AHCCCS Fee-For-Service Program
T(RBHA) Drug List (BHDL) INTRODUCTION

AHCCCS is pleased to provide the AHCCCS FFS Program T(RBHA)Drug List (BHDL) to be used when prescribing behavioral health medications for AHCCCS FFS members. For clarification, this BHDL is only for the AHCCCS FFS members and it does not apply to AHCCCS members enrolled in any of the AHCCCS Managed Care Contractors’ Health Plans. This document provides general information regarding the AHCCCS pharmacy benefit for FFS members. The drugs listed on the BHDL are intended to provide clinically appropriate, cost-effective options for AHCCCS FFS members who require medically necessary behavioral health treatment. The drugs listed on the BHDL have been reviewed and approved by the Pharmacy and Therapeutics (P&T) Committee. However, the BHDL is not intended as a comprehensive listing of all drugs that may be reimbursed by AHCCCS. If a drug is not listed on the BHDL and is determined to be medically necessary, it may be requested through the prior authorization process.

OptumRx is the Pharmacy Benefit Manager (PBM) for the AHCCCS FFS Program.
OptumRx will facilitate the administration of the pharmacy benefit for the following populations:
· 	Acute FFS – Title XIX
· 	Long Term Care FFS – Title XIX
· 	KidsCare FFS – Title XXI
· 	AHCCCS FFS Members who are enrolled in a TRBHA (Tribal/Regional Behavioral
Health Authority)
· 	Members who are Dual Eligibles (AHCCCS FFS members who are also eligible for
Medicare)
· 	Federal Emergency Services (FES) Members whose coverage is limited to emergency dialysis service

Members may obtain additional pharmacy information on the OptumRx website at:
https://ahcccs.rxportal.mycatamaranrx.com/rxclaim/portal/memberLogin

Members and prescribing clinicians may also contact the OptumRx Customer Service Center at 1 (855) 577-6310, 24 hours per day, 365 days per year.

For Prior Authorization Requests and Information:
· 	Prescribing Clinicians may fax the completed prior authorization form to the OptumRx Prior
Authorization Unit at 1 (866) 463-4830.
· 	For telephonic requests for information, prescribing clinicians may call 1 (855) 577-6310 for assistance.
· 	Prescribers preferring to send a written request via the US Mail, may send the request to the following address:

Optum Rx Prior Authorization Department
P.O. Box 5252
Lisle, IL 60532- 5252

With regard to federal legend drugs, medically necessary federally reimbursable outpatient prescription drugs are covered for eligible AHCCCS FFS members when prescribed by an AHCCCS registered clinician who is licensed to prescribe federal legend drugs in the State of Arizona. Some medications may require prior authorization approval prior to dispensing the medication to the member.

Pharmacy and Therapeutics (P&T) Committee
The P&T Committee, comprised of physicians and pharmacists, meets quarterly to discuss a variety of clinical issues, which pertain to drug selections, including formulary additions, deletions and changes as well as pharmacy program management.

The P&T Committee evaluates clinical information for newly marketed drugs within 180 days of market launch and current medications on an annual basis. The evaluation may include, but is not limited to the following review categories:

· 	Safety
· 	Efficacy
· 	Comparative data and studies
· 	FDA approved indications
· 	Treatment and consensus guidelines
· 	Adverse events
· 	Contraindications/Warnings/Precautions
· 	Pharmacokinetics
· 	Dosage frequency and formulations
· 	Patient administration/compliance considerations
· 	Medical outcome and pharmacoeconomic studies

When a new drug is considered for inclusion on the ADL, it will be reviewed relative to similar drugs currently included on the ADL. The review process of a therapeutic class continually promotes the most clinically appropriate, useful, and cost-effective agents. All of the information in the ADL is provided as a reference for drug therapy selection. Specific drug selection for an individual member rests solely with the prescribing clinician.

Generic Drugs
Generic substitution is a pharmacy action whereby a generic equivalent of a drug is dispensed rather than the brand name drug product. The AHCCCS pharmacy benefit requires mandatory generic substitution. This means that if a generic drug is equivalent to the brand reference drug and is available, the generic drug will
be required for the filling and dispensing of the prescription for payment through the point-of-sale claims
adjudication system. Generically available drugs are indicated on the ADL and are printed in lower case, for example, amoxacillin.

The ADL is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state. Products are listed with the generic name and the brand name is included as a reference to assist the prescribing clinicians in product recognition. Generics drugs are to be considered as the first line of prescribing.  AHCCCS and its Contractors are required to use the most cost effective (least costly) clinically appropriate pharmaceutical treatment. The ADL also covers selected over-the-counter (OTC) products. Prescribing clinicians are encouraged to prescribe OTC medications when clinically appropriate.

Prior Authorization Procedures For Drugs Not Listed On The ADL
The drugs on the ADL have been selected to provide the most clinically appropriate and cost-effective medications for AHCCCS FFS members. When a drug not listed on the ADL is determined to be medically
necessary for the appropriate medical management of a specific member, the prescriber must submit a prior authorization request specifying the reasons supporting the medical necessity of the particular drug for the AHCCCS member. Requests for these exceptions must be submitted in writing by the prescribing clinician on the OptumRx-AHCCCS Prior Authorization Form and faxed to:

OptumRx - Prior Authorization Department
Fax Number: 1 (866) 463-4830
Telephone Number: 1 (855) 577-6310

The OptumRx-AHCCCS Prior Authorization Request Form is available on the AHCCCS website at www.azahcccs.gov under the Pharmacy Information section on the right side of the website. Appropriate clinical documentation must be provided to support the medical necessity for the drug being requested. Responses to requests will be provided within 2 business days of receipt unless the request is identified as urgent. If a request is identified as urgent, a response will be provided within 1 business day.

Prescribing clinicians are requested to adhere to the ADL when prescribing for AHCCCS FFS members. If a pharmacist receives a prescription for a drug not listed on the ADL, the pharmacist is expected to contact the prescribing clinician and request that the prescription be changed to a medication included on the ADL. If a medication on the ADL is not appropriate, the prescribing clinician is to be instructed to submit a prior authorization request form to OptumRx. Please contact the OptumRx Prior Authorization Department at 1 (855) 577-6310 with questions concerning the prior authorization process.

Dose Optimization Program – Quantity Limits (QL)
The ADL utilizes Quantity Limits for several drugs listed on the ADL. The intent of the quantity limits is to promote dose optimization and efficient medication dosing. Prescriptions for monthly quantities greater than the indicated limit require a prior authorization approval. For quantities greater than those listed on the ADL,
the prescribing clinician must submit a prior authorization request with supporting documentation for the
increased quantity of medication. The Dose Optimization Program is designed to consolidate medication dosage to the most efficient daily quantity to increase member adherence to therapy and also promote the efficient use of health care dollars. The limits for the program are established based on FDA approval for dosing and the availability of the total daily dose in the least amount of tablets or capsules daily.

Quantity limits are loaded in the prescription claims processing system to promote minimized dosing. The pharmacy claims processing system will prompt the pharmacist to request a new prescription order from the prescribing clinician for more efficient dosing.

Additions to the Dose Optimization Program are made from time to time and providers notified accordingly. As always, we recognize that a number of member-specific variables must be taken into consideration when drug therapy is prescribed and therefore overrides will be available through the prior authorization process. For any questions, please contact the OptumRx Customer Service Center at 1 (855) 577-6310.

Prescription Utilization Parameters
AHCCCS members may reorder or refill a non-narcotic prescription when seventy-five percent (75%) of the medication has been used. Members may reorder or refill a narcotic prescription when eighty-five percent
(85%) of the medication has been used.
If a point-of-sale claim is submitted before 75% of the non-narcotic medication has been used, based on the original days supply submitted on the claim, the claim will reject with a "refill too soon" message. The same will happen with for narcotic prescription refills not meeting the 85% utilization. Please call the OptumRx

Customer Service Department at 1 (855) 577-6310 with questions or for help with dosage change authorization override.

Drug Efficacy Study Implementation (DESI) Drugs
Drugs that were initially marketed between the years of 1938 and 1962 were approved as safe but were not required to provide the effectiveness for FDA approval. Beginning in 1962 legislation required all new drugs to be both safe and effective before they could be approved to be available and marketed. This requirement also applied retroactively to all drugs approved as safe from the years 1938-1962. As a result, the FDA established the DESI program to review the labeled indications and the effectiveness of the pre-1962 drugs
and to provide a determination of effectiveness. The “fully effective” determination was given for most of
these products and they remain in the marketplace today. A few DESI products remain classified as “less than fully effective” and are awaiting final administrative disposition from the FDA. In addition, if a drug is classified as DESI, there are many products listed as identical, similar, or related to actual DESI products. The AHCCCS FFS ADL does not pay for claims for DESI drugs that are considered “less than fully effective” drug products.

AHCCCS FFS Plan Exclusions
The following drug categories are excluded from coverage under the outpatient pharmacy benefit and are not part of the ADL:

· 	DESI Drugs that are determined to be “less than fully effective”
· 	Anti obesity agents
· 	Experimental / research drugs
· 	Cosmetic drugs
· 	Cosmetic drugs for hair growth
· 	Immunizations
· 	Nutritional / diet supplements
· 	Blood and blood plasma products
· 	Products to promote fertility
· 	Erectile dysfunction drugs
· 	Drugs from manufacturers that do not participate in the FFS Medicaid Drug Rebate Program
· 	Diagnostic products
· 	Medical supplies except:
o Syringes o Needles o Lancets
o Alcohol Swabs
o Spacers
o Blood glucose meters and test strips
· 	Intrauterine Devices

Notice
AHCCCS and OptumRx provide the information contained in the ADL, solely for the convenience of prescribing clinicians. AHCCCS does not warrant or assure accuracy of such information nor is the ADL intended to be an all inclusive medication list. This ADL is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs.

AHCCCS assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider must consult the drug manufacturer’s product literature or standard references for more detailed information.

AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List	
•  Generic Preferred Over Brand, Unless Specified as Brand Only	

Drug Class/Drug Name	Brand Only	PA Type	Quantity Limit	QL Days	
ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREX					
AMPHETAMINES**					
AMPHETAMINE SULFATE TABS		PA Required for < 6 years of age	60	30	
AMPHETAMINE‐DEXTROAMPHETAMINE CP24		PA Required for < 6 years of age	30	30	
AMPHETAMINE‐DEXTROAMPHETAMINE TABS		PA Required for < 6 years of age	60	30	
DEXTROAMPHETAMINE SULFATE CP24		PA Required for < 6 years of age	60	30	
DEXTROAMPHETAMINE SULFATE SOLN		PA Required for < 6 years of age	600	30	
DEXTROAMPHETAMINE SULFATE TABS		PA Required for < 6 years of age	60	30	
LISDEXAMFETAMINE DIMESYLATE CAPS		PA Required for < 6 years of age	30	30	
ATTENTION‐DEFICIT/HYPERACTIVITY DISORDER (ADHD) AG					
ATOMOXETINE HCL CAPS		PA Required	60	30	
CLONIDINE HCL (ADHD) MISC		PA Required			
CLONIDINE HCL (ADHD) TB12		PA Required for < 6 years of age			
GUANFACINE HCL (ADHD) TB24		PA Required for < 6 years of age	30	30	
STIMULANTS ‐ MISC.**					
DEXMETHYLPHENIDATE HCL CP24		PA Required for < 6 years of age	30	30	
DEXMETHYLPHENIDATE HCL TABS		PA Required for < 6 years of age			
METHYLPHENIDATE HCL CHEW		PA Required for < 6 years of age	60	30	
METHYLPHENIDATE HCL CP24		PA Required for < 6 years of age	30	30	
METHYLPHENIDATE HCL CPCR		PA Required for < 6 years of age	30	30	
METHYLPHENIDATE HCL SOLN		PA Required for < 6 years of age	600	30	
METHYLPHENIDATE HCL SUSR		PA Required for < 6 years of age	180	30	
METHYLPHENIDATE HCL TABS		PA Required for < 6 years of age	90	30	
METHYLPHENIDATE HCL TBCR		PA Required for < 6 years of age	60	30	
METHYLPHENIDATE PTCH		PA Required	30	30	
ANTIANXIETY AGENTS*					
ANTIANXIETY AGENTS ‐ MISC.**					
BUSPIRONE HCL TABS			120	30	

AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List	
•  Generic Preferred Over Brand, Unless Specified as Brand Only	

Drug Class/Drug Name	Brand Only	PA Type	Quantity Limit	QL Days	
HYDROXYZINE HCL SYRP					
HYDROXYZINE HCL TABS					
HYDROXYZINE PAMOATE CAPS					
MEPROBAMATE TABS					
BENZODIAZEPINES**					
ALPRAZOLAM CONC			120	30	
ALPRAZOLAM TABS			120	30	
ALPRAZOLAM TB24			120	30	
ALPRAZOLAM TBDP			120	30	
CHLORDIAZEPOXIDE HCL CAPS			120	30	
CLORAZEPATE DIPOTASSIUM TABS			120	30	
CLORAZEPATE DIPOTASSIUM TB24			60	30	
DIAZEPAM CONC			120	30	
DIAZEPAM SOLN			120	30	
DIAZEPAM TABS			120	30	
LORAZEPAM CONC			120	30	
LORAZEPAM TABS			120	30	
OXAZEPAM CAPS			120	30	
ANTICONVULSANTS*					
ANTICONVULSANTS ‐ BENZODIAZEPINES**					
CLONAZEPAM TABS			120	30	
CLONAZEPAM TBDP			120	30	
ANTICONVULSANTS ‐ MISC.**					
CARBAMAZEPINE CHEW					
CARBAMAZEPINE CP12					
CARBAMAZEPINE POWD					
CARBAMAZEPINE SUSP					
CARBAMAZEPINE TABS					

AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List	
•  Generic Preferred Over Brand, Unless Specified as Brand Only	

Drug Class/Drug Name	Brand Only	PA Type	Quantity Limit	QL Days	
CARBAMAZEPINE TB12					
GABAPENTIN CAPS					
GABAPENTIN SOLN					
GABAPENTIN TABS					
LAMOTRIGINE CHEW					
LAMOTRIGINE KIT					
LAMOTRIGINE TABS					
LAMOTRIGINE TB24					
LAMOTRIGINE TBDP					
OXCARBAZEPINE SUSP					
OXCARBAZEPINE TABS					
TOPIRAMATE TABS					
VALPROIC ACID**					
DIVALPROEX SODIUM CPSP					
DIVALPROEX SODIUM TB24					
DIVALPROEX SODIUM TBEC					
VALPROATE SODIUM SYRP					
VALPROIC ACID CAPS					
ANTIDEPRESSANTS*					
ALPHA‐2 RECEPTOR ANTAGONISTS (TETRACYCLICS)**					
MIRTAZAPINE TABS		PA Required for < 6 years of age	45	30	
MIRTAZAPINE TBDP		PA Required for < 6 years of age	45	30	
ANTIDEPRESSANTS ‐ MISC.**					
BUPROPION HCL TABS		PA Required for < 6 years of age	60	30	
BUPROPION HCL TB12		PA Required for < 6 years of age	60	30	
BUPROPION HCL TB24		PA Required for < 6 years of age	60	30	
BUPROPION HYDROBROMIDE TB24		PA Required			
MONOAMINE OXIDASE INHIBITORS (MAOIS)**					

AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List	
•  Generic Preferred Over Brand, Unless Specified as Brand Only	

Drug Class/Drug Name	Brand Only	PA Type	Quantity Limit	QL Days	
ISOCARBOXAZID TABS		PA Required for < 6 years of age			
PHENELZINE SULFATE TABS		PA Required for < 6 years of age			
SELEGILINE PT24		PA Required			
TRANYLCYPROMINE SULFATE TABS		PA Required for < 6 years of age			
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)**					
CITALOPRAM HYDROBROMIDE SOLN		PA Required for < 6 years of age	600	30	
CITALOPRAM HYDROBROMIDE TABS		PA Required for < 6 years of age	60	30	
ESCITALOPRAM OXALATE SOLN		PA Required for < 6 years of age	300	30	
ESCITALOPRAM OXALATE TABS		PA Required for < 6 years of age	60	30	
FLUOXETINE HCL CAPS		PA Required for < 6 years of age	120	30	
FLUOXETINE HCL CPDR		PA Required for < 6 years of age	120	30	
FLUOXETINE HCL LIQD		PA Required for < 6 years of age	120	30	
FLUOXETINE HCL SOLN		PA Required for < 6 years of age	120	30	
FLUOXETINE HCL TABS		PA Required for < 6 years of age	120	30	
FLUVOXAMINE MALEATE CP24		PA Required for < 6 years of age	90	30	
FLUVOXAMINE MALEATE TABS		PA Required for < 6 years of age	120	30	
PAROXETINE HCL SUSP		PA Required for < 6 years of age	300	30	
PAROXETINE HCL TABS		PA Required for < 6 years of age	30	30	
PAROXETINE HCL TB24		PA Required for < 6 years of age	30	30	
PAROXETINE MESYLATE TABS		PA Required			
SERTRALINE HCL CONC		PA Required for < 6 years of age			
SERTRALINE HCL TABS		PA Required for < 6 years of age	60	30	
SEROTONIN MODULATORS**					
NEFAZODONE HCL TABS		PA Required for < 6 years of age			
TRAZODONE HCL POWD		PA Required for < 6 years of age			
TRAZODONE HCL TABS		PA Required for < 6 years of age			
VILAZODONE HCL KIT		PA Required			
VILAZODONE HCL TABS		PA Required			

AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List	
•  Generic Preferred Over Brand, Unless Specified as Brand Only	

Drug Class/Drug Name	Brand Only	PA Type	Quantity Limit	QL Days	
SEROTONIN‐NOREPINEPHRINE REUPTAKE INHIBITORS (SNRI)					
DESVENLAFAXINE FUMARATE TB24		PA Required for < 6 years of age	30	30	
DESVENLAFAXINE SUCCINATE TB24		PA Required for < 6 years of age	30	30	
DESVENLAFAXINE TB24		PA Required for < 6 years of age	30	30	
DULOXETINE HCL CPEP		PA Required for < 6 years of age	60	30	
VENLAFAXINE HCL CP24		PA Required for < 6 years of age	60	30	
VENLAFAXINE HCL TABS		PA Required for < 6 years of age	120	30	
VENLAFAXINE HCL TB24		PA Required for < 6 years of age	60	30	
TRICYCLIC AGENTS**					
AMITRIPTYLINE HCL POWD		PA Required for < 6 years of age			
AMITRIPTYLINE HCL SOLN		PA Required for < 6 years of age			
AMITRIPTYLINE HCL TABS		PA Required for < 6 years of age			
AMOXAPINE TABS		PA Required for < 6 years of age			
CLOMIPRAMINE HCL CAPS		PA Required for < 6 years of age			
DESIPRAMINE HCL POWD		PA Required for < 6 years of age			
DESIPRAMINE HCL TABS		PA Required for < 6 years of age			
DOXEPIN HCL CAPS		PA Required for < 6 years of age	90	30	
DOXEPIN HCL CONC		PA Required for < 6 years of age	180	30	
IMIPRAMINE HCL POWD		PA Required for < 6 years of age			
IMIPRAMINE HCL TABS		PA Required for < 6 years of age			
IMIPRAMINE PAMOATE CAPS		PA Required for < 6 years of age			
NORTRIPTYLINE HCL CAPS		PA Required for < 6 years of age			
NORTRIPTYLINE HCL POWD		PA Required for < 6 years of age			
NORTRIPTYLINE HCL SOLN		PA Required for < 6 years of age			
PROTRIPTYLINE HCL TABS		PA Required for < 6 years of age			
TRIMIPRAMINE MALEATE CAPS		PA Required for < 6 years of age			
TRIMIPRAMINE MALEATE POWD		PA Required for < 6 years of age			
ANTIHISTAMINES*					

AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List	
•  Generic Preferred Over Brand, Unless Specified as Brand Only	

Drug Class/Drug Name	Brand Only	PA Type	Quantity Limit	QL Days	
ANTIHISTAMINES ‐ ETHANOLAMINES**					
DIPHENHYDRAMINE CITRATE TBDP					
DIPHENHYDRAMINE HCL CAPS					
DIPHENHYDRAMINE HCL CHEW					
DIPHENHYDRAMINE HCL ELIX					
DIPHENHYDRAMINE HCL LIQD					
DIPHENHYDRAMINE HCL STRP					
DIPHENHYDRAMINE HCL SUSR					
DIPHENHYDRAMINE HCL SYRP					
DIPHENHYDRAMINE HCL TABS					
DIPHENHYDRAMINE HCL TBDP					
ANTIHISTAMINES ‐ PIPERIDINES**					
CYPROHEPTADINE HCL SYRP					
CYPROHEPTADINE HCL TABS					
ANTIHYPERTENSIVES*					
ANTIADRENERGIC ANTIHYPERTENSIVES**					
CLONIDINE HCL PTWK					
CLONIDINE HCL TABS					
GUANFACINE HCL TABS			60	30	
PRAZOSIN HCL CAPS					
PRAZOSIN HCL POWD					
ANTIPARKINSON AGENTS*					
ANTIPARKINSON ANTICHOLINERGICS**					
BENZTROPINE MESYLATE SOLN					
BENZTROPINE MESYLATE TABS					
TRIHEXYPHENIDYL HCL ELIX					
TRIHEXYPHENIDYL HCL TABS					
ANTIPARKINSON DOPAMINERGICS**					

AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List	
•  Generic Preferred Over Brand, Unless Specified as Brand Only	

Drug Class/Drug Name	Brand Only	PA Type	Quantity Limit	QL Days	
AMANTADINE HCL CAPS					
AMANTADINE HCL SYRP					
AMANTADINE HCL TABS					
ANTIPSYCHOTICS/ANTIMANIC AGENTS*					
ANTIMANIC AGENTS**					
LITHIUM CARBONATE CAPS					
LITHIUM CARBONATE POWD					
LITHIUM CARBONATE TABS					
LITHIUM CARBONATE TBCR					
LITHIUM CITRATE SYRP					
LITHIUM SOLN					
ANTIPSYCHOTICS ‐ MISC.**					
CARBAMAZEPINE (ANTIPSYCHOTIC) CP12					
LURASIDONE HCL TABS		PA Required			
ZIPRASIDONE HCL CAPS		PA Required for < 6 years of age	60	30	
BENZISOXAZOLES**					
ILOPERIDONE TABS		PA Required			
PALIPERIDONE PALMITATE SUSP		PA Required			
PALIPERIDONE TB24		PA Required			
RISPERIDONE MICROSPHERES SUSR		PA Required for < 6 years of age			
RISPERIDONE SOLN		PA Required for < 6 years of age	240	30	
RISPERIDONE TABS		PA Required for < 6 years of age	60	30	
RISPERIDONE TBDP		PA Required for < 6 years of age	60	30	
BUTYROPHENONES**					
HALOPERIDOL DECANOATE SOLN		PA Required for < 6 years of age			
HALOPERIDOL LACTATE CONC		PA Required for < 6 years of age			
HALOPERIDOL LACTATE SOLN		PA Required for < 6 years of age			
HALOPERIDOL POWD		PA Required for < 6 years of age			

AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List	
•  Generic Preferred Over Brand, Unless Specified as Brand Only	

Drug Class/Drug Name	Brand Only	PA Type	Quantity Limit	QL Days	
HALOPERIDOL TABS		PA Required for < 6 years of age			
DIBENZAPINES**					
ASENAPINE MALEATE SUBL		PA Required			
CLOZAPINE SUSP		PA Required for < 6 years of age			
CLOZAPINE TABS		PA Required for < 6 years of age	150	30	
CLOZAPINE TBDP		PA Required for < 6 years of age	150	30	
LOXAPINE HCL CONC		PA Required for < 6 years of age			
LOXAPINE HCL SOLN		PA Required for < 6 years of age			
LOXAPINE SUCCINATE CAPS		PA Required for < 6 years of age			
OLANZAPINE PAMOATE SUSR		PA Required			
OLANZAPINE TABS		PA Required for < 6 years of age	30	30	
OLANZAPINE TBDP		PA Required for < 6 years of age	30	30	
QUETIAPINE FUMARATE TABS		PA Required for < 6 years of age	60	30	
QUETIAPINE FUMARATE TB24		PA Required			
PHENOTHIAZINES**					
CHLORPROMAZINE HCL CONC		PA Required for < 6 years of age			
CHLORPROMAZINE HCL CPCR		PA Required for < 6 years of age			
CHLORPROMAZINE HCL SOLN		PA Required for < 6 years of age			
CHLORPROMAZINE HCL SYRP		PA Required for < 6 years of age			
CHLORPROMAZINE HCL TABS		PA Required for < 6 years of age			
CHLORPROMAZINE SUPP		PA Required for < 6 years of age			
FLUPHENAZINE DECANOATE SOLN		PA Required for < 6 years of age			
FLUPHENAZINE ENANTHATE SOLN		PA Required for < 6 years of age			
FLUPHENAZINE HCL CONC		PA Required for < 6 years of age			
FLUPHENAZINE HCL ELIX		PA Required for < 6 years of age			
FLUPHENAZINE HCL SOLN		PA Required for < 6 years of age			
FLUPHENAZINE HCL TABS		PA Required for < 6 years of age			
MESORIDAZINE BESYLATE CONC		PA Required for < 6 years of age			

AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List	
•  Generic Preferred Over Brand, Unless Specified as Brand Only	

Drug Class/Drug Name	Brand Only	PA Type	Quantity Limit	QL Days	
MESORIDAZINE BESYLATE SOLN		PA Required for < 6 years of age			
MESORIDAZINE BESYLATE TABS		PA Required for < 6 years of age			
PERPHENAZINE CONC		PA Required for < 6 years of age			
PERPHENAZINE TABS		PA Required for < 6 years of age			
THIORIDAZINE HCL CONC		PA Required for < 6 years of age			
THIORIDAZINE HCL SUSP		PA Required for < 6 years of age			
THIORIDAZINE HCL TABS		PA Required for < 6 years of age			
TRIFLUOPERAZINE HCL CONC		PA Required for < 6 years of age			
TRIFLUOPERAZINE HCL POWD		PA Required for < 6 years of age			
TRIFLUOPERAZINE HCL SOLN		PA Required for < 6 years of age			
TRIFLUOPERAZINE HCL TABS		PA Required for < 6 years of age			
QUINOLINONE DERIVATIVES**					
ARIPIPRAZOLE SOLN	Brand Only	PA Required	150	30	
ARIPIPRAZOLE SUSR	Brand Only	PA Required			
ARIPIPRAZOLE TABS	Brand Only	PA Required for < 6 years of age	30	30	
ARIPIPRAZOLE TBDP	Brand Only	PA Required for < 6 years of age	30	30	
THIOXANTHENES**					
THIOTHIXENE CAPS		PA Required for < 6 years of age			
THIOTHIXENE HCL CONC		PA Required for < 6 years of age			
BETA BLOCKERS*					
BETA BLOCKERS NON‐SELECTIVE**					
NADOLOL TABS					
PROPRANOLOL HCL CONC					
PROPRANOLOL HCL CP24			30	30	
PROPRANOLOL HCL CPCR					
PROPRANOLOL HCL POWD					
PROPRANOLOL HCL SOLN					
PROPRANOLOL HCL SUSTAINED‐RELEASE BEADS CP24			30	30	

AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List	
•  Generic Preferred Over Brand, Unless Specified as Brand Only	

Drug Class/Drug Name	Brand Only	PA Type	Quantity Limit	QL Days	
PROPRANOLOL HCL TABS					
HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENT					
ANTIHISTAMINE HYPNOTICS**					
DIPHENHYDRAMINE HCL (SLEEP) CAPS					
DIPHENHYDRAMINE HCL (SLEEP) LIQD					
DIPHENHYDRAMINE HCL (SLEEP) TABS					
DIPHENHYDRAMINE HCL (SLEEP) TBDP					
HYPNOTICS ‐ TRICYCLIC AGENTS**					
DOXEPIN HCL (SLEEP) TABS		PA Required			
NON‐BARBITURATE HYPNOTICS**					
CHLORAL HYDRATE CAPS			60	30	
CHLORAL HYDRATE SUPP			30	30	
CHLORAL HYDRATE SYRP			150	30	
ESTAZOLAM TABS			30	30	
ESZOPICLONE TABS			30	30	
FLURAZEPAM HCL CAPS			30	30	
TEMAZEPAM CAPS			30	30	
TRIAZOLAM TABS			30	30	
ZALEPLON CAPS			30	30	
ZOLPIDEM TARTRATE SOLN		PA Required			
ZOLPIDEM TARTRATE SUBL		PA Required			
ZOLPIDEM TARTRATE TABS			60	30	
ZOLPIDEM TARTRATE TBCR			30	30	
SELECTIVE MELATONIN RECEPTOR AGONISTS**					
RAMELTEON TABS					
LAXATIVES*					
BULK LAXATIVES**					
FIBER CAPS					

AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List	
•  Generic Preferred Over Brand, Unless Specified as Brand Only	

Drug Class/Drug Name	Brand Only	PA Type	Quantity Limit	QL Days	
FIBER CHEW					
FIBER LIQD					
FIBER POWD					
FIBER TABS					
METHYLCELLULOSE (LAXATIVE) PACK					
METHYLCELLULOSE (LAXATIVE) POWD					
METHYLCELLULOSE (LAXATIVE) TABS					
PSYLLIUM CAPS					
PSYLLIUM GRAN					
PSYLLIUM PACK					
PSYLLIUM POWD					
PSYLLIUM WAFR					
LAXATIVES ‐ MISCELLANEOUS**					
LACTULOSE PACK					
LACTULOSE SOLN					
LACTULOSE SYRP					
SALINE LAXATIVES**					
MAGNESIUM CITRATE SOLN					
MAGNESIUM OXIDE (LAXATIVE) TABS					
MAGNESIUM SULFATE (LAXATIVE) LIQD					
STIMULANT LAXATIVES**					
BISACODYL ENEM					
BISACODYL KIT					
BISACODYL POWD					
BISACODYL SUPP					
BISACODYL TBEC					
CASCARA SAGRADA CAPS					
CASCARA SAGRADA EXTR					

AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List	
•  Generic Preferred Over Brand, Unless Specified as Brand Only	

Drug Class/Drug Name	Brand Only	PA Type	Quantity Limit	QL Days	
CASCARA SAGRADA LIQD					
CASCARA SAGRADA TABS					
SENNA KIT					
SENNA LEAV					
SENNA LIQD					
SENNA MISC					
SENNA POWD					
SENNA SYRP					
SENNA TABS					
SENNOSIDES CAPS					
SENNOSIDES CHEW					
SENNOSIDES GRAN					
SENNOSIDES LIQD					
SENNOSIDES STRP					
SENNOSIDES TABS					
SURFACTANT LAXATIVES**					
DOCUSATE SODIUM CAPS					
DOCUSATE SODIUM ENEM					
DOCUSATE SODIUM LIQD					
DOCUSATE SODIUM POWD					
DOCUSATE SODIUM SYRP					
DOCUSATE SODIUM TABS					
MOUTH/THROAT/DENTAL AGENTS*					
THROAT PRODUCTS ‐ MISC.**					
ARTIFICIAL SALIVA AERS					
ARTIFICIAL SALIVA GEL					
ARTIFICIAL SALIVA GUM					
ARTIFICIAL SALIVA KIT					

AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List	
•  Generic Preferred Over Brand, Unless Specified as Brand Only	

Drug Class/Drug Name	Brand Only	PA Type	Quantity Limit	QL Days	
ARTIFICIAL SALIVA LOZG					
ARTIFICIAL SALIVA PACK					
ARTIFICIAL SALIVA SOLN					
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENT					
AGENTS FOR CHEMICAL DEPENDENCY**					
ACAMPROSATE CALCIUM TBEC			180	30	
DISULFIRAM TABS					
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC.*					
PIMOZIDE TABS					
THYROID AGENTS*					
THYROID HORMONES**					
LEVOTHYROXINE SODIUM TABS			30	30	
LIOTHYRONINE SODIUM TABS			30	30	
URINARY ANTISPASMODICS*					
URINARY ANTISPASMODICS**					
BETHANECHOL CHLORIDE TABS					
VITAMINS*					
OIL SOLUBLE VITAMINS**					
VITAMIN E CAPS					
VITAMIN E CHEW					
VITAMIN E LIQD					
VITAMIN E TABS					
WATER SOLUBLE VITAMINS**					
NIACIN CPCR					
NIACIN ELIX					
NIACIN POWD					
NIACIN TABS					
NIACIN TBCR					

AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List	
•  Generic Preferred Over Brand, Unless Specified as Brand Only	

Drug Class/Drug Name	Brand Only	PA Type	Quantity Limit	QL Days	
NIACINAMIDE POWD					
NIACINAMIDE TABS					
NIACINAMIDE TBCR					
PYRIDOXINE HCL CAPS					
PYRIDOXINE HCL CPCR					
PYRIDOXINE HCL LOZG					
PYRIDOXINE HCL LPOP					
PYRIDOXINE HCL POWD					
PYRIDOXINE HCL SOLN					
PYRIDOXINE HCL TABS					
PYRIDOXINE HCL TBCR					
RIBOFLAVIN CAPS					
RIBOFLAVIN POWD					
RIBOFLAVIN TABS					
THIAMINE HCL CAPS					
THIAMINE HCL POWD					
THIAMINE HCL SOLN					
THIAMINE HCL TABS					
THIAMINE MONONITRATE POWD					
THIAMINE MONONITRATE TABS