOSE-HYPROMELLOSE GEL	VARIOUS				
CARBOXYMETHYLCELLULOSE SODIUM (OPHTH) SOUTION	VARIOUS				
CARBOXYMETHYLCELLULOSE SODIUM (OPHTH) GEL	VARIOUS				
HYPROMELLOSE (GONIOSCOPIC) SOLUTION	VARIOUS				
HYPROMELLOSE (OPHTH) SOSY	VARIOUS				
METHYLCELLULOSE (OPHTH) SOLUTION	VARIOUS				
POLYSORBATE 80 (OPHTH) SOLUTION	VARIOUS				
POLYVINYL ALCOHOL SOLUTION	VARIOUS				
POLYETHYLENE GLYCOL-PROPYLENE GLYCOL (OPHTH) SOLUTION	VARIOUS				
PROPYLENE GLYCOL (OPHTH) SOLUTION	VARIOUS				
OPHTHALMIC DECONGESTANTS					
HYPROMELLOSE-NAPHAZOLINE-POLYSORBATE 80-ZINC SULFATE SOLUTION	CLEAR EYES COOLING COMFORT ITCHY EYE RELIEF				
NAPHAZOLINE HCL SOLUTION	GENTEAL				
NAPHAZOLINE W/ PHENIRAMINE SOLUTION	NAPHCON-A				
NAPHAZOLINE W/ ZINC SULFATE SOLUTION	CVS REDNESS RELIEF				

                                    AHCCCS Fee-For-Service DUAL Eligible Members Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS DUAL Program Drug List Effective Date: 8/1/2019	

Drug Class/Drug Name	
Reference Brand Name	
PA Type	
Quantity Limit	
QL Days	
NAPHAZOLINE-GLYCERIN SOLUTION	CLEAR EYES REDNESS RELIEF				
NAPHAZOLINE-GLYCERIN-ZINC SULFATE SOLUTION	CLEAR EYES TRIPLE ACTION RELIEF				
NAPHAZOLINE-POLYETHYLENE GLYCOL 300 SOLUTION	CLEAR EYES COOLING COMFORT REDNESS RELIEF				
PHENYLEPHRINE HCL (OPHTH) SOLUTION	VISINE-LR				
PHENYLEPHRINE W/ ZINC SULFATE SOLUTION	VISINE-AC				
TETRAHYDROZOLINE W/ POLYETHYLENE GLYCOL SOLUTION	OPCON-A				
TETRAHYDROZOLINE W/ ZINC SULFATE SOLUTION	ADVANCED LUBRICANT				
TETRAHYDROZOLINE-DEXTRAN-POLYETHYLENE GLYCOL-POVIDONE SOLUTION	CLEAR EYES COMPLETE 7 SYMPTOM RELIEF				
TETRAHYDROZOLINE-GLYCERIN-HYPROMELLOSE-PEG 400 SOLUTION	VISINE ADVANCED RELIEF				
TETRAHYDROZOLINE-GLYCERIN-HYPROMELLOSE-PEG 400-ZINC SULFATE SOLUTION	VISINE MAXIMUM REDNESS RELIEF				
TETRAHYDROZOLINE-POLYVINYL ALCOHOL-POVIDONE SOLUTION	CLEAR EYES FOR DRY EYES PLUS REDNESS RELIEF				
OPHTHALMICS - MISC.					
KETOTIFEN FUMARATE (OPHTH) SOLUTION	VISINE TOTALITY MULTI-SYMPTOM/HYDROBLEND				
SODIUM CHLORIDE HYPERTONIC SOLUTION	VARIOUS				
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENT					
SMOKING DETERRENTS					
NICOTINE KIT	NICOTINE TRANSDERMAL SYSTEM		84	180	
NICOTINE POLACRILEX GUM	VARIOUS		540	180	
NICOTINE POLACRILEX LOZENGE	VARIOUS		540	180	
NICOTINE PATCH 24-HOUR	NICODERM CQ		84	180	
ULCER DRUGS					
H-2 ANTAGONISTS					
FAMOTIDINE CHEWABLE	PEPCID AC				
FAMOTIDINE TABLETS	PEPCID AC				
RANITIDINE HCL TABLETS	WAL-ZAN 75				
PROTON PUMP INHIBITORS					
LANSOPRAZOLE CAPSULE DELAYED RELEASE	HEARTBURN RELIEF 24 HOUR		30	30	
OMEPRAZOLE MAGNESIUM CAPSULE DELAYED RELEASE	OMEPRAZOLE MAGNESIUM		60	30	
VAGINAL PRODUCTS					
SPERMICIDES					
NONOXYNOL-9 FILM	VCF VAGINAL CONTRACEPTIVE FILM				
NONOXYNOL-9 FOAM	VCF VAGINAL CONTRACEPTIVE FOAM				
NONOXYNOL-9 GEL	SHUR-SEAL				
NONOXYNOL-9 MISC	TODAY SPONGE				
NONOXYNOL-9 SUPPOSITORY	ENCARE				

                                    AHCCCS Fee-For-Service DUAL Eligible Members Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS DUAL Program Drug List Effective Date: 8/1/2019	

Drug Class/Drug Name	
Reference Brand Name	
PA Type	
Quantity Limit	
QL Days	
VAGINAL ANTI-INFECTIVES					
CLOTRIMAZOLE VAGINAL CREAM	GYNE-LOTRIMIN				
MICONAZOLE NITRATE VAGINAL SUPPOSITORY	SM MICONAZOLE 7				
MICONAZOLE NITRATE VAGINAL KIT	MICONAZOLE 3 COMBO PACK				
VITAMINS					
OIL SOLUBLE VITAMINS					
VITAMIN E CAPSULES	VARIOUS				
VITAMIN E LIQUID	VARIOUS				
VITAMIN E OIL	VARIOUS				
VITAMIN E TABLETS	VARIOUS				
WATER SOLUBLE VITAMINS					
NIACIN CAPSULE CONTROLLED RELEASE	VARIOUS				
NIACIN TABLETS	VARIOUS				
NIACIN TABLET CONTROLLED RELEASE	VARIOUS				
PYRIDOXINE HCL CAPSULES	VARIOUS				
PYRIDOXINE HCL TABLETS	VARIOUS				
PYRIDOXINE HCL TABLET CONTROLLED RELEASE	VARIOUS				
THIAMINE HCL CAPSULES	VARIOUS				
THIAMINE HCL TABLETS	VARIOUS