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: 1/1/2022	
Drugs Not On The List Are Messaged 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 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		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 CAPSULE 24-HOUR	RITALIN LA	BRAND ONLY	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 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	Catapres			PA Required for Ages < 6 years			
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	
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 or nursing.
The prescriber must note the following ICD- 10 codes on the prescription:
O09.91- Supervision of high risk pregnancy, 1st Trimester.
O09.92- Supervision of high risk pregnancy, 2nd Trimester.
O09.93- Supervision of high risk pregnancy, 3rd Trimester.
O09.91- Supervision of high risk pregnancy- use for Postpartum Nursing
Mothers.
The first digit of the diagnosis code is the Letter - O and the second is a Zero - 0			
BUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE FILM	SUBOXONE FILM	BRAND ONLY	PREFERRED DRUG				
BUPRENORPHINE SOLUTION PREFILLED SYRINGE	SUBLOCADE		PREFERRED DRUG	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: 1/1/2022	
Drugs Not On The List Are Messaged 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 SUBLINGUAL	
BUPRENORPHINE HCL-NALOXONE HCL DIHYDRATE	GENERIC
FORMULATIONS 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: 1/1/2022	
Drugs Not On The List Are Messaged 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	

LORAZEPAM TAB 2 MG	
VARIOUS			PA Required for > 1 Anxiolytic drug in a 30-
day time period.	
60.00	
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: 1/1/2022	
Drugs Not On The List Are Messaged 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	

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						
VALPROATE SODIUM SYRUP	DEPAKENE						
VALPROIC ACID CAPSULES	DEPAKENE						
ANTIDEPRESSANTS							
ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)							

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: 1/1/2022	
Drugs Not On The List Are Messaged 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	
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	
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	BUDEPROPION 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	
CITALOPRAM HYDROBROMIDE			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	

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: 1/1/2022	
Drugs Not On The List Are Messaged 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	
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	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				
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						

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: 1/1/2022	
Drugs Not On The List Are Messaged 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	
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	
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	
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 LAUROXIL PREFILLED SYRINGE	ARISTADA INITIO	BRAND ONLY	PREFERRED DRUG	PA Required for Ages < 18 years	2.00	365.00	
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	
RISPERIDONE PREFILLED SYRINGE	PERSERIS	BRAND ONLY	PREFERRED DRUG	PA Required for Ages < 18 years	2.00	28.00	
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			

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: 1/1/2022	
Drugs Not On The List Are Messaged 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	
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							
PROPRANOLOL HCL CAPSULE 24-HOUR	INDERAL LA				30.00	30.00	
PROPRANOLOL HCL SOLUTION	PROPRANOLOL HCL						
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			
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	

PREFERRED DRUG	Patient must have tried two preferred
agents (Temazepam, Zolpidem and Eszopiclone)	

30.00	

30.00	
LAXATIVES							
BULK LAXATIVES							

FIBER CAPSULES	ADVANCED FIBER
COMPLEX/ACIDOPHILUS						
FIBER CHEWABLE TABLETS	FIBER SELECT GUMMIES						
FIBER POWDER	FIBER						
FIBER TABLETS	FIBER COMPLETE						
METHYLCELLULOSE (LAXATIVE) POWDER	CITRUCEL FIBER LAXATIVE						
METHYLCELLULOSE (LAXATIVE) TABLETS	CITRUCEL						
PSYLLIUM CAPSULES	NAT-RUL PSYLLIUM SEED HUSKS						
PSYLLIUM PACK	METAMUCIL SMOOTH TEXTURE						
PSYLLIUM WAFER	METAMUCIL						
LAXATIVES - MISCELLANEOUSELLANEOUS							
LACTULOSE SOLUTION	LACTULOSE						
SALINE LAXATIVES							
MAGNESIUM CITRATE SOLUTION	CITROMA						
MAGNESIUM OXIDE (LAXATIVE) TABLETS	PHILLIPS						
STIMULANT 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: 1/1/2022	
Drugs Not On The List Are Messaged 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	
BISACODYL ENEMA	FLEET BISACODYL						
BISACODYL SUPPOSITORY	BISAC-EVAC						
BISACODYL TABLET ENTERIC COATED	ALOPHEN						
CASCARA SAGRADA CAPSULES	CASCARA SAGRADA						
CASCARA SAGRADA TABLETS	CASCARA SAGRADA						
SENNA LEAV	SENNA LEAVES						
SENNA SYRUP	SENNA						
SENNOSIDES CAPSULES	SENNA						
SURFACTANT LAXATIVES							
DOCUSATE SODIUM CAPSULES	COLACE						
DOCUSATE SODIUM TABLETS	DOK						
DOCUSATE SODIUM LIQUID	PEDIA-LAX						
DOCUSATE SODIUM SYRUP	DIOCTO						
MOUTH/THROAT/DENTAL AGENTS							
THROAT PRODUCTS - MISCELLANEOUS.							

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

ARTIFICIAL SALIVA SOLUTION	
BIOTENE MOISTURIZING MOUTH SPRAY						
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENT							
AGENTS FOR CHEMICAL DEPENDENCY							
ACAMPROSATE CALCIUM TABLET ENTERIC COATED	VARIOUS						
DISULFIRAM TABLETS	VARIOUS						
MOVEMENT DISORDER DRUG THERAPY							
DEUTETRABENAZINE TABLETS	AUSTEDO			PA Required			
VALBENAZINE TOSYLATE CAPSULES	INGREZZA			PA Required			
RESTLESS LEG SYNDROME (RLS) AGENTS							
PIMOZIDE TABLETS	ORAP			PA Required for < 12 Years of Age			
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						
WATER SOLUBLE VITAMINS							
NIACIN CAPSULE CONTROLLED RELEASE	NIACIN						
NIACIN TABLET CONTROLLED RELEASE	ENDUR-ACIN						
PYRIDOXINE HCL CAPSULES	NEURO-K-250 T.D.						
PYRIDOXINE HCL TABLETS	PYRIDOXINE HCL						
THIAMINE HCL TABLETS	VITAMIN B-1