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 are excluded from coverage under the outpatient pharmacy benefit:

DESI Drugs that are determined to be “less than fully effective”
Experimental / research drugs
Cosmetic drugs
Cosmetic drugs for hair growth
Child and Adolescent Immunizations
Nutritional / diet supplements
Blood and blood plasma products
Drugs and products to promote fertility
Drugs used for erectile dysfunction
Drugs from manufacturers that do not participate in the FFS Medicaid Drug Rebate Program
Diagnostic products
Medical supplies except:
Syringes
Needles
Lancets
Alcohol Swabs
Blood glucose meters and test strips
Inhale Spacers
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 information4nor 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 Behavioral Health Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only			AHCCCS TRBHA Program Drug List Effective Date: 7/1/2018		
Drugs Not On The List Are Message Back To The Pharmacy As PA Required	

Drug Class/Drug Name	
Reference Brand Name	
Brand Only	Preferred Drug
Status	
PRIOR AUTHORIZATION REQUIRED	
Quantity Limit	
QL Days	
ADHD							
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 CAPSULE 24-HOUR	DEXEDRINE		Preferred Drug	PA Required for ages < 6 years	60.00	30.00	
DEXTROAMPHETAMINE SULFATE TABLETS	ZENZEDI		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	Brand Only	Preferred Drug	PA Required for ages < 6 years	60.00	30.00	
METHYLPHENIDATE HCL CHEWABLE TABLETS	METHYLIN	Brand Only	Preferred Drug	PA Required for ages < 6 years	90.00	30.00	
METHYLPHENIDATE HCL CHEWABLE TABLETS EXTENDED RELEASE	QUILLICHEW ER	Brand Only	Preferred Drug	PA Required for ages < 6 years	30.00	30.00	
METHYLPHENIDATE HCL CAPSULE 24-HOUR	RITALIN LA /APTENSIO XR	Brand Only	Preferred Drug	PA Required for ages < 6 years	30.00	30.00	
METHYLPHENIDATE HCL CAPSULE 24-HOUR	VARIOUS		Preferred Drug	PA Required for ages < 6 years	30.00	30.00	
METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE	METADATE CD		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 SUSPENSION	QUILLIVANT XR	Brand Only	Preferred Drug	PA Required for ages < 6 years	150.00	30.00	
METHYLPHENIDATE HCL TABLETS	VARIOUS		Preferred Drug	PA Required for ages < 6 years	90.00	30.00	
METHYLPHENIDATE HCL TABLET 24-HOUR	METHYLPHENIDATE HCL ER		Preferred Drug	PA Required for ages < 6 years	60.00	30.00	
METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE	METHYLPHENIDATE HCL ER		Preferred Drug	PA Required for ages < 6 years	60.00	30.00	
MISCELLANEOUS AGENTS							
ATOMOXETINE HCL CAPSULES	STRATTERA	Brand Only	Preferred Drug	PA Required for ages < 6 years	30.00	30.00	
CENTRAL ALPHA AGONISTS							
CLONIDINE HCL	Catapres			PA Required for Ages < 6 years			
CLONIDINE HCL (ADHD) TABLET 12-HOUR	KAPVAY	Brand Only	Preferred Drug	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	
CLONIDINE HCL PATCH WEEKLY	CATAPRES-TTS			PA Required for Ages < 6 years	4.00	28.00	
GUANFACINE HCL TABLETS	Tenex			PA Required for Ages < 6 years			
ANALGESICS - OPIOID							
OPIOID PARTIAL AGONISTS							

BUPRENORPHINE	

VARIOUS			PA Required unless the member is pregnant the prescriber must note the following ICD- 10 codes on the prescription:
O09.91- Supervision of high risk preganancy, 1st Trimester.
O09.92- Supervision of high risk preganancy, 2nd Trimester.
O09.93- Supervision of high risk preganancy, 3rd Trimester.
O09.91- Supervision of high risk preganancy- use for Post-Partum Nursing
Mothers.			

AHCCCS Fee-For-Service TRBHA Behavioral Health Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS TRBHA Program Drug List Effective Date: 7/1/2018	
Drugs Not On The List Are Message Back To The Pharmacy As PA Required	

Drug Class/Drug Name	
Reference Brand Name	
Brand Only	Preferred Drug
Status	
PRIOR AUTHORIZATION REQUIRED	
Quantity Limit	
QL Days	
BUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE FILM	SUBOXONE FILM	Brand Only	Preferred Drug				

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

AHCCCS Fee-For-Service TRBHA Behavioral Health Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS TRBHA Program Drug List Effective Date: 7/1/2018	
Drugs Not On The List Are Message Back To The Pharmacy As PA Required	

Drug Class/Drug Name	
Reference Brand Name	
Brand Only	Preferred Drug
Status	
PRIOR AUTHORIZATION REQUIRED	
Quantity Limit	
QL Days	

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

AHCCCS Fee-For-Service TRBHA Behavioral Health Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS TRBHA Program Drug List Effective Date: 7/1/2018	
Drugs Not On The List Are Message Back To The Pharmacy As PA Required	

Drug Class/Drug Name	
Reference Brand Name	
Brand Only	Preferred Drug
Status	
PRIOR AUTHORIZATION REQUIRED	
Quantity Limit	
QL Days	

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

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

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

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

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	
ANTICONVULSANTS - MISCELLANEOUS.							
CARBAMAZEPINE CHEWABLE TABLETS	CARBAMAZEPINE						
CARBAMAZEPINE CAPSULE 12-HOUR	CARBATROL						
CARBAMAZEPINE SUSPENSION	TEGRETOL						
CARBAMAZEPINE TABLETS	EPITOL						
CARBAMAZEPINE (ANTIPSYCHOTIC) CAPSULE 12-HOUR	EQUETRO						
CARBAMAZEPINE TABLET 12-HOUR	TEGRETOL-XR						
GABAPENTIN CAPSULES	NEURONTIN						
GABAPENTIN SOLUTION	NEURONTIN						
GABAPENTIN TABLETS	NEURONTIN						
LAMOTRIGINE CHEWABLE TABLETS	LAMICTAL						
LAMOTRIGINE TABLETS	LAMICTAL						
LAMOTRIGINE TABLET 24-HOUR	LAMICTAL XR						
OXCARBAZEPINE SUSPENSION	TRILEPTAL						
OXCARBAZEPINE TABLETS	TRILEPTAL						
TOPIRAMATE TABLETS	TOPAMAX						
DIVALPROEX SODIUM CAPSULE SPRINKLE	DEPAKOTE SPRINKLES						
DIVALPROEX SODIUM TABLET 24-HOUR	DEPAKOTE ER						
DIVALPROEX SODIUM TABLET ENTERIC COATED	DEPAKOTE						

AHCCCS Fee-For-Service TRBHA Behavioral Health Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS TRBHA Program Drug List Effective Date: 7/1/2018	
Drugs Not On The List Are Message Back To The Pharmacy As PA Required	

Drug Class/Drug Name	
Reference Brand Name	
Brand Only	Preferred Drug
Status	
PRIOR AUTHORIZATION REQUIRED	
Quantity Limit	
QL Days	
VALPROATE SODIUM SYRUP	DEPAKENE						
VALPROIC ACID CAPSULES	DEPAKENE						
ANTIDEPRESSANTS							
ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)							
MIRTAZAPINE TABLETS	REMERON			PA Required for ages < 6 years	30.00	30.00	
MIRTAZAPINE TABLET DISPERSIBLE	REMERON SOLTAB			PA Required for ages < 6 years	30.00	30.00	
MONOAMINE OXIDASE INHIBITORS (MAOIS)							
ISOCARBOXAZID TABLETS	MARPLAN			PA Required for ages < 6 years			
PHENELZINE SULFATE TABLETS	NARDIL			PA Required for ages < 6 years			
SELEGILINE PATCH 24-HOUR	EMSAM			PA Required			
TRANYLCYPROMINE SULFATE TABLETS	PARNATE			PA Required for ages < 6 years			
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	BUDEPROPION SR			PA Required for ages < 6 years	60.00	30.00	
BUPROPION HCL TABLET 24-HOUR	WELLBUTRIN XL			PA Required for ages < 6 years	30.00	30.00	
MAPROTILINE HCL TABLETS	MAPROTILINE HCL			PA Required for ages < 6 years			
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)							
CITALOPRAM HYDROBROMIDE SOLUTION	CITALOPRAM HYDROBROMIDE			PA Required for ages < 6 years	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 SOLUTION	LEXAPRO			PA Required for ages < 6 years	600.00	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	600.00	30.00	
FLUOXETINE HCL TABLETS - WEEKLY	PROZAC WEEKLY			PA Required			
FLUVOXAMINE MALEATE CAPSULE 24-HOUR 100MG	LUVOX CR			PA Required for Ages < 6 years	90.00	30.00	
FLUVOXAMINE MALEATE CAPSULE 24-HOUR 150MG	LUVOX CR			PA Required for Ages < 6 years	60.00	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 SUSPENSION	PAXIL			PA Required for Ages < 6 years	900.00	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	
PAROXETINE HCL TABLET 24-HOUR	PAXIL CR			PA Required for Ages < 6 years	90.00	30.00	
PAROXETINE MESYLATE TABLETS	PEXEVA			PA Required			
SERTRALINE HCL CONCENTRATE	ZOLOFT			PA Required for Ages < 6 years	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	

AHCCCS Fee-For-Service TRBHA Behavioral Health Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS TRBHA Program Drug List Effective Date: 7/1/2018	
Drugs Not On The List Are Message Back To The Pharmacy As PA Required	

Drug Class/Drug Name	
Reference Brand Name	
Brand Only	Preferred Drug
Status	
PRIOR AUTHORIZATION REQUIRED	
Quantity Limit	
QL Days	
SERTRALINE HCL TABLETS 100MG	ZOLOFT			PA Required for Ages < 6 years	60.00	30.00	
VILAZODONE HCL TABLETS	VIIBRYD			PA Required			
SEROTONIN MODULATORS							
NEFAZODONE 50MG	VARIOUS			PA Required for Ages < 6 years	60.00	30.00	
NEFAZODONE 100MG	VARIOUS			PA Required for Ages < 6 years	60.00	30.00	
NEFAZODONE 150MG	VARIOUS			PA Required for Ages < 6 years	120.00	30.00	
NEFAZODONE 200MG	VARIOUS			PA Required for Ages < 6 years	90.00	30.00	
NEFAZODONE 250MG	VARIOUS			PA Required for Ages < 6 years	60.00	30.00	
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)							
DESVENLAFAXINE SUCCINATE TABLET SR 24HR 25 MG (BASE EQUIV)	PRISTIQ			PA Required for Ages < 6 years	120.00	30.00	
DESVENLAFAXINE SUCCINATE TABLET SR 24HR 50 MG (BASE EQUIV)	PRISTIQ			PA Required for Ages < 6 years	120.00	30.00	
DESVENLAFAXINE SUCCINATE TABLET SR 24HR 100 MG (BASE EQUIV)	PRISTIQ			PA Required for Ages < 6 years	120.00	30.00	
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	
VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 25MG	VENLAFAXINE HCL			PA Required for Ages < 6 years	120.00	30.00	
VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 37.5MG	VENLAFAXINE HCL			PA Required for Ages < 6 years	90.00	30.00	
VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 50MG	VENLAFAXINE HCL			PA Required for Ages < 6 years	90.00	30.00	
VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 75MG	VENLAFAXINE HCL			PA Required for Ages < 6 years	150.00	30.00	
VENLAFAXINE HCL TABLETS - IMMEDIATE RELEASE ONLY 100MG	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	AMOXAPINE			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			
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 CAPSULES	SURMONTIL			PA Required for ages < 6 years			
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				

AHCCCS Fee-For-Service TRBHA Behavioral Health Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS TRBHA Program Drug List Effective Date: 7/1/2018	
Drugs Not On The List Are Message Back To The Pharmacy As PA Required	

Drug Class/Drug Name	
Reference Brand Name	
Brand Only	Preferred Drug
Status	
PRIOR AUTHORIZATION REQUIRED	
Quantity Limit	
QL Days	
NALTREXONE SUSPENSION	VIVITROL		Preferred Drug				
ANTIHISTAMINES							
ANTIHISTAMINES - ETHANOLAMINES							
DIPHENHYDRAMINE HCL CAPSULES	VARIOUS						
DIPHENHYDRAMINE HCL CHEWABLE TABLETS	VARIOUS						
DIPHENHYDRAMINE HCL ELIXIR	VARIOUS						
DIPHENHYDRAMINE HCL LIQUID	VARIOUS						
DIPHENHYDRAMINE HCL STRIP - REMOVE	VARIOUS						
DIPHENHYDRAMINE HCL SUSPENSION	VARIOUS						
DIPHENHYDRAMINE HCL SYRUP	VARIOUS						
DIPHENHYDRAMINE HCL TABLETS	VARIOUS						
DIPHENHYDRAMINE HCL TABLET DISPERSIBLE - REMOVE	VARIOUS						
ANTIHISTAMINES - PIPERIDINES							
CYPROHEPTADINE HCL SYRUP	CYPROHEPTADINE HCL						
CYPROHEPTADINE HCL TABLETS	CYPROHEPTADINE HCL						
ANTIHYPERTENSIVES							
ANTIADRENERGIC ANTIHYPERTENSIVES							
PRAZOSIN HCL CAPSULES	MINIPRESS						
ANTIPARKINSON AGENTS							
ANTIPARKINSON ANTICHOLINERGICS							
BENZTROPINE MESYLATE SOLUTION	COGENTIN						
BENZTROPINE MESYLATE TABLETS	BENZTROPINE MESYLATE						
TRIHEXYPHENIDYL HCL ELIXIR	TRIHEXYPHENIDYL HCL						
TRIHEXYPHENIDYL HCL TABLETS	TRIHEXYPHENIDYL HCL						
ANTIPARKINSON DOPAMINERGICS							
AMANTADINE HCL CAPSULES	AMANTADINE HCL						
AMANTADINE HCL SYRUP	AMANTADINE HCL						
AMANTADINE HCL TABLETS	AMANTADINE HCL						
ANTIPSYCHOTICS/ANTIMANIC AGENTS							
ANTIMANIC AGENTS							
LITHIUM CARBONATE CAPSULES	LITHIUM CARBONATE						
LITHIUM CARBONATE TABLETS	LITHIUM CARBONATE						
LITHIUM CARBONATE TABLET CONTROLLED RELEASE	LITHOBID						
LITHIUM SOLUTION	LITHIUM						
ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL ORAL AGENTS							
ARIPIPRAZOLE TABLETS	ABILIFY		Preferred Drug	PA Required for Ages < 6 years	30.00	30.00	
ARIPIPRAZOLE ORALLY DISPERSABLE TABLET	ABILIFY		Preferred Drug	PA Required for Ages < 6 years	30.00	30.00	
ARIPIPRAZOLE SOLUTION	ABILIFY		Preferred Drug	PA Required for Ages < 6 years	150.00	30.00	
ASENAPINE MALEATE SUBLINGUAL	SAPHRIS	Brand Only	Preferred Drug	PA Required for Ages < 6 years	60.00	30.00	
CLOZAPINE ORALLY DISPERSABLE TABLET	FAZACLO		Preferred Drug	PA Required for Ages < 18 years	150.00	30.00	
CLOZAPINE TABLETS	CLOZARIL		Preferred Drug	PA Required for Ages < 18 years	150.00	30.00	
LURASIDONE HCL TABS	LATUDA	Brand Only	Preferred Drug	PA Required for Ages < 6 years	30.00	30.00	
OLANZAPINE ORALLY DISPERSABLE TABLET 5MG	ZYPREXA ZYDIS		Preferred Drug	PA Required for Ages < 6 years	60.00	30.00	
OLANZAPINE ORALLY DISPERSABLE TABLET 10MG	ZYPREXA ZYDIS		Preferred Drug	PA Required for Ages < 6 years	60.00	30.00	
OLANZAPINE ORALLY DISPERSABLE TABLET 15MG	ZYPREXA ZYDIS		Preferred Drug	PA Required for Ages < 6 years	30.00	30.00	

AHCCCS Fee-For-Service TRBHA Behavioral Health Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS TRBHA Program Drug List Effective Date: 7/1/2018	
Drugs Not On The List Are Message Back To The Pharmacy As PA Required	

Drug Class/Drug Name	
Reference Brand Name	
Brand Only	Preferred Drug
Status	
PRIOR AUTHORIZATION REQUIRED	
Quantity Limit	
QL Days	
OLANZAPINE ORALLY DISPERSABLE TABLET 20MG	ZYPREXA ZYDIS		Preferred Drug	PA Required for Ages < 6 years	30.00	30.00	
OLANZAPINE TABLETS	ZYPREXA		Preferred Drug	PA Required for Ages < 6 years	30.00	30.00	
QUETIAPINE FUMARATE TABLETS	SEROQUEL		Preferred Drug	PA Required for Ages < 6 years	60.00	30.00	
RISPERIDONE ORALLY DISPERSABLE TABLET	RISPERIDONE ODT		Preferred Drug	PA Required for Ages < 6 years	60.00	30.00	
RISPERIDONE ORAL SOLUTION	RISPERDAL		Preferred Drug	PA Required for Ages < 6 years	240.00	30.00	
RISPERIDONE TABLETS	RISPERDAL		Preferred Drug	PA Required for Ages < 6 years	60.00	30.00	
ZIPRASIDONE HCL CAPSULES	GEODON		Preferred Drug	PA Required for Ages < 6 years	60.00	30.00	
ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL LONG ACTING INJECTABLES							
ARIPIPRAZOLE LAUROXIL	ARISTADA	Brand Only	Preferred Drug	PA Required for Ages < 18 years	1.00	30.00	
ARIPIPRAZOLE SUSPENSION	ABILIFY MAINTENA	Brand Only	Preferred Drug	PA Required for Ages < 18 years	1.00	30.00	
PALIPERIDONE PALMITATE SUSPENSION	INVEGA SUSTENNA	Brand Only	Preferred Drug	PA Required for Ages < 18 years	1.00	30.00	
PALIPERIDONE PALMITATE SUSPENSION	INVEGA TRINZA	Brand Only	Preferred Drug	PA Required for Ages < 18 years	1.00	90.00	
RISPERIDONE MICROSPHERES SUSPENSION	RISPERDAL CONSTA	Brand Only	Preferred Drug	PA Required for Ages < 18 years	2.00	30.00	
ANTIPSYCHOTICS - FIRST GENERATION -TYPICAL ORAL AGENTS							
CHLORPROMAZINE HCL SOLUTION	VARIOUS			PA Required for Ages < 6 years			
CHLORPROMAZINE HCL TABLETS	VARIOUS			PA Required for Ages < 6 years			
FLUPHENAZINE HCL CONCENTRATE	VARIOUS			PA Required for Ages < 6 years			
FLUPHENAZINE HCL ELIXIR	VARIOUS			PA Required for Ages < 6 years			
FLUPHENAZINE HCL TABLETS	VARIOUS			PA Required for Ages < 6 years			
HALOPERIDOL LACTATE CONCENTRATE	VARIOUS			PA Required for Ages < 6 years			
HALOPERIDOL TABLETS	VARIOUS			PA Required for Ages < 6 years			
LOXAPINE SUCCINATE CAPSULES	LOXITANE			PA Required for Ages < 6 years			
PERPHENAZINE TABLETS	VARIOUS			PA Required for Ages < 6 years			
PIMOZIDE	ORAP			PA Required for Ages < 6 years			
THIORIDAZINE HCL TABLETS	VARIOUS			PA Required for Ages < 6 years			
THIOTHIXENE CAPSULES	VARIOUS			PA Required for Ages < 6 years			
TRIFLUOPERAZINE HCL TABLETS	VARIOUS			PA Required for Ages < 6 years			
ANTIPSYCHOTICS - FIRST GENERATION -TYPICAL -LONG ACTING INJECTIONS							
FLUPHENAZINE DECANOATE SOLUTION	FLUPHENAZINE DECANOATE			PA Required for Ages < 18 years			
HALOPERIDOL DECANOATE SOLUTION	HALDOL DECANOATE			PA Required for Ages < 18 years			
BETA BLOCKERS							
BETA BLOCKERS NON-SELECTIVE							
NADOLOL TABLETS	CORGARD						
PROPRANOLOL HCL CAPSULE 24-HOUR	INDERAL LA				30.00	30.00	
PROPRANOLOL HCL SOLUTION	PROPRANOLOL HCL						
PROPRANOLOL HCL SUSTAINED-RELEASE BEADS CAPSULE 24-HOUR	INDERAL XL				30.00	30.00	
PROPRANOLOL HCL TABLETS	PROPRANOLOL HCL						
HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENT							
ANTIHISTAMINE HYPNOTICS							
DIPHENHYDRAMINE HCL (SLEEP) CAPSULES	VARIOUS						
DIPHENHYDRAMINE HCL (SLEEP) LIQUID	VARIOUS						
DIPHENHYDRAMINE HCL (SLEEP) TABLETS	VARIOUS						
DIPHENHYDRAMINE HCL (SLEEP) TABLET DISPERSIBLE	VARIOUS						
HYPNOTICS - TRICYCLIC AGENTS							
DOXEPIN HCL (SLEEP) TABLETS	SILENOR			PA Required			

AHCCCS Fee-For-Service TRBHA Behavioral Health Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS TRBHA Program Drug List Effective Date: 7/1/2018	
Drugs Not On The List Are Message Back To The Pharmacy As PA Required	

Drug Class/Drug Name	
Reference Brand Name	
Brand Only	Preferred Drug
Status	
PRIOR AUTHORIZATION REQUIRED	
Quantity Limit	
QL Days	
NON-BARBITURATE HYPNOTICS							
TEMAZEPAM CAPSULES 15MG & 30MG	RESTORIL			PA Required for > 1 Hypnotic	30.00	30.00	
ZOLPIDEM TARTRATE TABLETS 5MG	AMBIEN			PA Required for > 1 Hypnotic	60.00	30.00	
ZOLPIDEM TARTRATE TABLETS 10MG	AMBIEN			PA Required for > 1 Hypnotic	30.00	30.00	
SELECTIVE MELATONIN RECEPTOR AGONISTS							

RAMELTEON TABLETS	
ROZEREM			Patient must have tried Temazepam and
Zolpidem			
LAXATIVES							
BULK LAXATIVES							

FIBER CAPSULES	ADVANCED FIBER
COMPLEX/ACIDOPHILUS						
FIBER CHEWABLE TABLETS	FIBER SELECT GUMMIES						
FIBER LIQUID	LIQUAFIBER						
FIBER POWDER	FIBER						
FIBER TABLETS	FIBER COMPLETE						
METHYLCELLULOSE (LAXATIVE) PACK	CITRUCEL FIBER LAXATIVE						
METHYLCELLULOSE (LAXATIVE) POWDER	CITRUCEL FIBER LAXATIVE						
METHYLCELLULOSE (LAXATIVE) TABLETS	CITRUCEL						
PSYLLIUM CAPSULES	NAT-RUL PSYLLIUM SEED HUSKS						
PSYLLIUM PACK	METAMUCIL SMOOTH TEXTURE						
PSYLLIUM POWDER	KONSYL						
PSYLLIUM WAFER	METAMUCIL						
LAXATIVES - MISCELLANEOUSELLANEOUS							
LACTULOSE PACK	KRISTALOSE						
LACTULOSE SOLUTION	LACTULOSE						
SALINE LAXATIVES							
MAGNESIUM CITRATE SOLUTION	CITROMA						
MAGNESIUM OXIDE (LAXATIVE) TABLETS	PHILLIPS						
STIMULANT LAXATIVES							
BISACODYL ENEMA	FLEET BISACODYL						
BISACODYL KIT	DULCOLAX BOWEL PREP KIT						
BISACODYL SUPPOSITORY	BISAC-EVAC						
BISACODYL TABLET ENTERIC COATED	ALOPHEN						
CASCARA SAGRADA CAPSULES	CASCARA SAGRADA						
CASCARA SAGRADA EXTR	CASCARA SAGRADA						
CASCARA SAGRADA TABLETS	CASCARA SAGRADA						
SENNA LEAV	SENNA LEAVES						
SENNA MISCELLANEOUS	CORRECTOL HERBAL TEA						
SENNA SYRUP	SENNA						
SENNA TABLETS	NATURAL SENNA LAXATIVE						
SENNOSIDES CAPSULES	SENNA						
SENNOSIDES CHEWABLE TABLETS	BLACK DRAUGHT						
SENNOSIDES LIQUID	AGORAL MAXIMUM STRENGTH						
SENNOSIDES TABLETS	DR EDWARDS OLIVE LAXATIVE						
SURFACTANT LAXATIVES							

AHCCCS Fee-For-Service TRBHA Behavioral Health Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS TRBHA Program Drug List Effective Date: 7/1/2018	
Drugs Not On The List Are Message Back To The Pharmacy As PA Required	

Drug Class/Drug Name	
Reference Brand Name	
Brand Only	Preferred Drug
Status	
PRIOR AUTHORIZATION REQUIRED	
Quantity Limit	
QL Days	
DOCUSATE SODIUM CAPSULES	COLACE						
DOCUSATE SODIUM ENEMA	DOCUSOL KIDS						
DOCUSATE SODIUM LIQUID	PEDIA-LAX						
DOCUSATE SODIUM SYRUP	DIOCTO						
MOUTH/THROAT/DENTAL AGENTS							
THROAT PRODUCTS - MISCELLANEOUS.							
ARTIFICIAL SALIVA AEROSOL SOLUTION	AQUORAL						

ARTIFICIAL SALIVA GEL	BIOTENE ORALBALANCE DRY MOUTH
MOISTURIZING						
ARTIFICIAL SALIVA GUM	BIOTENE DRY MOUTH GUM						

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

ARTIFICIAL SALIVA SOLUTION	
BIOTENE MOISTURIZING MOUTH SPRAY						
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENT							
AGENTS FOR CHEMICAL DEPENDENCY							
ACAMPROSATE CALCIUM TABLET ENTERIC COATED	VARIOUS						
DISULFIRAM TABLETS	VARIOUS						
POSTHERPETIC NEURALGIA (PHN) AGENTS							
GABAPENTIN (ONCE-DAILY) TABLETS	GRALISE			PA Required			
RESTLESS LEG SYNDROME (RLS) AGENTS							
GABAPENTIN ENACARBIL TABLETS ER	HORIZANT			PA Required			
PIMOZIDE TABLETS	ORAP						
THYROID AGENTS							
THYROID HORMONES							
LEVOTHYROXINE SODIUM TABLETS	LEVO-T				30.00	30.00	
LIOTHYRONINE SODIUM TABLETS	CYTOMEL				30.00	30.00	
VITAMINS							
OIL SOLUBLE VITAMINS							
VITAMIN E CAPSULES	VITAMIN E						
VITAMIN E CHEWABLE TABLETS	KEY-E						
VITAMIN E LIQUID	LIQUI-E						
VITAMIN E TABLETS	VITAMIN E						
WATER SOLUBLE VITAMINS							
NIACIN CAPSULE CONTROLLED RELEASE	NIACIN						
NIACIN TABLETS	NIACIN						
NIACIN TABLET CONTROLLED RELEASE	ENDUR-ACIN						
NIACINAMIDE TABLETS	NIACINAMIDE						
NIACINAMIDE TABLET CONTROLLED RELEASE	NIACINAMIDE PROLONGED RELEASE						
PYRIDOXINE HCL CAPSULES	NEURO-K-250 T.D.						
PYRIDOXINE HCL LOZENGE	B-NATAL						
PYRIDOXINE HCL LOLLIPOP	B-NATAL						
PYRIDOXINE HCL SOLUTION	PYRIDOXINE HCL						

AHCCCS Fee-For-Service TRBHA Behavioral Health Drug List	
Generic Preferred Over Brand, Unless Specified as Brand Only	AHCCCS TRBHA Program Drug List Effective Date: 7/1/2018	
Drugs Not On The List Are Message Back To The Pharmacy As PA Required	

Drug Class/Drug Name	
Reference Brand Name	
Brand Only	Preferred Drug
Status	
PRIOR AUTHORIZATION REQUIRED	
Quantity Limit	
QL Days	
PYRIDOXINE HCL TABLETS	PYRIDOXINE HCL						
PYRIDOXINE HCL TABLET CONTROLLED RELEASE	VITAMIN B-6						
RIBOFLAVIN CAPSULES	RIBOFLAVIN						
RIBOFLAVIN TABLETS	VITAMIN B-2						
THIAMINE HCL CAPSULES	THIAMINE						
THIAMINE HCL SOLUTION	THIAMINE HCL						
THIAMINE HCL TABLETS	VITAMIN B-1