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Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days ABACAVIR SULFATE SOLUTION ZIAGENABACAVIR SULFATE TABLETS ZIAGENABACAVIR SULFATE-LAMIVUDINE TABLETS EPZICOMABACAVIR SULFATE-LAMIVUDINE-ZIDOVUDINE TABLETS TRIZIVIRABACAVIR-DOLUTEGRAVIR-LAMIVUDINE TABLETS TRIUMEQ
ACAMPROSATE CAMPRAL
Long Term Care Only ; See Behavioral
Health Drug ListACARBOSE TABLETS PRECOSE
ACEBUTOLOL HCL CAPSULES SECTRALACETAMINOPHEN CAPSULES VARIOUSACETAMINOPHEN CHEWABLE TABLETS VARIOUSACETAMINOPHEN ELIXIR VARIOUSACETAMINOPHEN LIQUID VARIOUSACETAMINOPHEN SUPPOSITORY FEVERALL INFANTSACETAMINOPHEN SUSPENSION TYLENOL INFANTSACETAMINOPHEN TABLETS VARIOUS
ACETAMINOPHEN W/ CODEINE SOLUTION VARIOUS
PA Required for > 2 Short Acting
Narcotics Fill
ACETAMINOPHEN W/ CODEINE TABLETS VARIOUS
PA Required for > 2 Short Acting
Narcotics FillACETAZOLAMIDE CAPSULE 12-HOUR DIAMOXACETAZOLAMIDE TABLETS ACETAZOLAMIDEACETIC ACID SOLUTION ACETIC ACIDACYCLOVIR BUCCAL TABLET ZOVIRAX
ACYCLOVIR CAPSULES ZOVIRAXACYCLOVIR CREAM ZOVIRAXACYCLOVIR OINTMENT 15G ZOVIRAX 15 GM 30ACYCLOVIR SUSPENSION ZOVIRAXACYCLOVIR TABLETS ZOVIRAXADALIMUMAB HUMIRA Preferred Drug PA RequiredADEFOVIR DIPIVOXIL TABLETS HEPSERA PA RequiredADEFOVIR DIPIVOXIL TABLETS HEPSERA PA Required
ALBENDAZOLE TABLETS ALBENZAALBUMIN (URINE) TEST STRIPS ALBUMIN TEST STRIPSALBUTEROL SULFATE AEROSOL PROAIR HFAALBUTEROL SULFATE NEBULIZER ALBUTEROL SULFATEALBUTEROL SULFATE SYRUP ALBUTEROL SULFATEALBUTEROL SULFATE TABLETS ALBUTEROL ALCLOMETASONE DIPROPIONATE CREAM ACLOVATE
ALCOHOL SWABS PADS
ALCOH-GLOVE CONTOURED
WIPEALENDRONATE SODIUM TABLETS ALENDRONATE SODIUM
ALLOPURINOL TABLETS ZYLOPRIM
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
Page 1 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
ALPHA1-PROTEINASE INHIBITOR (HUMAN) SOLUTION ARALAST NP PA RequiredALPHA-TOCOPHEROL CAPSULES VITAMIN E
ALPRAZOLAM CONC 1 MG/ML ALPRAZOLAM INTENSOL
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 ML 15
ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.25 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.5 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
ALPRAZOLAM ORALLY DISINTEGRATING TAB 1 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
ALPRAZOLAM ORALLY DISINTEGRATING TAB 2 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30
ALPRAZOLAM TAB 0.25 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
ALPRAZOLAM TAB 0.5 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
ALPRAZOLAM TAB 1 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
ALPRAZOLAM TAB 2 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30
ALPRAZOLAM TAB SR 24HR 0.5 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 30 30
ALPRAZOLAM TAB SR 24HR 1 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 30 30
ALPRAZOLAM TAB SR 24HR 2 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 30 30
ALPRAZOLAM TAB SR 24HR 3 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 30 30ALUM & MAG HYDROXIDE-SIMETHICONE SUSPENTION MAALOX MAXIMUMALUMINU,M/MAGNESIOUM HYDROXIDE SUSPENSION MYLANTAALUMINUM & MAGNESIOUM HYDROXIDE SUSPENSION MAALOX ALUMINUM CHLORIDE SOLUTION DRYSOL
AMANTADINE HCL CAPSULES AMANTADINE HCLAMANTADINE HCL SYRUP AMANTADINE HCLAMANTADINE HCL TABLETS AMANTADINE HCLAMBRISENTAN TABLETS LETAIRIS PA RequiredAMILORIDE HCL - HYDROCHLOROTHIAZIDE TABLET MODURETICAMILORIDE HCL TABLET MIDAMORAMINOCAPROIC ACID SYRUP AMICARAMINOCAPROIC ACID TABLETS AMICAR
AMIODARONE HCL TABLETS 200MG PACERONEAMITRIPTYLINE HCL TABLETS ELAVIL PA Required for ages < 6 years
AMLODIPINE BESYLATE TABLETS NORVASC 30 30
Page 2 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
AMLODIPINE BESYLATE-BENAZEPRIL HCL CAPSULES LOTRELAMOXAPINE TABLETS ASENDIN PA Required for ages < 6 yearsAMOXICILLIN & POT CLAVULANATE CHEWABLE TABLETS AUGMENTINAMOXICILLIN & POT CLAVULANATE SUSPENSION AUGMENTINAMOXICILLIN & POT CLAVULANATE TABLET 12-HOUR AUGMENTIN XRAMOXICILLIN CAPSULES AMOXICILLINAMOXICILLIN CHEWABLE TABLETS AMOXICILLINAMOXICILLIN SUSPENSION AMOXICILLIN
AMOXICILLIN TABLETS AMOXICILLINAMPHETAMINE-DEXTROAMPHETAMINE CAPSULE 24-HOUR ADDERALL XR Brand Only Preferred Drug PA Required for Ages < 6 years 30 30
AMPHETAMINE-DEXTROAMPHETAMINE TABLETS ADDERALL Brand & Generic Preferred Drug PA Required for Ages < 6 years 60 30AMPICILLIN CAPSULES AMPICILLINAMPICILLIN SUSPENSION AMPICILLINANASTROZOLE TABLETS ARIMIDEX PA RequiredANTIPYRINE-BENZOCAINE SOLUTION AURODEX
ANTIPYRINE-BENZOCAINE-POLYCOSANOL SOLUTION OTIC CAREAPIXABAN TABLETS ELIQUIS Preferred Drug 60 30APREPITANT CAPSULES EMEND 6 21
ARIPIPRAZOLE LAUROXIL ARISTADA Preferred Drug
PA Required for Ages < 18 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 1 30
ARIPIPRAZOLE SUSPENSION ABILIFY MAINTENA Preferred Drug
PA Required for Ages < 18 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 1 30
ARIPIPRAZOLE TABLETS ABILIFY Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 30 30ARTEMETHER-LUMEFANTRINE TABLETS COARTEMARTIFICAL TEARS TEARSARTIFICIAL SALIVA ARTIFICIAL SALIVAARTIFICIAL TEARS OINTMENT VARIOUS
ASENAPINE MALEATE SUBLINGUAL SAPHRIS Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 60 30
Page 3 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
ASPIRIN BUFFERED TABLET ASCRIPTINASPIRIN CHEWABLE TABLETS VARIOUSASPIRIN SUPPOSITORY VARIOUSASPIRIN TABLETS VARIOUSASPIRIN TABLETS CONTROLLED RELEASE ASPIRINASPIRIN TABLETS DELAYED RELEASEATAZANAVIR SULFATE CAPSULES REYATAZATAZANAVIR SULFATE PACKETS REYATAZ
ATAZANAVIR SULFATE-COBICISTAT TABLETS EVOTAZATENOLOL & CHLORTHALIDONE TABLETS TENORETIC 50ATENOLOL TABLETS TENORMINATOMOXETINE HCL CAPSULES STRATTERA Brand Only Preferred Drug PA Required for Ages < 6 years 30 30ATORVASTATIN CALCIUM TABLETS LIPITOR 30 30ATOVAQUONE-PROGUANIL HCL TABLETS MALARONEATROPINE SULFATE OINTMENT ATROPINE SULFATEATROPINE SULFATE SOLUTION ISOPTO ATROPINE
AXITINIB TABLETS INLYTA PA RequiredAZATHIOPRINE TABLETS IMURANAZELASTINE HCL SOLUTION 0.1% ASTELINAZITHROMYCIN EXTENDED RELEASE ORAL SUSPENSION ZITHROMAXAZITHROMYCIN PACKETS ZITHROMAXAZITHROMYCIN SUSPENSION ZITHROMAXAZITHROMYCIN TABLETS ZITHROMAXBACITRACIN OINTMENT BACIGUENT
BACITRACIN OINTMENT 500 UNIT/GM BACITRACIN 3.5GM 7BACITRACIN ZINC OINTMENT BACITRACINBACITRACIN-POLYMYXIN B OINTMENT POLYSPORINBACITRACIN-POLYMYXIN B OINTMENT POLYCINBACITRACIN-POLYMYXIN-NEOMYCIN HC OINTMENT CORTISPORINBACITRACIN-POLY-NEOMYCIN-HC OINTMENT NEO-POLYCIN HCBACLOFEN TABLETS BACLOFENBALSALAZIDE DISODIUM CAPSULES COLAZAL 270 30
BALSALAZIDE DISODIUM TABLETS GIAZO 270 30BECLOMETHASONE DIPROPIONATE INHALER QVAR Preferred DrugBENAZEPRIL HCL TABLETS BENAZEPRIL HCLBENZONATATE CAPSULES TESSALON PERLESBENZOYL PEROXIDE BAR VARIOUSBENZOYL PEROXIDE CREAM VARIOUSBENZOYL PEROXIDE FOAM VARIOUSBENZOYL PEROXIDE GEL VARIOUS
BENZOYL PEROXIDE LIQUID VARIOUSBENZOYL PEROXIDE LOTION VARIOUS
BENZTROPINE MESYLATE TABLETS BENZTROPINE MESYLATE
Page 4 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
BETAMETHASONE DIPROPIONATE AUGMENTED CREAM ACLOVATEBETAMETHASONE DIPROPIONATE AUGMENTED GEL 0.05% DIPROLENE 50 GM 30BETAMETHASONE DIPROPIONATE AUGMENTED LOTION 0.05% DIPROLENEBETAMETHASONE DIPROPIONATE AUGMENTED OINTMENT 0.05% DIPROLENE 50 GM 30BETAMETHASONE DIPROPRIONATE CREAM 0.05%BETAMETHASONE DIPROPRIONATE LOTION 0.05% 118 ML 30BETAMETHASONE VALERATE CREAM VARIOUSBETAMETHASONE VALERATE LOTION VARIOUS
BETAMETHASONE VALERATE OINTMENT 0.1% VARIOUSBETAXOLOL HCL SOLUTION BETAXOLOL HCLBETAXOLOL HCL SUSPENSION BETOPTIC-SBETAXOLOL HCL TABLETS KERLONEBETHANECHOL CHLORIDE TABLETS URECHOLINEBEXAROTENE CAPSULES TARGRETIN PA RequiredBISACODYL SUPPOSITORY DULCOLAXBISACODYL TABLET DELAYED RELEASE DULCOLAX
BISMUTH SUBSALICYLATE CHEW TABLET PEPTO-BISMOLBISMUTH SUBSALICYLATE SUSPENSION PEPTO-BISMOLBISMUTH SUBSALICYLATE TABLET PEPTO-BISMOLBISOPROLOL FUMARATE - HYDROCHLOROTHIAZIDE TABLETS ZIACBISOPROLOL FUMARATE TABLETS ZEBETABLOOD GLUCOSE CALIBRATION LIQUID (HIGH, LOW, NORMAL) VARIOUSBLOOD GLUCOSE MONITORING DEVICES VARIOUSBLOOD GLUCOSE MONITORING KIT W/ DEVICE VARIOUS
BLOOD GLUCOSE MONITORS & TEST STRIPS VARIOUSBOSENTAN TABLETS TRACLEER PA RequiredBRIMONIDINE TARTRATE SOLUTION ALPHAGAN PBRINZOLAMIDE SUSPENSION AZOPTBROMOCRIPTINE MESYLATE CAPSULES PARLODELBROMOCRIPTINE MESYLATE TABLETS PARLODELBROMPHENIRAMINE & PSEUDOEPHEDRINE CAPSULE VARIOUS
BROMPHENIRAMINE & PSEUDOEPHEDRINE CAPSULE CONTROLLED RELEASE VARIOUSBROMPHENIRAMINE & PSEUDOEPHEDRINE ELIXIR VARIOUSBROMPHENIRAMINE & PSEUDOEPHEDRINE LIQUID VARIOUSBROMPHENIRAMINE & PSEUDOEPHEDRINE SYRUP VARIOUS 480 ML 30BROMPHENIRAMINE &PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUSBROMPHENIRAMINE MALEATE J-TAN PD
BROMPHENIRAMINE-DEXTROMETHORPHAN-PHENYLEPHRINE LIQUID/TABLETS VARIOUS
BUDESONDIE INHALATION POWDER PULMICORT FLEXHALER Brand Only Preferred Drug PA RequiredBUDESONIDE (INHALATION) SUSPENSION PULMICORT RESPULES Brand Only Preferred Drug PA RequiredBUDESONIDE CAPSULES ENTOCORT EC
Page 5 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
BUDESONIDE-FORMOTEROL FUMARATE DIHYDRATE AEROSOL SYMBICORT Preferred Drug Step Therapy
Patient must have tried
one steroid inhaler:
Beclomethasone
Dipropionate,
Budesonide,
Fluticasone Propionate,
or MometasoneBUMETANIDE TABLETS BUMETANIDE
BUPRENORPHINE SUBUTEXPA Required; See Behavioral Health
Drug ListBUPRENORPHINE PATCH WEEKLY BUTRANS Preferred PA Required
BUPRENORPHINE/NALOXONE SUBOXONE FILM BRAND
Long Term Care Only ; See Behavioral
Health Drug List
BUPROPION HCL (SMOKING DETERRENT) TABLET 12-HOUR BUPROBAN
84-day
supply 180BUPROPION HCL TABLET 12-HOUR BUDEPRION SR PA Required for Ages < 6 years 60 30BUPROPION HCL TABLET 24-HOUR 150MG WELLBUTRIN XL PA Required for Ages < 6 years 30 30BUPROPION HCL TABLET 24-HOUR 300MG WELLBUTRIN XL PA Required for Ages < 6 years 30 30BUPROPION HCL TABLETS 75MG, 100MG WELLBUTRIN PA Required for Ages < 6 years 120 30
BUSPIRONE HCL TAB 10 MG BUSPIRONE HCL
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
BUSPIRONE HCL TAB 15 MG BUSPIRONE HCL
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
BUSPIRONE HCL TAB 5 MG BUSPIRONE HCL
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
BUSPIRONE HCL TAB 7.5 MG BUSPIRONE HCL
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
BUSPIRONE HCL TABLETS 30 MG BUSPIRONE HCL
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30BUTALBITAL-ACETAMINOPHEN CAPSULES TENCON
BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAPSULES FIORICETBUTALBITAL-ACETAMINOPHEN-CAFFEINE TABLETS ESGIC
BUTALBITAL-ACETAMINOPHEN-CAFFEINE W/ CODEINE CAPSULES FIORICET/CODEINE
PA Required for > 2 Short Acting
Narcotics FillBUTALBITAL-ASPIRIN-CAFFEINE CAPSULES FIORINALBUTALBITAL-ASPIRIN-CAFFEINE TABLETS BUTAL/ASA/CAFF
BUTALBITAL-ASPIRIN-CAFFEINE W/COD CAPSULES ASCOMP/CODEINE
PA Required for > 2 Short Acting
Narcotics Fill
CABERGOLINE TABLET CABERGOLINE CALAMINE LOTION CALAMINE
CALCIPOTRIENE CREAM DOVONEX
Page 6 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
CALCIPOTRIENE FOAM DOVONEXCALCIPOTRIENE OINTMENT DOVONEXCALCIPOTRIENE SOLUTION DOVONEXCALCITONIN (SALMON) SOLUTION MIACALCINCALCITRIOL CAPSULES VARIOUSCALCITRIOL OINTMENT VECTICALCALCIUM ACETATE (PHOSPHATE BINDER) CAPSULES PHOSLOCALCIUM ACETATE (PHOSPHATE BINDER) SOLUTION PHOSLYRA
CALCIUM ACETATE (PHOSPHATE BINDER) TABLETS ELIPHOSCALCIUM CARBONATE CHEW TABLETS TUMSCALCIUM CARBONATE W/ VITAMIN D CAPSULES VARIOUSCALCIUM CARBONATE W/ VITAMIN D CHEW TABLETS VARIOUSCALCIUM CARBONATE W/ VITAMIN D TABLETS VARIOUSCALCIUM CARGONATE TABLRETS TUMSCALCIUM CITRATE TABLETS CITRACALCALCIUM TABLETS VARIOUS
CALCIUM W/ VITAMIN D CAPSULES VARIOUSCALCIUM W/ VITAMIN D EFFERVESCENT TABLETS VARIOUSCALCIUM W/ VITAMIN D WAFER VARIOUS
CAPTOPRIL & HYDROCHLOROTHIAZIDE TABLETS
CAPTOPRIL/
HYDROCHLOROTHIAZIDECAPTOPRIL TABLETS CAPTOPRILCARBAMAZEPINE CAPSULE 12-HOUR CARBATROLCARBAMAZEPINE CAPSULE 12-HOUR EQUETRO
CARBAMAZEPINE CHEWABLE TABLETS CARBAMAZEPINECARBAMAZEPINE SUSPENSION TEGRETOLCARBAMAZEPINE TABLET 12-HOUR TEGRETOL-XRCARBAMAZEPINE TABLETS EPITOLCARBAMIDE PEROXIDE OTIC SOLUTION DEBROXCARBIDOPA-LEVODOPA ORALLY DISINTEGRATING TABLETS VARIOUSCARBIDOPA-LEVODOPA TABLETS SINEMETCARBINOXAMINE - PSEUDOEPHEDRINE SYRUP CYDEC
CARBOXYMETHYLCELLULOSE SODIUM GEL REFRESHCARBOXYMETHYLCELLULOSE SODIUM SOLUTION REFRESHCARISOPRODOL TABLETS SOMACARTEOLOL HCL SOLUTION CARTEOLOL HCLCARVEDILOL TABLETS COREGCEFACLOR CAPSULES CEFACLORCEFACLOR MONOHYDRATE TABLET SR 12 HR CECLORCEFACLOR SUSPENSION CEFACLOR
CEFADROXIL CAPSULES CEFADROXILCEFADROXIL SUSPENSION CEFADROXIL
CEFADROXIL TABLETS CEFADROXIL
Page 7 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
CEFDINIR CAPSULES CEFDINIRCEFDINIR SUSPENSION CEFDINIRCEFIXIME CAPSULES SUPRAX 1 30CEFIXIME CHEWABLE TABLETS SUPRAX 1 30CEFIXIME SUSPENSION SUPRAX 1 30CEFIXIME TABLETS SUPRAX 1 30CEFPODOXIME PROXETIL SUSPENSION CEFPODOXIME PROXETILCEFPODOXIME PROXETIL TABLETS CEFPODOXIME PROXETIL
CEFPROZIL SUSPENSION CEFPROZILCEFPROZIL TABLETS CEFPROZILCEFUROXIME AXETIL SUSPENSION CEFTINCEFUROXIME AXETIL TABLETS CEFTINCELECOXIB CAPSULES CELEBREX PA RequiredCEPHALEXIN CAPSULES KEFLEXCEPHALEXIN SUSPENSION CEPHALEXINCEPHALEXIN TABLETS CEPHALEXIN
CETIRIZINE HCL CAPSULES ZYRTEC ALLERGY 30 30CETIRIZINE HCL CHEWABLE TABLETS VARIOUS 30 30CETIRIZINE HCL ORALLY DISINTEGRATING TABLETS ZYRTEC ALLERGY 30 30CETIRIZINE HCL SYRUP VARIOUS 150 ML 30CETIRIZINE HCL TABLETS VARIOUS 30 30CETIRIZINE-PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUS 30 30
CHLORDIAZEPOXIDE HCL CAP 10 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30
CHLORDIAZEPOXIDE HCL CAP 25 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30
CHLORDIAZEPOXIDE HCL CAP 5 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30CHLORHEXIDINE GLUCONATE SOLUTION PERIOGARDCHLOROQUINE PHOSPHATE TABLETS CHLOROQUINE PHOSPHATECHLOROTHIAZIDE SUSPENSION DIURILCHLOROTHIAZIDE TABLETS CHLOROTHIAZIDE
CHLORPHENIRAMINE &PSEUDOEPHEDRINE CHEWABLE TABLETS VARIOUSCHLORPHENIRAMINE &PSEUDOEPHEDRINE LIQUID VARIOUS 480 ML 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE SOLUTION VARIOUS 480 ML 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE SYRUP VARIOUS 480 ML 30CHLORPHENIRAMINE &PSEUDOEPHEDRINE TABLETS VARIOUSCHLORPHENIRAMINE MALEAT TABLET CHLORPHENIRAMINE
CHLORPHENIRAMINE MALEATE SYRUP CHLORPHENIRAMINE MALEATE
Page 8 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
CHLORPROMAZINE HCL SOLUTION VARIOUS
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medications
CHLORPROMAZINE HCL TABLETS VARIOUS
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medicationsCHLORPROPAMIDE TABLETS CHLORPROPAMIDECHLORTHALIDONE TABLETS CHLORTHALIDONECHOLECALCIFEROL CAPSULES VITAMIN D3
CHOLECALCIFEROL TABLETS VITAMIN D3CHOLESTYRAMINE LIGHT PACKETS PREVALITECHOLESTYRAMINE LIGHT POWDER PREVALITE
CHOLESTYRAMINE PACKETS QUESTRANCHOLESTYRAMINE POWDER QUESTRANCHOLINE & MAGNESIUM SALICYLATES LIQUID TRILISATECHOLINE & MAGNESIUM SALICYLATES TABLETS TRILISATECICLOPIROX OLAMINE CREAM LOPROXCICLOPIROX SOLUTION PENLACCICLOPIROX SOLUTION - VITAMIN E CICLODAN KITCIDOFOVIR IV VISTIDE PA Required
CILOSTAZOL TABLETS PLETALCIMETIDINE HCL SOLUTION TAGAMETCIMETIDINE HCL TABLETS TAGAMETCINACALCET HCL TABLETS SENSIPAR PA RequiredCIPROFLOX HCl-CIPROFLOX BETAINE TABLETS SR CIPRO XRCIPROFLOXACIN HCL OINTMENT CILOXANCIPROFLOXACIN HCL SOLUTION CILOXANCIPROFLOXACIN HCL TABLETS CIPROFLOXACIN HCL
CIPROFLOXACIN ORAL SUSPENSION CIPROCIPROFLOXACIN-DEXAMETHASONE CIPRODEXCITALOPRAM HBR SOLUTION VARIOUS PA Required for Ages < 6 years 600 ML 30CITALOPRAM HBR TABLETS 10 MG, 20 MG CELEXA PA Required for Ages < 6 years 60 30CITALOPRAM HBR TABLETS 40 MG CELEXA PA Required for Ages < 6 years 30 30CLARITHROMYCIN SUSPENSION CLARITHROMYCINCLARITHROMYCIN TABLET 24-HOUR BIAXIN XLCLARITHROMYCIN TABLETS BIAXIN
CLEMASTINE FUMARATE SYRUP CLEMASTINE FUMARATECLEMASTINE FUMARATE TABLETS CLEMASTINE FUMARATE
CLINDAMYCIN HCl CAPSULES CLEOCIN
Page 9 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
CLINDAMYCIN PHOSPHATE FOAM EVOCLINCLINDAMYCIN PHOSPHATE GEL CLEOCIN-TCLINDAMYCIN PHOSPHATE LOTION CLEOCIN-TCLINDAMYCIN PHOSPHATE SOLUTION CLEOCIN-TCLINDAMYCIN PHOSPHATE VAGINAL CREAM CLEOCINCLINDAMYCIN PHOSPHATE VAGINAL SUPPOSITORY CLEOCINCLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE BENZACLINCLOBAZAM SUSPENSION ONFI PA Required
CLOBAZAM TABLETS ONFI PA RequiredCLOBETASOL PROPIONATE CREAM 0.05% TEMOVATE 60 GM 30CLOBETASOL PROPIONATE EMULSION FOAM 0.05% TEMOVATECLOBETASOL PROPIONATE FOAM 0.05% OLUX 100 ML 30CLOBETASOL PROPIONATE GEL 0.05% TEMOVATE 60 GM 30CLOBETASOL PROPIONATE LOTION 0.05% CLOBEX 118 ML 30CLOBETASOL PROPIONATE OINTMENT 0.05% TEMOVATE 60 GM 30CLOBETASOL PROPIONATE SHAMPOO VARIOUS
CLOBETASOL PROPIONATE SOLUTION VARIOUSCLOMIPRAMINE HCL TABLETS ANAFRANIL PA Required for ages < 6 years
CLONAZEPAM 0.5 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic120 30
CLONAZEPAM 1.0 MGVARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic120 30
CLONAZEPAM 2 MGVARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic60 30
CLONAZEPAM ODT 0.125MGVARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic120 30
CLONAZEPAM ODT 0.25MGVARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic120 30
CLONAZEPAM ODT 0.5 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic120 30
CLONAZEPAM ODT 1MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic120 30
CLONAZEPAM ODT 2MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic60 30
CLONAZEPAM ORALLY DISINTEGRATING TAB 0.125 MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM ORALLY DISINTEGRATING TAB 0.25 MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM ORALLY DISINTEGRATING TAB 0.5 MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM ORALLY DISINTEGRATING TAB 1 MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM ORALLY DISINTEGRATING TAB 2 MG CLONAZEPAM ODT PA Required for > 1 Anxiolytics Fill 60 30CLONAZEPAM TAB 0.5 MG KLONOPIN PA Required for > 1 Anxiolytics Fill 120 30
CLONAZEPAM TAB 1 MG KLONOPIN PA Required for > 1 Anxiolytics Fill 120 30CLONAZEPAM TAB 2 MG KLONOPIN PA Required for > 1 Anxiolytics Fill 60 30
CLONIDINE HCL CATAPRES PA Required for ages < 6 years
Page 10 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
CLONIDINE HCl (ADHD) TABLET 12-HOUR KAPVAY Brand Only Preferred Drug PA Required for ages < 6 years 120 30CLONIDINE HCL (ADHD) TABLET 12-HOUR KAPVAY Brand Only Preferred Drug PA Required for Ages < 6 years 120 30CLONIDINE HCL PATCH-WEEKLY CATAPRES-TTS-1 PA Required for Ages <6 years 4 28CLONIDINE HCL TABLETS CATAPRES PA Required for Ages <6 years
CLONIDINE HCL TRANSDERMAL PATCH CATAPRES PATCHES PA Required for Ages < 6 years 4 28CLOPIDOGREL BISULFATE TABLETS PLAVIX
CLORAZEPATE DIPOTASSIUM TAB 15 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30
CLORAZEPATE DIPOTASSIUM TAB 15 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30
CLORAZEPATE DIPOTASSIUM TAB 3.75 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
CLORAZEPATE DIPOTASSIUM TAB 3.75 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
CLORAZEPATE DIPOTASSIUM TAB 7.5 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
CLORAZEPATE DIPOTASSIUM TAB 7.5 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30CLOTRIMAZOLE CREAM LOTRIMINCLOTRIMAZOLE OINTMENT LOTRIMINCLOTRIMAZOLE SOLUTION VARIOUSCLOTRIMAZOLE TROC CLOTRIMAZOLECLOTRIMAZOLE VAGINAL CREAM GYNE-LOTRIMINCLOTRIMAZOLE VAGINAL TABLET CLOTRIMAZOLE
CLOTRIMAZOLE W/ BETAMETHASONE CREAM LOTRISONE
CLOTRIMAZOLE W/ BETAMETHASONE LOTION
CLOTRIMAZOLE/
BETAMETHASONE
DIPROPIONATE
CLOZAPINE ORALLY DISPERSABLE TABLET FAZACLO Preferred Drug
PA Required for Ages < 18 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 150 30
CLOZAPINE TABLETS CLOZARIL Preferred Drug
PA Required for Ages < 18 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 150 30COBICISTAT TABLETS TYBOST 30 30COLCHICINE TABLETS COLCRYS PA Required
COLESTIPOL HCL GRANULES COLESTIDCOLESTIPOL HCL PACKETS COLESTID
COLESTIPOL HCL TABLETS COLESTID
Page 11 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
CONDOMS - FEMALE MISC. FC FEMALE CONDOM
CONDOMS - MALE MISC. LIFESTYLES ASSORTED COLORSCONJUGATED ESTROGENS-MEDROXYPROGESTERONE ACETATE TABLETS PREMPROCRIZOTINIB CAPSULES XALKORI PA RequiredCROMOLYN SODIUM NASAL AEROSOL CROMOLYN SODIUMCROMOLYN SODIUM NEBULIZER CROMOLYN SODIUMCROMOLYN SODIUM ORAL CONCENTATE VARIOUS
CROMOLYN SODIUM SOLUTION CROMOLYN SODIUMCROTAMITON CREAM EURAXCROTAMITON LOTION EURAXCYANOCOBALAMIN TABLETS VITAMIN B12
CYCLOBENZAPRINE HCL TABLETS 5MG, 10MG FLEXERIL
PA Required for dosages other than
5mg and 10mg tabletsCYCLOPENTOLATE HCL SOLUTION CYCLOGYLCYCLOSPORINE CAPSULES SANDIMMUNE
CYCLOSPORINE EMULSION RESTASIS PA RequiredCYCLOSPORINE MODIFIED (FOR MICROEMULSION) CAPSULES GENGRAFCYCLOSPORINE MODIFIED (FOR MICROEMULSION) SOLUTION GENGRAFCYCLOSPORINE SOLUTION SANDIMMUNECYPROHEPTADINE HCL SYRUP CYPROHEPTADINE HCLCYPROHEPTADINE HCL TABLETS CYPROHEPTADINE HCLDABIGATRAN ETEXILATE MESYLATE CAPSULES PRADAXA Preferred Drug 60 30DANAZOL CAPSULES DANAZOL
DANTROLENE SODIUM CAPSULES DANTRIUMDAPSONE GEL DAPSONEDAPSONE TABLETS DAPSONEDARUNAVIR ETHANOLATE SUSPENSION PREZISTADARUNAVIR ETHANOLATE TABLETS PREZISTADARUNAVIR-COBICISTAT TABLETS PREZCOBIXDASATINIB TABLETS SPRYCEL PA RequiredDELAVIRDINE MESYLATE TABLETS RESCRIPTOR
DEMECLOCYCLINE HCL TABLETS DEMECLOCYCLINE HCL PA RequiredDESIPRAMINE HCL TABLETS NORPRAMIN PA Required for ages < 6 yearsDESMOPRESSIN ACETATE NASAL SOLUTION VARIOUSDESMOPRESSIN ACETATE REFRIGERATED SOLUTION VARIOUSDESMOPRESSIN ACETATE SOLUTION VARIOUSDESMOPRESSIN ACETATE SPRAY REFRIGERATED SOLUTION VARIOUSDESMOPRESSIN ACETATE SPRAY SOLUTION VARIOUSDESMOPRESSIN ACETATE TABLETS VARIOUS PA Required
DESOGESTREL & ETHINYL ESTRADIOL TABLETS APRIDESOGESTREL-ETHINYL ESTRADIOL (BIPHASIC) TABLETS AZURETTEDESOGESTREL-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS CAZIANT
Page 12 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
DESONIDE CREAM DESOWENDESONIDE GEL DESONATEDESONIDE LOTION DESOWENDESONIDE OINTMENT DESOWEN
DESVENLAFAXINE ER TABLETS PRISTIQ PA Required for Ages < 6 years
25mg:120
50mg: 120
100mg: 120
30
30
30DEXAMETHASONE CONCENTRATE DEXAMETHASONE INTENSOL
DEXAMETHASONE ELIXIR VARIOUS
DEXAMETHASONE SODIUM PHOSPHATE SOLUTION
DEXAMETHASONE SODIUM
PHOSPHATEDEXAMETHASONE SOLUTION DEXAMETHASONEDEXAMETHASONE SUSPENSION MAXIDEXDEXAMETHASONE TABLETS DEXAMETHASONE
DEXCHLORPHENIRAMINE MALEATE SYRUP
DEXCHLORPHENIRAMINE
MALEATE
DEXMETHYLPHENIDATE HCL ER CAPSULE FOCALIN XR Brand Only Preferred Drug PA Required for ages < 6 years 60 30DEXMETHYLPHENIDATE HCL TABLETS FOCALIN Brand Only Preferred Drug PA Required for ages < 6 years 60 30DEXTROAMPHETAMINE SULFATE VARIOUS Preferred Drug PA Required for ages < 6 years 60 30DEXTROAMPHETAMINE SULFATE CAPSULE 24-HOUR VARIOUS Preferred Drug PA Required for ages < 6 years 60 30DEXTROMETHORPHAN HBR CAPSULE ROBITUSSINDEXTROMETHORPHAN HBR SYRUP ROBITUSSINDEXTROMETHORPHAN POLISTIREX LIQUID DELSYMDEXTROMETHORPHAN-GUAIFENESIN LIQUID VARIOUS 480 ML 30
DEXTROMETHORPHAN-GUAIFENESIN SYRUP VARIOUS 480 ML 30DEXTROMETHORPHAN-GUAIFENESIN TABLET VARIOUSDEXTROMETHORPHAN-GUAIFENESIN TABLET 12-HOUR MUCINEX DMDIAPHRAGM ARC-SPRING DPRH CAYA
DIAPHRAGM COIL SPRING KIT
ORTHO DIAPHRAGM COIL
SPRING KIT 50
DIAPHRAGM FLAT SPRING KIT
ORTHO DIAPHRAGM FLAT
SPRING KIT 55
DIAPHRAGM WIDE SEAL DPRH
WIDE-SEAL SILICONE
DIAPHRAGM KIT 60DIAPHRAGMS - OTHER+A1294 OMNIFLEX DIAPHRAGM
DIAZEPAM CONC 5 MG/ML DIAZEPAM INTENSOL
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 ML 30DIAZEPAM RECTAL GEL DELIVERY SYSTEM 10 MG DIASTAT PA Required for > 1 Anxiolytics Fill 2 30DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2.5 MG DIASTAT PA Required for > 1 Anxiolytics Fill 2 30DIAZEPAM RECTAL GEL DELIVERY SYSTEM 20 MG DIASTAT PA Required for > 1 Anxiolytics Fill 2 30
DIAZEPAM SOLN 1 MG/ML VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 300 ML 30
Page 13 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
DIAZEPAM TAB 10 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
DIAZEPAM TAB 2 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
DIAZEPAM TAB 5 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30DICLOFENAC POTASSIUM CAPSULE VOLTARENDICLOFENAC POTASSIUM PACKET DICLOFENAC
DICLOFENAC POTASSIUM TABLET CATAFLAMDICLOFENAC SODIUM GEL 1% DICLOFENAC GELDICLOFENAC SODIUM SOLUTION DICLOFENAC SODIUMDICLOFENAC SODIUM TABLET 24-HOUR VOLTAREN-XRDICLOFENAC SODIUM TABLET ENTERIC COATED VOLTARENDICLOFENAC W/ MISOPROSTOL TABLET DELAYED RELEASE ARTHROTEC 50DICLOXACILLIN SODIUM CAPSULES DICLOXACILLIN SODIUMDICLOXACILLIN SODIUM CAPSULES
DICYCLOMINE HCL CAPSULES VARIOUSDICYCLOMINE HCL SOLUTION VARIOUSDICYCLOMINE HCL TABLETS VARIOUS
DIDANOSINE CAPSULE DELAYED RELEASE VIDEX ECDIDANOSINE SOLUTION VIDEX PEDIATRICDIFLUNISAL TABLETS DIFLUNISALDIGOXIN SOLUTION DIGOXINDIGOXIN TABLETS LANOXIN
DIHYRDROERGOTAMIN MESYLATE NASAL MIGRANAL 4 28DILTIAZEM HCL CAPSULE 12-HOUR DILTIAZEM HCL ERDILTIAZEM HCL CAPSULE CONTROLLED RELEASE DILTIAZEM HCL ERDILTIAZEM HCL COATED BEADS CAPSULE CONTROLLED RELEASE CARDIZEM CD 30 30DILTIAZEM HCL COATED BEADS TABLET 24-HOUR CARDIZEM LA
DILTIAZEM HCL EXTENDED RELEASE BEADS CAPSULE CONTROLLED RELEASE TAZTIA XT 30 30DILTIAZEM HCL TABLETS CARDIZEM
DIMENHYDRINATE CHEW TABLET DRAMAMINEDIMENHYDRINATE TABLET DRAMAMINEDIPHENHYDRAMINE HCL CAPSULES VARIOUSDIPHENHYDRAMINE HCL CHEWABLE TABLETS VARIOUS
DIPHENHYDRAMINE HCL CREAM
ANTI-ITCH MAXIMUM
STRENGTHDIPHENHYDRAMINE HCl CREAM BENADRYLDIPHENHYDRAMINE HCL ELIXIR VARIOUS
DIPHENHYDRAMINE HCL GEL BENADRYL ITCH STOPPINGDIPHENHYDRAMINE HCL LIQUID VARIOUS
DIPHENHYDRAMINE HCL SOLUTION VARIOUS
Page 14 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
DIPHENHYDRAMINE HCL SOLUTION
BENADRYL MAXIMUM
STRENGTHDIPHENHYDRAMINE HCL SUSPENSION VARIOUSDIPHENHYDRAMINE HCL SYRUP VARIOUSDIPHENHYDRAMINE HCL TABLETS VARIOUSDIPHENOXYLATE W/ ATROPINE LIQUID DIPHENOXYLATE/ATROPINEDIPHENOXYLATE W/ ATROPINE TABLETS LOMOTILDIPYRIDAMOLE TABLETS PERSANTINE
DISOPYRAMIDE PHOSPHATE CAPSULE 12-HOUR NORPACE CRDISOPYRAMIDE PHOSPHATE CAPSULES NORPACE
DISULFIRAM ANTABUSE
Long Term Care Only ; See Behavioral
Health Drug ListDIVALPROEX SODIUM SPRINKLE CAPSULES DEPAKOTE SPRINKLESDIVALPROEX SODIUM TABLET 24-HOUR DEPAKOTE ERDIVALPROEX SODIUM TABLET ENTERIC COATED DEPAKOTEDOCOSANOL 10% CREAM ABREVA
DOCUSATE CALCIUM CAPSULE SURFAKDOCUSATE SODIUM CPASULES COLACEDOFETILIDE CAPSULES TIKOSYN PA RequiredDOLASETRON MESYLATE TABLETS ANZEMET PA RequiredDOLUTEGRAVIR TIVICAYDONEPEZIL HYDROCHLORIDE ORALLY DISINTEGRATING TABLETS ARICEPT ODT PA RequiredDONEPEZIL HYDROCHLORIDE TABLETS ARICEPT PA RequiredDORNASE ALFA SOLUTION PULMOZYME PA Required
DORZOLAMIDE HCL SOLUTION TRUSOPTDORZOLAMIDE HCL-TIMOLOL MALEATE SOLUTION COSOPTDOXAZOSIN MESYLATE TABLET 24-HOUR CARDURA XLDOXAZOSIN MESYLATE TABLETS CARDURADOXEPIN HCL CAPSULES DOXEPIN HCL PA Required for ages < 6 years 90 30DOXEPIN HCL CONCENTRATE DOXEPIN HCL PA Required for ages < 6 years 180 ML 30DOXEPIN HCL TABLETS SILENOR PA RequiredDOXYCYCLINE HYCLATE CAPSULES 50MG, 100MG VIBRAMYCIN
DOXYCYCLINE HYCLATE SUSPENSION VIBRAMYCINDOXYCYCLINE HYCLATE TABLETS 20MG, 100MG ORAXYLDOXYCYCLINE MONOHYDRATE CAPSULES 50MG, 100MG MONODOXDOXYLAMINE SUCCINATE (SLEEP) TAB SLEEP AIDDRONEDARONE HCL TABLETS MULTAQ PA RequiredDROSPIRENONE-ETHINYL ESTRADIOL TABLETS OCELLA
DULOXETINE CAPSULES CYMBALTA PA Required for Ages < 6 years
20mg: 120
30mg: 120
60mg: 60
30
30
30ECONAZOLE NITRATE CREAM SPECTAZOLE
EFAVIRENZ CAPSULES SUSTIVA
Page 15 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
EFAVIRENZ TABLETS SUSTIVA
EFAVIRENZ-EMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS ATRIPLAELBASVIR-GRAZOPREVIR TABLETS ZEPATIER Preferred Drug PA RequiredELTROMBOPAG OLAMINE TABLETS PROMACTA PA RequiredELVITEGRAVIR-COBICISTAT-EMTRICITABINE-TENOFOVIR TABLETS STRIBILDEMTRICITABINE CAPSULES EMTRIVAEMTRICITABINE SOLUTION EMTRIVA
EMTRICITABINE-RILPIVIRINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS COMPLERAEMTRICITABINE-TENOFOVIR DISOPROXIL FUMARATE TABLETS TRUVADA PA Required
ENALAPRIL MALEATE & HYDROCHLOROTHIAZIDE TABLETS
ENALAPRIL MALEATE/
HYDROCHLOROTHIAZIDEENALAPRIL MALEATE SOLUTION EPANEDENALAPRIL MALEATE TABLETS VASOTECENFUVIRTIDE SOLUTION FUZEON PA Required 1 30
ENOXAPARIN SODIUM INJ 100 MG/ML ENOXAPARIN INJ 100MG/ML Preferred Drug 60 30ENOXAPARIN SODIUM INJ 120 MG/0.8ML ENOXAPARIN INJ 120/0.8ML Preferred Drug 60 30ENOXAPARIN SODIUM INJ 150 MG/ML ENOXAPARIN INJ 150MG/ML Preferred Drug 60 30
ENOXAPARIN SODIUM INJ 30 MG/0.3ML ENOXAPARIN INJ 30/0.3ML Preferred Drug 60 30ENOXAPARIN SODIUM INJ 300 MG/3ML ENOXAPARIN INJ 300/3ML Preferred Drug 60 30ENOXAPARIN SODIUM INJ 40 MG/0.4ML ENOXAPARIN INJ 40/0.4ML Preferred Drug 60 30ENOXAPARIN SODIUM INJ 60 MG/0.6ML ENOXAPARIN INJ 60/0.6ML Preferred Drug 60 30ENOXAPARIN SODIUM INJ 80 MG/0.8ML ENOXAPARIN INJ 80/0.8ML Preferred Drug 60 30
ENTACAPONE TABLETS COMTANENTECAVIR SOLUTION BARACLUDE PA RequiredENTECAVIR SOLUTION BARACLUDE PA RequiredENTECAVIR TABLETS BARACLUDE PA RequiredENTECAVIR TABLETS BARACLUDE PA RequiredEPINEPHRINE SELF-INJECTED EPIPEN-JR 2-PAK Preferred Drug PA Required for > 2 Per Month 2 30EPINEPHRINE SELF-INJECTED EPIPEN 2-PAK Preferred Drug PA Required for > 2 Per Month 2 30EPLERENONE TABLETS INSPRA PA Required
EPOETIN ALFA SOLUTION EPOGEN PA RequiredEPOPROSTENOL SODIUM SOLUTION FLOLAN PA Required
ERGOCALCIFEROL CAPSULES VARIOUSERGOTAMINE W/ CAFFEINE SUPPOSITORY MIGERGOT 12 30ERGOTAMINE W/ CAFFEINE TABLETS CAFERGOTERLOTINIB HCL TABLETS TARCEVA PA RequiredERYTHROMYCIN GEL ERYGELERYTHROMYCIN OINTMENT ILOTYCIN
ERYTHROMYCIN PADS 2% ERYTHROMYCINERYTHROMYCIN SOLUTION ERYTHROMYCINERYTHROMYCIN-SULFISOXAZOLE SUSPENSION E.S.P.
Page 16 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
ESCITALOPRAM OXALATE SOLUTION LEXAPRO PA Required for Ages < 6 years 600 ML 30ESCITALOPRAM OXALATE TABLETS LEXAPRO PA Required for Ages < 6 years 5mg: 60 30ESTAZOLAM TABLETS ESTAZOLAM PA Required for Ages <6 years 30 30ESTERIFIED ESTROGENS TABLETS MENESTESTRADIOL & NORETHINDRONE ACETATE TABLETS VARIOUSESTRADIOL ACETATE VAGINAL RING FEMRINGESTRADIOL PATCH-TWICE WEEKLY ALORAESTRADIOL PATCH-WEEKLY MENOSTARESTRADIOL TABLETS ESTRACE
ESTRADIOL VAGINAL CREAM ESTRACEESTRADIOL VAGINAL RING ESTRINGESTRADIOL VAGINAL TABLETS VAGIFEMESTRADIOL-LEVONORGESTREL PATCH-WEEKLY CLIMARA PATCHESTROGENS, CONJUGATED SYNTHETIC A TABLETS CENESTINESTROGENS, CONJUGATED TABLETS PREMARINESTROGENS, CONJUGATED VAGINAL CREAM PREMARINESTROPIPATE TABLETS ORTHO-EST
ESZOPICLONE TABLETS LUNESTA
PA Required for Ages <6 years
PA Required for > 1 Hypnotic Drug 30 30ETANERCEPT ENBREL Preferred Drug PA RequiredETHAMBUTOL HCL TABLETS MYAMBUTOLETHOSUXIMIDE CAPSULES ZARONTINETHOSUXIMIDE SOLUTION ZARONTINETHYNODIOL DIACET & ETHINYL ESTRADIOL TABLETS KELNOR 1/35ETODOLAC CAPSULES LODINE
ETODOLAC TABLETS LODINEETODOLAC TABLETS EXTENDED RELEASE ETODOLAC ERETONOGESTREL-ETHINYL ESTRADIOL RING NUVARINGETOPOSIDE CAPSULES ETOPOSIDE PA RequiredETRAVIRINE TABLETS INTELENCEEVEROLIMUS (IMMUNOSUPPOSITORYRESSANT) TABLETS ZORTRESS PA RequiredEVEROLIMUS SOLUBLE TABLET AFINITOR DISPERZ PA RequiredEVEROLIMUS TABLETS AFINITOR PA Required
EXEMESTANE TABLETS AROMASIN PA RequiredEXENATIDE PEN BYDUREON PEN Preferred Drug PA RequiredEXENATIDE SUSPENSION PEN BYETTA PEN Preferred Drug PA RequiredEXENATIDE VIAL BYDUREON Preferred Drug PA RequiredEZETIMIBE TABLETS ZETIA PA RequiredFAMCICLOVIR TABLETS FAMVIR PA RequiredFAMOTIDINE CHEWABLE TABLETS PEPCID AC
FAMOTIDINE SUSPENSION PEPCIDFAMOTIDINE TABLETS PEPCID ACFEBUXOSTAT TABLETS ULORIC PA Required
FELBAMATE SUSPENSION FELBATOL
Page 17 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
FELBAMATE TABLETS FELBATOLFELODIPINE TABLET 24-HOUR FELODIPINE ERFENOFIBRATE MICRONIZED CAPSULES 43MG, 134MG, 200MG ANTARAFENOFIBRIC ACID TABLETS FIBRICORFENOPROFEN CALCIUM CAPSULES NALFONFENOPROFEN CALCIUM TABLETS FENOPROFEN CALCIUM
FENTANYL PATCH 72-HOUR 12mcg, 25mcg, 50mcg, 75mcg & 100mcg
DURAGESIC 12mcg, 25mcg,
50mcg, 75mcg & 100mcg Preferred PA Required
FERROUS FUMARATE TABLETS VARIOUS
FERROUS GLUCONATE TABLETS VARIOUS
FERROUS SULFATE TABLETS VARIOUS
FEXOFENADINE HCL ORALLY DISINTEGRATING TABLETS ALLEGRA ALLERGY CHILDRENS 30 30
FEXOFENADINE HCL SUSPENSION ALLEGRA ALLERGY CHILDRENS 150 ML 30
FEXOFENADINE HCL TABLETS ALLEGRA ALLERGY CHILDRENS 30 30FEXOFENADINE-PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUS 30 30FEXOFENADINE-PSEUDOEPHEDRINE TABLET 24-HOUR VARIOUS 30 30FILGRASTIM SOLUTION NEUPOGEN Brand Only PA RequiredFINASTERIDE TABLETS 5MG ONLY PROSCARFINGOLIMOD HCL CAPSULES GILENYA PA RequiredFLECAINIDE ACETATE TABLETS TAMBOCORFLUCONAZOLE SUSPENSION DIFLUCAN 600 ML 30
FLUCONAZOLE TABLETS DIFLUCAN 60 30FLUCYTOSINE CAPSULES ANCOBON PA RequiredFLUDROCORTISONE ACETATE TABLETS FLORINEFFLUNISOLIDE SOLUTION FLUNISOLIDEFLUOCINOLONE ACETONIDE CREAM FLUOCINOLONE ACETONIDEFLUOCINOLONE ACETONIDE OIL DERMA-SMOOTHE/FS BODYFLUOCINOLONE ACETONIDE OINTMENT SYNALARFLUOCINOLONE ACETONIDE SHAMPOO CAPEX
FLUOCINOLONE ACETONIDE SOLUTION SYNALARFLUOCINONIDE CREAM 0.05% VARIOUSFLUOCINONIDE EMULSIFIED BASE CREAM VARIOUSFLUOCINONIDE GEL 0.05% VARIOUS 60 GM 30FLUOCINONIDE OINTMENT 0.05% VARIOUS 60 GM 30FLUOCINONIDE SOLUTION VARIOUSFLUOROMETHOLONE OINTMENT FMLFLUOROMETHOLONE SUSPENSION FML LIQUIFILM
FLUOXETINE HCL CAPSULES PROZAC PA Required for Ages < 6 years
10mg: 60
20mg: 120
40mg: 60
30
30
30
Page 18 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
FLUOXETINE HCL DR CAPSULES PROZAC WEEKLY PA RequiredFLUOXETINE HCL SOLUTION PROZAC PA Required for Ages < 6 years 600 ML 30FLUOXYMESTERONE TABLETS ANDROXY
FLUPHENAZINE DECANOATE SOLUTION FLUPHENAZINE DECANOATE
PA Required for Ages < 18 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medications
FLUPHENAZINE HCL CONCENTRATE VARIOUS
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medications
FLUPHENAZINE HCL ELIXIR VARIOUS
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medications
FLUPHENAZINE HCL TABLETS VARIOUS
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medicationsFLURANDRENOLIDE CREAM CORDRAN
FLURANDRENOLIDE LOTION CORDRANFLURANDRENOLIDE OINTMENT CORDRAN
FLURAZEPAM HCL CAPSULES FLURAZEPAM HCL
PA Required for Ages <6 years
PA Required for > 1 Hypnotic Drug 30 30FLURBIPROFEN SODIUM SOLUTION OCUFENFLURBIPROFEN TABLETS FLURBIPROFENFLUTAMIDE CAPSULES FLUTAMIDEFLUTICASONE PROPIONATE HFA AEROSOL FLOVENT HFA Preferred Drug
FLUTICASONE PROPIONATE CREAM VARIOUSFLUTICASONE PROPIONATE LOTION VARIOUSFLUTICASONE PROPIONATE OINTMENT VARIOUSFLUTICASONE PROPIONATE SUSPENSION FLONASE
Page 19 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
FLUTICASONE-SALMETEROL AEROSOL ADVAIR HFA
Covered for Ages
4-12 ONLY Step Therapy
Patient must have tried
one steroid inhaler:
Beclomethasone
Dipropionate,
Budesonide,
Fluticasone Propionate,
or Mometasone
FLUTICASONE-SALMETEROL AEROSOL POWDER BREATH ACTIVATED ADVAIR DISKUS Preferred Drug Step Therapy
Patient must have tried
one steroid inhaler:
Beclomethasone
Dipropionate,
Budesonide,
Fluticasone Propionate,
or Mometasone
FLUVOXAMINE MALEATE ER CAPSULES LUVOX CR PA Required for Ages < 6 years
100mg: 90
150mg: 60
30
30
FLUVOXAMINE MALEATE TABLETS LUVOX PA Required for Ages < 6 years
25mg: 60
50mg: 180
100mg: 90
30
30
30FOLIC ACID TABLETS VARIOUS
FORMOTEROL FUMARATE CAPSULES FORADIL AEROSOLLIZER PA RequiredFOSAMPRENAVIR CALCIUM SUSPENSION LEXIVAFOSAMPRENAVIR CALCIUM TABLETS LEXIVAFOSCARNET SODIUM FOSCAVIR PA Required
FOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDE TABLETS
FOSINOPRIL SODIUM/
HYDROCHLOROTHIAZIDEFOSINOPRIL SODIUM TABLETS FOSINOPRIL SODIUMFUROSEMIDE SOLUTION FUROSEMIDE
FUROSEMIDE TABLETS LASIXGABAPENTIN CAPSULES 100MG, 300MG, 400MG NEURONTINGABAPENTIN SOLUTION NEURONTINGABAPENTIN TABLETS 600MG NEURONTINGABAPENTIN TABLETS 800MG NEURONTINGABAPENTIN TABLETS EXTENDED RELEASE GRALISE PA RequiredGABAPENTIN TABLETS EXTENDED RELEASE HORIZANT PA RequiredGALANTAMINE HYDROBROMIDE CAPSULE CONTROLLED RELEASE RAZADYNE ER PA Required
GALANTAMINE HYDROBROMIDE SOLUTION RAZADYNE PA RequiredGALANTAMINE HYDROBROMIDE TABLETS RAZADYNE PA RequiredGANCICLOVIR GEL ZIRGAN
Page 20 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
GANCICLOVIR SODIUM CYTOVENE PA RequiredGEFITINIB TABLETS IRESSA PA RequiredGEMFIBROZIL TABLETS LOPIDGENTAMICIN SULFATE CREAM GENTAMICIN SULFATEGENTAMICIN SULFATE OINTMENT GENTAMICIN SULFATEGENTAMICIN SULFATE OINTMENT GARAMYCINGENTAMICIN SULFATE SOLUTION GARAMYCINGENTAMICIN-PREDNISOLONE ACETATE OINTMENT PRED-G S.O.P.
GENTAMICIN-PREDNISOLONE ACETATE SUSPENSION PRED-GGLATIRAMER ACETATE COPAXONE Brand Only PA RequiredGLIMEPIRIDE TABLETS AMARYLGLIPIZIDE TABLET 24-HOUR GLUCATROL XLGLIPIZIDE TABLETS GLUCOTROLGLIPIZIDE-METFORMIN HCL TABLETS GLIPIZIDE/METFORMIN HCLGLUCAGON (RDNA) KIT GLUCAGON EMERGENCY KIT 1 30GLUCAGON CHEW TABLETS VARIOUS
GLUCAGON GEL VARIOUSGLYBURIDE MICRONIZED TABLETS GLYNASEGLYBURIDE TABLETS DIABETAGLYBURIDE-METFORMIN HCL TABLETS GLUCOVANCEGLYCOPYRROLATE SOLUTION VARIOUSGLYCOPYRROLATE TABLETS VARIOUSGRANISETRON HCL SOLUTION VARIOUS PA RequiredGRANISETRON HCL TABLETS VARIOUS PA Required
GRISEOFULVIN MICROSIZE SUSPENSION GRISEOFULVIN MICROSIZEGRISEOFULVIN MICROSIZE TABLETS GRIFULVIN VGRISEOFULVIN ULTRAMICROSIZE TABLETS GRIS-PEGGUAIFENESIN LIQUID VARIOUS 480 ML 30GUAIFENESIN SYRUP VARIOUS 480 ML 30GUAIFENESIN TABLET 12-HOUR VARIOUSGUAIFENESIN TABLETS VARIOUSGUAIFENESIN-CODEINE SYRUP ROBITUSSIN AC 240 ML 12
GUANFACINE HCL TENEX PA Required for ages < 6 yearsGUANFACINE HCL (ADHD) TABLET 12-HOUR GUANFACINE HCL ER Preferred Drug PA Required for ages < 6 years 30 30GUANFACINE HCL (ADHD) TABLET 24-HOUR GUANFACINE ER Preferred Drug PA Required for Ages < 6 years 30 30GUANFACINE HCL TABLETS TENEX PA Required for Ages <6 years
HALOPERIDOL DECANOATE SOLUTION HALDOL DECANOATE 50
PA Required for Ages < 18 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medications
Page 21 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
HALOPERIDOL LACTATE CONCENTRATE VARIOUS
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medications
HALOPERIDOL TABLETS VARIOUS
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medicationsHEPARIN (PORCINE) IN SODIUM CHLORIDE SOLUTION HEPARIN SODIUM/NACL 0.9%HEPARIN SOD (PORCINE) IN D5W SOLUTION HEPARIN SODIUM/D5WHEPARIN SODIUM SOLUTION HEPARIN SODIUMHEPARIN SODIUM LOCK FLUSH SOLUTION HEPARIN LOCK FLUSHHOMATROPINE HBR SOLUTION ISOPTO HOMATROPINEHYDRALAZINE HCL TABLETS HYDRALAZINE HCL
HYDROCHLOROTHIAZIDE CAPSULES 12.5MG MICROZIDEHYDROCHLOROTHIAZIDE TABLETS 25MG, 50MG HYDROCHLOROTHIAZIDEHYDROCODONE BITARTRATE ER TABLETS 24-HR ABUSE DETERRANT HYSINGLA ER Brand Only Preferred PA RequiredHYDROCODONE W/ HOMATROPINE SYRUP VARIOUS 240 ML 12HYDROCODONE W/ HOMATROPINE TABLETS VARIOUS
HYDROCODONE-ACETAMINOPHEN CAPSULES HYDROGESIC
PA Required for > 2 Short Acting
Narcotics Fill
HYDROCODONE-ACETAMINOPHEN SOLUTION HYCET
PA Required for > 2 Short Acting
Narcotics Fill
HYDROCODONE-ACETAMINOPHEN TABLETS VERDROCET
PA Required for > 2 Short Acting
Narcotics Fill
HYDROCODONE-IBUPROFEN TABLETS REPREXAIN
PA Required for > 2 Short Acting
Narcotics FillHYDROCORTISONE (INTRARECTAL) ENEMA COLOCORTHYDROCORTISONE (RECTAL) CREAM PROCTOCORTHYDROCORTISONE ACETATE (INTRARECTAL) FOAM CORTIFOAM
HYDROCORTISONE ACETATE CREAM ANUSOL-HCHYDROCORTISONE ACETATE OINTMENT ANUSOL-HCHYDROCORTISONE BUTYRATE CREAM VARIOUSHYDROCORTISONE BUTYRATE LOTION VARIOUSHYDROCORTISONE BUTYRATE OINTMENT VARIOUSHYDROCORTISONE BUTYRATE SOLUTION VARIOUSHYDROCORTISONE CREAM VARIOUSHYDROCORTISONE LOTION VARIOUS
HYDROCORTISONE OINTMENT VARIOUSHYDROCORTISONE SOD SUCCINATE SOLUTION (INJECTABLE) A-HYDROCORT Long Term Care Only
HYDROCORTISONE SOLUTION VARIOUS
Page 22 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
HYDROCORTISONE TABLETS HYDROCORTISONEHYDROCORTISONE VALERATE CREAM VARIOUSHYDROCORTISONE VALERATE OINTMENT VARIOUSHYDROCORTISONE W/ACETIC ACID SOLUTION ACETASOL HCHYDROGEN PEROXIDE SOLUTION HYDROGEN PEROXIDE
HYDROMORPHONE HCL LIQUID DILAUDID
PA Required for > 2 Short Acting
Narcotics Fill
HYDROMORPHONE HCL SUPPOSITORY HYDROMORPHONE HCL
PA Required for > 2 Short Acting
Narcotics Fill
HYDROMORPHONE HCL TABLETS DILAUDID
PA Required for > 2 Short Acting
Narcotics FillHYDROXYCHLOROQUINE SULFATE TABLETS PLAQUENILHYDROXYPROGESTERONE CAPROATE 1250 MG/5ML VIAL MAKENA PA RequiredHYDROXYPROGESTERONE CAPROATE 250 MG/1ML VIAL MAKENA PA RequiredHYDROXYPROPYL METHYLCELLULOSE GEL LACRI-LUBEHYDROXYPROPYL METHYLCELLULOSE SOLUTION LACRI-LUBE
HYDROXYZINE HCL SYRUP HYDROXYZINE HCL 300 ML 30HYDROXYZINE HCL TABLETS HYDROXYZINE HCL 240 30HYDROXYZINE PAMOATE CAPSULES VISTARIL 120 30
HYOSCYAMINE SULFATE CONTROLLED RELEASE TABLET VARIOUSHYOSCYAMINE SULFATE ELIXIR VARIOUSHYOSCYAMINE SULFATE ORALLY DISINTEGRATING TABLETS VARIOUSHYOSCYAMINE SULFATE SOLUTION VARIOUSHYOSCYAMINE SULFATE SUBLINGUAL VARIOUS
HYOSCYAMINE SULFATE TABLET 12-HOUR VARIOUSHYOSCYAMINE SULFATE TABLETS VARIOUSIBRUTINIB CAPSULES IMBRUVICA PA RequiredIBUPROFEN CAPSULES ADVILIBUPROFEN CHEWABLE TABLETS CHILDRENS MOTRINIBUPROFEN SUSPENSION CHILDRENS MOTRINIBUPROFEN TABLETS ADVIL IDURSULFASE SOLUTION ELAPRASE PA Required
ILOPROST SOLUTION VENTAVIS PA RequiredIMATINIB MESYLATE TABLETS GLEEVEC PA RequiredIMIGLUCERASE SOLUTION CEREZYME PA RequiredIMIPRAMINE HCL CAPSULES TOFRANIL PA Required for ages < 6 yearsIMIPRAMINE HCL TABLETS TOFRANIL PA Required for ages < 6 yearsIMIPRAMINE PAMOATE CAPSULES TOFRANIL PM PA Required for ages < 6 yearsINDAPAMIDE TABLETS INDAPAMIDEINDINAVIR SULFATE CAPSULES CRIXIVAN
INDOMETHACIN CAPSULE CONTROLLED RELEASE INDOMETHACIN CRINDOMETHACIN CAPSULES VARIOUSINDOMETHACIN SUPPOSITORY INDOCIN
Page 23 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
INDOMETHACIN SUSPENSION INDOCININSULIN ASPART NOVOLOG Preferred DrugINSULIN ASPART NOVOLOG CARTRIDGE Preferred DrugINSULIN ASPART NOVOLOG FLEXPEN Preferred DrugINSULIN ASPART PROTAMINE SUSPENSION & INSULIN ASPART NOVOLOG MIX 70/30 Preferred Drug
INSULIN ASPART PROTAMINE SUSPENSION & INSULIN ASPART NOVOLOG MIX 70/30 FLEXPEN Preferred DrugINSULIN DETEMIR SOLUTION LEVEMIR Preferred Drug
INSULIN DETEMIR SUSPENSION LEVEMIR FLEXPEN/FLEXTOUCH Preferred DrugINSULIN GLARGINE SOLUTION LANTUS Preferred DrugINSULIN GLARGINE SUSPENSION LANTUS SOLOSTAR Preferred DrugINSULIN INFUSION PUMP SUPPLIES VARIOUSINSULIN LISPRO (HUMAN) SOLUTION HUMALOG Preferred DrugINSULIN LISPRO (HUMAN) SUSPENSION HUMALOG KWIKPEN Preferred Drug
INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION HUMALOG MIX 75/25 KWIKPEN Preferred Drug
INSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION HUMALOG MIX 50/50 KWIKPEN Preferred DrugINSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION HUMALOG MIX 50/50 VIAL Preferred DrugINSULIN LISPRO PROTAMINE & LISPRO (HUMAN) SUSPENSION VIAL HUMALOG MIX 75/25 Preferred DrugINSULIN NEEDLES VARIOUSINSULIN NPH (HUMAN) (ISOPHANE) SUSPENSION HUMULIN N Preferred DrugINSULIN NPH (HUMAN) (ISOPHANE) SUSPENSION HUMULIN N KWIKPEN Preferred Drug
INSULIN NPH ISOPHANE & REG (HUMAN) SUSPENSION HUMULIN 70/30 Preferred DrugINSULIN NPH ISOPHANE & REG (HUMAN) SUSPENSION HUMULIN PEN 70/30 Preferred DrugINSULIN PEN NEEDLES VARIOUS
INSULIN REGULAR (HUMAN) PEN
HUMULIN R U-500 PEN
(CONCENTRATED) Preferred Drug PA RequiredINSULIN REGULAR (HUMAN) SOLUTION HUMULIN R Preferred Drug
INSULIN REGULAR (HUMAN) SOLUTION
HUMULIN R U-500
(CONCENTRATED) Preferred Drug PA Required
INSULIN SYRINGE VARIOUSINTERFERON ALFA-2B SOLUTION INTRON A PA RequiredINTERFERON ALFA-2B SOLUTION INTRON A PA RequiredINTERFERON ALFA-N3 SOLUTION ALFERON N PA RequiredINTERFERON BETA-1A KIT AVONEX PA RequiredINTERFERON BETA-1A SOLUTION REBIF REBIDOSE PA RequiredINTERFERON BETA-1B KIT BETASERON PA RequiredINTERFERON GAMMA-1B SOLUTION ACTIMMUNE PA Required
IODOQUINOL TABLETS YODOXINIPRATROPIUM BROMIDE HFA AEROSOL ATROVENT HFA Preferred DrugIPRATROPIUM BROMIDE NASAL SOLUTION ATROVENT NS
Page 24 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
IPRATROPIUM BROMIDE SOLUTION IPRATROPIUM BROMIDE Preferred DrugIPRATROPIUM BROMIDE SOLUTION ATROVENT IPRATROPIUM-ALBUTEROL AEROSOL COMBIVENT RESPIMAT Preferred Drug IPRATROPIUM-ALBUTEROL NEBULIZER SOLUTION DUONEB Preferred DrugIRBESARTAN TABLETS AVAPROIRBESARTAN-HYDROCHLOROTHIAZIDE TABLETS AVALIDEISOCARBOXAZID TABLET MARPLAN PA Required for Ages < 6 yearsISONIAZID SYRUP ISONIAZID
ISONIAZID TABLETS ISONIAZIDISONIAZID-RIFAMPIN-PYRAZINAMIDE TABLETS RIFATERISOSORBIDE DINITRATE CAPSULE CONTROLLED RELEASE DILATRATE SRISOSORBIDE DINITRATE SUBLINGUAL ISOSORBIDE DINITRATEISOSORBIDE DINITRATE TABLET CONTROLLED RELEASE ISOSORBIDE DINITRATE ERISOSORBIDE DINITRATE TABLETS ISORDIL TITRADOSEISOSORBIDE MONONITRATE TABLET 24-HOUR IMDURISOSORBIDE MONONITRATE TABLETS ISOSORBIDE MONONITRATE
ISOTRETINOIN CAPSULES AMNESTEEM PA RequiredISRADIPINE CAPSULES ISRADIPINEITRACONAZOLE CAPSULES SPORANOX PA RequiredITRACONAZOLE SOLUTION SPORANOX PA RequiredITRACONAZOLE TABLETS ONMEL PA RequiredIVERMECTIN LOTION SKLICE PA RequiredIVERMECTIN TABLETS STROMECTOLKAOLIN-PECTIN SUSPENSION KAOPECTATE
KETOCONAZOLE GEL VARIOUSKETOCONAZOLE CREAM VARIOUSKETOCONAZOLE FOAM VARIOUSKETOCONAZOLE SHAMPOO VARIOUSKETOCONAZOLE TABLETS KETOCONAZOLEKETOPROFEN CAPSULES ORUDISKETOPROFEN CAPSULES SUSTAINED RELEASE ORUDISKETOROLAC TROMETHAMINE SOLUTION ACULAR LS
KETOROLAC TROMETHAMINE TABLETS KETOROLAC TROMETHAMINE 20 30KETOTIFEN FUMARATE SOLUTION ALAWAYLABETALOL HCL TABLETS TRANDATELACOSAMIDE SOLUTION VIMPAT PA RequiredLACOSAMIDE TABLETS VIMPAT PA RequiredLACTIC ACID (AMMONIUM LACTATE) CREAM LAC-HYDRINLACTIC ACID (AMMONIUM LACTATE) LOTION LAC-HYDRIN
LACTULOSE SOLUTION LACTULOSELAMIVUDINE (HBV) SOLUTION EPIVIR HBV
LAMIVUDINE (HBV) TABLETS EPIVIR HBV
Page 25 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
LAMIVUDINE SOLUTION EPIVIRLAMIVUDINE TABLETS EPIVIRLAMIVUDINE-ZIDOVUDINE TABLETS COMBIVIRLAMOTRIGINE CHEWABLE TABLETS LAMICTAL+B135LAMOTRIGINE ORALLY DISINTEGRATING TABLETS 100MG LAMICTAL ODTLAMOTRIGINE ORALLY DISINTEGRATING TABLETS 200MG LAMICTAL ODTLAMOTRIGINE ORALLY DISINTEGRATING TABLETS 25MG, 50MG LAMICTAL ODTLAMOTRIGINE TABLET 24-HOUR LAMICTAL XR
LAMOTRIGINE TABLETS 100MG LAMICTALLAMOTRIGINE TABLETS 150MG 200MG LAMICTALLAMOTRIGINE TABLETS 25MG LAMICTALLANCET DEVICES MISC. VARIOUSLANCETS MISC. VARIOUSLANSOPRAZOLE CAPSULE DELAYED RELEASE PREVACIDLANSOPRAZOLE SUSPENSION FIRST-LANSOPRAZOLELANTHANUM CARBONATE CHEWABLE TABLETS FOSRENOL PA Required
LANTHANUM CARBONATE PACKETS FOSRENOL PA RequiredLAPATINIB DITOSYLATE TABLETS TYKERB PA RequiredLATANOPROST SOLUTION XALATAN 2.5ML 30LEDIPASVIR-SOFOSBUVIR TABLETS HARVONI Preferred Drug PA RequiredLEFLUNOMIDE TABLETS ARAVALENALIDOMIDE CAPSULES REVLIMID PA RequiredLEUCOVORIN CALCIUM TABLETS LEUCOVORIN CALCIUM PA RequiredLEUPROLIDE ACETATE (3 MONTH) KIT LUPRON DEPOT PA Required
LEUPROLIDE ACETATE (4 MONTH) KIT LUPRON DEPOT PA RequiredLEUPROLIDE ACETATE (CPP) (3 MONTH) KIT LUPRON DEPOT-PED PA RequiredLEUPROLIDE ACETATE (CPP) KIT LUPRON DEPOT-PED PA RequiredLEUPROLIDE ACETATE KIT LUPRON DEPOT PA RequiredLEVETIRACETAM SOLUTION KEPPRALEVETIRACETAM TABLET 24-HOUR KEPPRA XRLEVETIRACETAM TABLETS KEPPRALEVOBUNOLOL HCL SOLUTION LEVOBUNOLOL HCL
LEVOFLOXACIN SOLUTION LEVAQUINLEVOFLOXACIN TABLETS LEVAQUINLEVONORGESTREL & ETHINYL ESTRADIOL TABLETS AUBRALEVONORGESTREL TABLETS PLAN BLEVONORGESTREL-ETHINYL ESTRADIOL (91-DAY) TABLETS AMETHIA LOLEVONORGESTREL-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS ENPRESSE-28LEVOTHYROXINE SODIUM TABLETS LEVO-TLIDOCAINE HCL CREAM 4% ASPERCREME OTC
LIDOCAINE HCL GEL XYLOCAINELIDOCAINE HCL LOCAL INJECTION XYLOCAINE PA Required (FOR ESRD ONLY)
LIDOCAINE HCl LOCAL INJECTION PRESERVATIVE FREE XYLOCAINE-MPF PA Required (FOR ESRD ONLY)
Page 26 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
LIDOCAINE HCL SOLUTION VARIOUSLIDOCAINE OINTMENT 5% VARIOUS PA Required 50 GM 30LIDOCAINE PATCH LIDODERM PA RequiredLIDOCAINE-PRILOCAINE CREAM EMLALINACLOTIDE CAPSULES LINZESS PA RequiredLINAGLIPTIN TABLET TRADJENTA Preferred Drug PA RequiredLINAGLIPTIN/METFORMIN TABLETS JENTADUETO Preferred Drug PA RequiredLINDANE LOTION KWELL
LINDANE SHAMPOO KWELLLINEZOLID SUSPENSION ZYVOX PA RequiredLINEZOLID TABLETS ZYVOX PA RequiredLIOTHYRONINE SODIUM TABLETS CYTOMELLIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE ZENPEP Brand Only Preferred Drug 500 30LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE 5000 U PANCRELIPASE 5000 U Brand Only Preferred Drug 500 30LIPASE-PROTEASE-AMYLASE CAPSULE DELAYED RELEASE CREON Brand Only Preferred Drug 500 30LIRAGLUTIDE SOLUTION VICTOZA Preferred Drug PA Required
LISDEXAMFETAMINE DIMESYLATE CAPSULES VYVANSE Brand Only Preferred Drug PA Required for Ages < 6 years 30 30LISINOPRIL & HYDROCHLOROTHIAZIDE TABLETS ZESTORETICLISINOPRIL TABLETS ZESTRIL
LITHIUM CARBONATE CAPSULES LITHIUM CARBONATE
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications
LITHIUM CARBONATE TABLET CONTROLLED RELEASE LITHOBID
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications
LITHIUM CARBONATE TABLETS LITHIUM CARBONATE
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications
LITHIUM SOLUTION LITHIUM
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medicationsLODOXAMIDE TROMETHAMINE SOLUTION ALOMIDELOPERAMIDE HCL CAPSULES LOPERAMIDE HCLLOPERAMIDE HCL CHEWABLE TABLETS IMODIUM A-DLOPERAMIDE HCL LIQUID LOPERAMIDE HCLLOPERAMIDE HCL SUSPENSION IMODIUM A-D
LOPERAMIDE HCL TABLETS IMODIUM A-DLOPINAVIR-RITONAVIR SOLUTION KALETRA
LOPINAVIR-RITONAVIR TABLETS KALETRA
Page 27 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
LORATADINE & PSEUDOEPHEDRINE TABLET 12-HOUR ALAVERT ALLERGY/SINUS 30 30LORATADINE & PSEUDOEPHEDRINE TABLET 24-HOUR CLARITIN-D 24 HOUR 30 30LORATADINE CAPSULES CLARITIN 30 30LORATADINE CHEWABLE TABLETS CLARITIN 30 30LORATADINE ORALLY DISINTEGRATING TABLETS CLARITIN REDITABS 30 30LORATADINE SYRUP CLARITIN 150 ML 30LORATADINE TABLETS ALAVERT 30 30
LORAZEPAM CONC 2 MG/ML LORAZEPAM INTENSOL
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 ML 30
LORAZEPAM TAB 0.5 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
LORAZEPAM TAB 1 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 120 30
LORAZEPAM TAB 2 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30LOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDE TABLETS HYZAAR
LOSARTAN POTASSIUM TABLETS COZAARLOVASTATIN TABLETS MEVACOR 30 30
LOXAPINE SUCCINATE CAPSULES LOXITANE
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medicationsLUBIPROSTONE CAPSULES AMITIZA PA Required
LURASIDONE HCL TABS LATUDA Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 30 30MAGNESIOUN CITRATE SOLUTION MAG CITRATEMAGNESIUM HYDROXIDE SUSPENSION MILK OF MAGNESIAMAGNESIUM HYDROXIDE SUSPENSION CONCENTRATE MILK OF MAGNESIA
MAGNESIUM OXIDE CAPSULES VARIOUSMAGNESIUM OXIDE TABLETS VARIOUSMAPROTILINE HCL TABLETS LUDIOMIL PA Required for ages < 6 yearsMARAVIROC TABLETS SELZENTRY PA RequiredMECASERMIN SOLUTION INCRELEX PA RequiredMECLIZINE HCL CHEWABLE TABLETS BONINEMECLIZINE HCL TABLETS BONINEMECLOFENAMATE SODIUM CAPSUL MECLOFENAMATE
MEDROXYPROGESTERONE ACETATE SUSPENSION
DEPO-PROVERA
CONTRACEPTIVE
MEDROXYPROGESTERONE ACETATE TABLETS PROVERA
Page 28 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
MEFENAMIC ACID CAPSULE PONSTELMEGESTROL ACETATE SUSPENSION MEGACEMEGESTROL ACETATE TABLETS MEGACEMELOXICAM SUSPENSION MOBICMELOXICAM TABLETS MOBICMEMANTINE HCL SOLUTION NAMENDA PA RequiredMEMANTINE HCL TABLETS NAMENDA PA Required
MEPERIDINE HCL TABLETS DEMEROL
PA Required for > 2 Short Acting
Narcotics Fill
MEPROBAMATE TABLETS VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 AnxiolyticMERCAPTOPURINE SUSPENSION PURIXANMERCAPTOPURINE TABLETS PURINETHOLMESALAMINE CAPSULE CONTROLLED RELEASE PENTASA 270 30MESALAMINE ENEMA MESALAMINE 240 30MESALAMINE TABLET ENTERIC COATED ASACOL HD 120 30
MESALAMINE W/ CLEANSER KIT ROWASA 240 30 METAPROTERENOL SULFATE TABLETS METAPROTERENOL SULFATE METFORMIN HCL SOLUTION RIOMETMETFORMIN HCL TABLET 24-HOUR (GENERIC OF GLUCOPHAGE XR ONLY- 500MG
& 750MG) VARIOUS
PA Required for Osmotic and Modified
Release Products METFORMIN HCL TABLETS GLUCOPHAGE
METHADONE VARIOUS
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List. Only available at an Opioid
Treatment CenterMETHAZOLAMIDE TABLETS NEPTAZANEMETHENAMINE MANDELATE SUSPENSION METHENAMINEMETHENAMINE MANDELATE TABLETS HIPREXMETHIMAZOLE TABLETS TAPAZOLEMETHOCARBAMOL TABLETS ROBAXINMETHOTREXATE SODIUM TABLETS RHEUMATREX
METHOTREXATE SODIUM TABLETS METHOTREXATEMETHSCOPOLAMINE BROMIDE TABLETS PAMINEMETHYCLOTHIAZIDE TABLETS AQUATENSENMETHYLDOPA TABLETS METHYLDOPAMETHYLERGONOVINE MALEATE TABLETS METHERGINEMETHYLNALTREXONE BROMICE INJECTION RELISTOR PA RequiredMETHYLPHENIDATE HCL CAPSULE 24-HOUR RITALIN LA 10MG Brand Only Preferred Drug PA Required for Ages < 6 years 30 30METHYLPHENIDATE HCL CAPSULE 24-HOUR APTENSIO XR Brand Only Preferred Drug PA Required for Ages < 6 years 30 30
METHYLPHENIDATE HCL CAPSULE 24-HOUR VARIOUS Preferred Drug PA Required for Ages < 6 years 30 30METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE METADATE CD Preferred Drug PA Required for Ages < 6 years 30 30METHYLPHENIDATE HCL CHEWABLE TABLETS METHYLIN Preferred Drug PA Required for Ages < 6 years 90 30
Page 29 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
METHYLPHENIDATE HCL CHEWABLE TABLETS EXTENDED RELEASE QUILLICHEW ER Brand Only Preferred Drug PA Required for Ages < 6 years 30 30METHYLPHENIDATE HCL SOLUTION METHYLIN Brand Only Preferred Drug PA Required for ages < 6 years 300ML 30METHYLPHENIDATE HCL SUSPENSION QUILLIVANT XR Brand Only Preferred Drug PA Required for ages < 6 years 150ML 30METHYLPHENIDATE HCL TABLET 24-HOUR METHYLPHENIDATE HCL ER Preferred Drug PA Required for Ages < 6 years 60 30METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE METHYLPHENIDATE HCL ER Preferred Drug PA Required for Ages < 6 years 60 30METHYLPHENIDATE HCL TABLET SUSTAINED RELEASE RITALIN SR PA Required for ages < 6 years 60 30METHYLPHENIDATE HCL TABLETS VARIOUS Preferred Drug PA Required for Ages < 6 years 90 30METHYLPHENIDATE HCL TD PATCH DAYTRANA Brand Only Preferred Drug PA Required for ages < 6 years 30 30
METHYLPREDNISOLONE ACETATE SUSPENSION (INJECTABLE) DEPO-MEDROL Long Term Care OnlyMETHYLPREDNISOLONE SOD SUCC SOLUTION (INJECTABLE) A-METHAPRED Long Term Care OnlyMETHYLPREDNISOLONE TABLETS MEDROLMETIPRANOLOL SOLUTION METIPRANOLOLMETOCLOPRAMIDE HCL ORALLY DISINTEGRATING TABLETS VARIOUSMETOCLOPRAMIDE HCL SOLUTION VARIOUSMETOCLOPRAMIDE HCL TABLETS VARIOUSMETOLAZONE TABLETS ZAROXOLYN
METOPROLOL - HYDROCHLOROTHIAZIDE TABLETS LOPRESSOR HCTMETOPROLOL SUCCINATE TABLET 24-HOUR TOPROL XLMETOPROLOL TARTRATE TABLETS METOPROLOL TARTRATEMETRONIDAZOLE CAPSULE FLAGYLMETRONIDAZOLE CREAM METROCREAMMETRONIDAZOLE GEL METROGELMETRONIDAZOLE LOTION METROLOTIONMETRONIDAZOLE TABLET SR FLAGYL ER
METRONIDAZOLE TABLETS FLAGYLMETRONIDAZOLE VAGINAL GEL 0.75% METROGELMEXILETINE HCL CAPSULES MEXILETINE HCLMICONAZOLE NITRATE LIQUID VARIOUSMICONAZOLE NITRATE CREAM VARIOUSMICONAZOLE NITRATE POWDER VARIOUS
MICONAZOLE NITRATE VAGINAL
MONISTAT 3 COMBINATION
PACKETS
MICONAZOLE NITRATE VAGINAL SUPPOSITORY MICONAZOLE 3MIDODRINE HCL TABLETS MIDODRINEMILNACIPRAN HCL TABLETS SAVELLA 60 30MINOCYCLINE HCL CAPSULES MINOCINMINOXIDIL TABLETS MINOXIDILMIRTAZAPINE ORALLY DISINTEGRATING TABLETS 15MG REMERON SOLTAB PA Required for Ages < 6 years 30 30MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 30MG REMERON SOLTAB PA Required for Ages < 6 years 30 30MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG REMERON SOLTAB PA Required for Ages < 6 years 30 30
MIRTAZAPINE TABLETS 30MG MIRTAZAPINE PA Required for Ages < 6 years 30 30MIRTAZAPINE TABLETS 45MG MIRTAZAPINE PA Required for Ages < 6 years 30 30
MIRTAZAPINE TABLETS 7.5MG, 15MG MIRTAZAPINE PA Required for Ages < 6 years 30 30
Page 30 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
MISOPROSTOL TABLETS CYTOTECMOEXIPRIL - HYDROCHLOROTHIAZIDE TABLETS UNIRETICMOEXIPRIL HCL TABLETS UNIVASC
MOMETASONE FUROATE (INHALATION) AEROSOL POWDER BREATH ACTIVATED
ASMANEX TWISTHALER 30
METERED DOSES Preferred DrugMOMETASONE FUROATE CREAM ELOCONMOMETASONE FUROATE OINTMENT ELOCONMOMETASONE FUROATE SOLUTION ELOCON
MOMETASONE FUROATE-FORMOTEROL FUMARATE DIHYDRATE AEROSOL DULERA Preferred Drug Step Therapy
Patient must have tried
one steroid inhaler:
Beclomethasone
Dipropionate,
Budesonide,
Fluticasone Propionate,
or MometasoneMONTELUKAST SODIUM CHEWABLE TABLETS SINGULAIR 30 30MONTELUKAST SODIUM GRANULES SINGULAIR 30 30MONTELUKAST SODIUM TABLETS SINGULAIR 30 30
MORPHINE SULFATE SOLUTION MORPHINE SULFATE
PA Required for > 2 Short Acting
Narcotics Fill
MORPHINE SULFATE SUPPOSITORY MORPHINE SULFATE
PA Required for > 2 Short Acting
Narcotics Fill
MORPHINE SULFATE TABLET CONTROLLED RELEASE MS CONTIN Preferred PA Required
MORPHINE SULFATE TABLETS MORPHINE SULFATE
PA Required for > 2 Short Acting
Narcotics FillMORPHINE-NALTREXONE CAPSULE CONTROLLED RELEASE RELEASE EMBEDA Preferred PA RequiredMOXIFLOXACIN HCL SOLUTION AVELOXMOXIFLOXACIN HCL SOLUTION VIGAMOXMULTIPLE VITAMIN CAPSULES VARIOUSMULTIPLE VITAMIN TABLETS VARIOUS
MULTIPLE VITAMIN W/ MINERALS CAPSULES VARIOUSMULTIPLE VITAMIN W/ MINERALS CHEW TABLETS VARIOUSMULTIPLE VITAMIN W/ MINERALS LIQUID VARIOUSMULTIPLE VITAMIN W/ MINERALS TABLETS VARIOUSMUPIROCIN CALCIUM CREAM BACTROBANMUPIROCIN OINTMENT BACTROBANMYCOPHENOLATE MOFETIL CAPSULES CELLCEPTMYCOPHENOLATE MOFETIL SUSPENSION CELLCEPT
MYCOPHENOLATE MOFETIL TABLETS CELLCEPTMYCOPHENOLATE SODIUM TABLET DELAYED RELEASE MYFORTICNABUMETONE TABLETS NABUMETONE
Page 31 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
NADOLOL TABLETS CORGARDNALOXONE NASAL SPRAY NARCAN NASAL Preferred DrugNALOXONE SYRINGE NALOXONE Preferred DrugNALOXONE VIAL NALOXONE Preferred Drug
NALTREXONE REVIA
Long Term Care Only ; See Behavioral
Health Drug List
NALTREXONE VIVITROL
Long Term Care Only ; See Behavioral
Health Drug List
NAPHAZOLINE HCL SOLUTION VASOCLEARNAPHAZOLINE W/ PHENIRAMINE SOLUTION NAPHCON-ANAPROXEN SODIUM CAPSULE ALEVE. ANAPROXNAPROXEN SODIUM TABLETS ALEVE. ANAPROXNAPROXEN SUSPENSION NAPROSYNNAPROXEN TABLETS NAPROSYNNAPROXEN TABLETS ENTERIC COATED NAPROSYN ECNAPROXEN TABLETS SUSTAINED RELEASE ANAPROX DS
NATAMYCIN SUSPENSION NATACYNNATEGLINIDE TABLETS STARLIX
NEFAZODONE TABLETS VARIOUS PA Required for Ages < 6 years
50mg: 60
100mg: 60
150mg: 120
200mg: 90
250mg: 60
30
30
30
30
30NELFINAVIR MESYLATE TABLETS VIRACEPT
NEOMYCIN SULFATE TABLETS NEOMYCIN SULFATENEOMYCIN-BACITRACIN ZN-POLYMYXIN OINTMENT NEO-POLYCINNEOMYCIN-BACITRACIN-POLYMYXIN OINTMENT NEOSPORINNEOMYCIN-POLYMY-DEXAMETH OINTMENT MAXITROLNEOMYCIN-POLYMY-DEXAMETH SUSPENSION MAXITROLNEOMYCIN-POLYMYXIN-GRAMICIDIN SOLUTION NEOSPORINNEOMYCIN-POLYMYXIN-HC SOLUTION CORTISPORINNEOMYCIN-POLYMYXIN-HC SUSPENSION NEO/POLYMYXIN/HC
NEVIRAPINE SUSPENSION VIRAMUNENEVIRAPINE TABLET 24-HOUR VIRAMUNE XRNEVIRAPINE TABLETS VIRAMUNENIACIN (ANTIHYPERLIPIDEMIC) TABLETS NIACORNIACIN CAPSULES NIACIN ERNIACIN TAB CR 250MG, 500MG, 750MG SLO-NIACIN (OTC)NIACIN TABLETS NIACIN NIACIN TABLETS CONTROLLED RELEASE NIACIN ER
NIACINAMIDE TABLETS VARIOUSNIACINAMIDE TABLETS CR VARIOUSNICARDIPINE HCL CAPSULE 12-HOUR CARDENE SR
Page 32 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
NICARDIPINE HCL CAPSULES NICARDIPINE HCLNICLOSAMIDE NICLOCIDE
NICOTINE INHA NICOTROL INHALER
84-day
supply 180
NICOTINE PATCH NICODERM CQ
84-day
supply 180
NICOTINE POLACRILEX GUM NICORETTE GUM
84-day
supply 180
NICOTINE POLACRILEX LOZENGE COMMIT
84-day
supply 180
NICOTINE SOLUTION NICOTROL NS
84-day
supply 180NIFEDIPINE CAPSULES PROCARDIANIFEDIPINE TABLET 24-HOUR ADALAT CC 60 30NILOTINIB HCL CAPSULES TASIGNA PA RequiredNIMODIPINE CAPSULES NIMODIPINE
NIMODIPINE SOLUTION NYMALIZENISOLDIPINE TABLET 24-HOUR SULARNIT REMOVER - GEL LICEOUT
NIT REMOVER - SHAMPOO LICEOUTNITROFURANTOIN CAPSULE MACRODANTINNITROFURANTOIN MACROCRYSTALLINE CAPSULES MACROBIDNITROFURANTOIN SUSPENSION FURADANTINNITROGLYCERIN CAPSULE CONTROLLED RELEASE NITRO-TIME
NITROGLYCERIN OINTMENT NITRO-BIDNITROGLYCERIN PATCH 24-HOUR NITRO-DURNITROGLYCERIN SUBLINGUAL NITROSTATNIZATIDINE CAPSULES AXIDNIZATIDINE ORAL SOLUTION AXID
NONOXYNOL-9 FOAM
VCF VAGINAL CONTRACEPTIVE
FOAMNONOXYNOL-9 GEL SHUR-SEAL
NORETHINDRONE & ETHINYL ESTRADIOL TABLETS BALZIVA NORETHINDRONE & MESTRANOL TABLETS NECON 1/50-28NORETHINDRONE ACETATE & ETHINYL ESTRADIOL TABLETS GILDESS 1/20NORETHINDRONE ACETATE TABLETS AYGESTINNORETHINDRONE ACETATE-ETHINYL ESTRADIOL-FE TABLETS ESTROSTEP FENORETHINDRONE TABLETS CAMILANORETHINDRONE-ETHINYL ESTRADIO+A894L (TRIPHASIC) TABLETS CYCLAFEM 7/7/7NORETHINDRONE-ETHINYL ESTRADIOL (BIPHASIC) TABLETS NECON 10/11-28
NORGESTIMATE-ETHINYL ESTRADIOL (TRIPHASIC) TABLETS ORTHO TRI-CYCLENNORGESTIMATE-ETHINYL ESTRADIOL TABLETS ESTARYLLANORGESTREL & ETHINYL ESTRADIOL TABLETS CRYSELLE-28
Page 33 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
NORTRIPTYLINE HCL CAPSULES PAMELOR PA Required for ages < 6 yearsNORTRYIPTYLINE HCL SOLUTION PAMELOR PA Required for ages < 6 yearsNYSTATIN CREAM VARIOUSNYSTATIN POWDER NYAMYCNYSTATIN CAPSULES BIO-STATINNYSTATIN OINTMENT VARIOUSNYSTATIN POWDER NYSTATINNYSTATIN SUSPENSION MYCOSTATIN
NYSTATIN TABLETS NYSTATINOFLOXACIN SOLUTION OCUFLOXOFLOXACIN SOLUTION OFLOXACINOFLOXACIN TABLETS OFLOXACIN
OLANZAPINE ORALLY DISPERSABLE TABLET ZYPREXA ZYDIS Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications
5mg: 60
10mg: 60
15MG: 30
20mg: 30
30
30
30
OLANZAPINE TABLETS ZYPREXA Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 30 30
OLMESARTAN MEDOXOMIL - HYDROCHLOROTHIAZIDE TABLETS BENICAR HCT Step Therapy
Member must have
tried Losartan
Potassium/HCTZ &
Irbesartan/HCTZOLMESARTAN MEDOXOMIL TABLETS BENICAR OLOPATADINE HCL SOLUTION PATANOLOLSALAZINE SODIUM CAPSULES DIPENTUM 120 30OMBITASVIR-PARITAPREVIR-RITONAVIR & DASABUVIR TABLET 24-HOUR VIEKIRA XR Preferred Drug PA Required
OMBITASVIR-PARITAPREVIR-RITONAVIR & DASABUVIR TABLET THERAPY PACK VIEKIRA PAK Preferred Drug PA Required
OMBITASVIR-PARITAPREVIR-RITONAVIR TABLETS TECHNIVIE Preferred Drug PA RequiredOMEGA 3 FATTY ACID CAPSULES FISH OILOMEPRAZOLE CAPSULE DELAYED RELEASE PRILOSECOMEPRAZOLE SUSPENSION FIRST-OMEPRAZOLEONDANSETRON HCL TABLETS ZOFRAN PA Required for tablets > 8mg 30 30ONDANSETRON HCL TABLETS ORALLY DISINTEGRATING ZOFRAN ODT PA Required for tablets > 8mg 30 30ORIORANOLOL - HYDROCHLOROTHIAZIDE TABLETS INDERIDEOSELTAMIVIR PHOSPHATE CAPSULES TAMIFLU 20 270
OSELTAMIVIR PHOSPHATE SUSPENSION TAMIFLUOXAPROZIN TABLETS DAYPRO
Page 34 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
OXAZEPAM CAP 10 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30
OXAZEPAM CAP 15 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30
OXAZEPAM CAP 30 MG VARIOUS
PA Required for Ages < 6 years
PA Required for > 1 Anxiolytic 60 30OXCARBAZEPINE SUSPENSION TRILEPTALOXCARBAZEPINE TABLETS TRILEPTAL
OXCARBAZEPINE TABLETS SUSTAINED RELEASE OXTELLAR XR PA Required OXYBUTYNIN CHLORIDE SYRUP VARIOUSOXYBUTYNIN CHLORIDE TABLET 24-HOUR DITROPAN XLOXYBUTYNIN CHLORIDE TABLETS VARIOUS
OXYCODONE HCL CAPSULES OXYCODONE HCL
PA Required for > 2 Short Acting
Narcotics Fill
OXYCODONE HCL CONCENTRATE OXYCODONE HCL
PA Required for > 2 Short Acting
Narcotics
OXYCODONE HCL SOLUTION OXYCODONE HCL
PA Required for > 2 Short Acting
Narcotics FillOXYCODONE HCL TABLET 12-HOUR ABUSE DETERRANT OXYCONTIN Brand Only Preferred PA Required
OXYCODONE HCL TABLETS ROXICODONE
PA Required for > 2 Short Acting
Narcotics Fill
OXYCODONE W/ ACETAMINOPHEN CAPSULES
OXYCODONE/
ACETAMINOPHEN
PA Required for > 2 Short Acting
Narcotics Fill
OXYCODONE W/ ACETAMINOPHEN SOLUTION ROXICET
PA Required for > 2 Short Acting
Narcotics Fill
OXYCODONE W/ ACETAMINOPHEN TABLETS ENDOCET
PA Required for > 2 Short Acting
Narcotics Fill
OXYCODONE W/ASPIRIN TABLETS PERCODAN
PA Required for > 2 Short Acting
Narcotics Fill
OXYCODONE-IBUPROFEN TABLETS OXYCODONE/IBUPROFEN
PA Required for > 2 Short Acting
Narcotics OYSTER SHELL CALCIUM TABLETS VARIOUS
PALIPERIDONE PALMITATE SUSPENSION INVEGA SUSTENNA Preferred Drug
PA Required for Ages < 18 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 1 30
PALIPERIDONE PALMITATE SUSPENSION INVEGA TRINZA Preferred Drug
PA Required for Ages < 18 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 1 90
Page 35 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
PALIVIZUMAB SOLUTION INJECTION SYNAGIS
PA Required - if approved the
prescriber may be required to buy and
bill a medical claim for the drugPANTOPRAZOLE SODIUM SUSPENSION PACKET DELAYED RELEASE PROTONIXPANTOPRAZOLE SODIUM TABLET ENTERIC COATED PROTONIXPAROXETINE HCL ER TABLETS 12.5 MG PAXIL CR PA Required for Ages < 6 years 90 30PAROXETINE HCL ER TABLETS 25 MG PAXIL CR PA Required for Ages < 6 years 60 30
PAROXETINE HCL ER TABLETS 37.5 MG PAXIL CR PA Required for Ages < 6 years 30 30PAROXETINE HCL SUSPENSION PAXIL Brand Only PA Required for Ages < 6 years 900 ML 30
PAROXETINE HCL TABLETS PAXIL PA Required for Ages < 6 years
10mg: 30
20mg: 30
30mg: 30
40mg: 45
30
30
30
30PAROXETINE MESYLATE TABLETS PEXEVA PA RequiredPAZOPANIB HCL TABLETS VOTRIENT PA Required
PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE SOLUTION COLYTEPEGFILGRASTIM SOLUTION NEULASTA PA RequiredPEGINTERFERON ALFA-2A SOLUTION PEGASYS Preferred Drug PA RequiredPEGINTERFERON ALFA-2B (ANTINEOPLASTIC) KIT SYLATRON PA RequiredPEGINTERFERON ALFA-2B KIT PEGINTRON Preferred Drug PA RequiredPENICILLAMINE CAPSULES CUPRIMINEPENICILLIN V POTASSIUM SOLUTION PENICILLIN V POTASSIUMPENICILLIN V POTASSIUM TABLETS PENICILLIN V POTASSIUM
PENTOSAN POLYSULFATE SODIUM CAPSULES ELMIRON PA RequiredPENTOXIFYLLINE TABLET CONTROLLED RELEASE TRENTALPERINDOPRIL ERBUMINE TABLETS ACEONPERMETHRIN CREAM ELIMITEPERMETHRIN CRÈME RINSE NIXPERMETHRIN SPRAY & PYRETHINS-PUPERONYL BUTOXIDE SHAMPOO KIT NIX
PERPHENAZINE TABLETS VARIOUS
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medicationsPHENAZOPYRIDINE HCL TABLETS PYRIDIUMPHENELZINE SULFATE TABLET NARDIL PA Required for Ages < 6 yearsPHENOBARBITAL & HYOSCYAMINE SOLUTION LEVSIN-PBPHENOBARBITAL & HYOSCYAMINE TABLET LEVSIN-PBPHENOBARBITAL SOLUTION PHENOBARBITAL
PHENOBARBITAL TABLETS PHENOBARBITALPHENYLEPHRINE HCL SOLUTION NEOFRINPHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN CAPSULES VARIOUS
Page 36 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN LIQUID
ROBITUSSIN CHILDRENS COUGH
& COLD CF 480 ML 30PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN SYRUP VARIOUS 480 ML 30
PHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN TABLET 12-HOUR VARIOUSPHENYLEPHRINE W/ DEXTROMETHORPHAN-GUAIFENESIN TABLETS VARIOUSPHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN ELIXIR VARIOUS 480 ML 30
PHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN LIQUID
DIMETAPP
DEXTROMETHORPHAN COLD &
COUGH 480 ML 30PHENYLEPHRINE-BROMPHENIRAMINE-DEXTROMETHORPHAN SYRUP VARIOUS 480 ML 30PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN DROPS VARIOUS PA Required for < 6 years oldPHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN LIQUID VARIOUS 480 ML 30
PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN SYRUP VARIOUS 480 ML 30
PHENYLEPHRINE-CHLORPHENIRAMINE-DEXTROMETHORPHAN TABLETS VARIOUS
PHENYLEPHRINE-GUAIFENESIN CAPSULES VARIOUS
PHENYLEPHRINE-GUAIFENESIN LIQUID
TRIAMINIC CHEST/ NASAL
CONGESTION 480 ML 30
PHENYLEPHRINE-GUAIFENESIN SYRUP
TRIAMINIC CHEST & NASAL
CONGESTION 480 ML 30PHENYLEPHRINE-GUAIFENESIN TABLETS VARIOUSPHENYTOIN CHEWABLE TABLETS DILANTIN INFATABLETS
PHENYTOIN SODIUM EXTENDED CAPSULES DILANTINPHENYTOIN SUSPENSION DILANTIN-125PHYTONADIONE TABLET MEPHYTON - VITAMIN KPILOCARPINE HCL GEL PILOPINE HSPILOCARPINE HCL SOLUTION ISOPTO CARPINE
PIMOZIDE ORAP
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medicationsPINDOLOL TABLETS PINDOLOLPIOGLITAZONE HCL TABLETS ACTOSPIOGLITAZONE HCL-METFORMIN HCL TABLET 24-HOUR ACTOPLUS MET XRPIOGLITAZONE HCL-METFORMIN HCL TABLETS ACTOPLUS METPIROXICAM CAPSULES FELDENEPODOFILOX SOLUTION CONDYLOX
POLYETHYLENE GLYCOL 3350 ORAL PACKET MIRALAXPOLYETHYLENE GLYCOL-PROPYLENE GLYCOL SOLUTION SYSTANE
POLYMYXIN B-TRIMETHOPRIM SOLUTION POLYTRIM
Page 37 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
PONATINIB HCL TABLETS ICLUSIG PA Required 60 30POSACONAZOLE SUSPENSION NOXAFIL PA RequiredPOSACONAZOLE TABLET ENTERIC COATED NOXAFIL PA RequiredPOTASSIUM CHLORIDE CAPSULES CONTROLLED RELEASE MICRO-KPOTASSIUM CHLORIDE GRANULES VARIOUSPOTASSIUM CHLORIDE MICROENCAPSULATED CRYSTALS CR VARIOUSPOTASSIUM CHLORIDE ORAL LIQUID K-LORPOTASSIUM CHLORIDE POWDER PACKETS KLOR-CON
POTASSIUM CHLORIDE TABLETS CONTROLLED RELEASE K-TABPOTASSIUM CITRATE & CITRIC ACID SOLUTION K CITRATEPOTASSIUM CITRATE TABLETS CONTROLLED RELEASE UROCIT-KPOTASSIUM TABLETS VARIOUSPRAMIPEXOLE DIHYDROCHLORIDE TABLETS MIRAPEXPRAMIPEXOLE DIHYDROCHLORIDE TABLETS SR 24 HR MIRAPEX ERPRAMLINITIDE SYMLINPEN Preferred Drug PA RequiredPRAMLINTIDE SYMLINPEN 60 Preferred Drug PA Required
PRAMOXINE-HC FOAM EPIFOAMPRAVASTATIN SODIUM TABLETS PRAVACOL 30 30PRAZIQUANTEL TABLETS BILTRICIDEPRAZOSIN HCL CAPSULES MINIPRESSPREDNISOLONE ACETATE SUSPENSION PRED MILDPREDNISOLONE SODIUM PHOSPHATE ORALLY DISINTEGRATING TABLETS ORAPRED ODTPREDNISOLONE SODIUM PHOSPHATE SOLUTION ORAPRED
PREDNISOLONE SODIUM PHOSPHATE SOLUTION
PREDNISOLONE SODIUM
PHOSPHATEPREDNISOLONE SYRUP PRELONEPREDNISOLONE TABLETS VARIOUSPREDNISONE CONCENTRATE PREDNISONE INTENSOLPREDNISONE SOLUTION PREDNISONEPREDNISONE TABLETS PREDNISONEPREGABALIN CAPSULES LYRICA PA RequiredPREGABALIN SOLUTION LYRICA PA Required
PRENATAL MULTIVITAMINES WITH MINERAL W/FE-FA VARIOUSPRENATAL MULTIVITAMINS WITH OR WITHOUT MINERALS W/ FOLATE VARIOUSPRENATAL VIT W/IRON CARBONYL-FA TABLET VARIOUSPRIMAQUINE PHOSPHATE TABLETS PRIMAQUINE PHOSPHATEPRIMIDONE TABLETS MYSOLINEPROBENECID TABLETS PROBENECIDPROCAINAMIDE CHL TABLET CONTROLLED RELEASE PROCAN SRPROCAINAMIDE HCL CAPSULE PROCAINAMIDE
PROCARBAZINE HCL CAPSULES MATULANEPROCHLORPERAZINE MALEATE TABLETS COMPAZINE
PROCHLORPERAZINE SUPPOSITORY COMPAZINE
Page 38 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
PROGESTERONE MICRONIZED CAPSULES PROMETRIUMPROGESTERONE VAGINAL GEL CRINONEPROGESTERONE VAGINAL SUPPOSITORY PROGESTERONE
PROMETHAZINE & PHENYLEPHRINE SYRUP
PROMETHAZINE/
PHENYLEPHRINE 480 ML 30PROMETHAZINE HCL SUPPOSITORY PHENERGANPROMETHAZINE HCl SYRUP PHENERGANPROMETHAZINE HCL TABLETS PROMETHAZINE HCL
PROMETHAZINE W/CODEINE SYRUP PROMETHAZINE/CODEINE 240 ML 12
PROMETHAZINE-DEXTROMETHORPHAN SYRUP
PROMETHAZINE/
DEXTROMETHORPHAN 480 ML 30PROPAFENONE HCL CAPSULE 12-HOUR RYTHMOL SRPROPAFENONE HCL TABLETS RYTHMOLPROPANTHELINE BROMIDE TABLETS VARIOUSPROPRANOLOL HCL CAPSULE CONTROLLED RELEASE INDERAL LAPROPRANOLOL HCL SOLUTION PROPRANOLOL HCL
PROPRANOLOL HCL TABLETS INDERALPROPYLTHIOURACIL TABLETS PROPYLTHIOURACILPROTRIPTYLINE HCL TABLETS VIVACTIL PA Required for ages < 6 yearsPSEUDOEPHED-BROMPHEN-DM ELIXIR VARIOUS 480 ML 30PSEUDOEPHED-BROMPHEN-DM SYRUP VARIOUS 480 ML 30PSEUDOEPHEDRINE HCL LIQUID SUDAFED CHILDRENSPSEUDOEPHEDRINE HCL SYRUP PSEUDOEPHEDRINEPSEUDOEPHEDRINE HCL TABLET 12-HOUR NASAL DECONGESTANT
PSEUDOEPHEDRINE HCL TABLET 24-HOUR SUDAFED 24 HOURPSEUDOEPHEDRINE HCL TABLETS SUDAFEDPSEUDOEPHEDRINE W/ CODEINE-GUAIFENESIN SYRUP VARIOUS 240 ML 12PSEUDOEPHEDRINE W/ DM-GG LIQUID VARIOUSPSYLLIUM CAPSULE METAMUCILPSYLLIUM POWDER METAMUCILPYRAZINAMIDE TABLETS PYRAZINAMIDEPYRETHRINS-PIPERONYL BUTOXIDE GEL A-200
PYRETHRINS-PIPERONYL BUTOXIDE LIQUID BARCPYRETHRINS-PIPERONYL BUTOXIDE SHAMPOO LICIDEPYRIDOSTIGMINE BROMIDE SYRUP MESTINON SYRUPPYRIDOSTIGMINE BROMIDE TABLET MESTINON PYRIDOSTIGMINE BROMIDE TABLET CONTROLLED RELEASE MESTINON TIMESPANPYRIDOXINE HCL TABLETS VITAMIN B6PYRIMETHAMINE TABLET DARAPRIM
Page 39 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
QUETIAPINE FUMARATE TABLETS SEROQUEL Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 60 30QUINAPRIL - HYDROCHLOROTHIAZIDE TABLETS ACCURETICQUINAPRIL HCL TABLETS ACCUPRILQUINIDINE GLUCONATE TABLET CONTROLLED RELEASE QUINIDINE GLUCONATE CR
QUINIDINE SULFATE TABLET CONTROLLED RELEASE QUINIDINE SULFATE ERQUINIDINE SULFATE TABLETS QUINIDINE SULFATEQUININE SULFATE CAPSULES QUALAQUINRALOXIFENE HCL TABLETS EVISTARALTEGRAVIR POTASSIUM CHEWABLE TABLETS ISENTRESSRALTEGRAVIR POTASSIUM PACKETS ISENTRESSRALTEGRAVIR POTASSIUM TABLETS ISENTRESSRAMELTEON TABLETS ROZEREM PA Required
RAMIPRIL CAPSULES ALTACERANITIDINE HCL CAPSULES RANITIDINE HCLRANITIDINE HCL SUSPENSION DEPRIZINE FUSEPAQRANITIDINE HCL SYRUP ZANTACRANITIDINE HCL TABLETS ZANTAC 75RANOLAZINE TABLET 12-HOUR RANEXA PA RequiredREPAGLINIDE TABLETS PRANDINRIBAVIRIN (HEPATITIS C) CAPSULES VARIOUS Preferred Drug PA Required
RIBAVIRIN (HEPATITIS C) TABLETS VARIOUS Preferred Drug PA RequiredRIFABUTIN CAPSULE MYCOBUTINRIFAMPIN CAPSULES RIFADINRILPIVIRINE HCL TABLETS EDURANTRILUZOLE TABLET RILUTEKRIMANTADINE HYDROCHLORIDE TABLETS FLUMADINE
RISPERIDONE MICROSPHERES SUSPENSION RISPERDAL CONSTA Preferred Drug
PA Required for Ages < 18 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 2 30
RISPERIDONE ORAL SOLUTION RISPERDAL Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 240 ML 30
Page 40 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
RISPERIDONE ORALLY DISPERSABLE TABLET RISPERIDONE ODT Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 60 30
RISPERIDONE TABLETS RISPERDAL Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 60 30RITONAVIR CAPSULES NORVIRRITONAVIR SOLUTION NORVIRRITONAVIR TABLETS NORVIRRIVAROXABAN DOSE PACK XARELTO DOSE PACK Preferred Drug 51 30RIVAROXABAN TABLETS XARELTO Preferred Drug 60 30RIVASTIGMINE PATCH EXELON PA Required
RIVASTIGMINE TARTRATE CAPSULES EXELON PA RequiredRIVASTIGMINE TARTRATE SOLUTION EXELON PA RequiredRIZATRIPTAN BENZOATE ORALLY DISINTEGRATING TABLETS9 MAXALT-MLT 9 30RIZATRIPTAN BENZOATE TABLETS MAXALT 9 30ROPINIROLE HYDROCHLORIDE TABLETS REQUIPROPINIROLE HYDROCHLORIDE TABLETS SR 24 HR REQUIP XLRUFINAMIDE SUSPENSION BANZEL PA RequiredRUFINAMIDE TABLETS BANZEL PA Required
RUXOLITINIB PHOSPHATE TABLETS JAKAFI PA RequiredSACROSIDASE SOLUTION SUCRAID PA RequiredSACUBITRIL / VALSARTAN ENTRESTO PA RequiredSALICYLIC ACID CREAM SALACYNSALICYLIC ACID FOAM SALVAXSALICYLIC ACID GEL KERALYTSALICYLIC ACID LIQUID VIRASALSALICYLIC ACID LOTION SALACYN
SALICYLIC ACID SHAMPOO SALEXSALICYLIC ACID SOLUTION VARIOUSSALIVA SUBSTITUTE SPRAY SALIVARTSALMETEROL XINAFOATE AEROSOL POWDER BREATH ACTIVATED SEREVENT DISKUS PA RequiredSALSALATE TABLETS DISALCIDSAQUINAVIR MESYLATE CAPSULES INVIRASESAQUINAVIR MESYLATE TABLETS INVIRASESAXAGLIPTIN TABLET ONGLYZA Preferred Drug PA Required
SAXAGLIPTIN/METFORMIN ER TABLETS KOMBLIGLYZE XR Preferred Drug PA RequiredSCOPOLAMINE HBR SOLUTION ISOPTO HYASINE
SELEGILINE HCL CAPSULES ELDEPRYL
Page 41 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
SELEGILINE HCL ORALLY DISINTEGRATING TABLET ELDEPRYLSELEGILINE HCL TABLETS VARIOUSSELEGILINE TD PATCH ENSAM PA RequiredSELENIUM SULFIDE LOTION SELSUN SHAMPOOSELENIUM SULFIDE-PYRITHIONE ZINC IN UREA SHAMPOO SELSUMSELIGILENE EMSAM PA RequiredSENNA TABLES CONCENTRATED SENNA CONCSENNA TABLET SENNA
SENNOSIDES TABLETS SENOKOTSENNOSIDES-DOCUMSATE SDOIUM TABLET SENOKOT SSERTRALINE HCL CONCENTRATE ZOLOFT PA Required for Ages < 6 years 300 ML 30
SERTRALINE HCL TABLETS ZOLOFT PA Required for Ages < 6 years
25mg: 90
50mg: 120
100mg: 60
30
30
30SEVELAMER CARBONATE PACKETS RENVELA PA Required
SEVELAMER CARBONATE TABLETS RENVELA PA RequiredSEVELAMER HCL TABLETS RENAGEL PA RequiredSILDENAFIL CITRATE (PULMONARY HYPERTENSION) SUSPENSION REVATIO PA Required
SILDENAFIL CITRATE (PULMONARY HYPERTENSION) TABLETS REVATIO PA RequiredSILVER SULFADIAZINE CREAM SILVADENESIMETHICONE CAPSULES MYLICONSIMETHICONE CHEW TABLETS MYLICONSIMETHICONE SUSPENSION MYLICON
SIMVASTATIN TABLETS ZOCOR 30 30SIROLIMUS SOLUTION RAPAMUNESIROLIMUS TABLETS RAPAMUNESITAGLIPTIN PHOSPHATE TABLETS JANUVIA Preferred Drug PA RequiredSITAGLIPTIN-METFORMIN HCL TABLET 24-HOUR JANUMET XR Preferred Drug PA RequiredSITAGLIPTIN-METFORMIN HCL TABLETS JANUMET Preferred Drug PA RequiredSODIUM CHLORIDE NEBULIZER SOLUTION NEBUSAL / HYPERSAL
SODIUM FLUORIDE CHEWABLE TABLETS LUDENTSODIUM FLUORIDE LOZG LOZI-FLURSODIUM FLUORIDE SOLUTION FLUOR-A-DAYSODIUM FLUORIDE TABLETS SODIUM FLUORIDESODIUM PHOSPHATE - ENEMA FLEET ENEMASODIUM PHOSPHATE - SOLUTION VARIOUSSODIUM POLYSTYRENE SULFONATE POWDER KAYEXALATESODIUM POLYSTYRENE SULFONATE SUSPENSION KIONEX
SOFOSBUVIR-VELPATASVIR TABLETS EPCLUSA
Preferred Drug
for:
1. Genotypes 2
2. Genotype 3 PA Required
Page 42 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
SOMATROPIN NORDITROPIN Preferred Drug PA RequiredSOMATROPIN NUTROPIN AQ Preferred Drug PA RequiredSOMATROPIN GENOTROPIN Preferred Drug PA RequiredSORAFENIB TOSYLATE TABLETS NEXAVAR PA RequiredSOTALOL HCL SOLUTION SOTYLIZE
SOTALOL HCL TABLETS BETAPACE
SPACER/AEROSOL-HOLDING CHAMBER SUPPOSITORYLIES - MASKS
MASK VORTEX/
BABY WHIRL DUCKLING 2 365
SPACER/AEROSOL-HOLDING CHAMBERS DEVICE
AEROCHAMBER
MINI AEROCHAMBER 2 365SPINOSAD SUSPENSION NATROBA PA RequiredSPIRONOLACTONE & HYDROCHLOROTHIAZIDE TABLETS ALDACTAZIDESPIRONOLACTONE SUSPENSION SPIRONOLACTONESPIRONOLACTONE TABLETS ALDACTONE
STAVUDINE CAPSULES ZERITSTAVUDINE SOLUTION ZERITSUCRALFATE TABLETS CARAFATESULFACETAMIDE SODIUM LIQUID OVACE WASHSULFACETAMIDE SODIUM LOTION KLARONSULFACETAMIDE SODIUM OINTMENT SULFACETAMIDE SODIUMSULFACETAMIDE SODIUM SOLUTION BLEPH-10SULFACETAMIDE SOD-PREDNISOLONE OINTMENT BLEPHAMIDE S.O.P.
SULFACETAMIDE SOD-PREDNISOLONE SOLUTION
SULFACETAMIDE
SODIUM/PREDNISOLONE
SODIUM PHOSPHATESULFACETAMIDE SOD-PREDNISOLONE SUSPENSION BLEPHAMIDESULFADIAZINE TABLETS SULFADIAZINESULFAMETHOXAZOLE-TRIMETHOPRIM SUSPENSION SULFATRIM PEDIATRICSULFAMETHOXAZOLE-TRIMETHOPRIM TABLETS BACTRIMSULFANILAMIDE VAGINAL CREAM AVC
SULFASALAZINE TABLET ENTERIC COATED AZULFIDINE EN-TABLETS 240 30SULFASALAZINE TABLETS AZULFIDINE 240 30SULINDAC TABLETS SULINDACSUMATRIPTAN NASAL SOLUTION IMITREX 6 30SUMATRIPTAN SUCCINATE SUBCUTANEOUS SOLUTION IMITREX 2 30SUMATRIPTAN SUCCINATE TABLETS IMITREX 9 30SUNITINIB MALATE CAPSULES SUTENT PA RequiredTACROLIMUS CAPSULE CONTROLLED RELEASE ASTAGRAF XL
TACROLIMUS CAPSULES HECORIATADALAFIL (PULMONARY HYPERTENSION) TABLETS ADCIRCA PA RequiredTAFLUPROST SOLUTION ZIOPTAN
Page 43 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
TAMOXIFEN CITRATE TABLETS TAMOXIFEN CITRATETAMSULOSIN HCL CAPSULES FLOMAXTELBIVUDINE TABLETS TYZEKA PA RequiredTELBIVUDINE TABLETS TYZEKA PA Required
TEMAZEPAM CAPSULES 15MG, 30MG RESTORIL
PA Required for Ages <6 years
PA Required for > 1 Hypnotic Drug 30 30TENOFOVIR DISOPROXIL FUMARATE ORAL POWDER VIREADTENOFOVIR DISOPROXIL FUMARATE TABLETS VIREAD
TERAZOSIN HCL CAPSULES TERAZOSIN HCLTERBINAFINE HCl CREAM LAMISIL AFTERBINAFINE HCL PACKETS LAMISIL 90 365TERBINAFINE HCL TABLETS LAMISIL 90 365TERCONALZOLE BAGINAL CREAM TERAZOLTESTOSTERONE CYPIONATE SOLUTION DEPO-TESTOSTERONE PA RequiredTESTOSTERONE ENANTHATE SOLUTION TESTOSTERONE ENANTHATE PA RequiredTESTOSTERONE GEL ANDROGEL PA Required
TESTOSTERONE PATCH ANDRODERM PA RequiredTESTOSTERONE SOLUTION AXIRON PA RequiredTHALIDOMIDE CAPSULES THALOMID PA Required
THEOPHYLINE TABLETS SR 12 HR THEOPHYLLINETHEOPHYLLINE CAPSULE CONTROLLED RELEASE THEOPHYLLINETHEOPHYLLINE CAPSULES SR 12 HR THEOPHYLLINETHEOPHYLLINE CAPSULES SR 24 HR THEOPHYLLINETHIAMINE HCL TABLETS VITAMIN B1
THIAMINE MONONITRATE TABLETS VITAMIN B1
THIORIDAZINE HCL TABLETS VARIOUS
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medications
THIOTHIXENE CAPSULES VARIOUS
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medicationsTHYROID TABLETS ARMOUR THYROIDTIAGABINE HCL TABLETS GABITRIL PA RequiredTICAGRELOR TABLETS BRILINTA PA RequiredTIMOLOL MALEATE SOLUTION TIMOPTIC-XETIMOLOL MALEATE SOLUTION TIMOPTIC
TIOTROPIUM BROMIDE MONOHYDRATE CAPSULES SPIRIVA HANDIHALER Preferred DrugTIPRANAVIR CAPSULES APTIVUS
TIPRANAVIR SOLUTION APTIVUS
Page 44 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
TIZANIDINE HCL TABLETS TIZANIDINE HCLTOBRAMYCIN NEBULIZED BETHKIS Preferred Drug PA RequiredTOBRAMYCIN NEBULIZED KITABIS Preferred Drug PA RequiredTOBRAMYCIN OINTMENT TOBREX 3.5GM 7TOBRAMYCIN SOLUTION TOBREXTOBRAMYCIN-DEXAMETHASONE OINTMENT 0.3-0.1% TOBRADEXTOBRAMYCIN-DEXAMETHASONE SUSPENSION TOBRADEX STTOLAZAMIDE TABLETS TOLINASE
TOLBUTAMIDE TABLETS TOLBUTAMIDETOLMETIN SODIUM CAPSULE TOLMETIN SODIUMTOLNAFTATE CREAM TINACTINTOLNAFTATE SOLUTION TINACTIN
TOLTERODINE TARTRATE CAPSULE CONTROLLED RELEASE DETROL LA STEP THERAPY
Member must have
tried oxybutynin &
tolterodine
TOLTERODINE TARTRATE TABLETS DETROL STEP THERAPY
Member must have
tried oxybutynin TOPIRAMATE SPRINKLE CAPSULES TOPAMAX SPRINKLESTOPIRAMATE TABLETS TOPAMAX
TOREMIFENE CITRATE TABLETS FARESTON PA RequiredTORSEMIDE TABLETS DEMADEX
TRAMADOL HCL TABLETS ULTRAM
PA Required for > 2 Short Acting
Narcotics Fill
TRAMADOL-ACETAMINOPHEN TABLETS ULTRACET
PA Required for > 2 Short Acting
Narcotics FillTRANDOLAPRIL TABLETS MAVIKTRANYLCYPROMINE SULFATE TABLET PARNATE PA Required for Ages < 6 yearsTRAVOPROST SOLUTION TRAVATAN Z
TRAZODONE HCL TABLETS TRAZODONE HCL PA Required for Ages < 6 years
50mg:90
100mg:120
150mg: 60
300mg 30
30
30
30
30
TREPROSTINIL SODIUM SOLUTION REMODULIN PA RequiredTREPROSTINIL SOLUTION TYVASO PA RequiredTRETINOIN (CHEMOTHERAPY) CAPSULES TRETINOIN PA Required For > 26 Years of AgeTRETINOIN CREAM RETIN-A PA Required FOR > 26 Years of AgeTRETINOIN GEL RETIN-A PA Required FOR > 26 Years of AgeTRIAMCINOLONE ACETONIDE (TOPICAL) AEROSOL VARIOUSTRIAMCINOLONE ACETONIDE (TOPICAL) CREAM VARIOUSTRIAMCINOLONE ACETONIDE (TOPICAL) LOTION VARIOUS
TRIAMCINOLONE ACETONIDE (TOPICAL) OINTMENT VARIOUSTRIAMCINOLONE ACETONIDE DENTAL PASTE VARIOUS
TRIAMCINOLONE ACETONIDE NASAL NASACORT AQ
Page 45 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
TRIAMCINOLONE ACETONIDE ORAL PASTE ORALONETRIAMCINOLONE ACETONIDE SUSPENSION (INJECTABLE) KENALOG-10 Long Term Care OnlyTRIAMCINOLONE DIACETATE SUSPENSION (INJECTABLE) TRIAMCINOLONE Long Term Care Only
TRIAMCINOLONE HEXACETONIDE SUSPENSION (INJECTABLE)
ARISTOSPAN INTRALESIONAL &
INTRA-ARTICULAR Long Term Care OnlyTRIAMTERENE & HYDROCHLOROTHIAZIDE CAPSULES DYAZIDETRIAMTERENE & HYDROCHLOROTHIAZIDE TABLETS MAXZIDE-25TRIAMTERENE CAPSULES DYRENIUM
TRIAZOLAM TABLETS HALCION
PA Required for Ages <6 years
PA Required for > 1 Hypnotic Drug 30 30
TRIFLUOPERAZINE HCL TABLETS VARIOUS
PA Required for Ages < 6 years Long
Term Care Only -Please refer to the
AHCCCS Behavioral Health Drug List
for additional medicationsTRIFLURIDINE SOLUTION VIROPTIC
TRIHEXYPHENIDYL HCL ELIXIR TRIHEXYPHENIDYL HCLTRIHEXYPHENIDYL HCL TABLETS TRIHEXYPHENIDYL HCLTRIMETHOBENZAMIDE HCL CAPSULES TIGANTRIMETHOPRIM TABLET TRIMETHOPRIMTRIMIPRAMINE MALEATE CAPSULES TRIMIPRAMINE PA Required for ages < 6 yearsTROPICAMIDE SOLUTION MYDRIACYLTROSPIUM CHLORIDE TABLETS SANCTURAUREA CREAM CARMOL-40
URINE GLUCOSE MONITORING KIT VARIOUSURINE GLUCOSE-KETONES TEST STRIPS VARIOUSURSODIOL CAPSULES ACTIGALLURSODIOL TABLETS URSO 250VALACYCLOVIR HCL TABLETS VALTREX PA RequiredVALGANCICLOVIR HCL SOLUTION VALCYTE PA RequiredVALGANCICLOVIR HCL TABLETS VALCYTE PA RequiredVALPROATE SODIUM SYRUP DEPAKENE
VALPROIC ACID CAPSULES DEPAKENEVALPROIC ACID CAPSULES DELAYED RELEASE STAVZORVALSARTAN - HYDROCHLOROTHIAZIDE TABLETS DIOVAN HCTVALSARTAN TABLETS DIOVANVANCOMYCIN HCL CAPSULES VANCOCIN HCL PA Required
VANCOMYCIN HCL SOLUTION
Available through a
compounding pharmacy PA RequiredVANDETANIB TABLETS CAPRELSA PA Required
VARENICLINE TARTRATE TABLETS CHANTIX
84-day
supply 180
VEMURAFENIB TABLETS ZELBORAF PA Required
Page 46 of 48
Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
VENLAFAXINE HCL ER CAPSULES EFFEXOR XR PA Required for Ages < 6 years
37.5mg: 90
75mg: 90
150mg: 30
30
30
30VENLAFAXINE HCL ER CAPSULES 37.5 MG VENLAFAXINE PA Required for Ages < 6 years 120 30
VENLAFAXINE HCL TABLETS (IMMEDIATE RELEASE ONLY) VENLAFAXINE PA Required for Ages < 6 years
25mg: 120
37.5mg: 90
50mg: 90
75mg: 150
100mg: 90
30
30
30
30
30VERAPAMIL HCL CAPSULE CONTROLLED RELEASE VERELAN PM 30 30VERAPAMIL HCL TABLET CONTROLLED RELEASE CALAN SR 30 30VERAPAMIL HCL TABLETS VERAPAMIL HCLVILAZODONE HCL STARTER KIT VIIBRYD PA RequiredVILAZODONE HCL TABLETS VIIBRYD PA RequiredVITAMIN E CAPSULES VITAMIN EVITAMIN E TABLETS VITAMIN E
VORICONAZOLE SUSPENSION VFEND PA RequiredVORICONAZOLE TABLETS VFEND PA RequiredVORINOSTAT CAPSULES ZOLINZA PA Required
WARFARIN SODIUM TABLETS COUMADIN
Brand or
Generic Preferred DrugZAFIRLUKAST TABLETS ACCOLATE
ZALEPLON CAPSULES SONATA
PA Required for Ages <6 years
PA Required for > 1 Hypnotic Drug 30 30
ZANAMIVIR AEROSOL POWDER BREATH ACTIVATED RELENZA DISKHALER 40 270ZIDOVUDINE CAPSULES RETROVIRZIDOVUDINE SYRUP RETROVIRZIDOVUDINE TABLETS ZIDOVUDINEZINC OXIDE CREAM DESITINZINCE OXIDE OINTMENT DESITIN
ZIPRASIDONE HCL CAPSULES GEODON Preferred Drug
PA Required for Ages < 6 years
Long Term Care Only -Please refer to
the AHCCCS Behavioral Health Drug
List for additional medications 60 30ZOLMITRIPTAN ORALLY DISINTEGRATING TABLETS ZOMIG ZMT 12 28ZOLMITRIPTAN TABLETS ZOMIG 12 28ZOLPIDEM TARTRATE SOLUTION ZOLPIMIST PA Required
ZOLPIDEM TARTRATE TABLETS AMBIEN
PA Required for Ages <6 years
PA Required for > 1 Hypnotic Drug
60: 5MG
30: 10MG
30
30
ZOLPIDEM TARTRATE TABLETS CONTROLLED RELEASE AMBIEN CR PA Required ZOLPIDEM TARTRATE TABLETS SUBLINGUAL INTERMEZZO PA Required
ZOLPIDEM TARTRATE TABLETS SUBLINGUAL EDLUAR PA Required
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Drug Class/Drug Name Reference Brand Name Brand Only
Preferred
Drug Status Prior Authorization Type
Step Therapy
Requirements
Quantity
Limit
QL
Days
CENPATICO INTEGRATED CARE COMPREHENSIVE DRUG LIST BY DRUG NAME
• Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Only Comprehensive Drug List Effective Date: 10/01/2017 • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization PMA_10-11-1
ZONISAMIDE CAPSULES ZONEGRANDIPROLENE
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