Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
ADHD/ANTI-NARCOLEPSY								
AMPHETAMINES								
AMPHETAMINE-DEXTROAMPHETAMINE CAPSULE 24-HOUR	ADDERALL XR	Brand Only	Preferred Drug	PA Required for Ages < 6 years		30.00	30.00	
AMPHETAMINE-DEXTROAMPHETAMINE TABLETS	ADDERALL	Brand and Generic	Preferred Drug	PA Required for Ages < 6 years		60.00	30.00	
DEXTROAMPHETAMINE SULFATE TABLETS	VARIOUS		Preferred Drug	PA Required for Ages < 6 years		60.00	30.00	
LISDEXAMFETAMINE DIMESYLATE CAPSULES	VYVANSE	Brand Only	Preferred Drug	PA Required for Ages < 6 years		30.00	30.00	
STIMULANTS								
DEXMETHYLPHENIDATE HCL CAPSULE 24-HOUR	FOCALIN XR	Brand Only	Preferred Drug	PA Required for Ages < 6 years		60.00	30.00	
DEXMETHYLPHENIDATE HCL TABLETS	FOCALIN		Preferred Drug	PA Required for Ages < 6 years		60.00	30.00	
METHYLPHENIDATE HCL CAPSULE 24-HOUR	RITALIN LA	Brand Only	Preferred Drug	PA Required for Ages < 6 years		30.00	30.00	
METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE	VARIOUS		Preferred Drug	PA Required for Ages < 6 years		30.00	30.00	
METHYLPHENIDATE PATCH	DAYTRANA	Brand Only	Preferred Drug	PA Required for Ages < 6 years		30.00	30.00	
METHYLPHENIDATE HCL SOLUTION	METHYLIN	Brand Only	Preferred Drug	PA Required for Ages < 6 years		300.00	30.00	
METHYLPHENIDATE HCL TABLETS	VARIOUS		Preferred Drug	PA Required for Ages < 6 years		90.00	30.00	
METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE	CONCERTA ONLY	Brand Only	Preferred Drug	PA Required for Ages < 6 years		60.00	30.00	
MISCELLANEOUS AGENTS								
ATOMOXETINE HCL CAPSULES	VARIOUS		Preferred Drug	PA Required for Ages < 6 years		30.00	30.00	
CENTRAL ALPHA-AGONISTS								
CLONIDINE HCL TABLETS	CATAPRES			PA Required for Ages < 6 years				
CLONIDINE HCL TD PATCH WEEKLY	CATAPRES PATCHES			PA Required for Ages < 6 years		4	28	
CLONIDINE HCL (ADHD) TABLET 12-HOUR	CLONIDINE ER			PA Required for Ages < 6 years		120.00	30.00	
GUANFACINE HCL (ADHD) TABLET 24-HOUR	GUANFACINE ER		Preferred Drug	PA Required for Ages < 6 years		30.00	30.00	
GUANFACINE HCL TABLETS	TENEX			PA Required for Ages < 6 years				
AMINOGLYCOSIDES								
AMINOGLYCOSIDES								
NEOMYCIN SULFATE TABLETS	NEOMYCIN SULFATE							
PAROMOMYCIN SULFATE CAPSULES	PAROMOMYCIN SULFATE							
TOBRAMYCIN NEBULIZED	KITABIS AND BETHKIS	Brand Only	Preferred Drug	PA Required				
ANALGESICS - ANTI-INFLAMMATORY								
ANTIRHEUMATIC ANTIMETABOLITES								
METHOTREXATE SODIUM (ANTIRHEUMATIC) TABLETS	RHEUMATREX							
ANTIRHEUMATIC - ENZYME INHIBITORS								

TOFACITINIB CITRATE	XELJANZ IMMEDIATE
RELEASE ONLY	
Brand Only	
Preferred Drug	
PA Required				
ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES								
ADALIMUMAB	HUMIRA		Preferred Drug	PA Required				
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)								
CELECOXIB CAPSULES	CELEBREX							
DICLOFENAC SODIUM TABLET 24-HOUR	VOLTAREN-XR					30.00	30.00	
DICLOFENAC SODIUM TABLET ENTERIC COATED	DICLOFENAC SODIUM DR							
DICLOFENAC TABLET ENTERIC COATED	DICLOFENAC SODIUM EC							
ETODOLAC CAPSULES	ETODOLAC							
ETODOLAC TABLETS	ETODOLAC							
ETODOLAC TABLET 24-HOUR	ETODOLAC ER							
FENOPROFEN CALCIUM CAPSULES	NALFON							
FENOPROFEN CALCIUM TABLETS	FENOPROFEN CALCIUM							
FLURBIPROFEN TABLETS	FLURBIPROFEN							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
IBUPROFEN CAPSULES	ADVIL							
IBUPROFEN CHEWABLE TABLETS	CHILDRENS MOTRIN							
IBUPROFEN SUSPENSION	CHILDRENS MOTRIN							
IBUPROFEN TABLETS	ADVIL JUNIOR STRENGTH							
INDOMETHACIN CAPSULES	TIVORBEX							
INDOMETHACIN CAPSULE CONTROLLED RELEASE	INDOMETHACIN CR							
INDOMETHACIN SUPPOSITORY	INDOCIN							
INDOMETHACIN SUSPENSION	INDOCIN							
KETOROLAC TROMETHAMINE TABLETS	KETOROLAC TROMETHAMINE					20.00	30.00	
MEFENAMIC ACID CAPSULES	PONSTEL							
MELOXICAM SUSPENSION	MOBIC							
MELOXICAM TABLETS	MOBIC							
NABUMETONE TABLETS	NABUMETONE							
NAPROXEN SODIUM	ALEVE							
NAPROXEN SODIUM TABLETS	ANAPROX							
NAPROXEN SUSPENSION	NAPROSYN							
NAPROXEN TABLETS	NAPROSYN							
NAPROXEN TABLET ENTERIC COATED	EC-NAPROSYN							
OXAPROZIN TABLETS	DAYPRO							
PIROXICAM CAPSULES	FELDENE							
SULINDAC TABLETS	SULINDAC							
PHOSPHODIESTERASE 4 (PDE4) INHIBITORS								
APREMILAST	OTEZLA	Brand Only	Preferred Drug	PA Required				
PYRIMIDINE SYNTHESIS INHIBITORS								
LEFLUNOMIDE TABLETS	ARAVA							
SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS								
ETANERCEPT	ENBREL		Preferred Drug	PA Required				
ANALGESICS - NONNARCOTIC								
ANALGESIC COMBINATIONS								
BUTALBITAL-ACETAMINOPHEN-CAFFEINE TABLETS	VARIOIUS					120.00	30.00	
BUTALBITAL-ASPIRIN-CAFFEINE TABLETS	VARIOUS					120.00	30.00	
ANALGESICS OTHER								
ACETAMINOPHEN CAPSULES	ACETAMINOPHEN							
ACETAMINOPHEN CHEWABLE TABLETS	CHILDRENS MEDI-TABLETS							
ACETAMINOPHEN ELIXIR	MEDI-TABLETS CHILDRENS							

ACETAMINOPHEN LIQUID	LITTLE REMEDIES FOR FEVERS
FEVER/PAIN RELIEVER CHILDRENS							
ACETAMINOPHEN SOLUTION	ACETAMINOPHEN							
ACETAMINOPHEN SUPPOSITORY	FEVERALL INFANTS							
ACETAMINOPHEN SUSPENSION	TYLENOL INFANTS							

ACETAMINOPHEN SYRUP	TRIAMINIC FEVER REDUCER PAIN
RELIEVER CHILDRENS							
ACETAMINOPHEN TABLETS	MEDI-TABLETS							
ACETAMINOPHEN TABLET CONTROLLED RELEASE	TYLENOL 8 HOUR							
ACETAMINOPHEN ORALLY DISPERSABLE TABLET	MAPAP CHILDRENS							
SALICYLATES								
ASPIRIN CHEWABLE TABLETS	ST JOSEPH ADULT							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
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							
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	EMBEDA		Preferred Drug	PA Required				
MORPHINE SULFATE TABLET CONTROLLED RELEASE	MS CONTIN		Preferred Drug	PA Required				
OXYCODONE CAPSULE ER 12-HOUR ABUSE-DETERRENT	XTAMPZA ER		Preferred Drug	PA Required				
TRAMADOL HCL ER TABLET 24-HOUR	TRAMADOL HCL ER		Preferred Drug	PA Required				
SHORT-ACTING OPIOID AGONISTS								

HYDROMORPHONE HCL LIQUID	

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

HYDROMORPHONE HCL SUPPOSITORY	

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

HYDROMORPHONE HCL TABLETS	

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

MEPERIDINE HCL TABLETS	

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

MORPHINE SULFATE SOLUTION	

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

MORPHINE SULFATE SUPPOSITORY	

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

MORPHINE SULFATE TABLETS	

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

OXYCODONE HCL CAPSULES	

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

OXYCODONE HCL CONCENTRATE	

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

OXYCODONE HCL SOLUTION	

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

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	

OXYCODONE HCL TABLETS	

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

TRAMADOL HCL TABLETS	

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

ACETAMINOPHEN W/ CODEINE SOLUTION	

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

ACETAMINOPHEN W/ CODEINE TABLETS	

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

BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/ CODEINE CAPSULES	

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

BUTALBITAL-ASPIRIN-CAFFEINE W/COD CAPSULES	

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

HYDROCODONE-ACETAMINOPHEN CAPSULES	

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

HYDROCODONE-ACETAMINOPHEN SOLUTION	

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

HYDROCODONE-ACETAMINOPHEN TABLETS	

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

HYDROCODONE-IBUPROFEN TABLETS	

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

OXYCODONE W/ ACETAMINOPHEN CAPSULES	

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

OXYCODONE W/ ACETAMINOPHEN SOLUTION	

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

OXYCODONE W/ ACETAMINOPHEN TABLETS	

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

OXYCODONE-IBUPROFEN TABLETS	

OXYCODONE/IBUPROFEN			PA Required for > 2 Different Short Acting Opioid Medications in a 30-day
time period.				
OPIOID PARTIAL AGONISTS								

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	

BUPRENORPHINE VARIOUS	

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 PATCH WEEKLY	BUTRANS	Brand Only	Preferred Drug	PA Required				
BUPRENORPHINE SOLUTION PREFILLED SYRINGE	SUBLOCADE		Preferred Drug	PA Required				
BUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE FILM	SUBOXONE FILM	Brand Only	Preferred Drug					

BUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE SUBLINGUAL	
BUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE	GENERIC FORMULATIONS
ONLY	

Preferred Drug					

METHADONE	
VARIOUS			Only avaliable at an Opioid Treatment
Program (OTP) provider.				
ANDROGENS-ANABOLIC								
ANDROGENS**								
DANAZOL CAPSULES	DANAZOL							
TESTOSTERONE CYPIONATE KIT	TESTONE CIK			PA Required				
TESTOSTERONE CYPIONATE SOLUTION	DEPO-TESTOSTERONE			PA Required				
TESTOSTERONE ENANTHATE SOLUTION	TESTOSTERONE ENANTHATE			PA Required				
TESTOSTERONE GEL	ANDROGEL/TESTIM	Brand Only		PA Required				
TESTOSTERONE PATCH 24-HOUR	ANDRODERM			PA Required				
ANORECTAL AGENTS								
INTRARECTAL STEROIDS								
HYDROCORTISONE (INTRARECTAL) ENEMA	COLOCORT							
HYDROCORTISONE ACETATE (INTRARECTAL) FOAM	CORTIFOAM							
RECTAL STEROIDS								
HYDROCORTISONE (RECTAL) CREAM	PROCTOCORT							
ANTACIDS								
ANTACIDS - CALCIUM SALTS								

CALCIUM CARBONATE (ANTACID) CHEWABLE TABLETS	CHILDRENS MYLANTA UPSET
STOMACH RELIEF							
CALCIUM CARBONATE (ANTACID) TABLETS	CALCIUM CARBONATE							
ANTACIDS - BICARBONATE								
SODIUM BICARBONATE (ANTACID) TABLETS	SODIUM BICARBONATE							
ANTACID COMBINATIONS								
ALUM & MAG HYDROX-SIMETHICONE SUSPENSION	ANTACID FAST ACTING							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
ANTACIDS - MAGNESIUM SALTS								
MAGNESIUM OXIDE TABLETS	MAGNESIUM OXIDE							
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							
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.								
HYDROXYZINE HCL SYRUP	ATARAX SYRUP					300.00	30.00	
HYDROXYZINE HCL TABLETS	ATARAX TABLETS					240.00	30.00	
HYDROXYZINE PAMOATE CAPSULES	VISTARIL					120.00	30.00	

BUSPIRONE HCL TAB 5 MG	
BUSPIRONE HCL			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

BUSPIRONE HCL TAB 7.5 MG	
BUSPIRONE HCL			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

BUSPIRONE HCL TAB 10 MG	
BUSPIRONE HCL			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

BUSPIRONE HCL TAB 15 MG	
BUSPIRONE HCL			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

BUSPIRONE HCL TAB 30 MG	
BUSPIRONE HCL			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
60.00	
30.00	
BENZODIAZEPINES								

ALPRAZOLAM CONC 1 MG/ML	
ALPRAZOLAM INTENSOL			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
60.00	
15.00	

ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.25 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.5 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

ALPRAZOLAM ORALLY DISINTEGRATING TAB 1 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

ALPRAZOLAM ORALLY DISINTEGRATING TAB 2 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
60.00	
30.00	

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	

ALPRAZOLAM TAB 0.25 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

ALPRAZOLAM TAB 0.5 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

ALPRAZOLAM TAB 1 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

ALPRAZOLAM TAB 2 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
60.00	
30.00	

ALPRAZOLAM TAB SR 24HR 0.5 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
30.00	
30.00	

ALPRAZOLAM TAB SR 24HR 1 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
30.00	
30.00	

ALPRAZOLAM TAB SR 24HR 2 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
30.00	
30.00	

ALPRAZOLAM TAB SR 24HR 3 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
30.00	
30.00	

CHLORDIAZEPOXIDE HCL CAP 10 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
60.00	
30.00	

CHLORDIAZEPOXIDE HCL CAP 25 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
60.00	
30.00	

CHLORDIAZEPOXIDE HCL CAP 5 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
60.00	
30.00	
CLONAZEPAM 0.5 MG	Klonopin			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		120.00	30.00	
CLONAZEPAM 1.0 MG	Klonopin			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		120.00	30.00	
CLONAZEPAM 2 MG	Klonopin			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		60.00	30.00	
CLONAZEPAM ODT 0.125MG	VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		120.00	30.00	
CLONAZEPAM ODT 0.25MG	VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		120.00	30.00	
CLONAZEPAM ODT 0.5 MG	VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		120.00	30.00	
CLONAZEPAM ODT 1MG	VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		120.00	30.00	
CLONAZEPAM ODT 2MG	VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		60.00	30.00	

CLORAZEPATE DIPOTASSIUM TAB 15 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
60.00	
30.00	

CLORAZEPATE DIPOTASSIUM TAB 3.75 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

CLORAZEPATE DIPOTASSIUM TAB 7.5 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

DIAZEPAM CONC 5 MG/ML	
DIAZEPAM INTENSOL			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
60.00	
30.00	

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	

DIAZEPAM SOLN 1 MG/ML	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
300.00	
30.00	

DIAZEPAM TAB 10 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

DIAZEPAM TAB 2 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

DIAZEPAM TAB 5 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

LORAZEPAM CONC 2 MG/ML	
LORAZEPAM INTENSOL			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
60.00	
30.00	

LORAZEPAM TAB 0.5 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

LORAZEPAM TAB 1 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

LORAZEPAM TAB 2 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
60.00	
30.00	

OXAZEPAM CAP 10 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
60.00	
30.00	

OXAZEPAM CAP 15 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
60.00	
30.00	

OXAZEPAM CAP 30 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
60.00	
30.00	
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 NEBULIZED	CROMOLYN SODIUM							
BRONCHODILATORS - ANTICHOLINERGICS								
ACLIDINIUM BROMIDE AEROSOL SOLUTION	TUDORZA PRESSAIR		Preferred Drug					
IPRATROPIUM BROMIDE HFA AEROSOL SOLUTION	ATROVENT HFA		Preferred Drug					
IPRATROPIUM BROMIDE SOLUTION	IPRATROPIUM BROMIDE		Preferred Drug					
TIOTROPIUM BROMIDE MONOHYDRATE CAPSULES	SPIRIVA HANDIHALER		Preferred Drug					

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
LEUKOTRIENE MODULATORS								
MONTELUKAST SODIUM CHEWABLE TABLETS	SINGULAIR					30.00	30.00	
MONTELUKAST SODIUM GRANULES	SINGULAIR			PA Required for > 4 Years of Age				
MONTELUKAST SODIUM TABLETS	SINGULAIR					30.00	30.00	
STEROID INHALANTS								
BUDESONIDE (INHALATION) SUSPENSION 0.25MG/2ML,
0.5MG/2ML & 1MG/2ML	
VARIOUS		
Preferred Drug					
BUDESONIDE (INHALATION) AEROSOL 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 INHALER	
ProAir	
Brand Only	Preferred Drug Only
ProAir					
ALBUTEROL SULFATE NEBULIZED	ALBUTEROL SULFATE							
ALBUTEROL SULFATE SYRUP	ALBUTEROL SULFATE							
BUDESONIDE-FORMOTEROL FUMARATE DIHYDRATE INHALER	SYMBICORT	Brand Ony	Preferred Drug					

FLUTICASONE-SALMETEROL ORAL INHALATION	
ADVAIR DISKUS	
Brand Only	
Preferred Drug					
FLUTICASONE-SALMETEROL INHALER	ADVAIR HFA	Brand Only	Preferred Drug					
IPRATROPIUM-ALBUTEROL INHALER	COMBIVENT		Preferred Drug					
IPRATROPIUM-ALBUTEROL AEROSOL SOLUTION	COMBIVENT RESPIMAT		Preferred Drug					
IPRATROPIUM-ALBUTEROL SOLUTION	DUONEB		Preferred Drug					
MOMETASONE FUROATE-FORMOTEROL FUMARATE DIHYDRATE
INHALER	
DULERA	
Brand Only	
Preferred Drug					
SALMETEROL XINAFOATE INHALER BREATH ACTIVATED	SEREVENT DISKUS		Preferred Drug	PA Required				
TIOTROPIUM BROMIDE-OLODATEROL HCL AEROSOL SOLUTION	STIOLTO RESPIMAT		Preferred Drug	PA Required		1.00	30.00	
UMECLIDINIUM-VILANTEROL AEROSOL POWDER	ANORO ELLIPT A		Preferred Drug	PA Required		1.00	30.00	
XANTHINES								
THEOPHYLLINE CAPSULE 24-HOUR	THEO-24							
THEOPHYLLINE ELIXIR	ELIXIROPHYLLIN							
THEOPHYLLINE SOLUTION	THEOPHYLLINE							
THEOPHYLLINE TABLET 12-HOUR	THEOCHRON							
THEOPHYLLINE TABLET 24-HOUR	THEOPHYLLINE ER							
ANTICOAGULANTS								
COUMARIN ANTICOAGULANTS								
WARFARIN SODIUM TABLETS	COUMADIN							
DIRECT FACTOR XA INHIBITORS								
APIXABAN TABLETS	ELIQUIS	Brand Only	Preferred Drug			60.00	30.00	
APIXABAN TABLETS STARTER PACK	ELIQUIS STARTER PACK	Brand Only	Preferred Drug			74.00	365.00	
RIVAROXABAN TABLETS	XARELTO	Brand Only	Preferred Drug			60.00	30.00	
RIVAROXABAN TABLETS THERAPY PACK	XARELTO STARTER PACK	Brand Only	Preferred Drug			51.00	30.00	
HEPARINS AND HEPARINOID-LIKE AGENTS								
ENOXAPARIN SODIUM INJ 100 MG/ML	VARIOUS		Preferred Drug			60.00	30.00	
ENOXAPARIN SODIUM INJ 120 MG/0.8ML	VARIOUS		Preferred Drug			60.00	30.00	
ENOXAPARIN SODIUM INJ 150 MG/ML	VARIOUS		Preferred Drug			60.00	30.00	
ENOXAPARIN SODIUM INJ 30 MG/0.3ML	VARIOUS		Preferred Drug			60.00	30.00	

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
ENOXAPARIN SODIUM INJ 300 MG/3ML	VARIOUS		Preferred Drug			60.00	30.00	
ENOXAPARIN SODIUM INJ 40 MG/0.4ML	VARIOUS		Preferred Drug			60.00	30.00	
ENOXAPARIN SODIUM INJ 60 MG/0.6ML	VARIOUS		Preferred Drug			60.00	30.00	
ENOXAPARIN SODIUM INJ 80 MG/0.8ML	VARIOUS		Preferred Drug			60.00	30.00	
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								
DABIGATRAN ETEXILATE MESYLATE CAPSULES	PRADAXA	Brand Only	Preferred Drug			60.00	30.00	
ANTICONVULSANTS								
ANTICONVULSANTS - BENZODIAZEPINES								
CLOBAZAM SUSPENSION	ONFI			PA Required				
CLOBAZAM TABLETS	ONFI			PA Required				

CLONAZEPAM TAB 0.5 MG	
KLONOPIN			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

CLONAZEPAM TAB 1 MG	
KLONOPIN			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

CLONAZEPAM TAB 2 MG	
KLONOPIN			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
60.00	
30.00	

CLONAZEPAM ORALLY DISINTEGRATING TAB 0.125 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

CLONAZEPAM ORALLY DISINTEGRATING TAB 0.25 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

CLONAZEPAM ORALLY DISINTEGRATING TAB 0.5 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

CLONAZEPAM ORALLY DISINTEGRATING TAB 1 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
120.00	
30.00	

CLONAZEPAM ORALLY DISINTEGRATING TAB 2 MG	
VARIOUS			PA Required for > 1 Anxiolytic
Medication in a 30-day time period.		
60.00	
30.00	
DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG	DIASTAT					2.00	30.00	
DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG	DIASTAT					2.00	30.00	
DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG	DIASTAT					2.00	30.00	
ANTICONVULSANTS - MISC.								
CARBAMAZEPINE (ANTIPSYCHOTIC) CAPSULE 12-HOUR	EQUETRO							
CARBAMAZEPINE CHEWABLE TABLETS	CARBAMAZEPINE							
CARBAMAZEPINE CAPSULE 12-HOUR	CARBATROL							
CARBAMAZEPINE SUSPENSION	TEGRETOL							
CARBAMAZEPINE TABLETS	EPITOL							
CARBAMAZEPINE TABLET 12-HOUR	TEGRETOL-XR							
EZOGABINE TABLETS	POTIGA			PA Required				
GABAPENTIN CAPSULES	NEURONTIN							
GABAPENTIN SOLUTION	NEURONTIN							
GABAPENTIN TABLETS	NEURONTIN							
GABAPENTIN (ONCE-DAILY) TABLETS	GRALISE			PA Required				
GABAPENTIN ENACARBIL TABLET CONTROLLED RELEASE	HORIZANT			PA Required				
LACOSAMIDE SOLUTION	VIMPAT			PA Required				

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
LACOSAMIDE TABLETS	VIMPAT			PA Required				
LAMOTRIGINE CHEWABLE TABLETS	LAMICTAL							

LAMOTRIGINE KIT	LAMICTAL STARTER/TAKING
VALPROATE							
LAMOTRIGINE TABLETS	LAMICTAL							
LAMOTRIGINE TABLET 24-HOUR	LAMICTAL XR							
LAMOTRIGINE ORALLY DISPERSABLE TABLET	LAMICTAL ODT							
LEVETIRACETAM SOLUTION	KEPPRA							
LEVETIRACETAM TABLETS	KEPPRA							
LEVETIRACETAM TABLET 24-HOUR	KEPPRA XR							
OXCARBAZEPINE SUSPENSION	TRILEPTAL							
OXCARBAZEPINE TABLETS	TRILEPTAL							
OXCARBAZEPINE TABLET 24-HOUR	OXTELLAR XR							
PREGABALIN CAPSULES (25MG, 50MG, 75MG, 100MG, 150MG,
200MG)	
LYRICA					
90.00	
30.00	
PREGABALIN CAPSULES (225MG, 300MG)	LYRICA					60.00	30.00	
PREGABALIN SOLUTION	LYRICA					900.00	30.00	
PRIMIDONE TABLETS	MYSOLINE							
RUFINAMIDE SUSPENSION	BANZEL			PA Required				
RUFINAMIDE TABLETS	BANZEL			PA Required				
TOPIRAMATE CAPSULE 24-HOUR	TROKENDI XR							
TOPIRAMATE SPRINKLE CAPSULES	TOPAMAX SPRINKLE							
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							
VALPROIC ACID CAPSULES	DEPAKENE							
VALPROIC ACID CAPSULE DELAYED RELEASE	STAVZOR							
ANTIDEPRESSANTS								
ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)								
MIRTAZAPINE TABLETS	REMERON			PA Required for Ages < 6 years		30.00	30.00	
MIRTAZAPINE ORALLY DISPERSABLE TABLET	REMERON SOLTAB			PA Required for Ages < 6 years		30.00	30.00	

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
N-METHYL-D-ASPARTIC ACID (NMDA) RECEPTOR ANTAGONISTS								
ESKETAMINE HCL SOLUTION	SPRAVATO			PA Required				
NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIBITORS (NDRIS)								
BUPROPION HCL TABLETS	WELLBUTRIN			PA Required for Ages < 6 years		120.00	30.00	
BUPROPION HCL TABLET 12-HOUR	BUDEPRION SR			PA Required for Ages < 6 years		60.00	30.00	
BUPROPION HCL TABLET 24-HOUR (150MG and 300MG)	WELLBUTRIN XL			PA Required for Ages < 6 years		30.00	30.00	
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)								

CITALOPRAM HYDROBROMIDE SOLUTION	
CELEXA			PA Required for Ages < 6 years and for >
the age of 12 years of age		
600.00	
30.00	
CITALOPRAM HYDROBROMIDE TABLETS 10MG	CELEXA			PA Required for Ages < 6 years		60.00	30.00	
CITALOPRAM HYDROBROMIDE TABLETS 20MG	CELEXA			PA Required for Ages < 6 years		30.00	30.00	
CITALOPRAM HYDROBROMIDE TABLETS 40MG	CELEXA			PA Required for Ages < 6 years		30.00	30.00	
ESCITALOPRAM OXALATE TABLETS 5MG	LEXAPRO			PA Required for Ages < 6 years		60.00	30.00	
ESCITALOPRAM OXALATE TABLETS 10MG	LEXAPRO			PA Required for Ages < 6 years		30.00	30.00	
ESCITALOPRAM OXALATE TABLETS 20MG	LEXAPRO			PA Required for Ages < 6 years		30.00	30.00	
FLUOXETINE HCL CAPSULES ONLY 10MG	PROZAC			PA Required for Ages < 6 years		60.00	30.00	
FLUOXETINE HCL CAPSULES ONLY 20MG	PROZAC			PA Required for Ages < 6 years		120.00	30.00	
FLUOXETINE HCL CAPSULES ONLY 40MG	PROZAC			PA Required for Ages < 6 years		60.00	30.00	

FLUOXETINE HCL SOLUTION	
FLUOXETINE HCL			PA Required for Ages < 6 years and for >
the age of 12 years of age		
600.00	
30.00	
FLUVOXAMINE MALEATE TABLETS 25MG	LUVOX			PA Required for Ages < 6 years		60.00	30.00	
FLUVOXAMINE MALEATE TABLETS 50MG	LUVOX			PA Required for Ages < 6 years		180.00	30.00	
FLUVOXAMINE MALEATE TABLETS 100MG	LUVOX			PA Required for Ages < 6 years		90.00	30.00	
PAROXETINE HCL TABLETS 10MG	PAXIL			PA Required for Ages < 6 years		30.00	30.00	
PAROXETINE HCL TABLETS 20MG	PAXIL			PA Required for Ages < 6 years		30.00	30.00	
PAROXETINE HCL TABLETS 30MG	PAXIL			PA Required for Ages < 6 years		30.00	30.00	
PAROXETINE HCL TABLETS 40MG	PAXIL			PA Required for Ages < 6 years		45.00	30.00	

SERTRALINE HCL CONCENTRATE	
ZOLOFT			PA Required for Ages < 6 years and for >
the age of 12 years of age		
300.00	
30.00	
SERTRALINE HCL TABLETS 25MG	ZOLOFT			PA Required for Ages < 6 years		90.00	30.00	
SERTRALINE HCL TABLETS 50MG	ZOLOFT			PA Required for Ages < 6 years		120.00	30.00	
SERTRALINE HCL TABLETS 100MG	ZOLOFT			PA Required for Ages < 6 years		60.00	30.00	
SEROTONIN MODULATORS								
TRAZODONE HCL TABLETS 50MG	TRAZODONE HCL			PA Required for Ages < 6 years		90.00	30.00	
TRAZODONE HCL TABLETS 100MG	TRAZODONE HCL			PA Required for Ages < 6 years		120.00	30.00	
TRAZODONE HCL TABLETS 150MG	TRAZODONE HCL			PA Required for Ages < 6 years		60.00	30.00	
TRAZODONE HCL TABLETS 300MG	TRAZODONE HCL			PA Required for Ages < 6 years		30.00	30.00	
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRI)								
DULOXETINE HCL CAPSULE DELAYED RELEASE 20MG	CYMBALTA			PA Required for Ages < 6 years		120.00	30.00	
DULOXETINE HCL CAPSULE DELAYED RELEASE 30MG	CYMBALTA			PA Required for Ages < 6 years		120.00	30.00	
DULOXETINE HCL CAPSULE DELAYED RELEASE 60MG	CYMBALTA			PA Required for Ages < 6 years		60.00	30.00	

VENLAFAXINE HCL CONTROLLED RELEASE - CAPSULES ONLY 37.5MG	
EFFEXOR XR			
PA Required for Ages < 6 years		
90.00	
30.00	
VENLAFAXINE HCL CONTROLLED RELEASE - CAPSULES ONLY 75MG	EFFEXOR XR			PA Required for Ages < 6 years		90.00	30.00	

VENLAFAXINE HCL CONTROLLED RELEASE - CAPSULES ONLY 150MG	
EFFEXOR XR			
PA Required for Ages < 6 years		
30.00	
30.00	

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 25MG-
TABLETS ONLY	
VENLAFAXINE HCL			
PA Required for Ages < 6 years		
120.00	
30.00	
VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 37.5MG-
TABLETS ONLY	
VENLAFAXINE HCL			
PA Required for Ages < 6 years		
90.00	
30.00	
VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 50MG-
TABLETS ONLY	
VENLAFAXINE HCL			
PA Required for Ages < 6 years		
90.00	
30.00	
VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 75MG-
TABLETS ONLY	
VENLAFAXINE HCL			
PA Required for Ages < 6 years		
150.00	
30.00	
VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 100MG-
TABLETS ONLY	
VENLAFAXINE HCL			
PA Required for Ages < 6 years		
90.00	
30.00	
TRICYCLIC AGENTS								
AMITRIPTYLINE HCL TABLETS	AMITRIPTYLINE HCL			PA Required for Ages < 6 years				
AMOXAPINE TABLETS	VARIOUS			PA Required for ages < 6 years				
CLOMIPRAMINE HCL CAPSULES	ANAFRANIL			PA Required for Ages < 6 years				
DESIPRAMINE HCL TABLETS	NORPRAMIN			PA Required for Ages < 6 years				
DOXEPIN HCL CAPSULES	DOXEPIN HCL			PA Required for Ages < 6 years		90.00	30.00	
DOXEPIN HCL CONCENTRATE	DOXEPIN HCL			PA Required for Ages < 6 years		180.00	30.00	
IMIPRAMINE HCL TABLETS	TOFRANIL			PA Required for Ages < 6 years				
IMIPRAMINE PAMOATE CAPSULES	TOFRANIL-PM			PA Required for Ages < 6 years		30.00	30.00	
NORTRIPTYLINE HCL CAPSULES	PAMELOR			PA Required for Ages < 6 years				
NORTRIPTYLINE HCL SOLUTION	NORTRIPTYLINE HCL			PA Required for Ages < 6 years				
PROTRIPTYLINE HCL TABLETS	VIVACTIL			PA Required for Ages < 6 years				
TRIMIPRAMINE MALEATE	SURMONTIL			PA Required for Ages < 6 years				
ANTIDIABETICS								
ALPHA-GLUCOSIDASE INHIBITORS								
ACARBOSE TABLETS	PRECOSE							
ANTIDIABETIC - AMYLIN ANALOGS								
PRAMLINTIDE ACETATE SOLUTION PEN INJECTION	SYMLINPEN 60		Preferred Drug	PA Required				
ANTIDIABETIC COMBINATIONS								
ALOGLIPTIN-METFORMIN HCL TABLETS	KAZANO	Brand Only	Preferred Drug					
ALOGLIPTIN-PIOGLITAZONE TABLETS	OSENI	Brand Only	Preferred Drug					
CANAGLIFLOZIN-METFORMIN HCL	INVOKAMET	Brand Only	Preferred Drug	PA Required				
DAPAGLIFLOZIN - METFORMIN	XIGDUO XR	Brand Only	Preferred Drug	PA Required				
EMPAGLIFLOZIN-LINAGLIPTIN TABLETS	GLYXAMBI	Brand Only	Preferred Drug					
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		Preferred Drug					
LINAGLIPTIN-METFORMIN HCL TABLETS	JENTADUETO	Brand Only	Preferred Drug					
LINAGLIPTIN-METFORMIN HCL TABLET 24-HOUR	JENTADUETO XR	Brand Only	Preferred Drug					
PIOGLITAZONE HCL-METFORMIN HCL TABLETS	ACTOPLUS MET		Preferred Drug					
PIOGLITAZONE HCL-METFORMIN HCL TABLET 24-HOUR	ACTOPLUS MET XR		Preferred Drug					
SAXAGLIPTIN-METFORMIN HCL TABLETS	KOMBIGLYZE XR	Brand Only	Preferred Drug					
SITAGLIPTIN-METFORMIN HCL TABLETS	JANUMET	Brand Only	Preferred Drug					
SITAGLIPTIN-METFORMIN HCL TABLET 24-HOUR	JANUMET XR	Brand Only	Preferred Drug					
BIGUANIDES								
METFORMIN HCL TABLETS	GLUCOPHAGE							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	

METFORMIN HCL TABLET 24-HOUR (GENERIC OF GLUCOPHAGE XR ONLY- 500MG & 750MG)	Various
GENERIC OF GLUCOPHAGE XR ONLY- 500MG & 750MG			
PA Required for Osmotic and Modified Release Products				
DIABETIC OTHER								
DIAZOXIDE SUSPENSION	PROGLYCEM	Brand Only	Preferred Drug					
GLUCAGON (RDNA) KIT	GLUCAGON EMERGENCY KIT	Brand by Lilly				2.00	30.00	
GLUCAGON HCL (RDNA) SOLUTION	GLUCAGEN HYPOKIT					2.00	30.00	
MIFEPRISTONE (HYPERGLYCEMIA) TABLETS	KORLYM			PA Required				
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS								
ALOGLIPTIN BENZOATE TABLETS	NESINA	Brand Only	Preferred Drug					
LINAGLIPTIN TABLETS	TRADJENTA	Brand Only	Preferred Drug					
SAXAGLIPTIN HCL TABLETS	ONGLYZA	Brand Only	Preferred Drug					
SITAGLIPTIN PHOSPHATE TABLETS	JANUVIA	Brand Only	Preferred Drug					
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				
LIRAGLUTIDE SOLUTION PEN INJECTION	VICTOZA		Preferred Drug	PA Required				
INSULIN SENSITIZING AGENTS								
PIOGLITAZONE HCL TABLETS	ACTOS							
INSULIN								

INSULIN ASPART SOLUTION	
NOVOLOG	Authorized Generic
Only	
Preferred Drug					

INSULIN ASPART SOCT	
NOVOLOG PENFILL	Authorized Generic
Only	
Preferred Drug					

INSULIN ASPART SOLUTION PEN INJECTION	
NOVOLOG FLEXPEN	Authorized Generic
Only	
Preferred Drug					
INSULIN ASPART PROTAMINE & ASPART (HUMAN) SUSPENSION
(70/30)	
NOVOLOG MIX 70/30	Authorized Generic
Only	
Preferred Drug					
INSULIN ASPART PROTAMINE & ASPART (HUMAN) SUSPENSION
PEN INJECTION (70/30)	NOVOLOG MIX 70/30 PREFILLED
FLEXPEN	Authorized Generic
Only	
Preferred Drug					
INSULIN DETEMIR SOLUTION	LEVEMIR	Brand Only	Preferred Drug					
INSULIN DETEMIR SOLUTION PEN INJECTION	LEVEMIR FLEXPEN	Brand Only	Preferred Drug					
INSULIN GLARGINE SOLUTION	LANTUS	Brand Only	Preferred Drug					
INSULIN GLARGINE SOLUTION PEN INJECTION	LANTUS SOLOSTAR	Brand Only	Preferred Drug					

INSULIN LISPRO (HUMAN) SOLUTION	
HUMALOG	Authorized Generic
Only	
Preferred Drug					
INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION (75-
25)	
HUMALOG MIX 75/25	Authorized Generic
Only	
Preferred Drug					

INSULIN LISPRO (HUMAN) SOLUTION PEN INJECTION 100/ML	
HUMALOG JUNIOR KWIKPEN	Authorized Generic
Only	
Preferred Drug					

INSULIN LISPRO (HUMAN) SOLUTION PEN INJECTION 100/ML	
HUMALOG KWIKPEN	Authorized Generic
Only	
Preferred Drug					
INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION PEN
INJECTION (75-25)	
HUMALOG MIX 75/25 KWIKPEN	Authorized Generic
Only	
Preferred Drug					
INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION PEN
INJECTION (50-50)	
HUMALOG MIX 50/50 KWIKPEN	
Brand Only	
Preferred Drug					
INSULIN NPH (HUMAN) (ISOPHANE) SUSPENSION	HUMULIN N	Brand Only	Preferred Drug					

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
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	Brand Only	Preferred Drug					

INSULIN REGULAR (HUMAN) SOLUTION	
HUMULIN R U-500 (CONCENTRATED)	
Brand Only	
Preferred Drug	
PA Required				
INSULIN REGULAR (HUMAN) SOLUTION PEN INJECTION	HUMULIN R U-500 KWIKPEN	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				
SULFONYLUREAS								
CHLORPROPAMIDE TABLETS	CHLORPROPAMIDE							
GLIMEPIRIDE TABLETS	AMARYL							
GLIPIZIDE TABLETS	GLUCOTROL							
GLIPIZIDE TABLET 24-HOUR	GLIPIZIDE XL							
GLYBURIDE MICRONIZED TABLETS	GLYNASE							
GLYBURIDE TABLETS	DIABETA							
TOLAZAMIDE TABLETS	TOLAZAMIDE							
TOLBUTAMIDE TABLETS	TOLBUTAMIDE							
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					
NALTREXONE HCL TABLETS	NALTREXONE HCL		Preferred Drug					
NALTREXONE SUSPENSION	VIVITROL		Preferred Drug					
ANTIEMETICS								
5-HT3 RECEPTOR ANTAGONISTS								
DOLASETRON MESYLATE TABLETS	ANZEMET			PA Required				
GRANISETRON HCL SOLUTION	GRANISOL			PA Required				
GRANISETRON HCL TABLETS	GRANISETRON HCL			PA Required				
ONDANSETRON HCL SOLUTION	ZOFRAN					150.00	30.00	
ONDANSETRON HCL TABLETS	ZOFRAN					30.00	30.00	
ONDANSETRON ORALLY DISPERSABLE TABLET	ZOFRAN ODT					30.00	30.00	
ANTIEMETICS - ANTICHOLINERGIC								
MECLIZINE HCL CHEWABLE TABLETS	MECLIZINE HCL							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
MECLIZINE HCL TABLETS	MECLIZINE HCL							
TRIMETHOBENZAMIDE HCL CAPSULES	TIGAN							
TRIMETHOBENZAMIDE HCL SOLUTION	TIGAN							
ANTIEMETICS - MISCELLANEOUS								
DRONABINOL CAPSULES	MARINOL			PA Required				
DOXYLAMINE-PYRIDOXINE CAPSULES								
PROCHLORPERAZINE MALEATE TABLETS	COMPAZINE							
PROCHLORPERAZINE SUPPOSITORY	COMPAZINE							
SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONIST								
APREPITANT CAPSULES	EMEND					6.00	21.00	
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					90.00	365.00	
IMIDAZOLE-RELATED ANTIFUNGALS								
FLUCONAZOLE SUSPENSION	DIFLUCAN					600.00	30.00	
FLUCONAZOLE TABLETS	DIFLUCAN					60.00	30.00	
ANTIHISTAMINES								
ANTIHISTAMINES - ALKYLAMINES								
BROMPHENIRAMINE MALEATE	J-TAN PD							
CHLORPHENIRAMINE MALEATE TABLETS	CHLORPHENIRAMINE MALEATE							
DEXCHLORPHENIRAMINE MALEATE SYRUP	DEXCHLORPHENIRAMINE MALEATE							
ANTIHISTAMINES - ETHANOLAMINES								
CLEMASTINE FUMARATE SYRUP	CLEMASTINE FUMARATE							
CLEMASTINE FUMARATE TABLETS	CLEMASTINE FUMARATE							
DIPHENHYDRAMINE HCL CAPSULES	BANOPHEN							
DIPHENHYDRAMINE HCL CHEWABLE TABLETS	BENADRYL ALLERGY CHILDRENS							
DIPHENHYDRAMINE HCL ELIXIR	MEDI-PHEDRYL							
DIPHENHYDRAMINE HCL LIQUID	BANOPHEN							
DIPHENHYDRAMINE HCL SOLUTION	DIPHENHYDRAMINE HCL							
DIPHENHYDRAMINE HCL STRP	TRIAMINIC COUGH & RUNNY NOSE							
DIPHENHYDRAMINE HCL SUSPENSION	DICOPANOL FUSEPAQ							
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					30.00	30.00	
CETIRIZINE HCL CHEWABLE TABLETS	WAL-ZYR CHILDRENS					30.00	30.00	
CETIRIZINE HCL SYRUP	ALL DAY ALLERGY CHILDRENS					150.00	30.00	
CETIRIZINE HCL TABLETS	CETIRIZINE HCL					30.00	30.00	
CETIRIZINE HCL ORALLY DISPERSABLE TABLET	ZYRTEC ALLERGY					30.00	30.00	

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
FEXOFENADINE HCL SUSPENSION	ALLEGRA ALLERGY CHILDRENS					150.00	30.00	
FEXOFENADINE HCL TABLETS	ALLEGRA ALLERGY CHILDRENS					30.00	30.00	
FEXOFENADINE HCL ORALLY DISPERSABLE TABLET	ALLEGRA ALLERGY CHILDRENS					30.00	30.00	
LORATADINE CAPSULES	CLARITIN					30.00	30.00	
LORATADINE CHEWABLE TABLETS	CLARITIN					30.00	30.00	
LORATADINE SYRUP	CLARITIN					150.00	30.00	
LORATADINE TABLETS	ALAVERT					30.00	30.00	
LORATADINE ORALLY DISPERSABLE TABLET	CLARITIN REDITABLETS					30.00	30.00	
ANTIHISTAMINES - PHENOTHIAZINES								
PROMETHAZINE HCL SOLUTION	PROMETHAZINE HCL							
PROMETHAZINE HCL SUPPOSITORY	PHENADOZ							
PROMETHAZINE HCL TABLETS	PROMETHAZINE HCL							
ANTIHISTAMINES - PIPERIDINES								
CYPROHEPTADINE HCL SYRUP	CYPROHEPTADINE HCL							
CYPROHEPTADINE HCL TABLETS	CYPROHEPTADINE HCL							
ANTIHYPERLIPIDEMICS								
BILE ACID SEQUESTRANTS								
CHOLESTYRAMINE LIGHT PACK	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							
FENOFIBRIC ACID TABLETS	FIBRICOR							
GEMFIBROZIL TABLETS	LOPID							
HMG COA REDUCTASE INHIBITORS								
ATORVASTATIN CALCIUM TABLETS	LIPITOR					30.00	30.00	
LOVASTATIN TABLETS	LOVASTATIN					30.00	30.00	
PRAVASTATIN SODIUM TABLETS	PRAVASTATIN SODIUM					30.00	30.00	
ROSUVASTATIN CALCIUM TABLETS	CRESTOR					30.00	30.00	
SIMVASTATIN TABLETS	ZOCOR					30.00	30.00	
INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS								
EZETIMIBE TABLETS	ZETIA							
NICOTINIC ACID DERIVATIVES								
NIACIN CAPSULE CONTROLLED RELEASE	VARIOUS							
NIACIN TABLET CONTROLLED RELEASE	VARIOUS							
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							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
PERINDOPRIL ERBUMINE TABLETS	PERINDOPRIL ERBUMINE							
QUINAPRIL HCL TABLETS	ACCUPRIL							
RAMIPRIL CAPSULES	ALTACE							
TRANDOLAPRIL TABLETS	MAVIK							
ANGIOTENSIN II RECEPTOR ANTAGONISTS								
IRBESARTAN TABLETS	AVAPRO							
LOSARTAN POTASSIUM TABLETS	COZAAR							

OLMESARTAN MEDOXOMIL TABLETS	
BENICAR			
Step Therapy	Patient must have tried Irbesartan & Losartan			
VALSARTAN TABLETS	DIOVAN							
ANTIADRENERGIC ANTIHYPERTENSIVES								
CLONIDINE HCL PATCH WEEKLY	CATAPRES-TTS			PA Required for Ages < 6 years		4.00	28.00	
CLONIDINE HCL TABLETS	CATAPRES			PA Required for Ages < 6 years				
DOXAZOSIN MESYLATE TABLETS	CARDURA							
GUANFACINE HCL TABLETS	TENEX			PA Required for Ages < 6 years				
METHYLDOPA TABLETS	METHYLDOPA							
PRAZOSIN HCL CAPSULES	MINIPRESS							
TERAZOSIN HCL CAPSULES	TERAZOSIN HCL							
ANTIHYPERTENSIVE COMBINATIONS								
ATENOLOL & CHLORTHALIDONE TABLETS	VARIOUS							
BISOPROLOL & HYDROCHLOROTHIAZIDE TABLETS	ZIAC							

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							
METOPROLOL & HYDROCHLOROTHIAZIDE TABLETS	LOPRESSOR HCT							
MOEXIPRIL-HYDROCHLOROTHIAZIDE TABLETS	UNIRETIC							
OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TABLETS	BENICAR HCT							

PROPRANOLOL & HYDROCHLOROTHIAZIDE TABLETS	PROPRANOLOL/HYDROCHLOROTHIAZI
DE							
QUINAPRIL-HYDROCHLOROTHIAZIDE TABLETS	ACCURETIC							
VALSARTAN-HYDROCHLOROTHIAZIDE TABLETS	DIOVAN HCT							
DIRECT RENIN INHIBITORS								
ALISKIREN FUMARATE TABLETS	TEKTURNA			PA Required				
SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)								
EPLERENONE TABLETS	INSPRA			PA Required				
VASODILATORS								
HYDRALAZINE HCL TABLETS	HYDRALAZINE HCL							
MINOXIDIL TABLETS	MINOXIDIL							
ANTI-INFECTIVE AGENTS - MISC.								
ANTI-INFECTIVE AGENTS - MISC.								
METRONIDAZOLE CAPSULES	FLAGYL							
METRONIDAZOLE TABLETS	FLAGYL							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
RIFAXIMIN TABLETS	XIFAXAN							
TRIMETHOPRIM TABLETS	TRIMETHOPRIM							
VANCOMYCIN HCL CAPSULES	VANCOCIN HCL			PA Required				
VANCOMYCIN HCL SOLUTION	FIRST-VANCOMYCIN 25			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							
LINCOSAMIDES								
CLINDAMYCIN HCL CAPSULES	CLEOCIN							
CLINDAMYCIN PALMITATE HYDROCHLORIDE SOLUTION	CLEOCIN PEDIATRIC GRANULES							
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							
PYRIMETHAMINE TABLETS	DARAPRIM							
QUININE SULFATE CAPSULES	QUALAQUIN							
ANTIMYASTHENIC/CHOLINERGIC AGENTS								
ANTIMYASTHENIC/CHOLINERGIC AGENTS								
PYRIDOSTIGMINE BROMIDE SYRUP	MESTINON							
PYRIDOSTIGMINE BROMIDE TABLETS	MESTINON							
PYRIDOSTIGMINE BROMIDE TABLET CONTROLLED RELEASE	MESTINON TIMESPAN							
ANTIMYCOBACTERIAL AGENTS								
ANTI TB COMBINATIONS								
ISONIAZID & RIFAMPIN CAPSULES	RIFAMATE							
ANTIMYCOBACTERIAL AGENTS								
ETHAMBUTOL HCL TABLETS	MYAMBUTOL							
ISONIAZID SYRUP	ISONIAZID							
ISONIAZID TABLETS	ISONIAZID							
PYRAZINAMIDE TABLETS	PYRAZINAMIDE							
RIFAMPIN CAPSULES	RIFADIN							
ONCOLOGY -FEDERALLY REIMBURSABLE ANTINEOPLASTIC AGENTS,NOT LISTED BELOW, ARE AVAILABLE THROUGH PRIOR
AUTHORIZATION								
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES								
ALKYLATING AGENTS								
ALTRETAMINE CAPSULES	HEXALEN			PA Required				
CYCLOPHOSPHAMIDE CAPSULES	CYCLOPHOSPHAMIDE							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
CYCLOPHOSPHAMIDE TABLETS	CYCLOPHOSPHAMIDE							
LOMUSTINE CAPSULES	CEENU							
MELPHALAN TABLETS	ALKERAN	Brand Only		PA Required				
TEMOZOLOMIDE CAPSULES	TEMODAR			PA Required				
ANTIMETABOLITES								
MERCAPTOPURINE TABLETS	VARIOUS							
METHOTREXATE SODIUM TABLETS	METHOTREXATE							
ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS								
VISMODEGIB CAPSULES	ERIVEDGE			PA Required				
ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS								
ABIRATERONE ACETATE TABLETS	ZYTIGA			PA Required				
ANASTROZOLE TABLETS	ARIMIDEX			PA Required				
BICALUTAMIDE TABLETS	CASODEX							
DEGARELIXIR ACETATE SOLUTION	FIRMAGON			PA Required				
ESTRAMUSTINE PHOSPHATE SODIUM CAPSULES	EMCYT			PA Required				
EXEMESTANE TABLETS	AROMASIN			PA Required				
FLUTAMIDE CAPSULES	FLUTAMIDE							
LETROZOLE TABLETS	FEMARA			PA Required				
LEUPROLIDE ACETATE (3 MONTH) KIT	LUPRON DEPOT			PA Required				
LEUPROLIDE ACETATE (4 MONTH) KIT	LUPRON DEPOT			PA Required				
LEUPROLIDE ACETATE (6 MONTH) KIT	ELIGARD			PA Required				
LEUPROLIDE ACETATE KIT	LUPRON DEPOT			PA Required				
MEGESTROL ACETATE SUSPENSION	MEGACE ORAL							
MEGESTROL ACETATE TABLETS	MEGESTROL ACETATE							
MITOTANE TABLETS	LYSODREN							
NILUTAMIDE TABLETS	NILANDRON					60.00	30.00	
TAMOXIFEN CITRATE SOLUTION	SOLTAMOX							
TAMOXIFEN CITRATE TABLETS	TAMOXIFEN CITRATE							
TOREMIFENE CITRATE TABLETS	FARESTON			PA Required				
ANTINEOPLASTIC ENZYME INHIBITORS								
ALECTINIB HCL CAPSULES	ALECENSA			PA Required				
AXITINIB TABLETS	INLYTA			PA Required				
COBIMETINIB FUMARATE TABLETS	COTELLIC			PA Required				
CRIZOTINIB CAPSULES	XALKORI			PA Required				
DASATINIB TABLETS	SPRYCEL			PA Required				
ERLOTINIB HCL TABLETS	TARCEVA			PA Required				
EVEROLIMUS TABLETS	AFINITOR			PA Required				
EVEROLIMUS TBSO	AFINITOR DISPERZ			PA Required				
GEFITINIB TABLETS	IRESSA			PA Required				
IBRUTINIB CAPSULES	IMBRUVICA			PA Required				
IMATINIB MESYLATE TABLETS	GLEEVEC	Brand Only		PA Required				
IBRUTINIB TABLETS	IMBRUVICA			PA Required				
LAPATINIB DITOSYLATE TABLETS	TYKERB			PA Required				
IXAZOMIB CITRATE CAPSULES	NINLARO			PA Required				
NILOTINIB HCL CAPSULES	TASIGNA			PA Required				
PAZOPANIB HCL TABLETS	VOTRIENT			PA Required				
PONATINIB HCL TABLETS	ICLUSIG			PA Required				

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
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							
MITOTIC INHIBITORS								
ETOPOSIDE CAPSULES	ETOPOSIDE							
ANTIPARKINSON AGENTS								
ANTIPARKINSON ANTICHOLINERGICS								
BENZTROPINE MESYLATE TABLETS	BENZTROPINE MESYLATE							
TRIHEXYPHENIDYL HCL ELIXIR	TRIHEXYPHENIDYL HCL							
TRIHEXYPHENIDYL HCL TABLETS	TRIHEXYPHENIDYL HCL							
ANTIPARKINSON COMT INHIBITORS								
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 TABLET CONTROLLED RELEASE	SINEMET CR							
PRAMIPEXOLE DIHYDROCHLORIDE TABLETS	MIRAPEX							
ROPINIROLE HYDROCHLORIDE TABLETS	REQUIP							
ANTIPSYCHOTICS/ANTIMANIC AGENTS								
ANTIMANIC AGENTS								

LITHIUM CARBONATE CAPSULES	

LITHIUM CARBONATE			Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration				

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	

LITHIUM CARBONATE POWDER	

LITHIUM CARBONATE			Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration				

LITHIUM CARBONATE TABLETS	

LITHIUM CARBONATE			Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration				

LITHIUM CARBONATE TABLET CONTROLLED RELEASE	

LITHOBID			Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration				

LITHIUM SOLUTION	

LITHIUM			Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration				

ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL ORAL AGENTS								

ARIPIPRAZOLE TABLETS	

ABILIFY		

Preferred Drug	PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

30.00	

30.00	

CLOZAPINE ORALLY DISPERSABLE TABLET	

FAZACLO		

Preferred Drug	PA Required for Ages < 18 years Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or
other prescribers as approved by the FFS
Administration.		

150.00	

30.00	

CLOZAPINE TABLETS	

CLOZARIL		

Preferred Drug	PA Required for Ages < 18 years Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or
other prescribers as approved by the FFS
Administration.		

150.00	

30.00	

LURASIDONE HCL TABS	

LATUDA		

Preferred Drug	PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

30.00	

30.00	

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	

OLANZAPINE ORALLY DISPERSABLE TABLET 5MG	

ZYPREXA ZYDIS		

Preferred Drug	PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

60.00	

30.00	

OLANZAPINE ORALLY DISPERSABLE TABLET 10MG	

ZYPREXA ZYDIS		

Preferred Drug	PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

60.00	

30.00	

OLANZAPINE ORALLY DISPERSABLE TABLET 15MG	

ZYPREXA ZYDIS		

Preferred Drug	PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

30.00	

30.00	

OLANZAPINE ORALLY DISPERSABLE TABLET 20MG	

ZYPREXA ZYDIS		

Preferred Drug	PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

30.00	

30.00	

OLANZAPINE TABLETS	

ZYPREXA		

Preferred Drug	PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

30.00	

30.00	

QUETIAPINE FUMARATE TABLETS	

SEROQUEL		

Preferred Drug	PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

60.00	

30.00	

RISPERIDONE ORALLY DISPERSABLE TABLET	

RISPERIDONE ODT		

Preferred Drug	PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

60.00	

30.00	

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	

RISPERIDONE ORAL SOLUTION	

RISPERDAL		

Preferred Drug	PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

240.00	

30.00	

RISPERIDONE TABLETS	

RISPERDAL		

Preferred Drug	PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

60.00	

30.00	

ZIPRASIDONE HCL CAPSULES	

GEODON		

Preferred Drug	PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

60.00	

30.00	
ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL LONG ACTING
INJECTABLES								

ARIPIPRAZOLE LAUROXIL	

ARISTADA		

Preferred Drug	PA Required for < 18 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

1.00	

30.00	

ARIPIPRAZOLE LAUROXIL PREFILLED SYRINGE	

ARISTADA INITIO		

Preferred Drug	PA Required for Ages < 18 years Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or
other prescribers as approved by the FFS
Administration.		

2.00	

365.00	

ARIPIPRAZOLE SUSPENSION	

ABILIFY MAINTENA		

Preferred Drug	PA Required for < 18 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

1.00	

30.00	

PALIPERIDONE PALMITATE SUSPENSION	

INVEGA SUSTENNA		

Preferred Drug	PA Required for < 18 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

1.00	

30.00	

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	

PALIPERIDONE PALMITATE SUSPENSION	

INVEGA TRINZA		

Preferred Drug	PA Required for < 18 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

1.00	

84.00	

RISPERIDONE MICROSPHERES SUSPENSION	

RISPERDAL CONSTA		

Preferred Drug	PA Required for < 18 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

2.00	

28.00	

RISPERIDONE PREFILLED SYRINGE	

PERSERIS		

Preferred Drug	PA Required for < 18 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.		

2.00	

28.00	
ANTIPSYCHOTICS - FIRST GENERATION -TYPICAL ORAL AGENTS								

CHLORPROMAZINE HCL SOLUTION	

VARIOUS			PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.				

CHLORPROMAZINE HCL TABLETS	

VARIOUS			PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.				

FLUPHENAZINE HCL CONCENTRATE	

VARIOUS			PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.				

FLUPHENAZINE HCL ELIXIR	

VARIOUS			PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.				

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	

FLUPHENAZINE HCL TABLETS	

VARIOUS			PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.				

HALOPERIDOL LACTATE CONCENTRATE	

VARIOUS			PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.				

HALOPERIDOL TABLETS	

VARIOUS			PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.				

LOXAPINE SUCCINATE CAPSULES	

LOXITANE			PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.				

PERPHENAZINE TABLETS	

VARIOUS			PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.				

PIMOZIDE	

ORAP			PA Required for < 6 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.				

THIORIDAZINE HCL TABLETS	

VARIOUS			PA Required for < 6 years of age. Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.				

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	

THIOTHIXENE CAPSULES	

VARIOUS			PA Required for < 12 years of age. Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.				

TRIFLUOPERAZINE HCL TABLETS	

VARIOUS			PA Required for < 6 years of age. Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.				
ANTIPSYCHOTICS - FIRST GENERATION -TYPICAL -LONG ACTING
INJECTIONS								

FLUPHENAZINE DECANOATE SOLUTION	

FLUPHENAZINE DECANOATE			PA Required for < 18 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.				

HALOPERIDOL DECANOATE SOLUTION	

HALDOL DECANOATE 50			PA Required for < 18 years of age, Prior Authorization is not required when prescribed by a psychiatric clinician, a behavioral pediatrician or other prescribers as approved by the FFS
Administration.				
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					
30.00	
30.00	
COBICISTAT TABLETS	TYBOST					30.00	30.00	
DARUNAVIR ETHANOLATE SUSPENSION	PREZISTA							
DARUNAVIR ETHANOLATE TABLETS	PREZISTA							
DARUNAVIR-COBICISTAT TABLETS	PREZCOBIX							
DELAVIRDINE MESYLATE TABLETS	RESCRIPTOR							
DIDANOSINE CAPSULE DELAYED RELEASE	VIDEX EC							
DIDANOSINE SOLUTION	VIDEX PEDIATRIC							
DOLUTEGRAVIR SODIUM TABLETS	TIVICAY							
DORAVIRINE TABLETS	PIFELTRO							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
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					
30.00	
30.00	
EMTRICITABINE CAPSULES	EMTRIVA							
EMTRICITABINE SOLUTION	EMTRIVA							
EMTRICITABINE-RILPIVIRINE-TENOFOVIR ALAFENAMIDE FUMARATE
TABLETS	
ODEFSEY					
30.00	
30.00	
EMTRICITABINE-RILPIVIRINE-TENOFOVIR DISOPROXIL FUMARATE
TABLETS	
COMPLERA							
EMTRICITABINE-TENOFOVIR ALAFENAMIDE FUMARATE TABLETS	DESCOVY					30.00	30.00	
EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS	TRUVADA	Brand Only						
ENFUVIRTIDE SOLUTION	FUZEON			PA Required		1.00	30.00	
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							
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							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
ZIDOVUDINE SYRUP	RETROVIR							
ZIDOVUDINE TABLETS	ZIDOVUDINE							
CMV AGENTS								
VALGANCICLOVIR HCL SOLUTION	VALCYTE			PA Required				
VALGANCICLOVIR HCL TABLETS	VALCYTE			PA Required				
HEPATITIS AGENTS								
ADEFOVIR DIPIVOXIL TABLETS	HEPSERA			PA Required				
ENTECAVIR SOLUTION	BARACLUDE			PA Required				
ENTECAVIR TABLETS	BARACLUDE			PA Required				
GLECAPREVIR-PIBRENTASVIR TABLETS	MAVYRET		Preferred Drug	PA Required				
LAMIVUDINE (HBV) SOLUTION	EPIVIR HBV							
LAMIVUDINE (HBV) TABLETS	EPIVIR HBV							
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 TABLETS	
EPCLUSA	AUTHORIZED
GENERIC ONLY	
Preferred Drug	
PA Required				
TELBIVUDINE TABLETS	TYZEKA			PA Required				
HERPES AGENTS								
ACYCLOVIR SUSPENSION	ZOVIRAX							
ACYCLOVIR TABLETS	ZOVIRAX							
FAMCICLOVIR TABLETS	FAMVIR							
VALACYCLOVIR HCL TABLETS	VALTREX					30.00	30.00	
INFLUENZA AGENTS								
OSELTAMIVIR PHOSPHATE CAPSULES	TAMIFLU					20.00	270.00	
OSELTAMIVIR PHOSPHATE SUSPENSION	TAMIFLU							
RIMANTADINE HYDROCHLORIDE TABLETS	FLUMADINE							
ZANAMIVIR AEPB	RELENZA DISKHALER					40.00	270.00	
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				
IMMUNE GLOBULIN	GAMMAGARD S-D LIQUID (INJ)	Brand Only	Preferred Drug	PA Required				
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				
IMMUNOSUPRESSIVE AGENTS								
AZATHIOPRINE TABLETS	IMURAN							
CYCLOSPORINE CAPSULES	SANDIMMUNE							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
CYCLOSPORINE MODIFIED (FOR MICROEMULSION) CAPSULES	GENGRAF							
CYCLOSPORINE MODIFIED (FOR MICROEMULSION) SOLUTION	GENGRAF							
CYCLOSPORINE SOLUTION	SANDIMMUNE							
EVEROLIMUS (IMMUNOSUPPRESSANT) 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 24-HOUR	ASTAGRAF XL							
POTASSIUM REMOVING RESINS								
SODIUM POLYSTYRENE SULFONATE POWDER	KAYEXALATE							
SODIUM POLYSTYRENE SULFONATE SUSPENSION	KIONEX							
SODIUM ZIRCONIUM CYCLOSILICATE PACK	LOKELMA					30.00	30.00	
BETA BLOCKERS								
ALPHA-BETA BLOCKERS								
CARVEDILOL TABLETS	COREG							
LABETALOL HCL TABLETS	TRANDATE							
BETA BLOCKERS CARDIO-SELECTIVE								
ATENOLOL TABLETS	TENORMIN							
ATENOLOL/CHLORTHALIDONE	VARIOUS							
BISOPROLOL FUMARATE TABLETS	ZEBETA							
BISOPRODOL/HCTZ	VARIOUS							
METOPROLOL SUCCINATE TABLET 24-HOUR	TOPROL XL							
METOPROLOL TARTRATE TABLETS	METOPROLOL TARTRATE							
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 24-HOUR	INDERAL LA							
PROPRANOLOL HCL SOLUTION	PROPRANOLOL HCL							
PROPRANOLOL HCL TABLETS	PROPRANOLOL HCL							
SOTALOL AF TABLETS	SOTALOL HCL (AF)							
SOTALOL HCL SOLUTION	SOTALOL HYDROCHLORIDE							
SOTALOL HCL TABLETS	BETAPACE							
CALCIUM CHANNEL BLOCKERS								
CALCIUM CHANNEL BLOCKERS								
AMLODIPINE BESYLATE TABLETS	NORVASC					30.00	30.00	
DILTIAZEM HCL COATED BEADS CAPSULE 24-HOUR	CARDIZEM CD							
DILTIAZEM HCL CAPSULE 12-HOUR	DILTIAZEM HCL ER					60.00	30.00	
DILTIAZEM HCL CAPSULE 24-HOUR	DILTIAZEM HCL ER					30.00	30.00	
DILTIAZEM HCL EXTENDED RELEASE BEADS CAPSULE 24-HOUR	TAZTIA XT							
DILTIAZEM HCL TABLETS	CARDIZEM							
FELODIPINE TABLET 24-HOUR	FELODIPINE ER							
NIFEDIPINE CAPSULES	PROCARDIA							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
NIFEDIPINE TABLET 24-HOUR	ADALAT CC					30.00	30.00	
NIMODIPINE CAPSULES	NIMODIPINE							
VERAPAMIL HCL CAPSULE SR	VERELAN PM							
VERAPAMIL HCL TABLETS	VERAPAMIL HCL					30.00	30.00	
VERAPAMIL HCL TABLET CONTROLLED RELEASE	CALAN SR					30.00	30.00	
CARDIOTONICS								
CARDIAC GLYCOSIDES								
DIGOXIN SOLUTION	DIGOXIN							
DIGOXIN TABLETS	LANOXIN							
CARDIOVASCULAR AGENTS - MISC.								
CARDIOVASCULAR AGENTS MISC. - COMBINATIONS								
SACUBITRIL-VALSARTAN TABS	ENTRESTO							
PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR
ANTAGONIST								
AMBRISENTAN TABLETS	LETAIRIS	Brand Only	Preferred Drug	PA Required				
BOSENTAN TABLETS (62.5MG AND 125MG)	TRACLEER	Brand Only	Preferred Drug	PA Required				
PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITOR								

SILDENAFIL CITRATE (PULMONARY HYPERTENSION) SUSPENSION	

REVATIO SUSPENSION	

Brand Only	PREFERRED FOR UNDER THE AGE OF
12	

PA Required FOR > 12 YEARS OF AGE				
SILDENAFIL CITRATE (PULMONARY HYPERTENSION) TABLETS	VARIOIUS		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							
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					1.00	30.00	
CEFIXIME CHEWABLE TABLETS	SUPRAX					1.00	30.00	
CEFIXIME SUSPENSION	SUPRAX					1.00	30.00	
CEFIXIME TABLETS	SUPRAX					1.00	30.00	
CEFPODOXIME PROXETIL SUSPENSION	CEFPODOXIME PROXETIL							
CEFPODOXIME PROXETIL TABLETS	CEFPODOXIME PROXETIL							
CONTRACEPTIVES								

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
COMBINATION CONTRACEPTIVES - ORAL								
DESOGESTREL & ETHINYL ESTRADIOL TABLETS	APRI							
DESOGESTREL-ETHINYL ESTRADIOL (BIPHASIC) TABLETS	AZURETTE							
DESOGESTREL-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS	CAZIANT							
DROSPIRENONE-ETHINYL ESTRADIOL TABLETS	GIANVI							
ETHYNODIOL DIACET & ETH ESTRAD TABLETS	KELNOR 1/35							
LEVONORGESTREL & ETH ESTRADIOL TABLETS	AUBRA							
LEVONORGESTREL-ETH ESTRADIOL (TRIPHASIC) TABLETS	ENPRESSE-28							
LEVONORGESTREL-ETHINYL ESTRADIOL (91-DAY) TABLETS	AMETHIA LO							
LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS) TABLETS	AMETHYST							
NORETHINDRONE ACE-ETHINYL ESTRADIOL-FE CAPSULES	TAYTULLA							
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TABLETS	JUNEL FE							
NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE CHEWABLES	MELODETTA 24 FE							
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							
PROGESTIN CONTRACEPTIVES - IMPLANTS								
ETONOGESTREL IMPLANT	NEXPLANON							
PROGESTIN CONTRACEPTIVES - INJECTABLE								

MEDROXYPROGESTERONE ACETATE (CONTRACEPTIVE) SUSPENSION	
DEPO-PROVERA 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							
PROGESTIN CONTRACEPTIVES - TRANSDERMAL								
NORELGESTROMIN-ETHINYL ESTRADIOL PATCH WEEKLY	XULANE							
CORTICOSTEROIDS								
GLUCOCORTICOSTEROIDS								
CORTISONE ACETATE TABLETS	CORTISONE ACETATE							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
DEXAMETHASONE CONCENTRATE	DEXAMETHASONE INTENSOL							
DEXAMETHASONE ELIXIR	BAYCADRON							
DEXAMETHASONE SOLUTION	DEXAMETHASONE							
DEXAMETHASONE TABLETS	DEXAMETHASONE							
HYDROCORTISONE SOD SUCCINATE SOLUTION	A-HYDROCORT			Prior Authorization Required				
METHYLPREDNISOLONE ACETATE SUSPENSION	DEPO-MEDROL			Prior Authorization Required				
METHYLPREDNISOLONE SOD SUCC SOLUTION	A-METHAPRED			Prior Authorization Required				
METHYLPREDNISOLONE TABLETS	MEDROL							
PREDNISOLONE ACETATE SUSPENSION	FLO-PRED							
PREDNISOLONE SODIUM PHOSPHATE SOLUTION	ORAPRED							

PREDNISOLONE SODIUM PHOSPHATE ORALLY DISPERSABLE TABLET	
ORAPRED ODT							
PREDNISOLONE SYRUP	PRELONE							
PREDNISOLONE TABLETS	MILLIPRED							
PREDNISONE CONCENTRATE	PREDNISONE INTENSOL							
PREDNISONE SOLUTION	PREDNISONE							
PREDNISONE TABLETS	PREDNISONE							
PREDNISONE TABLET ENTERIC COATED	RAYOS							
TRIAMCINOLONE ACETONIDE SUSPENSION	KENALOG-10			Prior Authorization Required				
TRIAMCINOLONE DIACETATE SUSPENSION	TRIAMCINOLONE			Prior Authorization Required				
MINERALOCORTICOIDS								
FLUDROCORTISONE ACETATE TABLETS	FLUDROCORTISONE ACETATE							
COUGH/COLD/ALLERGY								
ANTITUSSIVES								
BENZONATATE CAPSULES	TESSALON PERLES							

HYDROCODONE W/ HOMATROPINE SYRUP	HYDROCODONE BITARTRATE/HOMATROPINE
METHYLBROMIDE			

PA Required for < 18 years of age		

240.00	

12.00	
HYDROCODONE W/ HOMATROPINE TABLETS	TUSSIGON			PA Required for < 18 years of age				
COUGH/COLD/ALLERGY COMBINATIONS								
BROMPHENIRAMINE & PSEUDOEPH	J-TAN D PD							
BROMPHENIRAMINE & PSEUDOEPH TABLET 12-HOUR	BPM PSEUDO							
CETIRIZINE-PSEUDOEPHEDRINE TABLET 12-HOUR	KLS ALLER-TEC D					30.00	30.00	
CHLORPHENIRAMINE & PSEUDOEPH CHEWABLE TABLETS	DICEL							
CHLORPHENIRAMINE & PSEUDOEPH LIQUID	LOHIST-D							
CHLORPHENIRAMINE & PSEUDOEPH SOLUTION	NEUTRAHIST							
CHLORPHENIRAMINE & PSEUDOEPH SYRUP	EQ TRIACTING COLD/ALLERGY							
CHLORPHENIRAMINE & PSEUDOEPH TABLETS	SUDOGEST SINUS & ALLERGY							
CHLORPHENIRAMINE W/ CODEINE LIQUID	CODAR AR			PA Required for < 18 years of age		240.00	12.00	
DEXTROMETHORPHAN-GUAIFENESIN	BRONCOTRON							
DEXTROMETHORPHAN-GUAIFENESIN LIQUID	NORTUSS-EX							
DEXTROMETHORPHAN-GUAIFENESIN TABLET 12-HOUR	MUCINEX DM							

DIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN LIQUID	THERAFLU WARMING RELIEF FLU &
SORE THROAT							

DIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN PACK	MUCINEX FAST-MAX NIGHT TIME
COLD & FLU							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
DIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN
SUSPENSION	TYLENOL CHILDRENS PLUS COLD &
ALLERGY							
DIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN TABLETS	BENADRYL ALLERGY & COLD							

FEXOFENADINE-PSEUDOEPHEDRINE TABLET 12-HOUR	ALLEGRA-D 12 HOUR ALLERGY &
CONGESTION					
30.00	
30.00	

FEXOFENADINE-PSEUDOEPHEDRINE TABLET 24-HOUR	ALLEGRA-D 24 HOUR ALLERGY &
CONGESTION					
30.00	
30.00	
GUAIFENESIN-CODEINE	M-CLEAR			PA Required for < 18 years of age		240.00	12.00	
GUAIFENESIN-CODEINE LIQUID	DEX-TUSS			PA Required for < 18 years of age		240.00	12.00	
LORATADINE & PSEUDOEPHEDRINE TABLET 12-HOUR	ALAVERT ALLERGY/SINUS					30.00	30.00	
LORATADINE & PSEUDOEPHEDRINE TABLET 24-HOUR	CLARITIN-D 24 HOUR					30.00	30.00	
PHENYLEPHRINE W/ DM-GG CAPSULES	GILTUSS TR							

PHENYLEPHRINE W/ DM-GG LIQUID	ROBITUSSIN CHILDRENS COUGH &
COLD CF							
PHENYLEPHRINE W/ DM-GG SUSPENSION	BRONCOTRON-D							
PHENYLEPHRINE W/ DM-GG SYRUP	DESPEC DM							

PHENYLEPHRINE W/ DM-GG TABLETS	MUCINEX FAST-MAX SEVERE
CONGESTION & COUGH							
PHENYLEPHRINE W/ DM-GG TABLET 12-HOUR	GILTUSS TR							
PHENYLEPHRINE-BROMPHENIRAMINE W/ CODEINE	POLY-TUSSIN AC			PA Required for < 18 years of age		240.00	12.00	
PHENYLEPHRINE-BROMPHENIRAMINE-DM ELIXIR	DIMAPHEN DM COLD & COUGH					480.00	30.00	
PHENYLEPHRINE-BROMPHENIRAMINE-DM LIQUID	DIMETAPP DM COLD & COUGH					480.00	30.00	
PHENYLEPHRINE-BROMPHENIRAMINE-DM SYRUP	BPM-DM-PHEN					480.00	30.00	
PHENYLEPHRINE-CHLORPHEN-DM LIQUID	GENCONTUSS			PA Required				
PHENYLEPHRINE-CHLORPHEN-DM SOLUTION	FATHER JOHNS MEDICINE PLUS			PA Required				
PHENYLEPHRINE-CHLORPHEN-DM SYRUP	BALAMINE DM							
PHENYLEPHRINE-CHLORPHEN-DM TABLETS	PHENABID DM			PA Required				
PHENYLEPHRINE-GUAIFENESIN CAPSULES	DECONEX							

PHENYLEPHRINE-GUAIFENESIN LIQUID	TRIAMINIC CHEST/NASAL
CONGESTION							

PHENYLEPHRINE-GUAIFENESIN SYRUP	TRIAMINIC CHEST & NASAL
CONGESTION							
PHENYLEPHRINE-GUAIFENESIN TABLETS	LIQUIBID PD-R							
PROMETHAZINE & PHENYLEPHRINE SYRUP	PROMETHAZINE/PHENYLEPHRINE							
PROMETHAZINE W/CODEINE SYRUP	PROMETHAZINE/CODEINE			PA Required for < 18 years of age		240.00	12.00	

PROMETHAZINE-DM SYRUP	PROMETHAZINE/DEXTROMETHORPH
AN							
PSEUDOEPHEDRINE W/ CODEINE-GG	SUTTAR-2					240.00	12.00	
PSEUDOEPHEDRINE-BROMPHENIRAMINE-CODEINE LIQUID	CPB WC			PA Required for < 18 years of age		240.00	12.00	
PSEUDOEPHEDRINE-GUAIFENESIN CAPSULES	RESPAIRE-30							
PSEUDOEPHEDRINE-GUAIFENESIN LIQUID	TUSNEL PEDIATRIC							
PSEUDOEPHEDRINE-GUAIFENESIN SYRUP	ALTARUSSIN-PE							
PSEUDOEPHEDRINE-GUAIFENESIN TABLETS	AMBI 40PSE/400GFN							
PSEUDOEPHEDRINE-GUAIFENESIN TABLET 12-HOUR	MUCINEX D							
EXPECTORANTS								
GUAIFENESIN LIQUID	HERBAL EXPEC							
GUAIFENESIN PACK	MUCINEX FOR KIDS							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
GUAIFENESIN SOLUTION	TRIACTIN CHEST CONGESTION							
GUAIFENESIN SYRUP	DIABETIC TUSSIN EX							
GUAIFENESIN TABLETS	GUAIFENESIN							
GUAIFENESIN TABLET 12-HOUR	EQ MUCUS ER							
MISC. RESPIRATORY INHALANTS								
SODIUM CHLORIDE (INHALANT) NEBULIZED	SODIUM CHLORIDE							
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							
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 (TOPICAL) OINTMENT	BACIGUENT							
BACITRACIN ZINC OINTMENT	BACITRACIN							
BACITRACIN-POLYMYXIN B OINTMENT	POLYSPORIN							
BACITRACIN-POLYMYXIN-NEOMYCIN HC OINTMENT	CORTISPORIN							
GENTAMICIN SULFATE (TOPICAL) CREAM	GENTAMICIN SULFATE							
GENTAMICIN SULFATE (TOPICAL) OINTMENT	GENTAMICIN SULFATE							
MUPIROCIN CALCIUM (TOPICAL) CREAM	BACTROBAN							
MUPIROCIN OINTMENT	BACTROBAN							
NEOMYCIN-BACITRACIN-POLYMYXIN OINTMENT	LANABIOTIC							
ANTIFUNGALS - TOPICAL								
BUTENAFINE CREAM	MENTAX							
CICLOPIROX CREAM	VARIOUS							
CICLOPIROX 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							
MICONAZOLE NITRATE CREAM	VARIOUS							
MICONAZOLE NITRATE POWDER	VARIOUS							
NYSTATIN CREAM	VARIOUS							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
NYSTATIN OINTMENT	VARIOUS							
NYSTATIN POWDER	NYAMYC							
TOLNAFTATE AERO POWDER	VARIOUS							
TOLNAFTATE CREAM	VARIOUS							
TOLNAFTATE POWDER	VARIOUS							
TERBINAFINE CREAM	VARIOUS							
ANTIHISTAMINES-TOPICAL								
DIPHENHYDRAMINE HCL (TOPICAL) CREAM	ANTI-ITCH MAXIMUM STRENGTH							
DIPHENHYDRAMINE HCL (TOPICAL) GEL	BENADRYL ITCH STOPPING							
DIPHENHYDRAMINE HCL (TOPICAL) SOLUTION	BENADRYL MAXIMUM STRENGTH							
DICLOFENAC SODIUM (TOPICAL) GEL	VOLTAREN					100 GM	300.00	
ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOP								
BEXAROTENE (TOPICAL) GEL	TARGRETIN							
FLUOROURACIL (TOPICAL) CREAM	CARAC							
FLUOROURACIL (TOPICAL) SOLUTION	FLUOROURACIL							
ANTIPSORIATICS								
ACITRETIN CAPSULES	SORIATANE							
ANTHRALIN CREAM	DRITHO-CREME HP							
CALCIPOTRIENE CREAM	DOVONEX							
CALCIPOTRIENE FOAM	SORILUX							
CALCIPOTRIENE OINTMENT	CALCITRENE							
CALCIPOTRIENE SOLUTION	CALCIPOTRIENE							
METHOXSALEN RAPID CAPSULES	OXSORALEN ULTRA							
ANTISEBORRHEIC PRODUCTS								
SELENIUM SULFIDE LOTION	SELSUN SHAMPOO							
ANTIVIRALS - TOPICAL								
DOCOSANOL CREAM	ABREVA							
ACYCLOVIR OINTMENT	ZOVIRAX					15GM	30.00	
BURN PRODUCTS								
SILVER SULFADIAZINE CREAM	SILVADENE							
CORTICOSTEROIDS - TOPICAL LOW POTENCY								
HYDROCORTISONE CREAM	VARIOUS							
HYDROCORTISONE GEL	VARIOUS							
HYDROCORTISONE KIT	VARIOUS							
HYDROCORTISONE LOTION	VARIOUS							
HYDROCORTISONE OINTMENT	VARIOUS							
HYDROCORTISONE ACETATE CREAM 0.5%	VARIOUS							
HYDROCORTISONE ACETATE OINTMENT 1%	VARIOUS							
HYDROCORTISONE-ALOE VERA CREAM	VARIOUS							
FLUOCINOLONE 0.01% OIL	DERMA-SMOOTH OIL-FS	Brand Only						
CORTICOSTEROIDS - TOPICAL MEDIUM POTENCY								
FLUTICASONE PROPIONATE CREAM	VARIOUS							
FLUTICASONE PROPIONATE OINTMENT	VARIOUS							
MOMETASONE FUROATE CREAM	VARIOUS							
MOMETASONE FUROATE OINTMENT	VARIOUS							
MOMETASONE FUROATE SOLUTION	VARIOUS							
CORTICOSTEROIDS - TOPICAL HIGH POTENCY								

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
BETAMETHASONE DIPROPIONATE LOTION	VARIOUS							
BETAMETHASONE DIPROPIONATE/PROPYLENE GLYC. CREAM	VARIOUS							
BETAMETHASONE VALERATE CREAM	VARIOUS							
BETAMETHASONE VALERATE LOTION	VARIOUS							
BETAMETHASONE VALERATE OINTMENT	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	
EMOLLIENTS								
LACTIC ACID (AMMONIUM LACTATE) CREAM	NOBLE MYSTIQUE EMU-LAC							
LACTIC ACID (AMMONIUM LACTATE) FOAM	PRO:12 MOUSSE AL12							
LACTIC ACID (AMMONIUM LACTATE) LOTION	GERI-HYDROLAC 5							
ENZYMES - TOPICAL								
TACROLIMUS (TOPICAL) OINTMENT	PROTOPIC			PA Required				
VITAMINS A & D (TOPICAL) OINTMENT	CURAD VITAMIN A & D							
KERATOLYTIC/ANTIMITOTIC AGENTS								
SALICYLIC ACID CREAM	SALACYN							
SALICYLIC ACID FOAM	SALVAX							
SALICYLIC ACID GEL	KERALYT							
SALICYLIC ACID KIT	KERALYT SCALP							
SALICYLIC ACID LIQUID	VIRASAL							
SALICYLIC ACID LOTION	SALACYN							
SALICYLIC ACID SHAMPOO	SALEX							
SALICYLIC ACID SOLUTION	SALICYLIC ACID							
LOCAL ANESTHETICS - TOPICAL								
CAPSAICIN CREAM	VARIOUS							
LIDOCAINE CREAM 4%	ASPERCREME W/LIDOCAINE							
LIDOCAINE HCL GEL 2%	GLYDO							
LIDOCAINE HCL LOTION	LIDOCAINE HCL							
LIDOCAINE OINTMENT	LIDOCAINE			PA Required				
LIDOCAINE PATCH 4%	ASPERCREME					60.00	30.00	
LIDOCAINE PATCH 5%	LIDODERM					60.00	30.00	
LIDOCAINE-PRILOCAINE CREAM	EMLA							
MISC. TOPICAL								
ALUMINUM CHLORIDE SOLUTION	DRYSOL							
ZINC OXIDE (TOPICAL) OINTMENT	ZINC OXIDE							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
ZINC OXIDE (TOPICAL) PASTE	ZINC OXIDE							
PIGMENTING-DEPIGMENTING AGENTS								
METHOXSALEN (TOPICAL) LOTION	OXSORALEN							
ROSACEA AGENTS								
METRONIDAZOLE (TOPICAL) CREAM 0.75%	METROCREAM							
METRONIDAZOLE (TOPICAL) GEL 0.75%	ROSADAN							
METRONIDAZOLE (TOPICAL) LOTION	METROLOTION							
SCABICIDES & PEDICULICIDES								
CROTAMITON CREAM	EURAX							
CROTAMITON LOTION	EURAX							
IVERMECTIN (PEDICULICIDE) LOTION	SKLICE			PA Required				
LINDANE LOTION	LINDANE			PA Required				
LINDANE SHAMPOO	LINDANE			PA Required				
MALATHION LOTION	OVIDE							
PERMETHRIN 1%, 5%	NIX, ELIMITE							
PERMETHRIN CREAM	ACTICIN							
PERMETHRIN LIQUID	NIX CREME RINSE							
PERMETHRIN LOTION	LICE TREATMENT							
PYRETHRINS-PIPERONYL BUTOXIDE GEL	A-200							
PYRETHRINS-PIPERONYL BUTOXIDE KIT	PRONTO							
PYRETHRINS-PIPERONYL BUTOXIDE LIQUID	BARC							
PYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO	LICIDE							
SPINOSAD SUSPENSION	NATROBA			PA Required				
WOUND CARE PRODUCTS								
BECAPLERMIN GEL	REGRANEX			PA Required				
DIAGNOSTIC PRODUCTS								
DIAGNOSTIC TESTS								

GLUCOSE BLOOD STRIPS	TRUETRACK, ACCU-CHEK AVIVA, TRUE
METRIX					
200.00	
30.00	
DIGESTIVE AIDS								
DIGESTIVE ENZYMES								
LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE	CREON	Brand Only	Preferred Drug			300.00	30.00	
LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE	ZENPEP	Brand Only	Preferred Drug			300.00	30.00	
LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE 5000
UNITS	
PANCRELIPASE 5000 UNITS		
Preferred Drug			
300.00	
30.00	
SACROSIDASE SOLUTION	SUCRAID			PA Required				
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							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
FUROSEMIDE SOLUTION	FUROSEMIDE							
FUROSEMIDE TABLETS	LASIX							
TORSEMIDE TABLETS	DEMADEX							
POTASSIUM SPARING DIURETICS								
AMILORIDE HCL TABLETS	AMILORIDE HCL							
SPIRONOLACTONE TABLETS	ALDACTONE							
TRIAMTERENE CAPSULES	DYRENIUM							
THIAZIDES AND THIAZIDE-LIKE DIURETICS								
CHLOROTHIAZIDE SUSPENSION	DIURIL							
CHLOROTHIAZIDE TABLETS	CHLOROTHIAZIDE							
CHLORTHALIDONE TABLETS	CHLORTHALIDONE							
HYDROCHLOROTHIAZIDE 12.5MG CAPSULES	VARIOUS							
HYDROCHLOROTHIAZIDE TABLETS 25MG & 50MG	HYDROCHLOROTHIAZIDE							
INDAPAMIDE TABLETS	INDAPAMIDE							
METHYCLOTHIAZIDE TABLETS	METHYCLOTHIAZIDE							
METOLAZONE TABLETS	ZAROXOLYN							
ENDOCRINE AND METABOLIC AGENTS - MISC.								
BONE DENSITY REGULATORS								
ALENDRONATE SODIUM SOLUTION	ALENDRONATE SODIUM			PA Required				
ALENDRONATE SODIUM TABLETS	ALENDRONATE SODIUM					30.00	30.00	
CALCITONIN (SALMON) SOLUTION	FORTICAL							
DENOSUMAB	PROLIA			PA Required				
IBANDRONATE SODIUM	BONIVA							
RALOXIFENE TABLETS	VARIOUS							
TERIPARATIDE (RECOMBINANT)	FORTEO			PA Required				
GROWTH HORMONE RECEPTOR ANTAGONISTS								
PEGVISOMANT SOLUTION	SOMAVERT			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					30.00	30.00	
INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)								
MECASERMIN SOLUTION	INCRELEX			PA Required				

LHRH/GNRH AGONIST ANALOG PITUITARY SUPPOSITORYRESSANTS								
LEUPROLIDE ACETATE (CPP) (3 MONTH) KIT	LUPRON DEPOT-PED			PA Required				
LEUPROLIDE ACETATE (CPP) KIT	LUPRON DEPOT-PED			PA Required				
NAFARELIN ACETATE SOLUTION	SYNAREL			PA Required				
METABOLIC MODIFIERS								
CALCITRIOL CAPSULES	ROCALTROL							
CALCITRIOL SOLUTION	ROCALTROL							
CINACALCET HCL TABLETS	SENSIPAR							
IDURSULFASE SOLUTION	ELAPRASE			PA Required				
LEVOCARNITINE (METABOLIC MODIFIERS) SOLUTION	CARNITOR			PA Required				
LEVOCARNITINE (METABOLIC MODIFIERS) TABLETS	CARNITOR			PA Required				
POSTERIOR PITUITARY HORMONES								

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
DESMOPRESSIN ACETATE REFRIGERATED SOLUTION	DDAVP							
DESMOPRESSIN ACETATE SOLUTION	STIMATE							
DESMOPRESSIN ACETATE SPRAY REFRIGERATED SOLUTION	DESMOPRESSIN ACETATE							
DESMOPRESSIN ACETATE SPRAY SOLUTION	DDAVP							
DESMOPRESSIN ACETATE TABLETS	DDAVP							
PROLACTIN INHIBITORS								
CABERGOLINE TABLETS	CABERGOLINE			PA Required				
SOMATOSTATIC AGENTS								
LANREOTIDE ACETATE SOLUTION	SOMATULINE DEPOT			PA Required				
OCTREOTIDE ACETATE KIT	SANDOSTATIN LAR DEPOT			PA Required				
OCTREOTIDE ACETATE SOLUTION	SANDOSTATIN			PA Required				
ESTROGENS								
ESTROGEN COMBINATIONS								
CONJUGATED ESTROGENS-MEDROXYPROGESTERONE ACETATE
TABLETS	
PREMPRO							
ESTERIFIED ESTROGENS & METHYLTESTOSTERONE TABLETS	COVARYX HS							
ESTRADIOL & NORETHINDRONE ACETATE PATCH TWICE WEEKLY	COMBIPATCH							
ESTRADIOL & NORETHINDRONE ACETATE TABLETS	ACTIVELLA							
ESTRADIOL-LEVONORGESTREL PATCH WEEKLY	CLIMARA PRO							
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL TABLETS	FEMHRT LOW DOSE							
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 ANTIALLERGY AGENTS								
CROMOLYN SODIUM (MASTOCYTOSIS) CONCENTRATE	GASTROCROM							
GASTROINTMENTESTINAL CHLORIDE CHANNEL ACTIVATORS								
LUBIPROSTONE CAPSULES	AMITIZA			PA Required				
GASTROINTMENTESTINAL STIMULANTS								
METOCLOPRAMIDE HCL SOLUTION	METOCLOPRAMIDE HCL							
METOCLOPRAMIDE HCL TABLETS	REGLAN							
METOCLOPRAMIDE HCL ORALLY DISPERSABLE TABLET	METOZOLV ODT							
INFLAMMATORY BOWEL AGENTS								

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
BALSALAZIDE DISODIUM TABLETS	GIAZO		PREFERRED DRUG			270.00	30.00	
INFLIXIMAB-AXXQ FOR SOLUTION	AVSOLA	AVSOLA Brand Only	PREFERRED DRUG	PA Required				
MESALAMINE CAPSULE CONTROLLED RELEASE	PENTASA		PREFERRED DRUG			270.00	30.00	
MESALAMINE CAPSULE DELAYED RELEASE	DELZICOL	Brand Only	PREFERRED DRUG			180.00	30.00	
MESALAMINE CAPSULE 24-HOUR	APRISO	Brand Only	PREFERRED DRUG			120.00	30.00	
MESALAMINE ENEMA	SFROWASA	Brand Only	PREFERRED DRUG			30.00	30.00	
MESALAMINE TABLET ENTERIC COATED	LIALDA	Brand Only	PREFERRED DRUG			120.00	30.00	
MESALAMINE SUPPOSITORY	CANASA	Brand Only	PREFERRED DRUG			30.00	30.00	
SULFASALAZINE TABLETS	AZULFIDINE		PREFERRED DRUG			240.00	30.00	
SULFASALAZINE TABLET ENTERIC COATED	AZULFIDINE EN-TABLETS		PREFERRED DRUG			240.00	30.00	
INTESTINAL ACIDIFIERS								
LACTULOSE (ENCEPHALOPATHY) SOLUTION	LACTULOSE							
IRRITABLE BOWEL SYNDROME (IBS) AGENTS								
ALOSETRON HCL TABLETS	LOTRONEX			PA Required				
LINACLOTIDE CAPSULES	LINZESS			PA Required				
PHOSPHATE BINDER AGENTS								
CALCIUM ACETATE (PHOSPHATE BINDER) CAPSULES	VARIOUS		PREFERRED DRUG					
CALCIUM ACETATE (PHOSPHATE BINDER) TABLETS	VARIOUS		PREFERRED DRUG					
SEVELAMER CARBONATE TABLETS	RENVELA	VARIOUS	PREFERRED DRUG					
SEVELAMER CARBONATE POWDER	RENVELA							
SEVELAMER HCL TABLETS	RENAGEL							
GENITOURINARY AGENTS - MISCELLANEOUS								
ACIDIFIERS								
POTASSIUM & SODIUM ACID PHOSPHATES TABLETS	K-PHOS NO 2							
ALKALINIZERS								

POT & SOD CITRATES W/CITRIC AC SOLUTION	POTASSIUM CITRATE/SODIUM
CITRATE/CITRIC ACID							
POT & SOD CITRATES W/CITRIC AC SYRUP	CYTRA-3							

POTASSIUM CITRATE (ALKALINIZER) TABLET CONTROLLED RELEASE	
UROCIT-K 5							
POTASSIUM CITRATE-CITRIC ACID PACK	TARON-CRYSTALS							
POTASSIUM CITRATE-CITRIC ACID SOLUTION	POTASSIUM CITRATE/CITRIC ACID							
SODIUM CITRATE & CITRIC ACID SOLUTION	SHOHLS SOLUTION MODIFIED							
INTERSTITIAL CYSTITIS AGENTS								
PENTOSAN POLYSULFATE SODIUM CAPSULES	ELMIRON			PA Required				
PROSTATIC HYPERTROPHY AGENTS								
ALFUZOSIN HCL TABLET 24-HOUR	VARIOUS							
DOXAZOSIN MESYLATE TABLETS	VARIOUS							
DUTASTERIDE CAPS	VARIOUS							
FINASTERIDE TABLETS	PROSCAR							
TAMSULOSIN HCL CAPSULES	FLOMAX							
TERAZOSIN HCL CAPSULES	VARIOUS							
URINARY ANALGESICS								
PHENAZOPYRIDINE HCL	BARIDIUM							
PHENAZOPYRIDINE HCL TABLETS	PYRIDIUM							
GOUT AGENTS								
GOUT AGENT COMBINATIONS								

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
COLCHICINE W/ PROBENECID TABLETS	PROBENECID/COLCHICINE							
GOUT AGENTS								
ALLOPURINOL TABLETS	ZYLOPRIM							
COLCHICINE TABLETS	COLCRYS							
FEBUXOSTAT TABLETS	ULORIC					30.00	30.00	
URICOSURICS								
PROBENECID TABLETS	PROBENECID							
HEMATOLOGICAL AGENTS - MISC.								
HEMATORHEOLOGIC AGENTS								
PENTOXIFYLLINE TABLET CONTROLLED RELEASE	TRENTAL							
PLATELET AGGREGATION INHIBITORS								
ANAGRELIDE HCL CAPSULES	AGRYLIN							
CILOSTAZOL TABLETS	PLETAL							
CLOPIDOGREL BISULFATE TABLETS	PLAVIX							
DIPYRIDAMOLE TABLETS	PERSANTINE							
TICAGRELOR TABLETS	BRILINTA							
TICLOPIDINE HCL TABLETS	TICLOPIDINE HCL							
THROMBOLYTIC ENZYMES								
ALTEPLASE FOR SOLUTION	ACTIVASE					1.00	30.00	
GASTROINTESTINAL AGENTS - MISCELLANEOUS								
ANTIFLATULENTS								
SIMETHICONE SUSPENSION	CVS INFANTS GAS RELIEF							
HEMATOPOIETIC AGENTS								
AGENTS FOR GAUCHER DISEASE								
ELIGLUSTAT TARTRATE	CERDELGA (oral)			PA Required				
IMIGLUCERASE SOLUTION	CEREZYME 400 IU (IV)			PA Required				
TALIGLUCERASE ALFA	ELELYSO (IV)			PA Required				
MIGLUSTAT	MIGLUSTAT (AG) (oral)			PA Required				
VELAGLUCERASE ALFA	VPRIB 400 IU			PA Required				
FOLIC ACID/FOLATES								
FOLIC ACID CAPSULES	FA-8							
FOLIC ACID TABLETS	FOLIC ACID							
HEMATOPOIETIC GROWTH FACTORS								
ELTROMBOPAG OLAMINE TABLETS	PROMACTA	Brand Only	Preferred Drug	PA Required				
EPOETIN ALFA-EPBX SOLUTION	RETACRIT	Brand Only	Preferred Drug	PA Required				

FILGRASTIM SOLUTION	NEUPOGEN VIAL & DISPOSABLE
SYRINGE	
Brand Only	
Preferred Drug	
PA Required				
FILGRASTIM-AAF SOLUTION PREFILLED SYRINGE	NIVESTYM	Brand Only	Preferred Drug	PA Required				
PEGFILGRASTIM SOLUTION	UDENYCA	Brand Only	Preferred Drug	PA Required				
PEGFILGRASTIM-APGF SOLUTION PREFILLED SYRINGE	NYVEPRIA	Brand Only	Preferred Drug	PA Required				
PEGFILGRASTIM- JMDB SOLUTION	FULPHILIA	Brand Only	Preferred Drug	PA Required				
ROMIPLOSTIM	NPLATE	Brand Only	Preferred Drug	PA Required				
HEMATOPOIETIC MIXTURES								
FE FUMARATE-VITAMIN C-VITAMIN B12-FOLIC ACID CAPSULES	HEMATOGEN FA							
FERROUS FUMARATE W/ B12-VIT C-FA-IFC CAPSULES	TRICON							
FERROUS FUMARATE W/ FA-DSS-B COMPLEX-VIT C TABLETS	NEPHRON FA							
FOLATE-VITAMIN B12-INTRINSIC FACTOR TABLETS	INTRINSI B12/FOLATE							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
IRON COMBINATIONS	CORVITE 150							
IRON COMBINATIONS CAPSULES	HEMATOGEN							
IRON COMBINATIONS ELIXIR	HEMOCYTE-F							
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							
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							
HEMOSTATICS								
HEMOSTATICS - SYSTEMIC								
AMINOCAPROIC ACID SOLUTION	AMICAR							
AMINOCAPROIC ACID TABLETS	AMICAR							
HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENT								
ANTIHISTAMINE HYPNOTICS								
DIPHENHYDRAMINE HCL (SLEEP) CAPSULES	CVS NIGHTTIME SLEEP AID							
DIPHENHYDRAMINE HCL (SLEEP) TABLET	NIGHTTIME SLEEP-AID							
DIPHENHYDRAMINE HCL (SLEEP) LIQUID	ZZZQUIL							
DIPHENHYDRAMINE HCL (SLEEP) TABLET DISPERSIBLE	WAL-SOM							
BARBITURATE HYPNOTICS								
PHENOBARBITAL SOLUTION	PHENOBARBITAL							
PHENOBARBITAL TABLETS	PHENOBARBITAL							
NON-BARBITURATE HYPNOTICS								

ESZOPICLONE TABLETS	
LUNESTA			
PREFERRED DRUG	PA Required for Ages <6 years
PA Required for > 1 Hypnotic Drug	
30.00	
30.00	

TEMAZEPAM CAPSULES 15MG & 30MG	
RESTORIL			
PREFERRED DRUG	PA Required for Ages <6 years
PA Required for > 1 Hypnotic Drug	
30.00	
30.00	

ZOLPIDEM TARTRATE TABLETS 5MG	
AMBIEN			
PREFERRED DRUG	PA Required for Ages <6 years
PA Required for > 1 Hypnotic Drug	
60.00	
30.00	

ZOLPIDEM TARTRATE TABLETS 10MG	
AMBIEN			
PREFERRED DRUG	PA Required for Ages <6 years
PA Required for > 1 Hypnotic Drug	
30.00	
30.00	
SELECTIVE MELATONIN RECEPTOR AGONISTS								

RAMELTEON TABLETS	

ROZEREM	

Brand Only			
Patient must have tried two preferred agents (Temazepam, Zolpidem and Eszopiclone)	

30.00	

30.00	
HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENT								
ANTIHISTAMINE HYPNOTICS								
DOXYLAMINE SUCCINATE (SLEEP) TABLETS	RA NIGHT SLEEP AID							
LAXATIVES								

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
BULK LAXATIVES								

FIBER CAPSULES	ADVANCED FIBER
COMPLEX/ACIDOPHILUS							
FIBER TABLETS	FIBER COMPLETE							
FIBER CHEWABLES	EQ FIBER SUPPLEMENT							
FIBER LIQDID	LIQUAFIBER							
FIBER POWDER	SOLFIBER							
METHYLCELLULOSE (LAXATIVE) TABLETS	MIRAFIBER							
METHYLCELLULOSE (LAXATIVE) POWDER	CITRUCEL FIBER LAXATIVE							
METHYLCELLULOSE (LAXATIVE) PACKETS	CITRUCEL FIBER LAXATIVE							
PSYLLIUM CAPSULES	NAT-RUL PSYLLIUM SEED HUSKS							
PSYLLIUM PACK	METAMUCIL SMOOTH TEXTURE							
PSYLLIUM POWDER	KONSYL							
PSYLLIUM SUBLINGUAL	METAMUCIL							
LAXATIVE COMBINATIONS								

PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE SOLUTION	
COLYTE-FLAVOR PACKS							
PEG 3350-POTASSIUM CHLORIDE-SOD BICARBONATE-SOD CHLORIDE
SOLUTION	
GAVILYTE-N/FLAVOR PACK							
SENNOSIDES-DOCUSATE SODIUM TABLETS	SENNA-S							
LAXATIVES - MISCELLANEOUS								
GLYCERIN (LAXATIVE) SUPPOSITORIES	GLYCERIN CHILDREN							
LACTULOSE PACK	KRISTALOSE							
LACTULOSE SOLUTION	LACTULOSE							
POLYETHYLENE GLYCOL 3350 PACK	CLEARLAX							
POLYETHYLENE GLYCOL 3350 POWDER	CLEARLAX							
SALINE LAXATIVES								
MAGNESIUM CITRATE SOLNTION	CITROMA							
MAGNESIUM OXIDE (LAXATIVE) TABLETS	PHILLIPS							
SODIUM PHOSPHATES ENEMA	GNP ENEMA							
STIMULANT LAXATIVES								
BISACODYL ENEMA	FLEET BISACODYL							
BISACODYL KIT	DULCOLAX BOWEL PREP KIT							
BISACODYL POWDER	BISACODYL							
BISACODYL SUPPOSITORY	BISAC-EVAC							
BISACODYL TABLET ENTERIC COATED	ALOPHEN							
CASCARA SAGRADA CAPSULES	CASCARA SAGRADA							
CASCARA SAGRADA TABLETS	CASCARA SAGRADA							
CASCARA SAGRADA EXTRACT	CASCARA SAGRADA							
SENNA SYRP	SENNA							
SENNA MISC	CORRECTOL HERBAL TEA							
SENNA LEAV	SENNA LEAVES							
SENNOSIDES CAPSULES	RA SENNA							
SENNOSIDES TABLETS	SENNA-LAX							
SENNOSIDES CHEWABLES	RA LAXATIVE							
SENNOSIDES LIQUID	AGORAL MAXIMUM STRENGTH							
SENNOSIDES SYRUP	SENNA-GRX							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
SURFACTANT LAXATIVES								
DOCUSATE SODIUM CAPSULES	COLACE							
DOCUSATE SODIUM ENEMA	DOCUSOL KIDS							
DOCUSATE SODIUM LIQUID	PEDIA-LAX							
DOCUSATE SODIUM SYRUP	DIOCTO							
DOCUSATE SODIUM TABLETS	DOK							
MACROLIDES								
AZITHROMYCIN								
AZITHROMYCIN PACK	ZITHROMAX							
AZITHROMYCIN SUSPENSION	ZITHROMAX							
AZITHROMYCIN TABLETS	ZITHROMAX							
CLARITHROMYCIN								
CLARITHROMYCIN SUSPENSION	CLARITHROMYCIN							
CLARITHROMYCIN TABLETS	BIAXIN							
CLARITHROMYCIN TABLET 24-HOUR	BIAXIN XL							
ERYTHROMYCIN PRODUCTS REQUIRE PRIOR AUTHORIZATION								
FIDAXOMICIN								
FIDAXOMICIN TABLETS	DIFICID			PA Required				
MEDICAL DEVICES								
CONTRACEPTIVES								
CONDOMS - FEMALE MISC	FC FEMALE CONDOM					30.00	30.00	
CONDOMS - MALE MISC	LIFESTYLES ASSORTED COLORS					30.00	30.00	

CONDOMS LATEX LUBRICATED - MALE MISC	ATLAS COLORED LUBRICATED
CONDOM					
30.00	
30.00	

CONDOMS LATEX NON-LUBRICATED - MALE MISC	ATLAS COLORED
CONDOM/SPERMICIDE					
30.00	
30.00	
CONDOMS NON-LATEX NON-LUBRICATED - MALE MISC	TROJAN NATURALAMB					30.00	30.00	
DIAPHRAGM ARC-SPRING DPRH	CAYA					1.00	365.00	

DIAPHRAGM COIL SPRING KIT	ORTHO DIAPHRAGM COIL SPRING KIT
50					
1.00	
365.00	

DIAPHRAGM FLAT SPRING KIT	ORTHO DIAPHRAGM FLAT SPRING KIT
55					
1.00	
365.00	

DIAPHRAGM WIDE SEAL DPRH	WIDE-SEAL SILICONE DIAPHRAGM KIT
60					
1.00	
365.00	
DIAPHRAGMS DPRH	OMNIFLEX DIAPHRAGM					1.00	365.00	
DIABETIC SUPPLIES								

BLOOD GLUCOSE CALIBRATION LIQUID	ACCU-CHEK ACTIVE GLUCOSE
CONTROL SOLUTION							
BLOOD GLUCOSE MONITORING SUPPLIES DEVICE	TRUETRACK & TRUE METRIX							
BLOOD GLUCOSE MONITORING SUPPLIES KIT	TRUETRACK & TRUE METRIX							

CONTINUOUS BLOOD GLUCOSE SYSTEM RECEIVER	DEXCOM G6 & FREESTYLE LIBRE &
FREESTYLE LIBRE 2					
1.00	
365.00	
CONTINUOUS BLOOD GLUCOSE SYSTEM TRANSMITTER	DEXCOM G6					1.00	90.00	
CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR	DEXCOM G6					3.00	30.00	

CONTINUOUS BLOOD GLUCOSE SYSTEM SENSOR	
FREESTYLE LIBRE & FREESTYLE LIBRE 2					
2.00	
30.00	

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	

LANCET DEVICES MISC	ACCU-CHEK SOFTCLIX
LANCETDEVICECE							
LANCETS MISC	1ST CHOICE LANCETS SUPER THIN							

LANCETS MISC. KIT	ACCU-CHEK FASTCLIX
LANCETDEVICECE KIT							
LANCETS MISC. MISC	AUTOLET PLATFORMS							
MISC. DEVICECES								
ALCOHOL SWABS PADS	ALCOH-GLOVE CONTOURED WIPE							
PARENTERAL THERAPY SUPPLIES								
INSULIN PEN NEEDLE MISC	BD AUTOSHIELD 29G X 3/16"							

INSULIN SYRINGE/NEEDLE U-100 MISC	RELION INSULIN SYRINGE/U-
100/0.3ML/29G							

INSULIN SYRINGE/NEEDLE U-40 MISC	BD INSULIN SYRINGE U-40/1ML/25G X
5/8"							

INSULIN SYRINGES (DISPOSABLE) MISC	KMART VALU PLUS INSULIN
SYRINGE/0.3ML/30G							

SYRINGE/NEEDLE (DISP) 1 ML	MONOJECT MAGELLAN SYRINGE/SAFETY NEEDLE/1ML/23G X
1"							

SYRINGE/NEEDLE (DISP) 1 ML MISC	MONOJECT LIFESHIELD BLUNTCANNULA/REG LUER
SYR/1ML/18G X 1"							
RESPIRATORY THERAPY SUPPLIES								
PEAK FLOW METER W/INHALER ASSIST DEVICE KIT	AEROGEAR ASTHMA ACTION					2.00	365.00	
RESPIRATORY THERAPY DEVICE	AEROBIKA							
RESPIRATORY THERAPY  KIT	AIRS DISPOSABLE NEBULIZER							
RESPIRATORY THERAPY  MISC	ACE AEROSOL CLOUD ENHANCER					2.00	365.00	

SPACER/AEROSOL-HOLDING CHAMBER - MASKS MISC	MASK VORTEX/BABY WHIRL
DUCKLING							
SPACER/AEROSOL-HOLDING CHAMBERS DEVICE	AEROCHAMBER MINI CHAMBER					2.00	365.00	
SPACER/AEROSOL-HOLDING CHAMBERS MISC	AEROCHAMBER MINI CHAMBER							
MIGRAINE PRODUCTS								
MIGRAINE COMBINATIONS								
ERGOTAMINE W/ CAFFEINE SUPPOSITORY	MIGERGOT					12.00	30.00	
ERGOTAMINE W/ CAFFEINE TABLETS	CAFERGOT					40.00	30.00	
MIGRAINE PRODUCTS - MONOCLONAL ANTIBODIES								
GALCANEZUMAB-GNLM SOLUTION AUTOINJECTOR / PREFILLED
SYRINGE / PEN	
EMGALITY		
Preferred Drug	
PA Required		
1.00	
30.00	
CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR
ANTAGONIST								
ERENUMAB-AOOE SOLUTION AUTOINJECTOR	AIMOVIG		Preferred Drug	PA Required		1.00	30.00	
FREMANEZUMAB-VFRM SOLUTION AUTOINJECTOR	AJOVY		Preferred Drug	PA Required		1.00	30.00	
UBROGEPANT TABLETS	UBRELVY		Preferred Drug	PA Required		8.00	30.00	
SEROTONIN AGONISTS								
NARATRIPTAN HCL TABLETS	AMERGE		Preferred Drug			9.00	30.00	
RIZATRIPTAN BENZOATE TABLETS	MAXALT		Preferred Drug			9.00	30.00	
RIZATRIPTAN BENZOATE ORALLY DISPERSABLE TABLET	MAXALT-MLT		Preferred Drug			9.00	30.00	

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
SUMATRIPTAN SOLUTION NASAL SPRAY	IMITREX SPRAY	Brand Only	Preferred Drug			6.00	30.00	
SUMATRIPTAN SUCCINATE SOLUTION INJECTION	IMITREX		Preferred Drug			2.00	30.00	
SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTION	IMITREX STATDOSE SYSTEM		Preferred Drug			2.00	30.00	
SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE	IMITREX STATDOSE REFILL		Preferred Drug			2.00	30.00	
SUMATRIPTAN SUCCINATE TABLETS	IMITREX		Preferred Drug			9.00	30.00	
ZOLMITRIPTAN TABLETS	ZOMIG		Preferred Drug			9.00	30.00	
ZOLMITRIPTAN ORALLY DISPERSABLE TABLET	ZOMIG ZMT		Preferred Drug			9.00	30.00	

ZOLMITRIPTAN SOLUTION NASAL SPRAY	
ZOMIG SPRAY	
Brand Only	
Preferred Drug	Step Therapy - Must Try Imitrex Nasal
Spray		
6.00	
30.00	
MINERALS & ELECTROLYTES								
CALCIUM								
CALCIUM LACTATE CAPSULES	CAL-LAC							
CALCIUM LACTATE TABLETS	CALCIUM LACTATE							
FLUORIDE								
SODIUM FLUORIDE CHEWABLE TABLETS	LUDENT							
SODIUM FLUORIDE LOZG	LOZI-FLUR							
SODIUM FLUORIDE SOLUTION	FLUOR-A-DAY							
SODIUM FLUORIDE TABLETS	SODIUM FLUORIDE							
MAGNESIUM								
MAGNESIUM OXIDE (MG SUPPLEMENT) CAPSULES	MAGNESIUM							
MAGNESIUM OXIDE (MG SUPPLEMENT) TABLETS	MAG-200							
POTASSIUM								

POTASSIUM BICARB & CHLORIDE TABLET EFFERVESCENT	EFFERVESCENT
POTASSIUM/CHLORIDE							
POTASSIUM BICARBONATE TABLET EFFERVESCENT	EFFER-K							
POTASSIUM BICARBONATE-CITRIC ACID TABLET EFFERVESCENT	EFFER-K							
POTASSIUM CHLORIDE CAPSULE CONTROLLED RELEASE	KLOR-CON SPRINKLE							
POTASSIUM CHLORIDE LIQUID	K-SOL							
POTASSIUM CHLORIDE MICRO ENCAPSULESULATED CRYSTALS
CONTROLLED RELEASE	
KLOR-CON M10							
POTASSIUM CHLORIDE PACK	KLOR-CON							
POTASSIUM CHLORIDE TABLET CONTROLLED RELEASE	KLOR-CON 8							
SODIUM								
SODIUM CHLORIDE FLUSH SOLUTION	NORMAL SALINE FLUSH							
MOUTH/THROAT/DENTAL AGENTS								
ANTISEPTICS - MOUTH/THROAT								
CHLORHEXIDINE GLUCONATE (MOUTH-THROAT) SOLUTION	PAROEX							
STEROIDS - MOUTH/THROAT								
TRIAMCINOLONE ACETONIDE (MOUTH) PASTE	ORALONE					10.00	30.00	
ANESTHETICS TOPICAL ORAL								
LIDOCAINE HCL (MOUTH-THROAT) SOLUTION	LIDOCAINE VISCOUS							
THROAT PRODUCTS - MISC.								

ARTIFICIAL SALIVA KIT	ORAL RELIEF FOR DRY MOUTH&
DISCOMFORT							
ARTIFICIAL SALIVA LOZENGE	ACT DRY MOUTH							

ARTIFICIAL SALIVA SOLUTION	BIOTENE MOISTURIZING MOUTH
SPRAY							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
MULTIVITAMINS								
B-COMPLEX VITAMINS								
B-COMPLEX VITAMINS	B-COMPLEX							
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							
B-COMPLEX W/ FOLIC ACID								
B COMPLEX W/ C-BIOTIN-E-FOLIC ACID & IRON CARBONYL MISC	RENATABLETS WITH IRON							
B-COMPLEX W/ C & FOLIC ACID	MILCO-B-FORTE							
B-COMPLEX W/ C & FOLIC ACID CAPSULES	NEPHROCAPSULES							
B-COMPLEX W/ C & FOLIC ACID TABLETS	DIALYVITE							
B-COMPLEX W/ C-BIOTIN-D-ZINC & FOLIC ACID TABLETS	VITAL-D RX							
B-COMPLEX W/ LYSINE-MIN-FE & FOLIC ACID LIQUID	NUTRIVIT							
B-COMPLEX W/ LYSINE-ZN & FOLIC ACID LIQUID	SUPERVITE							
IRON W/ VITAMINS								
IRON W/ VITAMINS TABLETS	GERITOL COMPLETE					30.00	30.00	
MULTIPLE VITAMINS W/ IRON								
MULTIPLE VITAMINS W/ IRON TABLETS	MULTIPLE VITAMINS/IRON							
MULTIPLE VITAMINS W/ MINERALS								
MULTIPLE VITAMINS W/ MINERALS CAPSULES	VARIOUS					30.00	30.00	
MULTIPLE VITAMINS W/ MINERALS CHEWABLE TABLETS	VARIOUS					30.00	30.00	
MULTIPLE VITAMINS W/ MINERALS LIQUID	VARIOUS					30.00	30.00	
MULTIPLE VITAMINS W/ MINERALS TABLETS	VARIOUS					30.00	30.00	
PEDIATRIC MULTIPLE VITAMINS								
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							
PED MULTI VITAMINS W/FL & FE								
PEDIATRIC VITAMINS ACD FLUORIDE & IRON SOLUTION	TRI-VIT/FLUORIDE/IRON							
PED MV W/ FLUORIDE								
PEDIATRIC MULTIVITAMINS W/FL CHEWABLE TABLETS	MVC-FLUORIDE					30.00	30.00	
PEDIATRIC MULTIVITAMINS W/FL SOLUTION	QUFLORA PEDIATRIC							
PEDIATRIC MULTIVITAMINS W/FL SUSPENSION	POLY-VI-FLOR							
PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLUTION	TRIPLE-VITAMIN/FLUORIDE							
PED MULTI VITAMINS W/FL & FE								
PED MULTIVITAMINS W/FL & IRON SOLUTION	MULTI-VIT/IRON/FLUORIDE							
PRENATAL VITAMINS								
PRENATAL MULTIVIT-MIN W/FE-FA TABS	PRE-NATAL FORMULA					30.00	30.00	
PRENATAL MV & MIN W/FE FUMARATE-FA-DHA MISC	VITAFOL-OB+DHA					30.00	30.00	
PRENATAL MV & MIN W/FE POLYSACCHARIDE COMPLEX-FA-DHA
CAPS	
VITAFOL-ONE					
30.00	
30.00	
PRENATAL MV & MIN W/FE POLYSACCHARIDE COMPLEX-FA-DHA
MISC	
SELECT-OB+DHA					
30.00	
30.00	

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	

PRENATAL VIT W/ DOCUSATE-FE FUMARATE-FOLIC ACID TABS	PNV FERROUS
FUMARATE/DOCUSATE/FOLIC ACID					
30.00	
30.00	
PRENATAL VIT W/ FE BISGLYCINATE CHELATE-FOLIC ACID TABS	VINATE AZ EXTRA					30.00	30.00	
PRENATAL VIT W/ FE FUM-IRON POLYSACCH COMPLEX -FA-OMEGA 3
CAPS	
CONCEPT DHA					
30.00	
30.00	
PRENATAL VIT W/ FERROUS FUMARATE-FA-OMEGA 3 FATTY ACIDS
CAPS	
VIVA DHA					
30.00	
30.00	
PRENATAL VIT W/ FERROUS FUMARATE-FOLIC ACID CHEW	COMPLETENATE					30.00	30.00	
PRENATAL VIT W/ FERROUS FUMARATE-FOLIC ACID TABS	M-VIT					30.00	30.00	
PRENATAL VIT W/ FERROUS FUMARATE-L METHYLFOLATE-FOLIC
ACID TABS	
ZATEAN-PN					
30.00	
30.00	
PRENATAL VIT W/ IRON CARBONYL-FE ASPART GLYC-FA-OMEGA 3
CAPS	
FOLCAPS OMEGA 3					
30.00	
30.00	
PRENATAL VIT W/ IRON CARBONYL-FOLIC ACID TABS	PRENATABS RX					30.00	30.00	
PRENATAL VIT W/ SELENIUM-FE FUMARATE-FOLIC ACID TABS	VINATE M					30.00	30.00	
PRENATAL W/O VIT A W/ FE FUMARATE-DSS-FA-DHA CAPS	PRENEXA					30.00	30.00	
PRENATAL WITHOUT A VIT W/ FE FUMARATE-FOLIC ACID CHEW	VINATE CARE					30.00	30.00	
PRENATAL WITHOUT A VIT W/ FE FUM-IRON POLYSACCH COMPLEX -
FA CAPS	
CONCEPT OB					
30.00	
30.00	
PRENATAL WITHOUT VIT A W/ FE CARBONYL-FE GLUC-DOCUSATE-FA
TABS	
CITRANATAL RX					
30.00	
30.00	
MUSCULOSKELETAL THERAPY AGENTS								
CENTRAL MUSCLE RELAXANTS								
BACLOFEN TABLETS	BACLOFEN							
CYCLOBENZAPRINE HCL TABLETS 5MG & 10MG ONLY	FLEXERIL							
METAXALONE TABLETS	METAXALONE							
METHOCARBAMOL TABLETS	ROBAXIN							
ORPHENADRINE CITRATE TABLET 12-HOUR	ORPHENADRINE CITRATE CR							
TIZANIDINE HCL - 2mg and 4mg TABLETS ONLY	TIZANIDINE HCL							
DIRECT MUSCLE RELAXANTS								
DANTROLENE SODIUM CAPSULES	DANTRIUM							
NASAL AGENTS - SYSTEMIC AND TOPICAL								
NASAL AGENTS - MISCELLANEOUS								
SALINE NASAL SPRAY	SALINE NASAL SPRAY							
NASAL ANTIALLERGY								
AZELASTINE HCL SOLUTION 0.10%	ASTELIN							
NASAL ANTICHOLINERGICS								
IPRATROPIUM BROMIDE (NASAL) SOLUTION	ATROVENT							
NASAL STEROIDS								
FLUNISOLIDE (NASAL) SOLUTION	FLUNISOLIDE							
FLUTICASONE PROPIONATE (NASAL) SUSPENSION	FLONASE							
MOMETASONE FUROATE (NASAL) SUSPENSION	NASONEX							
SYMPATHOMIMETIC DECONGESTANTS								
PSEUDOEPHEDRINE HCL GEL	ELIXIRSURE CONGESTION							
PSEUDOEPHEDRINE HCL LIQUID	SUDAFED CHILDRENS							
PSEUDOEPHEDRINE HCL SYRUP	PSEUDOEPHEDRINE							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	

PSEUDOEPHEDRINE HCL TABLETS	SHOPKO NASAL DECONGESTANTMAXIMUM
STRENGTH							
PSEUDOEPHEDRINE HCL TABLET 12-HOUR	SHOPKO NASAL DECONGESTANT							
PSEUDOEPHEDRINE HCL TABLET 24-HOUR	SUDAFED 24 HOUR							
NUTRIENTS								
MISC. NUTRITIONAL SUBSTANCES								
OMEGA-3 FATTY ACIDS CAPSULES	FISH OIL							
OMEGA-3 FATTY ACIDS CAPSULE DELAYED RELEASE	FISH OIL							
OMEGA 3 FATTY ACIDS-OMEGA 6 FATTY ACIDS-OMEGA 9 FATTY
ACIDS CAPSULES	
OMEGA-3-6-9							
OPHTHALMIC AGENTS								
ARTIFICIAL TEARS AND LUBRICANTS								
ARTIFICIAL TEAR GEL GEL	VARIOUS							
ARTIFICIAL TEAR 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							
POLYETHYLENE GLYCOL 400 (OPHTH) GEL	VARIOUS							
POLYETHYLENE GLYCOL 400 (OPHTH) SOLUTION	VARIOUS							
POLYETHYLENE GLYCOL-PROPYLENE GLYCOL (OPHTH) SOLUTION	VARIOUS							
POLYSORBATE 80 (OPHTH) SOLUTION	VARIOUS							
POLYVINYL ALCOHOL SOLUTION	VARIOUS							
BETA-BLOCKERS - OPHTHALMIC								
BETAXOLOL HCL (OPHTH) SOLUTION	BETAXOLOL HCL							
BETAXOLOL HCL (OPHTH) SUSPENSION	BETOPTIC-S							
BRIMONIDINE TARTRATE-TIMOLOL MALEATE SOLUTION	COMBIGAN							
CARTEOLOL HCL (OPHTH) SOLUTION	CARTEOLOL HCL							
DORZOLAMIDE HCL-TIMOLOL MALEATE SOLUTION	COSOPT							
LEVOBUNOLOL HCL SOLUTION	LEVOBUNOLOL HCL							
METIPRANOLOL SOLUTION	METIPRANOLOL							
TIMOLOL MALEATE (OPHTH) DROPS	TIMOPTIC-XE							
TIMOLOL MALEATE (OPHTH) SOLUTION	TIMOPTIC							
TIMOLOL SOLUTION	BETIMOL							
CYCLOPLEGIC MYDRIATICS								
ATROPINE SULFATE (OPHTHALMIC) OINTMENT	ATROPINE SULFATE							
ATROPINE SULFATE (OPHTHALMIC) SOLUTION	ISOPTO ATROPINE							
CYCLOPENTOLATE HCL SOLUTION	CYCLOGYL							
HOMATROPINE HBR SOLUTION	ISOPTO HOMATROPINE							
TROPICAMIDE SOLUTION	TROPICAMIDE							
MIOTICS								
PILOCARPINE HCL GEL	PILOPINE HS							
PILOCARPINE HCL SOLUTION	ISOPTO CARPINE							
OPHTHALMIC ADRENERGIC AGENTS								

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
APRACLONIDINE HCL SOLUTION	IOPIDINE							
BRIMONIDINE TARTRATE SOLUTION	ALPHAGAN P							
OPHTHALMIC ANTI-INFECTIVES								
BACITRACIN (OPHTHALMIC) OINTMENT	BACITRACIN					3.50	7.00	
BACITRACIN-POLYMYXIN B (OPHTH) OINTMENT	POLYCIN							
CIPROFLOXACIN HCL (OPHTH) OINTMENT	CILOXAN							
CIPROFLOXACIN HCL (OPHTH) SOLUTION	CILOXAN							
ERYTHROMYCIN (OPHTH) OINTMENT	ILOTYCIN							
GENTAMICIN SULFATE (OPHTH) OINTMENT	GARAMYCIN							
GENTAMICIN SULFATE (OPHTH) SOLUTION	GARAMYCIN							
MOXIFLOXACIN HCL (OPHTH) SOLUTION	VIGAMOX							
NATAMYCIN SUSPENSION	NATACYN							
NEOMYCIN-BACITRACIN ZN-POLYMYXIN OINTMENT	NEO-POLYCIN							
NEOMYCIN-POLYMYXIN-GRAMICIDIN SOLUTION	NEOSPORIN							
OFLOXACIN (OPHTH) SOLUTION	OCUFLOX							
POLYMYXIN B-TRIMETHOPRIM SOLUTION	POLYTRIM							
SULFACETAMIDE SODIUM (OPHTH) OINTMENT	SULFACETAMIDE SODIUM							
SULFACETAMIDE SODIUM (OPHTH) SOLUTION	BLEPH-10							
TOBRAMYCIN (OPHTH) OINTMENT	TOBREX					3.50	7.00	
TOBRAMYCIN (OPHTH) SOLUTION	TOBREX							
TRIFLURIDINE SOLUTION	VIROPTIC							
OPHTHALMIC DECONGESTANTS								

HYPROMELLOSE-GLYCERIN-NAPHAZOLINE SOLUTION	CLEAR EYES FOR DRY EYES PLUS
REDNESS RELIEF							
HYPROMELLOSE-NAPHAZOLINE-POLYSORBATE 80-ZINC SULFATE
SOLUTION	CLEAR EYES COMPLETE 7 SYMPTOM
RELIEF							
NAPHAZOLINE HCL SOLUTION	VASOCLEAR							
NAPHAZOLINE W/ PHENIRAMINE SOLUTION	NAPHCON-A							
NAPHAZOLINE W/ ZINC SULFATE SOLUTION	VASOCLEAR A							
NAPHAZOLINE-GLYCERIN SOLUTION	CLEAR EYES REDNESS RELIEF							
NAPHAZOLINE-GLYCERIN-ZINC SULFATE SOLUTION	CLEAR EYES SEASONAL RELIEF							
NAPHAZOLINE-HYPROMELLOSE SOLUTION	CVS MAXIMUM REDNESS RELIEF							
NAPHAZOLINE-POLYETHYLENE GLYCOL 300 SOLUTION	CVS REDNESS RELIEF							
OXYMETAZOLINE HCL (OPHTH) SOLUTION	VISINE-LR							
PHENYLEPHRINE-POLYVINYL ALCOHOL SOLUTION	REFRESH REDNESS RELIEF							
TETRAHYDROZOLINE HCL (OPHTH) SOLUTION	ALTAZINE							
TETRAHYDROZOLINE W/ POLYETHYLENE GLYCOL SOLUTION	ADVANCED LUBRICANT							
TETRAHYDROZOLINE W/ ZINC SULFATE SOLUTION	VISINE-AC							
TETRAHYDROZOLINE-DEXTRAN-POLYETHYLENE GLYCOL-POVIDONE
SOLUTION	
VISINE ADVANCED RELIEF							

TETRAHYDROZOLINE-GLYCERIN-HYPROMELLOSE-PEG 400 SOLUTION	
VISINE MAXIMUM REDNESS RELIEF							
TETRAHYDROZOLINE-GLYCERIN-HYPROMELLOSE-PEG 400-ZINC
SULFATE SOLUTION	VISINE TOTALITY MULTI-
SYMPTOM/HYDROBLEND							
TETRAHYDROZOLINE-POLYVINYL ALCOHOL-POVIDONE SOLUTION	CLEAR EYES TRIPLE ACTION RELIEF							
OPHTHALMIC IMMUNOMODULATORS								
CYCLOSPORINE (OPHTH) EMULSION	RESTASIS							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
OPHTHALMIC STEROIDS								
BACITRACIN-POLY-NEOMYCIN-HC OINTMENT	NEO-POLYCIN HC							
DEXAMETHASONE (OPHTH) SUSPENSION	MAXIDEX							

DEXAMETHASONE SODIUM PHOSPHATE (OPHTH) SOLUTION	DEXAMETHASONE SODIUM
PHOSPHATE							
FLUOROMETHOLONE (OPHTH) OINTMENT	FML							
FLUOROMETHOLONE (OPHTH) 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							

NEOMYCIN-POLYMYXIN-HC (OPHTH) SUSPENSION	NEOMYCIN/POLYMYXIN/HYDROCORTI
SONE							
PREDNISOLONE ACETATE (OPHTH) SUSPENSION	PRED MILD							

PREDNISOLONE SODIUM PHOSPHATE (OPHTH) 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					3.50	7.00	
TOBRAMYCIN-DEXAMETHASONE SUSPENSION	TOBRADEX ST							
OPHTHALMICS - MISC.								
AZELASTINE HCL (OPHTH) SOLUTION	OPTIVAR							
BRINZOLAMIDE SUSPENSION	AZOPT	Brand Only						
BROMFENAC SODIUM (OPHTH) SOLUTION	PROLENSA							
CROMOLYN SODIUM (OPHTH) SOLUTION	CROMOLYN SODIUM							
DICLOFENAC SODIUM (OPHTH) SOLUTION	DICLOFENAC SODIUM							
DORZOLAMIDE HCL SOLUTION	TRUSOPT							
EPINASTINE HCL (OPHTH) SOLUTION	ELESTAT							
FLURBIPROFEN SODIUM SOLUTION	OCUFEN							
KETOROLAC TROMETHAMINE (OPHTH) SOLUTION	ACULAR LS							
KETOTIFEN FUMARATE (OPHTH) SOLUTION	ALAWAY							
LODOXAMIDE TROMETHAMINE SOLUTION	ALOMIDE							
OLOPATADINE HCL SOLUTION	PATANOL							
SODIUM CHLORIDE HYPERTONIC SOLUTION	MURO							
SODIUM CHLORIDE HYPERTONIC OINTMENT	MURO							
PROSTAGLANDINS - OPHTHALMIC								
LATANOPROST SOLUTION	XALATAN					2.50	30.00	
TAFLUPROST SOLUTION	ZIOPTAN			PA Required				
TRAVOPROST SOLUTION	TRAVATAN Z	Brand Only						
OTIC AGENTS								
OTIC AGENTS - MISCELLANEOUS								
ACETIC ACID (OTIC) SOLUTION	ACETIC ACID							
OTIC ANTI-INFECTIVES								
CIPROFLOXACIN HCL (OTIC) SOLUTION	VARIOIUS		PREFERRED DRUG					

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
OFLOXACIN (OTIC) SOLUTION	VARIOIUS							
OTIC COMBINATIONS								
CIPROFLOXACIN-DEXAMETHASONE	CIPRODEX	Brand Only	PREFERRED BRAND					
NEOMYCIN-POLYMYXIN-HC (OTIC) SOLUTION	VARIOUS		PREFERRED BRAND					
NEOMYCIN-POLYMYXIN-HC (OTIC) SUSPENSION	VARIOUS		PREFERRED BRAND					
OTIC STEROIDS								
FLUOCINOLONE ACETONIDE (OTIC) OIL	DERMOTIC							
HYDROCORTISONE W/ACETIC ACID SOLUTION	ACETASOL HC							
OXYTOCICS								
OXYTOCICS								
METHYLERGONOVINE MALEATE TABLETS	METHERGINE							
PASSIVE IMMUNIZING AGENTS								
MONOCLONAL ANTIBODIES								

PALIVIZUMAB SOLUTION	

SYNAGIS			PA Required - if approved the prescriber must buy and bill a medical claim for
the drug				
PENICILLINS								
AMINOPENICILLINS								
AMOXICILLIN CAPSULES	AMOXICILLIN							
AMOXICILLIN CHEWABLE TABLETS	AMOXICILLIN							
AMOXICILLIN SUSPENSION	AMOXICILLIN							
AMOXICILLIN TABLETS	AMOXICILLIN							
AMOXICILLIN TABLET 24-HOUR	MOXATAG							
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 TABLETS	AMOXICILLIN/CLAVULANATE
POTASSIUM							
AMOXICILLIN & POT CLAVULANATE TABLET 12-HOUR	AUGMENTIN XR							
PENICILLINASE-RESISTANT PENICILLINS								
DICLOXACILLIN SODIUM CAPSULES	DICLOXACILLIN SODIUM							
PROGESTINS								
PROGESTINS								
HYDROXYPROGESTERONE CAPROATE OIL	MAKENA 250 MG/ML	Brand Only		PA Required				
HYDROXYPROGESTERONE CAPROATE SOLUTION AUTOINJECTOR	MAKENA AUTO INJECTOR	Brand Only		PA Required				
MEDROXYPROGESTERONE ACETATE TABLETS	PROVERA							
PROGESTERONE MICRONIZED CAPSULES	PROMETRIUM							
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENT								
AGENTS FOR CHEMICAL DEPENDENCY								
ACAMPROSATE CALCIUM TABLET DELAYED RELEASE	VARIOUS							
DISULFIRAM TABLETS	VARIOUS							
ANTIDEMENTIA AGENTS								

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
DONEPEZIL HYDROCHLORIDE TABLETS	ARICEPT							
DONEPEZIL HYDROCHLORIDE ORALLY DISPERSABLE TABLET	ARICEPT ODT							
GALANTAMINE HYDROBROMIDE CAPSULE 24-HOUR	RAZADYNE ER			PA Required				
GALANTAMINE HYDROBROMIDE SOLUTION	RAZADYNE			PA Required				
GALANTAMINE HYDROBROMIDE TABLETS	RAZADYNE			PA Required				
MEMANTINE HCL CAPSULE 24-HOUR	NAMENDA XR			PA Required				
MEMANTINE HCL SOLUTION	NAMENDA			PA Required				
MEMANTINE HCL TABLETS	NAMENDA			PA Required				
RIVASTIGMINE PATCH 24-HOUR	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 TITRATION PACK			PA Required				
INTERFERON BETA-1B KIT	BETASERON			PA Required				
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.								
ERGOLOID MESYLATES TABLETS	ERGOLOID MESYLATES							

PIMOZIDE TABLETS	
ORAP			Prior Authorization is required for < 12
years of age.				
SMOKING DETERRENTS								
BUPROPION HCL (SMOKING DETERRENT) TABLET 12-HOUR	BUPROBAN					168.00	180.00	
NICOTINE INHALER	NICOTROL INHALER					1008.00	180.00	
NICOTINE KIT	NICOTINE TRANSDERMAL SYSTEM					84.00	180.00	
NICOTINE POLACRILEX GUM	KLS QUIT2					540.00	180.00	
NICOTINE POLACRILEX LOZENGE	COMMIT					540.00	180.00	
NICOTINE PATCH 24-HOUR	NICODERM CQ					84.00	180.00	
NICOTINE SOLUTION	NICOTROL NS					120.00	180.00	
VARENICLINE TARTRATE TABLETS	CHANTIX					168.00	180.00	
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				
IVACAFTOR PACK	KALYDECO			PA Required				
IVACAFTOR TABLETS	KALYDECO			PA Required				
SULFONAMIDES								
SULFONAMIDES								
SULFADIAZINE TABLETS	SULFADIAZINE							
TOXOIDS								
TOXOID COMBINATIONS								
DIPH-AC PERT-TET TOX AD-POLIO IPV-HAEMOPHIL B POLY VAC
SUSPENSION	
PENTACEL							
DIPH-TETANUS TOX AD-ACELL PERTUSSIS & POLIO VIRUS, IPV VAC
SUSPENSION	
KINRIX							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
DIPH-TETANUS TOX-ACELL PERT-HEPATITIS B RECOMB-POLIO IPV VA
SUSPENSION	
PEDIARIX							
DIPHTHERIA, ACELLULAR PERTUSSIS & TETANUS TOXOIDS
SUSPENSION	
INFANRIX							

DIPHTHERIA-TETANUS TOXOIDS (DT) SUSPENSION	DIPHTHERIA/TETANUS TOXOIDS
ADSORBED PEDIATRIC							
TETANUS TOXOID-DIPHTHERIA-ACELLULAR PERTUSSIS ADSORB
(TDAP) SUSPENSION	
BOOSTRIX							

TETANUS-DIPHTHERIA TOXOIDS (TD) INJECTION	TETANUS/DIPHTHERIA TOXOID-
ADSORBED PUROGENATED ADULT							

TETANUS-DIPHTHERIA TOXOIDS (TD) SUSPENSION	TETANUS/DIPHTHERIA TOXOIDS-
ADSORBED ADULT							
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 CAPSULES	TIROSINT					30.00	30.00	
LEVOTHYROXINE SODIUM TABLETS	LEVO-T					30.00	30.00	
LIOTHYRONINE SODIUM TABLETS	CYTOMEL					30.00	30.00	
THYROID TABLETS	ARMOUR THYROID							
ULCER DRUGS								
ANTISPASMODICS								
DICYCLOMINE HCL CAPSULES	BENTYL							
DICYCLOMINE HCL SOLUTION	DICYCLOMINE HCL							
DICYCLOMINE HCL TABLETS	BENTYL							
GLYCOPYRROLATE SOLUTION	CUVPOSA							
GLYCOPYRROLATE TABLETS	ROBINUL							
HYOSCYAMINE SULFATE ELIXIR	HYOSCYAMINE SULFATE					120.00	30.00	
HYOSCYAMINE SULFATE SOLUTION	HYOSCYAMINE SULFATE					120.00	30.00	
HYOSCYAMINE SULFATE SUBLINGUAL	HYOMAX-SL					120.00	30.00	
HYOSCYAMINE SULFATE TABLETS	LEVSIN					120.00	30.00	
HYOSCYAMINE SULFATE TABLET 12-HOUR	LEVBID					120.00	30.00	
HYOSCYAMINE SULFATE TABLET CONTROLLED RELEASE	SYMAX DUOTAB					120.00	30.00	
HYOSCYAMINE SULFATE ORALLY DISPERSABLE TABLET	ANASPAZ					120.00	30.00	
PROPANTHELINE BROMIDE TABLETS	PROPANTHELINE BROMIDE							
H-2 ANTAGONISTS								
FAMOTIDINE CHEWABLE TABLETS	PEPCID AC							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
FAMOTIDINE SUSPENSION	PEPCID							
FAMOTIDINE TABLETS	PEPCID AC							
NIZATIDINE CAPSULES	NIZATIDINE							
NIZATIDINE SOLUTION	AXID							
MISC. ANTI-ULCER								
SUCRALFATE TABLETS	CARAFATE							
PROTON PUMP INHIBITORS								
ESOMEPRAZOLE MAGNESIUM PACKETS	NEXIUM			PA Required for > 18 Years of Age		30.00	30.00	
ESOMEPRAZOLE MAGNESIUM CAPSULE DELAYED RELEASE	NEXIUM					60.00	30.00	
LANSOPRAZOLE CAPSULE DELAYED RELEASE	HEARTBURN RELIEF 24 HOUR					60.00	30.00	
LANSOPRAZOLE ORALLY DISPERSABLE TABLET	PREVACID SOLUTAB			PA Required for > 18 Years of Age		60.00	30.00	
OMEPRAZOLE CAPSULE DELAYED RELEASE	VARIOUS					60.00	30.00	
PANTOPRAZOLE SODIUM PACK	PROTONIX			PA Required for > 18 Years of Age		30.00	30.00	
ULCER DRUGS - PROSTAGLANDINS								
MISOPROSTOL TABLETS	CYTOTEC							
URINARY ANTI-INFECTIVES								
URINARY ANTI-INFECTIVES								

FOSFOMYCIN TROMETHAMINE PACK	
MONUROL				
Patient must have tried Cipro AND Macrobid			
NITROFURANTOIN MACROCRYSTAL CAPSULES	MACRODANTIN							
NITROFURANTOIN MONOHYD MACRO CAPSULES	MACROBID							
NITROFURANTOIN SUSPENSION	FURADANTIN							
URINARY ANTISPASMODICS								
URINARY ANTISPASMODIC - ANTIMUSCARINICS
(ANTICHOLINERGIC)								
FESOTERODINE FUMARATE	TOVIAZ		PREFERRED DRUG					
OXYBUTYNIN CHLORIDE SYRUP	OXYBUTYNIN CHLORIDE		PREFERRED DRUG					
OXYBUTYNIN CHLORIDE TABLETS	OXYBUTYNIN CHLORIDE		PREFERRED DRUG					
OXYBUTYNIN CHLORIDE TABLET 24-HOUR	DITROPAN XL		PREFERRED DRUG					
TOLTERODINE TARTRATE CAPSULE 24-HOUR	DETROL LA	Brand Only	PREFERRED DRUG					
TOLTERODINE TARTRATE TABLETS	DETROL	Brand Only	PREFERRED DRUG					
URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS								
BETHANECHOL CHLORIDE TABLETS	URECHOLINE							
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							
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 KIT	MONISTAT 3 COMBINATION PACK							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
MICONAZOLE NITRATE VAGINAL SUPPOSITORY	MICONAZOLE 3							
SULFANILAMIDE VAGINAL CREAM	AVC							
TERCONAZOLE VAGINAL CREAM	TERAZOL 7							
TERCONAZOLE VAGINAL SUPPOSITORY	TERAZOL 3							
TIOCONAZOLE VAGINAL	MONISTAT 1-DAY							
VAGINAL ESTROGENS								
ESTRADIOL ACETATE VAGINAL RING	FEMRING			PA Required		1.00	30.00	
ESTRADIOL VAGINAL CREAM	ESTRADIOL							
ESTRADIOL VAGINAL RING	ESTRING					1.00	90.00	
ESTRADIOL VAGINAL TABLETS	VAGIFEM							
ESTROGENS, CONJUGATED VAGINAL CREAM	PREMARIN					1.00	30.00	
VAGINAL PROGESTINS								
VASOPRESSORS								
ANAPHYLAXIS THERAPY AGENTS								

EPINEPHRINE SELF-INJECTABLE	EPINEPHRINE SELF-INJECTABLE (By
Mylan)	
Mylan Generic	
Preferred Drug	
PA Required for > 2 Per Month		
2.00	
30.00	

EPINEPHRINE SELF-INJECTABLE	EPINEPHRINE SELF-INJECTABLE (By
Mylan)	
Mylan Generic	
Preferred Drug	
PA Required for > 2 Per Month		
2.00	
30.00	
VASOPRESSORS								
MIDODRINE HCL TABLETS	MIDODRINE HCL							
VACCINES								
VIRAL VACCINES								
COVID-19 (SARS-COV-2) ADENOVIRUS VACCINE	ASTRAZENECA							
COVID-19 (SARS-COV-2) MRNA VIRUS VACCINE	MODERNA							
HEPATITIS B VACCINE (RECOMB) INJECTION	ENGERIX-B							
HEPATITIS B VACCINE (RECOMB) SUSPENSION	RECOMBIVAX HB							
HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT RECOMBINANT VACCINE
SUSPENSION	
GARDASIL 9							
HUMAN PAPILLOMAVIRUS (HPV) 9-VALENT RECOMBINANT VACCINE
SUSPENSION PREFILLED SYRINGE	
GARDASIL 9							
HUMAN PAPILLOMAVIRUS (HPV) BIVALENT (TYPES 16, 18) RECMB VA
SUSPENSION	
CERVARIX							
HUMAN PAPILLOMAVIRUS (HPV) QUADRIVALENT RECOMBINANT
VACCINE SUSPENSION	
GARDASIL							
INFLUENZA VIRUS VACCINE RECOMBINANT HEMAGGLUTININ (HA)
SOLUTION	
FLUBLOK							
INFLUENZA VIRUS VACCINE SPLIT SUSPENSION	FLUZONE SPLIT							
INFLUENZA VIRUS VACCINE SPLIT HIGH-DOSE PRESERVATIVE FREE
SUSPENSION PREFILLED SYRINGE	
FLUZONE HIGH-DOSE PF							
INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE SUSPENSION
PREFILLED SYRINGE	
FLUZONE PF							
INFLUENZA VIRUS VACCINE SPLIT QUADRIVALENT SUSPENSION	FLUZONE QUADRIVALENT							
INFLUENZA VIRUS VACCINE SPLIT QUADRIVALENT SUSPENSION
PREFILLED SYRINGE	
FLUZONE QUADRIVALENT							
INFLUENZA VIRUS VACCINE TISSUE-CULTURED SUBUNIT PSKT	MEDICAL PROVIDER EZ FLU SHOT							
INFLUENZA VIRUS VACCINE TISSUE-CULTURED SUBUNIT SUSPENSION
PREFILLED SYRINGE	
FLUCELVAX							

	 Fee-For-Service Acute/Long Term Care Program Drug List	
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified as Brand Only	
Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization	Effective Date: 10/1/2021	

Drug Class/Drug Name	
Reference Brand Name	Brand Only / Generic Notes	
Preferred Drug Status	
PA Type	
Step Therapy Requirements	Quantity Limit	
QL Days	
INFLUENZA VIRUS VACCINE TISSUE-CULTURED SUBUNIT
QUADRIVALEN SUSPENSION PREFILLED SYRINGE	
FLUCELVAX QUADRIVALENT							
INFLUENZA VIRUS VACCINE TYPES A & B PRESERVATIVE FREE PSKT	MEDICAL PROVIDER EZ FLU SHOT PF							
INFLUENZA VIRUS VACCINE TYPES A & B PRESERVATIVE FREE
SUSPENSION PREFILLED SYRINGE	
FLUVIRIN PF							

INFLUENZA VIRUS VACCINE TYPES A & B SURFACE ANTIGEN PSKT	MEDICAL PROVIDER SINGLE USE EZ
FLU SHOT							
INFLUENZA VIRUS VACCINE TYPES A & B SURFACE ANTIGEN
SUSPENSION	
FLUVIRIN							
INFLUENZA VIRUS VACCINE TYPES A & B SURFACE ANTIGEN
SUSPENSION PREFILLED SYRINGE	
FLUVIRIN							
INFLUENZA VIRUS VACCINE TYPES A & B SURFACE ANTIGEN ADJUVAN
SUSPENSION PREFILLED SYRINGE	
FLUAD							
MEASLES, MUMPS & RUBELLA VIRUS VACCINES INJECTION	M-M-R II							

MEASLES-MUMPS-RUBELLA-VARICELLA VIRUS VACCINES INJECTION	
PROQUAD							
PNEUMOCOCCAL 13-VALENT CONJUGATE VACCINE SUSPENSION	PREVNAR 13							
PNEUMOCOCCAL VAC POLYVALENT INJECTION	PNEUMOVAX 23/5 DOSE							
ZOSTER VACCINE LIVE SOLUTION RECONSTITUED	ZOSTAVAX							
VITAMINS								
OIL SOLUBLE VITAMINS								
ERGOCALCIFEROL CAPSULES	DRISDOL					12.00	30.00	
VITAMIN E CAPSULES	VITAMIN E							
VITAMIN D DROPS 400UNIT	D-VI-SOL			PA Required for > 2 years of age				
WATER SOLUBLE VITAMINS								
NIACIN CAPSULE CONTROLLED RELEASE	VARIOUS							
NIACIN TABLET CONTROLLED RELEASE	VARIOUS							
PYRIDOXINE HCL TABLETS	PYRIDOXINE HCL							
THIAMINE HCL TABLETS	VITAMIN B-1