TO SEARCH THIS DOCUMENT, PRESS THE CNTRL KEY AT THE SAME TIME AS THE ‘F’ KEY. A SEARCH WINDOW WILL APPEAR. ENTER THE NAME OF THE DRUG IN THE SEARCH BOX AND SELECT THE ARROW UP OR DOWN TO SEARCH THE DOCUMENT.
Drug List May 2016 The Phoenix Health Plan (PHP) Drug List is also available for printing at www.phoenixhealthplan.com
The PHP Drug List includes the required list of drugs from the AHCCCS Drug List and drugs PHP chooses to have in addition to that list.
PHOENIX HEALTH PLAN DRUG LIST The Phoenix Health Plan (PHP) Drug List was created to ensure safe, appropriate and cost-effective utilization of medications. With a primary consideration to provide comprehensive drug coverage for patients, the Drug List was evaluated in all therapeutic categories and contains those agents that offer the greatest value in each class. Provider’s utilization of the PHP Drug List ensures our member’s pharmaceutical needs are met in a high quality, cost-effective manner. Drug List development and maintenance is a dynamic process and is subject to periodic changes. THE PHP PHARMACY AND THERAPEUTICS COMMITTEE PURPOSE AND GOALS The PHP Pharmacy and Therapeutic (P & T) Committee consists of physicians, pharmacists, and other professionals representing various medical specialties, whose primary purpose is to develop and monitor the PHP Drug List and to establish programs and procedures to ensure high quality, cost-effective drug therapy. The PHP P & T regularly reviews new and existing medications to ensure the Drug List meets the needs of both members and providers. FUNCTION AND SCOPE: The P & T has the following primary functions: 1. To serve in an advisory capacity in all matters pertaining to use of drugs and drug therapy. 2. To perform a periodic review of the PHP Drug List and to provide advice to the plan regarding modifications of the Drug List based upon an objective analysis of the safety, efficacy, and costeffectiveness of each medication. 3. To develop educational programs and materials for health plan participants, physicians, and provider pharmacies related to drug use. 4. To evaluate and recommend drug therapy guidelines and prior authorization criteria based upon safety, efficacy, and cost-effectiveness. 5. To manage and review appropriateness of drug utilization. 6. To make recommendations for policies and procedures relating to drug handling and administration for health plan members.
PROCEDURES FOR AMENDING THE DRUG LIST Contracted physicians may request additions, deletions or change in prior authorization criteria for consideration by P&T Committee. Requests should include, as appropriate: Product information Indications for use Therapeutic advantage over medications currently on the formulary Which current formulary medication the proposed medication would replace Published supporting literature from peer reviewed medical journals Note: Drug company marketing materials will not be accepted Mail or fax requests to: Phoenix Health Plan C/O P & T Committee Pharmacy Director 7878 N. 16th St. Suite 105 Phoenix, AZ 85020 Fax: (602) 674-6652, (888) 887-9982 THE PHP DRUG LIST The PHP Drug List is a list of medications eligible for coverage by PHP and includes the AHCCCS Minimum Required Preferred Drug List. The covered medications are organized by therapy class. Both brands and generics are available, however, if a medication is available generically, only the generic formulation is covered. If a generic formulation becomes available sometime in the year, the brand formulation will no longer be covered and the generic will automatically process. For specific information about the medication, please refer to a comprehensive drug information resource and the product package insert. If a drug name does not appear on the list of Drug List Medications, the drug requires a prior authorization. Prior Authorization is a feature of your prescription benefit plan that helps ensure the appropriate use of selected prescription drugs. This program is designed to prevent improprer prescribing or use of certain drugs that may not be the best choice for a health condition. There are some drugs listed that have special restrictions and are noted in the last column of the Drug List. Please look to the website www.phoenixhealthplan.com for the most up-to-date Drug List. NON-COVERED MEDICATIONS Please note that certain medications are excluded by AHCCCS and thus are not covered by the plan. In order to reduce the risk of adverse effects to our patients, PHP will not cover drugs when prescribed for experimental or investigational uses. These medications include but are not limited to the following:
Drugs and products used for the treatment of ED (Erectile Dysfunction) Drugs used for Cosmetic Purposes (e.g. Topical Minoxidil) Experimental or Investigational Medications Medications purchased outside of the United States DESI (Drug Efficacy Study Implementation) drugs – drugs not deemed effective by the FDA. Medical Marijuana Drugs covered under Medicare Part D for AHCCCS members eligible for Medicare whether or not the member receives Medicare Part D coverage Drugs used for Infertility Treatment
INJECTABLE MEDICATIONS Injectable medications obtained by prescription, other than insulin, insulin supplies, and those specifically listed on the PHP Drug List, are eligible for coverage. Please note any special restrictions or prior authorization requirements for coverage of injectable medications. PHP may elect to provide coverage for other injectable medications and will advise our pharmacy benefit manager (PBM) that an exception is to be made. Members may not be asked to fill the prescription at a community pharmacy and bring it to the medical offices for administration. NON-PRESCRIPTION DRUGS If an over-the-counter (OTC) product is listed on the Drug List and a prescription is written and presented to the pharmacy, the product is covered by PHP. Insulin and insulin syringes are available to plan members with a prescription. OTC medications that are not listed in the Drug List are not available for coverage by the health plan unless prior authorization was obtained first. DIABETIC TESTING SUPPLIES As of June 15, 2015, PHP will only covers Abbott brand diabetic testing supplies (Freestyle and Precision glucose meters and test strips). If there is a medical reason why a different brand is required, providers may submit a prior authorization request to PHP and this request may be approved with appropriate supporting documentation. LIMITATIONS AND RESTRICTIONS The plan may have restrictions on certain Drug List medications. Restrictions are limitations on quantities, dosages or certain criteria. Drugs that require prior authorization or have special status (exempt for certain providers) may have quantity/dose restrictions. Unless indicated otherwise on the Drug List, all dosage forms and strengths of a listed medication are covered.
Step Therapy Some Drug List medications that usually require prior authorization may process via step therapy, a step-wise process in the pharmacy claims processing system. The pharmacy claims processing system detects first step medication fills in the past (up to 90 days) of a member’s prescription fills. If a member has been compliant, a prior authorization request submission is not necessary or required. The following medications may process in that manner: Budesonide/Formoterol (Symbicort®), Mometasone/Formoterol (Dulera), Fluticasone/Salmeterol (Advair®): If used for Asthma, these drugs are available if member is compliant in refilling his/her inhaled corticosteroid for at least two months. If used for COPD, these drugs are covered with prior authorization. Mometasone (Nasonex®): Available after at least two fills of first line nasal steroids (fluticasone, flunisolide, or OTC Nasacort). Oxycodone ER (Oxycontin®): Quantity 90 per month may be available after documented trial and failure of morphine ER and fentanyl patch therapy due to intolerance as documented by an FDA MedWatch 3500 form submission and medical records. Telmisartan (Micardis®): Available after at least one recent fill of a generic angiotensin receptor blocker (ARB) (irbesartan, losartan)
Tolterodine (Detrol®), Tolterodine ER (Detrol LA®): Available after at least two recent consecutive fills of a generic bladder control agent (oxybutynin, oxybutynin XL, trospium) SMOKING CESSATION PRODUCTS: Per AHCCCS, coverage is only for Title XIX members. Members are encouraged to enroll in ASH Line by calling 1-800-556-6222. Maximum supply is 12 weeks in six months. Prior Authorizations and Drug List Exceptions Physicians are encouraged to consult the PHP Drug List when prescribing medications for plan members. Drug List medications are available for plan members for the vast majority of therapeutic needs. If the patient requires medication that is not covered, the physician may submit a request through the Prior Authorization or Drug List Exception process using a Drug Prior Authorization or Drug List Exception Request Form. Documentation to support the request and the completed request form should be faxed to PHP c/o Pharmacy Services at (602) 674-6652 or (888) 887-9982. The information submitted must have the diagnosis for therapy requested, past therapeutic failures on List drugs and other pertinent patient information such as cholesterol panels, iron studies and other lab work supporting the request, according to PHP Policies & Procedures. To maintain continuity of care and drug safety, samples are not considered a therapeutic trial. However trial quantities of medications on the Drug List or authorized through the health plan will be considered for continuity of care. Prescription Quantities Prescriptions should be written for a therapeutic supply of medications. The amount to appropriately treat a medical condition may be 2, 7, or 14 days, up to a maximum of a 30-day supply. Trial quantities may be used when trying new treatments, if appropriate. TELEPHONE PRESCRIPTIONS Whenever possible, the patient should be given the prescription of a Drug List medication in writing. This will allow the patient to make use of the most convenient network pharmacy and enable the pharmacy to fill the prescription after normal office hours. INDIVIDUAL PRESCRIPTIONS Each prescription must legally be prescribed for one individual only. If prescribing for a family, each family member must receive a prescription.
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Analgesics and Non-Narcotics AntiInflammatories
NSAIDS
Additional Information
Generic Name
Reference Brand Name
Acetaminophen (caps, tabs, suppository, suspension, elixir, chew tabs)
Tylenol
Aspirin (chew tabs, suppository, tablets)
Aspirin
Buffered Aspirin
Bufferin, Ascriptin
Tramadol (tablets)
Ultram
Diclofenac (EC tablets)
Voltaren
Diclofenac ER (tablets)
Voltaren-XR
Diclofenac/ Misoprostol (EC tablets)
Arthrotec
Diflunisal (tablets)
Dolobid
Etodolac (capsules, tablets)
Various
Fenoprofen (capsules, tablets)
Nalfon
Flurbiprofen (tablets)
Ansaid
Ibuprofen (caps, tabs, suspension, chew tabs)
Motrin, Advil
Indomethacin (caps, suppository, suspension)
Indocin, Indomethacin CR
Ketoprofen (capsules)
Orudis
Ketorolac Tromethamine (oral tablets)
Toradol
Meloxicam (suspension, tablets)
Mobic
Nabumetone (tablets)
Relafen
Naproxen (tablets, suspension)
Naprosyn
Naproxen Sodium (tablets)
Anaprox, Aleve
Oxaprozin (tablets)
Daypro
Piroxicam (capsules)
Feldene
Salsalate (tablets)
Disalcid
1
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
QL:180 per 30 days
QL: 20 per 30 days
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Cox 2 Inhibitor
Narcotics - Short Acting PA required for > 2 short acting products. Quantity Limit of 180 applies to tablets & capsules.
Narcotics - Long Acting PA required for > 1 long acting product.
Anti-Infectives
Antifungals
Generic Name
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Sulindac (tablets)
Clinoril
Celecoxib (capsules)
Celebrex
PA
Acetaminophen / Codeine (solution, tablets)
Tylenol with Codeine
QL:180 per 30 days
Butalbital-Caffeine-APAP-Codeine (capsules)
Fioricet with Codeine
QL:180 per 30 days
Butalbital-Caffeine-ASA-Codeine (capsules)
Fiorinal with Codeine
QL:180 per 30 days
Hydrocodone-Ibuprofen (tablets)
Vicoprofen
QL:180 per 30 days
Hydrocodone / APAP (solution, tablets, capsules)
Various
QL:180 per 30 days Drug strengths covered are: 5/325 7/325 5/500 10/325 7.5/500
Hydromorphone (liquid, suppository, tablets)
Dilaudid
QL:180 per 30 days
Meperidine (tablets)
Demerol
QL:180 per 30 days
Morphine (solution, suppository, IR tablets)
Roxanol
QL:180 per 30 days QL: 500ml per 30 days
Oxycodone - ASA
Percodan
QL:180 per 30 days
Oxycodone - APAP (tablets, solution, capsules)
Percocet, Tylox
QL:180 per 30 days
Oxycodone IR (tablets, capsules, solution)
Roxicodone, Oxyfast
QL:180 per 30 days
Tramadol (tablets)
Ultram
QL:180 per 30 days
Fentanyl (transdermal)
Duragesic
Methadone (concentrate, solution, tablets)
Methadone Intensol, Dolophine
QL:180 per 30 days QL: 500ml per 30 days
Morphine ER (tablets)
MS Contin
QL: 90 per 30 days
Tramadol ER (tablets)
Tramadol ER
QL: 30 per 30 days
Oxycodone ER (tablets)
Oxycontin
PA QL: 90 per 30 days
Clotrimazole (troche)
Clotrimazole
2
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Antimycobacterials - Tuberculosis
Antiretrovirals and Protease Inhibitors
Generic Name
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Fluconazole (suspension, tablets)
Diflucan
QL:600ml per 30 days QL: 60 per 30 days
Flucytosine (capsules)
Ancobon
PA
Griseofulvin Microsize (suspension, tablets)
Griseofulvin Microsize, Grifulvin V
Griseofulvin Ultramicrosize (tablets)
Gris-Peg
Nystatin (capsules, powder, tablets)
Bio-Statin, Nystatin
Itraconazole (capsules, solution, tablets)
Sporanox, Onmel
Ketoconazole (tablets)
Ketoconazole
Posaconazole (suspension, tablet)
Noxafil
PA
Terbinafine (packets, tablets)
Lamisil
QL: 90 per year
Voriconazole (suspension, tablets)
Vfend
PA
Dapsone (tablets)
Dapsone
Ethambutol (tablets)
Myambutol
Isoniazid (syrup, tablets)
Various
Pyrazinamide (tablets)
Pyrazinamide
Rifampin (capsules)
Rifadin
Abacavir / Lamivudine / Zidovudine (tablets)
Trizivir
Abacavir/Dolutegravir/Lamivudine (tablets)
Triumeq
Abacavir Sulfate (solution, tablets)
Ziagen
Abacavir Sulfate / Lamivudine (tablets)
Epzicom
Atazanavir Sulfate (capsules, packets)
Reyataz
Atazanavir/Cobicistat (tablets)
Evotaz
3
PA
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Generic Name
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Darunavir Ethanolate (suspension, tablets)
Prezista
Darunavir/Cobicistat (tablets)
Prezcobix
Delaviridine Mesylate (tablets)
Rescriptor
Didanosine (capsules, solution)
Videx EC, Videx pediatric
Dolutegravir (tablets)
Tivicay
Efavirenz (capsules, tablets)
Sustiva
Efavirenz / Emtricitab/ Tenofovir (tablets)
Atripla
Elvitegravir (tablets)
Vitekta
Emtricitabine (capsules, solution)
Emtriva
Emtricitabine, Rilpivirine, Tenofovir (tablets)
Complera
Emtricitabine / Tenofovir (tablets)
Truvada
PA
Emtricitabine / Tenofovir/ Cobicistat / Elvitegravir (tablets)
Stribild
PA
Enfuvirtide (solution)
Fuzeon
PA QL: 1 per 30 days
Etravirine (tablets)
Intelence
Elvitegravir (tablets)
Vitekta
PA
Cobicistat (tablets)
Tybost
PA QL: 30 per 30 days
Fosamprenavir Calcium (suspension, tablets)
Lexiva
Indinavir Sulfate (capsules)
Crixivan
Lamivudine (solution, tablets)
Epivir
Lamivudine / Zidovudine (tablets)
Combivir
Lopinavir/Ritonavir (solution, tablets)
Kaletra
Maraviroc (tablets)
Selzentry
Nelfinavir Mesylate (tablets)
Viracept
4
PA
PA
PA
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Antiviral - CMV
Antiviral - Hepatitis B
Anti-Infectives (cont'd)
Generic Name
Reference Brand Name
Nevirapine (suspension, tablets)
Viramune
Nevirapine (tablets)
Viramune XR
Raltegravir Potassium (chew tabs, packets, tablets)
Isentress
Rilpivirine (tablets)
Edurant
Ritonavir (capsules, solution, tablets)
Norvir
Saquinavir Mesylate (capsules, tablets)
Invirase
Stavudine (capsules, solution)
Zerit
Tenofovir Disoproxil Fumarate (tablets)
Viread
Tipranavir (capsules, solution)
Aptivus
Zidovudine (capsules, syrup, tablets)
Retrovir
Cidofovir IV
Vistide
PA
Foscarnet Sodium (solution)
Foscavir
PA
Ganciclovir Sodium (solution)
Cytovene
PA
Valganciclovir HCl (solution, tablets)
Valcyte
PA
Adefovir Dipivoxil (tablets)
Hepsera
PA
Entecavir (solution, tablets)
Baraclude
PA
Telbivudine (tablets)
Tyzeka
PA
Sovaldi
PA AHCCCS Preferred Agent
Ledipasvir/Sofosbuvir (tablets)
Harvoni
PA AHCCCS Preferred Agent
Ombitasvir/Paritaprevir/ Ritonavir/Dasabuvir
Viekira Pak
PA
Boceprevir (capsules)
Victrelis
PA
Ribavirin (capsules, solution, tablets)
Copegus, Rebetol, Ribapak, Ribasphere
PA
Interferon Alfa-2b
Intron A
PA
Hepatitis C - Oral Sofosbuvir (tablets)
Heptitis C -Injectable
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
5
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Additional Information
Drug Subgroup
Antiviral - Influenza
Antiviral Miscellaneous
Generic Name
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Interferon Alfa-N3
Alferon N
PA
Interferon Alfacon-1
Infergen
PA
Interferon Gamma-1B
Actimmune
PA
Peginterferon Alfa-2B (antineoplastic) kit
Sylatron
PA
Peginterferon Alfa-2a
Pegasys
PA
Peginterferon Alfa-2b
Pegintron
PA
Oseltamivir Phosphate (capsules, suspension)
Tamiflu
PA required for > 1 Rx within 270 days QL: 10 day supply
Rimantadine HCl (tablets)
Flumadine
Amantadine (capsules, syrup, tablets)
Zanamivir
Relenza Diskhaler
Acyclovir (suspension, tablets)
Zovirax
Famciclovir (tablets)
Famvir
Valacyclovir HCl (tablets)
Valtrex
RSV
Antibiotics Cephalosporins
Antibiotics Cephalosporins
Antibiotics Cephalosporins
1st Generation
2nd Generation
3rd Generation
Palivizumab (solution)
Synagis
Cefadroxil (capsules, suspension, tablets)
Duricef
Cephalexin (capsules, suspension, tablets)
Keflex
Cefaclor (capsules, suspension)
Ceclor
Cefixime (capsules, chew tabs, suspension, tablets)
Suprax
Cefprozil (suspension, tablets)
Cefzil
Cefuroxime Axetil (suspension, tablets)
Ceftin
Cefdinir (capsules, suspension)
Omnicef
6
PA required for > 1 Rx within 270 days QL: 10 day supply
PA
PAif approved the prescriber may be required to buy and bill a medical claim for the drug
QL=1 per 30 days
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Antibiotics - Macrolides
Antibiotics - Miscellaneous
Generic Name
Reference Brand Name
Cefpodoxime (suspension, tablets)
Vantin
Azithromycin (packets, suspension, tablets)
Zithromax
Clarithromycin (suspension, tablets)
Biaxin, Biaxin XL
Erythromycin Base (tablets)
Various
Erythromycin Ethylsuccinate (suspension, tablets)
E.E.S. Granules, E.E.S. 400
Erythromycin Stearate (tablets)
Erythrocin
Clindamycin (capsules)
Cleocin
Chloroquine (tablets)
Aralen
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Dapsone (tablets) Linezolid (suspension, tablets)
Zyvox
PA
Tedizolid (tablets)
Sivextro
PA
Metronidazole (capsules, tablets)
Flagyl
Neomycin Sulfate (tablets)
Various
Nitrofurantoin (capsules)
Macrodantin
Piperazine (suspension, tablets)
Vermizine
Primaquine (tablets)
Antibiotics - Penicillins
Pyrimethamine (tablets)
Daraprim
Tobramycin (solution)
Tobi
PA
Vancomycin (capsules)
Vancocin
PA
Vancomycin powder for solution
Various
Amoxicillin (capsules, chew tabs, suspension, tablets)
Amoxil
Amoxicillin / Clavulanate (chew tabs, suspension, tablet)
Augmentin, Augmentin XR
Ampicillin (capsules, suspension)
Ampicillin
7
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Antibiotics - Quinalones
Antibiotics - Sulfonamides
Generic Name
Reference Brand Name
Dicloxacillin (capsules)
Dicloxacillin Sodium
Penicillin V Potassium (solution, tablets)
Penicillin V Potassium
Ciprofloxacin (tablets)
Cipro
Levofloxacin (solution, tablets)
Levaquin
Ofloxacin (tablets)
Floxin
Erythromycin / Sulfisoxazole (suspension)
E.S.P.
Sulfadiazine (tablets)
Various
Sulfamethoxazole/ Trimethoprim (suspension, tablets)
Sulfatrim Pediatric, Bactrim
Antibiotics - Tetracyclines
PA For SIADH (syndrome of inappropriate secretion of antidiuretic hormone)
Demeclocycline (tablets)
Antineoplastics Multiple Myeloma Submit a Prior Authorization for Oncology Agents Not Listed. Miscellaneous Agents
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Doxycycline Hyclate (capsules, tablets)
Vibramycin, Oraxyl, Doryx
Minocycline (capsules, tablets)
Minocin, Dynacin
Tetracycline (capsules)
Various
Lenalidomide (capsules)
Revlimid
PA
Thalidomide (capsules)
Thalomid
PA
Axitinib (tablets)
Inlyta
PA
Belinostat (solution)
Beleodaq
Bexarotene (capsules)
Targretin
Bicalutamide (tablets)
Casodex
Busulfan (tablets)
Myleran
Ceritinib (capsules)
Zykadia
8
PA
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Generic Name
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Chlorambucil (tablets)
Leukeran
Crizotinib (capsules)
Xalkori
Cyclophosphamide (capsules, tablets)
Cytoxan
Dasatinib (tablets)
Sprycel
PA
Erlotinib (tablets)
Tarceva
PA
Etoposide (capsules)
Etoposide
PA
Everolimus (tablets, solu tabs,)
Afinitor, Afinitor disperz
PA
Flutamide (capsules)
Various
Gefitinib (tablets)
Iressa
Hydroxyurea (capsules)
Hydrea
Ibrutinib (capsules)
Imbruvica
Idelalisib (tablet)
Zydelig
Imatinib (tablets)
Gleevec
PA
Lapatinib (tablets)
Tykerb
PA
Leuprolide
Lupron Depot 3 month & 4 month kit
PA
Megestrol (suspension, tablets)
Megace
Melphalan (tablets)
Alkeran
Mercaptopurine (suspension, tablets)
Purixan, Purinethol
Methotrexate (tablets)
Methotrexate
Nilotinib (capsules)
Tasigna
PA
Pazopanib (tablets)
Votrient
PA
Ponatinib (tablets)
Iclusig
PA
9
PA
PA
PA
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Chemotherapy Rescue/ Antidote Agents Antitussives
Non-Narcotic Cough Preparations
Generic Name
Reference Brand Name
Procarbazine (capsules)
Matulane
Ruxolitinib (tablets)
Jakafi
PA
Sorafenib (tablets)
Nexavar
PA
Sunitinib (capsules)
Sutent
PA
Thioguanine (tablets)
Tabloid
Toremifene (tablets)
Fareston
PA
Vandetanib (tablets)
Caprelsa
PA
Vemurafenib (tablets)
Zelboraf
PA
Vorinostat (capsules)
Zolinza
PA
Leucovorin (tablets)
Leucovorin Calcium
PA
Guaifenesin / Dextromethorphan
Robitussin DM, Various Generics
QL: 480ml per 30 days
Guaifenesin / Dextromethorphan / Robitussin CF, Various Pseudoephedrine Generics Dextromethorphan, Brompheniramine / Pseudoephedrine
Narcotic Cough Preparations Hydrocodone/Codeine
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
QL: 480ml per 30 days
CardoDex DM, Sildec DM, Andehist DM, etc.
QL: 480ml per 30 days
Chlorpheniramine / Dextromethorphan / Phenylephrine (drops, liquid, syrup, tablets)
Cardec DM Drops, Rondec DM Drops
PA Req for ages < 6 years QL: 480ml per 30 days
Promethazine / Dextromethorphan (syrup)
Various
QL: 480ml per 30 days
Promethazine / Phenylephrine (syrup)
Various
QL: 480ml per 30 days
Dextromethorphan Long Acting
Delsym Susp
Benzonatate (softgels)
Tessalon Perles
Guaifenesin (tablets)
Mucinex
Guaifenesin (liquid, syrup, tablets)
Robitussin Plain
QL: 480ml per 30 days
Guaifenesin / Phenylephrine (capsules, liquid, syrup, tablets)
Various
QL:480ml per 30 days
Guaifenesin / Codeine
Cheratussin AC, Mytussin AC, Various
QL: 480ml per 30 days
10
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Products
Autoimmune Disorders
Rheumatology, GI & Psoriatic
Generic Name
Reference Brand Name
Guaifenesin / Codeine / Pseudoephedrine (syrup)
Cheratussin DAC
QL: 480ml per 30 days
Hydrocodone / Homatropine (syrup, tablets)
Hydromet, HCTussin
QL: 240ml per 12 days
Promethazine / Codeine (syrup)
Various
QL: 480ml per 30 days
Abatacept
Orencia - IV
Medical w/PA Non-Preferred
Humira
PA AHCCCS Preferred Agent
Etanercept
Enbrel
PA AHCCCS Preferred Agent
Infliximab
Remicade
Medical w/ PA Non-Preferred
Tocilizumab
Actemra
Medical w/ PA Non-Preferred
Certolizumab
Cimzia
PA Non-Preferred
Anakinra
Kineret
PA Non-Preferred
Golimumab
Simponi
PA Non-Preferred
Ustekinumab
Stelara
PA Non-Preferred
Canakinumab
Ilaris
PA Non-Preferred
Secukinumab
Cosentyx
PA Non-Preferred
Vedolizumab
Entyvio
PA Non-Preferred
Rilonacept
Acralyst
PA Non-Preferred
Leflunomide (tablets)
Arava
Apremilast (tablets)
Otezla
PA Non-Preferred
Tofacitinib (tablets)
Xeljanz
PA Non-Preferred
Hydroxychloroquine (tablets)
Plaquenil
Methotrexate (tablets)
Rheumatrex
Amiodarone (tablets)
Pacerone
Injectable
Adalimumab
Oral
Cardiovascular Antiarrythymics - Class II
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
11
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Generic Name
Disopyramide Phosphate (capsules)
Norpace, Norpace CR
Dofetilide (capsules)
Tikosyn
PA
Dronedarone HCl (tablets)
Multaq
PA
Flecainide Acetate (tablets)
Tambocor
Mexiletine HCl (capsules)
Mexitil
Propafenone HCl (capsules, tablets)
Rythmol, Rythmol SR
Quinidine Gluconate (tablets)
Quinidine Gluconate CR
Quinidine Sulfate (tablets)
Antihypertensives Ace Inhibitors and Combination Products
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Quinidine Sulfate, Quinidine Sulfate ER
Sotalol (solution, tablets)
Sotylize , Betapace
Benazepril (tablets)
Lotensin
Benazepril - HCTZ (tablets)
Lotensin HCT
Captopril
Captopril Powder
Captopril (tablets)
Capoten
Captopril-HCTZ (tablets)
Capozide
Enalapril Maleate (solution, tablets)
Vasotec
Enalapril-HCTZ (tablets)
Vasoretic
Fosinopril Sodium (tablets)
Monopril
Fosinopril-HCTZ (tablets)
Monopril HCT
Lisinopril (tablets)
Prinivil, Zestril
Lisinopril-HCTZ (tablets)
Zestoretic
Moexipril (tablets)
Univasc
Moexipril-HCTZ (tablets)
Uniretic
Perindopril (tablets)
Aceon
12
Compound Limit
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Antihypertensives ARBs and Combination Products
Antihypertensives Beta Blockers and Combination Products
Generic Name
Reference Brand Name
Quinapril HCl (tablets)
Accupril
Quinapril-HCTZ (tablets)
Accuretic
Ramipril (capsules)
Altace
Trandolapril (tablets)
Mavik
Irbesartan (tablets)
Avapro
Losartan (tablets)
Cozaar
Losartan / HCTZ (tablets)
Hyzaar
Telmisartan
Micardis
Valsartan (tablets)
Diovan
Valsartan / HCTZ (tablets)
Diovan/HCT
Atenolol (tablets)
Tenormin
Atenolol/ Chlorthalidone (tablets)
Tenoretic 50
Bisoprolol/HCTZ
Ziac
Carvedilol (tablets)
Coreg
Labetalol (tablets)
Trandate
Metoprolol Succinate (tablets)
Toprol XL
Metoprolol Tartrate (tablets)
Lopressor
Nadolol (tablets)
Corgard
Pindolol (tablets)
Visken
Propranolol (capsules, solution, tablets)
Inderal LA , Inderal
Isosorbide Dinitrate (capsule, sublingual tabs, tablets)
ISDI, Isordil Titradose Dilatrate-SR
Isosorbide Mononitrate (tablets)
ISMO, Imdur
Nitroglycerin (capsules, sublingual tabs, solution)
Nitrostat Nitro-Time Nitrolingual pumpspray
Antihypertensives Nitrates
13
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
ST
IR only
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Antihypertensives Miscellaneous
Cardiovascular Calcium Channel Blockers (cont'd)
Generic Name
Reference Brand Name
Nitroglycerin topical (ointment)
Nitro-BID
Nitroglycerin (aerosol)
Nitromist
Nitroglycerin (patch)
Minitran
Digoxin (solution, tablets)
Lanoxin
Doxazosin (tablets)
Cardura
Hydralazine (solution, tablets)
Apresoline
Minoxidil (tablets)
Minoxidil
Prazosin (capsules)
Minipress
Ranolazine (tablets)
Ranexa
Terazosin (capsules)
Hytrin
Amlodipine Besylate (tablets)
Norvasc
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
PA
QL:30 per 30 days
Diltiazem (tablets)
Cardizem
Diltiazem CD (24-hour extended release capsule)
Cartia XT, Cardizem CD, Dilacor XT, Dilt CD, DILT XR, Taztia XT, Tiazac
QL:30 per 30 days
Diltiazem ER (12-hour extended release capsule)
Various
QL:60 per 30 days
Diltiazem LA (24-hour extended release tablet)
Cardizem LA, Matzim LA
QL:30 per 30 days
Felodipine (tablets)
Felodipine ER
Isradipine (capsules)
Dynacirc
Nicardipine (capsules)
Nicardipine HCL, Cardene SR
Nifedipine (capsules)
Procardia
Nifedipine XL (24-hour extended release tablet)
Adalat CC
Nimodipine (capsules, solution)
Nimodipine, Nymalize
Nisoldipine ER (tablets)
Sular
14
QL:30 per 30 days
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Cholesterol and Lipid Lowering Agents
Additional Information
Bile Acid Sequestrants
Folic Acid Derivatives
Miscellaneous
Nicotinic Acid Derivatives Statins
Diuretics
Loop Diuretics
Thiazide Diuretics
Miscellaneous
Generic Name
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Verapamil (tablets)
Calan
Verapamil ER (24-hour extended release capsule)
Verelan PM
QL:30 per 30 days
Verapamil ER (24-hour extended release tablet)
Calan SR
QL:30 per 30 days
Cholestyramine Light/ Cholestyramine (packets, powder)
Prevalite, Questran
Colestipol HCl (granules, packets, tablets)
Colestid
Fenofibrate (capsules, micro caps, tablets)
Tricor, Triglide, Lofibra, Antara, Lipofen
Fenofibric Acid (tablets)
Fibricor
Gemfibrozil (tablets)
Lopid
Ezetimibe (tablets)
Zetia
Omega-3 FFA OTC
Fish Oil
Niacin (tablets, capsules)
Niacor, Niaspan
Atorvastatin (tablets)
Lipitor
QL:30 per 30 days
Lovastatin (tablets)
Mevacor
QL:30 per 30 days
Pravastatin Sodium (tablets)
Pravachol
QL:30 per 30 days
Simvastatin (tablets)
Zocor
QL:30 per 30 days
Bumetanide (tablets)
Various
Furosemide (solution, tablets)
Lasix
Torsemide (tablets)
Demadex
Chlorothiazide (suspension, tablets)
Various
Hydrochlorothiazide (capsules, tablets)
Various
Acetazolamide (capsules)
Diamox
15
PA
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Generic Name
Amiloride (tablets)
Midamor
Amiloride/HCTZ (tablets)
Moduretic
Chlorthalidone (tablets)
Various
Eplerenone (tablets)
Inspra
Indapamide (tablets)
Various
Metolazone (tablets)
Zaroxolyn Aldactone
Spironolactone
Spironolactone Powder
Spironolactone / Hydrochlorothiazide (tablets)
Aldactazide
Triamterene / HCTZ (capsules, tablets)
Dyazide, Maxzide-25
Epinephrine self-injected
Epinephrine, Epipen, Epipen Jr
QL: 2 per 30 days AHCCCS Preferred Agent
Adrenaclick, Auvi-Q
PA QL: 2 per 30 days Non-Preferred
Epinephrine
Pulmonary Hypertension
PA
Spironolactone (tablets)
Cardiovascular Emergent Use Products (cont'd)
Miscellaneous Agents
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Compound Limit
Clonidine Hydrochloride (tablets)
Catapres
Clonidine Transdermal Patch
Catapres TTS-1
Digoxin (solution, tablets)
Digoxin, Lanoxin
Guanfacine (tablets)
Tenex
Hydralazine (tablets)
Apresoline
Methyldopa (tablets)
Aldomet
Midodrine (tablets)
Proamatine
Ranolazine (tablets)
Ranexa
PA
Sacubitril/Valsartan (tablets)
Entresto
PA
Ambrisentan (tablets)
Letairis
PA
16
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Central Nervous System
Drug Subgroup
ADHD
Additional Information
Non-Stimulant
PA required for ages 1 Anxiolytics fill 0.5mg, 1mg QL:120 per 30 days 2mg QL: 60 per 30 days
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Generic Name
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Clonazepam (ODT)
Clonazepam ODT
PA required for >1 Anxiolytics fill 0.125mg, 0.25mg, 0.5mg, 1mg QL:120 per 30 days 2mg QL: 60 per 30 days
Diazepam (rectal gel)
Diastat
2.5mg,10mg, 20mg QL: 2 per 30 days
Divalproex (capsules, tablets)
Depakote Sprinkles, Depakote ER, Depakote
Ethosuximide (capsules, solution)
Zarontin
Felbamate (suspension, tablets)
Felbatol
Gabapentin (capsules, solution, tablets)
Neurontin
Lamotrigine (chew tabs, tablets, ODT)
Lamictal+ B135, Lamictal, Lamictal XR, Lamictal ODT
Levetiracetam (solution, tablets)
Keppra, Keppra XR
Lacosamide (solution, tablets)
Vimpat
Oxcarbazepine (suspension, tablets)
Trileptal
Phenobarbital (solution, tablets)
Phenobarbital
Phenytoin (chew tabs, capsules, suspension)
Dilantin Infatablets, Dilantin, Dilantin-125
Pregabalin (capsules, solution)
Lyrica
Primidone (tablets)
Mysoline
Rufinamide (suspension, tablets)
Banzel
PA
Tiagabine (tablets)
Gabitril
PA
Topiramate (sprinkle capsules, tablets)
Topamax, Topamax Sprinkles
Valproate (syrup)
Depakene+B252
Valproic Acid (capsules)
Depakene
Zonisamide (capsules)
Zonegran
18
PA
PA
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Central Antidepressants Nervouse System (cont'd)
Additional Information
SSRIs
SARIs
Generic Name
Citalopram (solution, tablets)
Celexa
Escitalopram (solution, tablets)
Lexapro
Fluoxetine (capsules, solution, tablets)
Prozac
Fluvoxamine (tablets)
Luvox
Paroxetine (suspension, tablets)
Paxil
Sertraline (concentrate, tablets)
Zoloft
Trazodone (tablets)
Desyrel
Bupropion IR, SR, XL (tablets)
Wellbutrin IR, Budeprion SR, Wellbutrin XL
Venlafaxine (tablets)
Effexor, Venlafaxine ER
Venlafaxine ER (capsules)
Effexor XR
Mirtazapine (tablets, ODT)
Remeron, Remeron Soltab
Amitriptyline (tablets)
Elavil
PA Req for ages < 6 years
Clomipramine (capsules)
Anafranil
Long Term Care Only
Desipramine (tablets)
Norpramin
PA Req for ages < 6 years
Doxepin (capsules, solution)
Doxepin
Long Term Care Only
NDRIs
SNRIs
Miscellaneous Tricyclics
Imipramine HCL (tablets)
Antimigraine / Headaches
Miscellaneous – Oral tablets
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Tofranil,
PA Req for ages < 6 years
Imipramine Pamoate (capsules)
Tofranil-PM
Maprotiline (tablets)
Ludiomil
Nortriptyline (capsules, solution)
Pamelor
PA Req for ages < 6 years
Protriptyline (tablets)
Vivactil
PA Req for ages < 6 years
Butalbital-APAP-Caffeine (capsules, tablets)
Fioricet, Esgic
Butalbital-ASA-Caffeine (capsules, tablets)
Fiorinal
19
PA Req for ages < 6 years
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Rectal Preparation Triptans
Antiparkinson Agents
Generic Name
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Ergotamine Tartrate / Caffeine (tablets)
Cafergot
Ergotamine Tartrate / Caffeine (suppositories)
Migergot
QL: 12 per 30 days
Naratriptan (tablets)
Amerge
QL: 9 tablets per 30 days
Rizatriptan (tablets)
Maxalt
QL: 9 tablets per 30 days
Sumatriptan (tablets, injections, nasal sprays)
Imitrex
QL: 9 tablets per 30 days QL: 2 Injections per 30 days QL: 6 Doses per 30 days
Amantadine (capsules, syrup, tablets)
Symmetrel
Benztropine (tablets)
Cogentin
Bromocriptine mesylate (capsules, tablets)
Parlodel
Carbidopa-levodopa (tablets, ODT)
Sinemet
Entcatapone (tablets)
Comtan
Pramipexole (tablets)
Mirapex
Ropinirole (tablets)
Requip
Selegiline (capsules, tablets)
Eldepryl
Trihexyphenidyl (elixir, tablets)
Artane
20
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Generic Name
Reference Brand Name
Anxiolytics and Anxiolytics Hypnotics Anxiolytics Prior approval required for more than 1 anxiolytic prescription per month.
Niravam, Xanax
0.25mg, 0.5mg, 1mg QL:120 per 30 days 2mg QL:60 per 30 days
Alprazolam Intensol
1mg/ml QL: 60ml per 15 days
Xanax XR
0.5mg, 1mg, 2mg, 3mg QL: 30 per 30 days
Buspar
5mg, 7.5mg, 10mg, 15mg QL:120 per 30 days 30mg QL: 60 per 30 days
Clonazepam (tablets)
Klonopin
0.5mg, 1mg QL:120 per 30 days 2mg QL: 60 per 30 days
Chlordiazepoxide (capsules)
Librium
5mg, 10mg, 25mg QL:60 per 30 days
Clorazepate Dipotassium (tablets)
Tranxene T
3.75mg, 7.5mg QL:120 per 30 days 15mg QL: 60 per 30 days
Diazepam (tablets)
Valium
2mg, 5mg, 10mg QL:90 per 30 days
Diazepam Intensol
5mg/ml QL: 60ml per 30 days
Diazepam
1mg/ml QL: 300ml per 30 days
Ativan
0.5mg, 1mg QL:120 per 30 days 2mg QL: 60 per 30 days
Lorazepam
Lorazepam Intensol
2mg/ml QL: 60ml per 30 days
Oxazepam (capsules)
Serax
10mg, 15mg, 30mg QL:60 per 30 days
Chloral Hydrate (capsules)
Somnote
QL:30 per 30 days
Estazolam (tablets)
Prosom
QL:30 per 30 days
Alprazolam (ODT, tablets)
Alprazolam Alprazolam SR 24HR (tablets)
Hypnotics Prior approval required for greater than 1 hypnotic prescription per month.
Buspirone (tablets)
Diazepam Diazepam (solution)
Lorazepam (tablets)
Hypnotics
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
21
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Cognitive Disorders
Drug Subgroup
Additional Information
Acetylcholinesterase Inhibitors
NMDA Receptor Antagonists Dermatologics
Acne
Oral Topical
Antibacterials
Topical
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Flurazepam (capsules)
Dalmane
QL:30 per 30 days
Ramelteon (tablets)
Rozerem
PA
Temazepam (capsules)
Restoril
QL:30 per 30 days
Zaleplon (capsules)
Sonata
QL:30 per 30 days
Zolpidem Tartrate (tablets)
Ambien
QL: 30 for 10mg-per 30 days QL: 60 for 5mg- per 30 days
Donepezil (tablets, ODT)
Aricept, Aricept ODT
PA
Galantamine (capsule, solution, tablets)
Razadyne ER, Razadyne
PA
Rivastigmine (capsules, solution)
Exelon
PA
Rivastigmine (patch)
Exelon Patch
PA
Memantine (solution, tablets)
Namenda, Namenda XR
PA
Isotretinoin (capsules)
Accutane
PA
Benzoyl peroxide (bar, cream, foam, gel, liquid, lotion)
Various
Clindamycin 1% (gel, lotion, solution)
Cleocin-T
Erythromycin 2% (gel, solution)
Erythromycin
Salicylic acid (cream, foam, gel, liquid, lotion, shampoo, solution)
Various
Sulfacetamide (lotion)
Klaron
Tretinoin (cream, gel)
Retin A
Bacitracin / Neomycin / Polymyxin B (ointment)
Triple Antibiotic
Bacitracin/Polymyxin B (ointment)
Double Antibiotic
Bacitracin (ointment)
Bacitracin
Gentamicin (cream, ointment)
Gentamicin
Generic Name
22
PA Required for age 26 and older
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Antifungals
Antifungal / Glucocorticoid Combinations
Astringents Scabicides/ Pediculosides
Additional Information
Topical
Topical
Generic Name
Reference Brand Name
Metronidazole 0.75% Cream
MetroCream
Metronidazole 0.75% Gel
MetroGel
Metronidazole 0.75% lotion
Metrolotion
Mupirocin (cream, ointment)
Bactroban
Silver Sulfadiazine 1% Cream
Silvadene
Clotrimazole (cream, ointment, solution)
Clotrimazole
Ketoconazole (cream, gel, shampoo)
Ketoconazole
Miconazole (cream, liquid, powder)
Miconazole
Nystatin (cream, ointment, powder)
Nystatin
Terbinafine (cream)
Lamisil
Tolnaftate (cream)
Tinactin
Clotrimazole/ Betamethasone (cream, lotion)
Clotrimazole/ Betamethasone
Nystatin/ Triamcinolone (cream)
Mycolog
Hydrocortisone Butyrate (cream, lotion, ointment, solution)
Various
Betamethasone diproprionate (lotion, ointment)
Diprolene
Nystatin/TAC (ointment)
Nystatin/TAC Oint
Aluminum Chloride (solution)
Drysol
Crotamiton (cream, lotion)
Eurax
Ivermectin (lotion)
Sklice
Malathion (lotion)
Ovide
Permethrin 1%, 5% (cream, liquid, lotion)
Acticin, Nix, Elimite
Piperonyl Butoxide/Pyrethrins (gel, liquid, shampoo)
A-200, Barc, Licide
Spinosad (suspension)
Natroba
23
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Caution for use in 5 years of age and under.
PA
PA
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Anthelmintics
Plasmocides
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Albendazole (tablets)
Albenza
PA
Ivermectin (tablets)
Stromectol
PA
Praziquantel (tablets)
Biltricide
Artemether / Lumefantrine (tablets)
Coartem
Atovaquone / Proguanil (tablets)
Malarone
Chloroquine (tablets)
Aralen
Hydroxychloroquine (tablets)
Plaquenil
Generic Name
Primaquine Phosphate (tablets) Quinidine Gluconate (tablets)
Miscellaneous
Dermatologics - Class 1 Glucocorticoids
Topical
Super Potent
Quinine Sulfate (capsules)
Qualaquin
Ammonium Lactate (cream, lotion)
Lac-Hydrin
Capsaicin (cream)
Zostrix
Cod Liver Oil/Zinc (ointment)
Diaper Rash Ointment
Dexamethasone (concentrate, elixir, solution, tablets)
Dexamethasone Intensol, Decadron
Diphenhydramine HCL (cream, gel, solution)
Benadryl
Docosanol 10% (cream)
Abreva
Penciclovir 1% (cream)
Denavir
Pimecrolimus (cream)
Elidel
Selenium Sulfide 2.5% Lotion (shampoo)
Selenium Sulfide
Betamethasone Dipropionate Augmented (cream, gel, lotion, ointment)
Diprolene AF
Clobetasol Propionate (cream, emul foam, foam, gel, lotion, ointment, shampoo, solution)
Temovate
24
PA
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Class 2
Class 3
Class 4
Class 5
Class 6
Class 7 Miscellaneous Agents
Additional Information
Potent
Upper Mid
Mid Strength
Lower Mid Strength
Mild Potency
Least Potency Rectal
Generic Name
Reference Brand Name
Diflorasone Diacetate (emollient base cream)
Apexicon E
Fluocinonide (cream, emul base cream, gel, ointment, solution)
Lidex
Mometasone Furoate (ointment)
Elocon
Fluocinonide (cream)
Lidex Emollient
Fluticasone Propionate (ointment)
Cutivate
Betamethasone Valerate (cream, lotion, ointment)
Valisone
Fluocinolone Acetonide (ointment)
Synalar
Hydrocortisone Valerate (cream, ointment)
Westcort
Mometasone Furoate (cream, solution)
Elocon
Triamcinolone Acetonide (aerosol, cream, lotion, ointment)
Various
Desonide (cream, gel, lotion, ointment)
DesOwen
Flurandrenolide (cream, lotion, ointment, tape)
Cordran, Cordran Tape
Fluticasone Propionate (cream, lotion, ointment)
Cutivate
Alclometasone Dipropionate (cream, ointment)
Aclovate
Fluocinolone Acetonide (oil)
Derma-Smoothe/FS Body
Fluocinolone Acetonide (cream, solution)
Synalar
Hydrocortisone (cream, lotion, ointment, solution)
Cortaid/Hytone
Hydrocortisone (cream)
Proctocort
Hydrocortisone Acetate & Pramoxine (foam)
Proctofoam HC
Hydrocortisone (enema)
Colocort
Hydrocortisone Acetate (foam)
Cortifoam Aerosol
25
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Shampoo Oral - Topical Endocrine / Metabolic
Corticosteroids - Oral
Diabetic Agents
AlphaGlucosidase Inhibitors
Generic Name
Reference Brand Name
Fluocinolone Acetonide (shampoo)
Capex
Dental
Various
Fludrocortisone (tablets)
Florinef
Dexamethasone (tablets)
Various
Hydrocortisone (tablets)
Cortef
Methylprednisolone (tablets)
Medrol
Prednisolone Sodium Phosphate (solution, ODT)
Orapred, Orapred ODT
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Prednisolone (syrup, tablets)
Prelone, Various
Prednisone (concentrate, solution, tablets)
Prednisone Intesol, Prednisone
Acarbose (tablets)
Precose
Metformin (solution, tablets)
Riomet, Glucophage, Glucophage XR
Sitagliptin (tablets)
Januvia
Glyburide/Metformin (tablets)
Glucovance
Glipizide/Metformin (tablets)
Metaglip
Pioglitazone/ Metformin (tablets)
Actoplus Met, Actoplus Met XR
Sitagliptin/Metformin (tablets)
Janumet, Janumet XR
PA
Exenatide
Byetta
PA
NPH, Regular
Humulin / Novolin Vials
NPH
Humulin N KwikPens
NPH(Isophane)/Regular (Human)
Humulin 70/30
Biguanides
Dipeptidyl Peptidase-4 Inhibitor (DPP4) Combinations
Incretin Mimetics (GLP1) Insulins -
26
PA
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Meglitinides
Sulfonylureas
Generic Name
Reference Brand Name
Insurin Regular (Human) solution
Humulin R U-500 (concentrated)
Insulin Aspart
Novolog Vials
Insulin Aspart
Novolog Cartridges, FlexPens
Insulin Aspart Protamine/ Insulin Aspart
Novolog Mix 70/30Vials
Insulin Aspart Protamine/ Insulin Aspart
Novolog Mix 70/30FlexPens
Insulin Detemir
Levemir Vials
Insulin Detemir
Levemir FlexPens
Insulin Glargine
Lantus
Insulin Glargine
Lantus Solostar
Insulin Lispro
Humalog Vials
Insulin Lispro
Humalog KwikPens
Insulin Lispro Protamine/ Insulin Lispro
Humalog Mix75/25 Vial
Insulin Lispro Protamine/ Insulin Lispro
Humalog Mix 75/25 KwikPens
Nateglinide (tablets)
Starlix
Repaglinide (tablets)
Prandin
Chlorpropamide (tablets)
Chlorpropamide
Glimepiride (tablets)
Amaryl
Glipizide (tablets)
Glucotrol , Glucotrol XL
Glyburide (tablets)
Diabeta
Glyburide Micronized (tablets)
Glynase
Tolazamide (tablets)
Tolinase
Tolbutamide (tablets)
Tolbutamide
Glucagon
Glucagon Emergency Kit
Pioglitazone (tablets)
Actos
Miscellaneous Thiazolidinediones
27
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
QL:1 per 30 days
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Diabetic Testing Supplies
Additional Information
Generic Name
Diabetic Glucometers Abbott Brand Blood Glucose Monitoring Systems Diabetic Test Strips
Endocrine / Metabolic (cont'd)
Abbott Brand Blood Glucose Test Strips
Miscellaneous Agents
Osteoporosis Agents
Androgenic Agents
Topical
Injectable
Miscellaneous Oral
Thyroid Agents
FreeStyle Lite, FreeStyle Freedon Lite, FreeStyle Insulinx, Precision Xtra FreeStyle, Precision
Somatropin
Genotropin, Norditropin, Nutropin AQ
PA AHCCCS Preferred Agent
Somatropin
Serostim, Saizen, Zorbtive
PA Non-Preferred
Somatropin
Humatrope, Omnitrope, Zomacton
PA Non-Preferred
Mecasermin (solution)
Increlex
PA
Cinacalcet (tablets)
Sensipar
PA
Desmopressin (solution, spray solution, tablets)
DDAVP
Alendronate (tablets)
Fosamax
Calcitonin (Salmon) (solution)
Fortical, Miacalcin
Ibandronate (tablet)
Boniva
Raloxifene (tablets)
Evista
Testosterone Patch
Androderm
PA
Testosterone Gel
Androgel
PA
Testosterone Gel
Testim
PA
Testoserterone Cypionate (solution)
Depo-Testosterone
PA
Testosterone Enanthate (solution)
Testosterone
PA
Testosterone (solution)
Axiron
PA
Danazol (capsules)
Various
Fluoxymesterone (tablets)
Androxy
Liothyronine (tablets)
Cytomel
Growth Hormone
Insulin-like Growth Factor1 IGF-1
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
28
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
ENT Agents
Drug Subgroup
Ear Preprations
Dental
Nasal Preparations
Gastrointestinal Antidiarrheals
Additional Information
Generic Name
Reference Brand Name
Levothyroxine (tablets)
Synthroid, Levothroid, Levoxyl
Thyroid (tablets)
Armour Thyroid
Methimazole (tablets)
Tapazole
Propylthiouracil (tablets)
Propylthiouracil
Acetic Acid (solution)
Vosol
Acetic Acid / Hydrocortisone (solution)
Vosol HC
Antipyrine / Benzocaine (solution)
Auralgan
Antipyrine/Benzocaine/Polycosanol (solution)
Otic Care
Carbamide Peroxide (solution)
Debrox
Ciprofloxacin / Dexamethasone (suspension)
Ciprodex
Ciprofloxacin / Hydrocortisone (suspension)
Cipro Hc
Hydrocortisone / Neomycin / Polymyxin B (solution, suspension)
Cortisporin Otic
Ofloxacin (solution)
Floxin
Amlexanox (paste)
Aphthasol
Chlorhexidine (solution)
Periogard
Fluoride
Luride
Azelastine (solution)
Astelin
Flunisolide (solution)
Nasalide
Fluticasone Propionate (suspension)
Flonase
Ipratropium Bromide (solution)
Atrovent NS
Triamcinolone Acetonide (aerosol)
Nasacort OTC
Diphenoxylate /Atropine (liquid, tablets)
Lomotil
29
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Antiemetics
Antispasmodics
H2Blockers
Inflammatory Bowel Agents
Generic Name
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Kaolin-Pectin (suspension, chew tabs)
Kaopectate
Loperamide (capsules, chew tabs, liquid, suspension, tablets)
Various
Aprepitant (capsules)
Emend
QL: 6 per 21 days
Dolasetron (tablets)
Anzemet
PA
Granisetron (solution, tablets)
Kytril
PA
Meclizine (chew tabs, tablets)
Antivert
Ondansetron 4mg & 8mg (tablets)
Zofran 4mg & 8mg
Promethazine (suppository, tablets)
Phenergan
Prochlorperazine (suppository, tablets)
Compazine
Dicyclomine HCL (capsules, solution, tablets)
Bentyl
Glycopyrrolate (solution, tablets)
Robinul, Robinul Forte
Hyoscyamine (elixir, solution, sublingual, tablets, ODT)
NuLev, Cystospaz, Levbid, Levsinex, Levsin
Metoclopramide (solution, tablets, ODT)
Reglan
Propantheline Bromide (tablets)
Various
Terazosin (capsules)
Hytrin
Cimetidine (tablets)
Tagamet
Famotidine (chew tabs, suspension, tablets)
Pepcid, Pepcid AC
Ranitidine (capsules, suspension, syrup, tablets)
Zantac
Balsalazide (capsules, tablets)
Colazal, Giazo
Budesonide (capsules)
Entocort EC
30
QL: 30 per 30 days
QL: 120
QL:270 per 30 days
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Laxatives
Generic Name
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Mesalamine (capsules, enema, tablet, kit)
Apriso, Asacol HD, Canasa, Pentasa, Rowasa
QL: 240 per 30 days Pentasa QL: 270 per 30 days
Olsalazine Sodium (capsules)
Dipentum Capsule
QL: 120 per 30 days
Sulfasalazine (tablets)
Azulfidine, Azulfidine Entabs
QL: 240 per 30 days
Bisacodyl (tablets)
Dulcolax
Docusate Sodium (capsules)
Colace
Lactulose (solution)
Cephulac
Magnesium Citrate (solution) Magnesium Hydroxide (suspension)
Milk of Magnesia
Polyethylene Glycol
Miralax
Polyethylene Glycol 3350/ potassium chloride/sodium bicarbonate/sodium chloride (solution)
Colyte, Trilyte with Flavor Packs
Psyllium
Metamucil
Sennosides Pancreatic Enzymes
Proton Pump Inhbitors (PPIs)
Miscellaneous
Pancrelipase (capsules, tablets)
Creon DR, Viokace
QL: 500 per 30 days
Pancreaze
QL: 500 per 30 days
Ultresa
QL: 500 per 30 days
Zenpep DR
QL: 500 per 30 days
Lansoprazole (capsule, suspension)
Prevacid, FirstLansoprazole
Omeprazole (capsule, suspension)
Prilosec, FirstOmeprazole
Pantoprazole (tablets)
Protonix
Lubiprostone (capsules)
Amitiza
Linaclotide (capsules)
Linzess
Sucralfate (tablets)
Carafate
31
Tablets Only
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Ammonia Detoxicants Miscellaneous GI Agents
Genitourinary
BPH Agents
Overactive Bladder Agents
Miscellaneous
Gout & Hyperuricemia
Generic Name
Reference Brand Name
Ursodiol (capsules, tablets)
Actigall, Urso 250
Penicillamine (capsules)
Cuprimine
Lactulose
Various
Antacids
Maalox, Mylanta
Bismuth Subsalicylate
Pepto Bismol
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Calcium Carbonate
Tums
Magnesium Hydroxide
Milk of Magnesia
Simethicone
Mylicon
Doxazosin (tablets)
Cardura XL
Finasteride (tablets)
Proscar
Tamsulosin (capsules)
Flomax
Oxybutynin (syrup, tablets)
Ditropan
Oxybutynin XL (tablets)
Ditropan XL
Tolterodine (tablets)
Detrol
ST
Tolterodine LA (capsule)
Detrol LA
ST
Trospium (tablets)
Sanctura
Trospium ER (capsule)
Sanctura XR
Doxazosin (tablets)
Cardura
Pentosan Polysulfate (capsules)
Elmiron
Phenazopyridine (tablets)
Pyridium
Terazosin (capsules)
Hytrin
Allopurinol (tablets)
Zyloprim
Colchicine (tablets)
Colcrys
PA
Febuxostat (tablets)
Uloric
PA
Probenecid (tablets)
Probenecid
32
PA
PA
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Generic Name
Reference Brand Name
Hematologicals AntiCoagulants Eliquis
PA required for > 10-day supply
Dabigatran (capsules)
Pradaxa
PA required for > 10-day supply
Enoxaparin
Lovenox
PA required for > 10-day supply
Heparin Sodium (solution)
Heparin Sodium, Heparin Lock Flush
Rivaroxaban (tablets)
Xarelto
Ticagrelor (tablets)
Brilinta
Warfarin Sodium (tablets)
Coumadin
Aminocaproic Acid (syrup, tablets)
Amicar
Apixaban (tablets)
Miscellaneous Platelet Aggregation Inhibitors & Combinations
Hematopoietic Agents
Immunosuppressives
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
PA
Aspirin Cilostazol (tablets)
Pletal
Clopidogrel (tablets)
Plavix
Dipyridamole (tablets)
Persantine
Epoetic Alfa (solution
Epogen, Procrit
PA
Eltrombopag Olamine (tablets)
Promacta
PA
Filgrastim (solution)
Neupogen
PA
Pegfilgrastim (solution)
Neulasta
PA
Azathioprine (tablets)
Imuran
Cyclosporine (capsules, solution)
Sandimmume
Cyclosporine (for Microemulsion) (capsules, solution)
Gengraf
Everolimus (tablets)
Zortress
Mycophenolate (capsules, suspension, tablets)
Cellcept
Sirolimus (solution, tablets)
Rapamune
33
PA
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Ion- Removing/ Replacement Agents
Local Anesthetics
Metabolic Diseases
Enzyme Replacements
Multiple Sclerosis Agents
Injectables
Oral Muscle Relaxants
Musculoskeletal
Smooth Muscle
Generic Name
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Tacrolimus (capsules)
Hecoria, Astagraf XL
Calcium Acetate (capsules, solution, tablets)
Phoslo, Phoslyra, Eliphos
Sodium Polystyrene (powder)
Kayexalate
Sodium Polystyrene Sulfonate (suspension)
Kionex
Lanthanum Carbonate (chew tabs, packets)
Fosrenol
PA
Sevelamer HCl (tablets)
Renagel
PA
Sevelamer Carbonate (packets, tablets)
Renvela
PA
Lidocaine (cream, ointment)
Various
Lidocaine / Prilocaine (cream)
EMLA
Lidocaine Transdermal
Lidoderm Patch
Lidocaine Viscous (solution)
Various
Idursulfase (solution)
Elaprase
PA
Imiglucerase (solution)
Cerezyme
PA
Sacrosidase (solution)
Sucraid
PA
Glatiramer Acetate
Copaxone
PA
Interferon Beta -1A (solution)
Rebif Rebidose
PA
Interferon Beta-1A Kit
Avonex
PA
Interferon Beta-1B Kit
Betaseron
PA
Fingolimod HCl (capsules)
Gilenya
PA
Baclofen (tablets)
Lioresal
Dantrolene (capsules)
Dantrium
Methocarbamol (tablets)
Robaxin
Tizanidine (capsules, tablets)
Zanaflex
Cyclobenzaprine (tablets)
Flexeril
34
PA
5mg & 10mg tablets only
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Ophthalmic Agents
Drug Subgroup
Allergy
Antibiotics
Antibiotic /Steroid Combinations
Additional Information
Generic Name
Reference Brand Name
Ketorolac (solution)
Acular LS
Ketotifen (solution)
Alaway
Naphazoline (solution)
Vasoclear
Naphazoline / Pheniramine Maleate (solution)
Naphcon A, Opcon A
Ketorolac 0.5% (solution)
Acular
Cromolyn Sodium (solution)
Opticrom
Lodoxamide 0.1% (solution)
Alomide
Olopatadine HCl 0.1% (solution)
Patanol
Bacitracin
Various
Bacitracin / Polymyxin B (ointment)
Polysporin
Chloramphenicol (IV powder for solution)
Chloroptic
Ciprofloxacin (ointment, solution)
Ciloxan
Erythromycin (ointment)
Ilotycin
Gentamicin Sulfate (ointment, solution)
Garamycin /Gentak
Moxifloxacin (solution)
Vigamox
Natamycin (suspension)
Natacyn
Neomycin / Bacitracin / Polymyxin B (ointment)
Neosporin
Ofloxacin (solution)
Ocuflox
Polymyxin B / Trimethoprim (solution)
Polytrim
Sodium Sulfacetamide (ointment, solution)
Bleph-10
Tobramycin (ointment, solution)
Tobrex
Bacitracin / Neomycin / Polymixin B / Hydrocortisone Ointment
35
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Generic Name
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Neomycin / Bacitracin / Polymyxin B / Hydrocortisone
Antiviral
Glaucoma
Oral Tablets
Ophthalmic Drops
Neomycin / Polymyxin B / Dexamethasone (ointment, suspension)
Maxitrol
Prednisolone / Gentamcin Sulfate (ointment, suspension)
Pred-G S.O.P, Pred-G
Prednisolone Acetate / Sulfacetamide Sodium (ointment, solution, suspension)
Blephamide S.O.P, Blephamide
Tobramycin / Dexamethasone (ointment, suspension)
Tobradex, Tobradex ST
Trifluridine (solution)
Viroptic
Vidarabine
Vira-A
Acetazolamide (capsules, tablets)
Various
Methazolamide (tablets)
Neptazane
Betaxolol (suspension)
Betoptic -S
Brimonidine (solution)
Alphagan P
Brinzolamide (suspension)
Azopt
Carteolol (solution)
Carteolol
Dorzolamide (solution)
Trusopt
Dorzolamide / Timolol (solution)
Cosopt
Latanoprost (solution)
Xalatan
Levobunolol (solution)
Betagan
Metipranolol (solution)
Optipranolol
Pilocarpine (solution)
Isopto Carpine
Tafluprost (solution)
Zioptan
Timolol Maleate (solution)
Timoptic, Timoptic-XE
Travoprost (solution)
Travatan
Travoprost (solution)
Travatan Z
36
PA
QL: 2.5ML per 30 days
PA
PA
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Steroids
Miscellaneous
OTC Products
Devices
Additional Information
Generic Name
Reference Brand Name
Dexamethasone (suspension)
Maxidex
Dexamethasone Sodium Phosphate (solution)
Dexamethasone Sodium Phosphate
Fluorometholone (ointment, suspension)
FML, FML Liquifilm
Prednisolone Acetate (suspension)
Pred Mild
Prednisolone Sodium Phosphate (solution)
Prednisolone Sodium Phosphate
Atropine Sulfate (ointment, solution)
Atropine, Isopto Atropine
Betaxolol (solution)
Betoptic
Carboxymethyl-cellulose (CMC) 0.5%, 1%- OTC
Refresh
Cateolol (solution)
Carteolol HCL
Cromolyn (solution)
Various
Cyclopentolate HCl (solution)
Cyclogyl
Cyclosporine (emulsion)
Restasis
Diclofenac (solution)
Diclofenac Sodium
Dipivefrin (solution)
Propine
Flurbiprofen (solution)
Ocufen
Flurbiprofen 0.03% (solution)
Ocufen
Homatropine HBR (solution)
Isopto Homatropine
Hydroxypropyl cellulose- OTC
Lacri-Lube, Genteal
Phenylephrine (solution)
Altafrin
Pilocarpine Hydrochloride (gel, solution)
Pilopine HS, Pilocar
Scopolamine (solution)
Isopto Hyasine
Tropicamide (solution)
Mydriacyl
Blood glucose strips & monitors
Specific brands vary by health plan
37
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
PA
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Oral
Topical Respiratory
Antihistamines
First Generation
Second Generation
Generic Name
Reference Brand Name
Pen Needles
Various
Ferrous Sulfate tablets
Various
Ferrous Gluconate tablets
Various
Omega 3, etc fatty acids
Various
Alcohol Swabs
Alcohol Swabs
Brompheniramine Maleate
Various
Carbinoxamine/PSE
Rondec
Chlorpheniramine (elixir, tablets)
Chlorpheniramine
Clemastine (syrup, tablets)
Tavist
Cyproheptadine (syrup, tablets)
Periactin
Dexchlorpheniramine Maleate (syrup)
Dexchlorpheniramine Maleate
Diphenhydramine (capsules, chew tabs, elixir, liquid, solution, suspension, syrup, tablets)
Benadryl
Hydroxyzine (syrup, tablets)
Atarax
Hydroxyzine Pamoate (capsules)
Vistaril
Cetirizine (capsules, chew tabs, syrup, tablets, ODT)
Zyrtec
QL: 30 per 30 days QL: 150ml per 30 days
Allegra
QL: 30 per 30 days QL: 150ml per 30 days
Loratadine (capsules, chew tabs, syrup, tablets, ODT)
Claritin
QL: 30 per 30 days QL: 150ml per 30 days
Cetirizine / Pseudoephedrine (tablets)
Zyrtec D
QL:30 per 30 days
Chlorpheniramine / Pseudoephedrine (chew tabs, liquid, solution, syrup, tablets)
Various
QL: 480ml per 30 days
Fexofenadine/ Pseudoephedrine (tablets)
Allegra D
QL:30 per 30 days
Loratadine / Pseudoephedrine (tablets)
Alavert Allergy/Sinus, Claritin D
QL:30 per 30 days
Fexofenadine (suspension, tablets, ODT)
Antihistamines & Combinations
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
38
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Asthma / COPD
Additional Information
Generic Name
Reference Brand Name
Beclomethasone
QVAR
AHCCCS Preferred Agent
Fluticasone
Flovent HFA
AHCCCS Preferred Agent
Mometasone
Asmanex Twisthaler
AHCCCS Preferred Agent
Albuterol (syrup)
Albuterol Sulfate
Albuterol Sulfate
Proventil, Ventolin, ProAir
Metaproterenol (tablets)
Alupent
Formoterol
Foradil
PA
Salmeterol
Serevent Diskus
PA
Symbicort
ST AHCCCS Preferred Agent
Advair Diskus
ST AHCCCS Preferred Agent
Fluticasone / Salmeterol
Advair HFA
ST Covered for ages 4-12 only
Ipratropium / Albuterol
Combivent Inhaler, Combivent Respimat
Steroid Inhalers
BrochodilatorsShort Acting
Bronchodilators - Long Acting Combination Products
Budesonide/ Formoterol
Fluticasone / Salmeterol
Ipratropium / Albuterol Nebulizer Solution
Anticholinergics
LeukotrienesOral
Nebulizing Solutions
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Duoneb
Mometasone/ Formoterol
Dulera
Aclidinium Bromide
Tudorza Pressair
Ipratropium
Atrovent HFA
Tiotropium (aerosol, capsules)
Spiriva Handihaler, Spiriva Respimat
Montelukast (chew tabs, tablets)
Singulair
Zafirlukast (tablets)
Accolate
Albuterol Sulfate (solution)
Albuterol Sulfate
Budesonide (suspension)
Pulmicort
Cromolyn Sodium (solution)
Cromolyn Sodium
39
ST AHCCCS Preferred Agent
QL: 30 per 30 days
PA AHCCCS Preferred Agent
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Generic Name
Ipratropium (solution)
Ipratropium Bromide
Ipratropium / Albuterol (solution)
Various
Spacers
Aerochamber Aerochamber w/mask Optichamber
Hypertonic (7%) saline for inhalation
Hypersal
Benzonatate (capsules)
Tessalon Perles
Brompheniramine Pseudoephedrine (liquid, tablets)
Brompheniramine Pseudoephedrine
Miscellaneous
Miscellaneous Cough & Cold Combinations
Cystic Fibrosis Agents
QL: 2 per year
Brompheniramine / Dextromethorphan / Phenylephrine CardoDex DM, Sildec (elixir, liquid, syrup, tablets) DM, Andehist DM
QL: 480ml per 30 days
Guaifenesin / Dextromethorphan / Phenylephrine (capsules, liquid, syrup, tablets)
Robitussin PE, Robitussin Children’s/ Cough and Cold
QL: 480ml per 30 days
Guaifenesin / Codeine (syrup)
Cheratussin AC, Mytussin AC
QL: 240ml per 12 days
Guaifenesin / Dextromethorphan (tablet, liquid)
Robitussin DM, Mucinex DM
QL: 480ml per 30 days
Guiafenesin
Robitussin Plain
Promethazine / Dextromethorphan
Phenergan DM
Promethazine w Codeine
Phenergan / Codeine
Alpha1-Proteinase Inhibitor (Human) (solution)
Prolastin, Aralast NP
PA
Aztreonam (solution)
Cayston
PA Non-Preferred
Dornase Alfa (solution)
Pulmozyme
PA
Tobramycin
Kitabis Pak, Bethkis
PA AHCCCS Preferred Agent
Tobramycin
TOBI, TOBI Podhaler, Tobramycin
PA Non-Preferred
Pseudoephedrine Hydrochloride (liquid, syrup, tablets)
Sudafed Childrens, Sudafed, Sudafed 12 & 24 hour
QL
Aerochamber Aerochamber w/ Mask Optichamber
QL: 2 per year
Decongestants
Miscellaneuos
Reference Brand Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Spacers
40
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Smoking Deterrants
Drug Subgroup
Smoking Cessation - PA approval required for patients under the age of 18
Additional Information
Nicotine Products
Non-Nicotine
Vitamins Women’s Health
Prenatal Vitamins and Combinations Estrogen Replacement
Oral
Transdermal
Vaginal
Progestin Replacement
Oral
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
Generic Name
Reference Brand Name
Nicotine Gum
Nicorette
QL: 12-week supply within 180 days.
Nicotine Inhalers
Nicotrol
QL: 12-week supply within 180 days.
Nicotine Lozenges
Commit
QL: 12-week supply within 180 days.
Nicotine Patches
Nicoderm
QL: 12-week supply within 180 days.
Buproprion SR (tablets)
Zyban
QL: 12-week supply within 180 days.
Varenicline (tablets)
Chantix
QL: 12-week supply within 180 days.
Prenatal Vitamins (tablets)
Various
Esterified Estrogen (tablets)
Menest
Conjugated Estrogen Synthetic A (tablets)
Cenestin
Conjugated Estrogen (tablets)
Premarin
Estradiol (patch, tablets)
Estrace, Alora, Menostar
Estropipate (tablets)
Ortho-Est
Conjugated Estrogen-Medroxyprogesterone (tablets)
Prempro
Estrogen Patch
Vivelle Dot
Estrogen Patch
Estraderm
Estrogen Patch
Estradiol TDS
Estradiol-Levonorgestrel (patch)
Climara
Estradiol Ring
Estring
Estradiol Ring
Femring
PA
Conjugated Estrogen Vaginal Cream
Premarin Cream
PA
Estrogen Derivative Vaginal Cream
Estrace Cream
Estrogen Derivative Vaginal Tablet
Vagifem Tablet
Medroxyprogesterone acetate (tablets)
Provera
Norethindrone Acetate (tablets)
Aygestin
41
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Oral Contraceptives
Additional Information
Biphasic
Emergent Contraception
Women's Health (cont'd)
Oral Contraceptives (cont'd)
Generic Name
Reference Brand Name
Progesterone micronized (capsules)
Prometrium
DESOG-ET ESTRA/ETHIN ESTRA
Azurette, Kariva
EE 35 mcg/ Norethindrone 0.5 mg (10 days); 1 mg (11 days)
Necon 10/11
Norethindrone 0.4mg/ Ethinyl Estradiol 0.035mg
Balziva
Levonorgestrel 0.75 mg
Next Choice
Levonorgestrel 1.5 mg
Plan B One Step
Ethinyl Estradiol (EE) 20 mcg/ Levonorgestrel 0.1 mg
Alesse Aubra Aviane Lessina Lutera Sronyx
EE 20 mcg/ Norethindrone acetate 1 mg
Gildess 1/20 Loestrin 1/20 Loestrin Fe 1/20 Junel 1/20 Junel Fe 1/20 Microgestin 1/20 Microgestin Fe 1/20
EE 30 mcg/ Desogestrel 0.15 mg
Desogen Ortho-Cept Apri Reclipsen Solia
EE 30 mcg/ Levonorgestrel 0.15 mg
Nordette Levlen Levora Portia
EE 30 mcg/ Norethindrone acetate 1.5 mg
Loestrin 1.5/30 Loestrin Fe 1.5/30 Junel 1.5/30 Junel Fe 1.5/30 Microgestin 1.5/30 Microgestin Fe 1.5/30
EE 30 mcg/ Norgestrel 0.3 mg
Lo/Ovral, Cryselle Low-Ogestrel
EE 35 mcg/ Ethynodiol diacetate 1 mg
Demulen 1/35 Kelnor 1/35 Zovia 1/35
EE 30mcg/ Drospirenone 3mg
Ocella
Monophasic
42
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Generic Name
EE 35 mcg/ Norethindrone 0.5 mg
Brevicon Modicon Necon 0.5/35 Nortrel 0.5/35
EE 35 mcg/ Norethindrone 1 mg
Norinyl 1+35 Ortho-Novum 1/35 Necon 1/35 Nortrel 1/35
EE 35 mcg/ Norgestimate 0.25 mg
Ortho-Cyclen MonoNessa Previfem Sprintec
EE 50 mcg/ Ethynodiol diacetate 1 mg
Demulen 1/50 Zovia 1/50
EE 50 mcg/ Norgestrel 0.5 mg
Ogestrel
Mestranol 50 mcg/ Norethindrone 1 mg
Ortho-Novum 1/50 Norinyl 1+50 Necon 1/50
Norethindrone 0.35 mg
Jolivette Nor-QD Ortho Micronor Camila Errin Nora-BE
EE 25 mcg (21 days)/ Desogestrel 100 mcg (7 days); 125 mcg (7 days); 150 mcg (7 days)
Cyclessa Cesia Velivet Caziant
EE 30 mcg (6 days); 40 mcg (5 days); 30 mcg (10 days)/ Levonorgestrel 50 mcg (6 days); 75 mcg (5 days); 125 mcg (10 days)
Enpresse Trivora
EE 35 mcg (21 days)/ Norethindrone 0.5 mg (7 days); 1 mg (7 days); 0.5 mg (7 days)
Tri-Norinyl Aranelle Leena
EE 35 mcg (21 days)/ Norethindrone 0.5 mg (7 days); 0.75 mg (7 days); 1 mg (7 days)
Ortho-Novum 7/7/7 Necon 7/7/7 Nortrel 7/7/7 Cyclafem 7/7/7
Progestins Oral
Women's Health (cont'd)
Oral Contraceptives (cont'd)
Triphasics
Reference Brand Name
43
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
Drug Class
Drug Subgroup
Additional Information
Reference Brand Name
EE 35 mcg (21 days)/ Norgestimate 180 mcg (7 days); 215 mcg (7 days); 250 mcg (7 days)
Ortho Tri-Cyclen TriNessa Tri-Previfem Tri-Sprintec
EE 0.02mg/ Levonorgestrel 0.1mg
Amethia Lo
EE 15 mcg/day/ Etonorgestrel 120 mcg/day
NuvaRing
Medroxyprogesterone acetate 150 mg
Depo-Provera MPA
Diaphragms
Diaphragms
Condoms
FC Female Condom, Lifestyles Assorted
Spermacidal Foam / Jelly
Spermacidal Foam / Jelly
Anastrozole (tablets)
Arimidex
PA
Exemestane (tablets)
Aromasin
PA
Tamoxifen (tablets)
Nolvadex
Tretinoin (chemotherapy) (capsules)
Tretinoin
Methylergonovine Maleate (tablets)
Methergine
Oral Tablets
Fluconazole 150mg
Diflucan 150mg
Vaginal Preps
Clindamycin (cream, suppository)
Cleocin
Clotrimazole (cream)
Gyne-Lotrimin
Metronidazole (gel)
Metrogel
Miconazole (cream, suppository)
Monistat
Sulfanilamide (cream)
AVC Vaginal
Intravaginal Contraception
Injectable Contraception Miscellaneous – Contraception
Oncolytic Agents
Miscellaneous Vaginal AntiInfectives
Generic Name
Special Requirements: QL: Quantity Limit PA: Prior Authorization Required ST: Step Therapy
44
PA Req for >26 years of age
QL: 2 per 30 days
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016
The following medications are NOT applicable to Phoenix Helath Plan, they are for ALTCS ONLY: AHCCCS MINIMUM REQUIRED PRESCRIPTION DRUG LIST EFFECTIVE July 1, 2015
Drug Class
Central Nervous System ALTCS Only
Drug Subgroup
Antipsychotics
Additional Information
Generic Name
Reference Brand Name
Aripiprazole
Abilify, Abilify Discmelt
Atypicals
Abilify Aripiprazole
Special Requirments: QL: Quantity Limit PA: Prior Authorzation Required ST: Step Therapy ALTCS Only PA QL: 30 per 30 days ALTCS Only
Clozapine (ODT Formulation)
Fazaclo
QL:150ml per 30days ALTCS Only QL: 150 per 30 days ALTCS Only QL: 150 per 30 days
Lithium Carbonate
Lithium
ALTCS Only
Loxapine Succinate
Loxitane
ALTCS Only
Clozapine
Clozaril, Versacloz
ALTCS Only Olanzapine
Zyprexa QL:30 per 30 days ALTCS Only
Olanzapine ODT
Zyprexa Zydis
QL:30 per 30 days ALTCS Only
Quetiapine
Seroquel
QL: 60 per 30 days
Quetiapine XR
Seroquel XR
Risperidone
Risperdal
PA ALTCS Only ALTCS Only QL: 60 per 30 days
Risperidone M-Tab
Risperdal M-tab
ALTCS Only QL: 60 per 30 days
Ziprasidone
Geodon
ALTCS Only
Thorazine Prolixin Haldol Trilafon Mellaril Navane
QL: 60 per 30 days ALTCS Only ALTCS Only ALTCS Only ALTCS Only ALTCS Only ALTCS Only
Typicals
Chlorpromazine Fluphenazine Haloperidol Perphenazine Thioridazine Thiothixene
45
PHOENIX HEALTH PLAN PRESCRIPTION DRUG LIST EFFECTIVE May 1, 2016 Trifluoperazine Endocrine / Metbolic ALTCS Only
Injectables
Hydrocortisone Inj. Methylprednisolone Sod Succinate Methylprednisolone Acetate Triamcinolone Acetonide Triamcinolone Diacetate
Triamcinolone Hexacetonide
46
Stelazine
ALTCS Only
Depo-Medrol A-Hydrocort, AMethapred
ALTCS Only ALTCS Only
Solu-Medrol Kenalog-40 Triamcinolone Aristospan Intralesional & Intra-Articular
ALTCS Only ALTCS Only ALTCS Only ALTCS Only
