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CMDP Additional Preferred Drug List CMDP Additional Preferred Drug List • Generic Drugs Are Preferred Drugs Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 11/2/2018 Preferred Drug Quantity Drug Class/Drug Name Reference Brand Name Brand Only Status PA Type Step Therapy Requirements Limit QL Days ALTERNATIVE MEDICINES ALTERNATIVE MEDICINE MELATONIN CAP 5 MG CVS MELATONIN MELATONIN CAP 10 MG MELATONIN MELATONIN TAB 300 MCG MELATONIN MELATONIN TAB 1 MG MELATONIN MELATONIN TAB 3 MG GNP MELATONIN MELATONIN TAB 5 MG CVS MELATONIN MELATONIN TAB ER 1 MG MELATONIN TIMED RELEASE MELATONIN TAB ER 5 MG MELATONIN MELATONIN TAB ER 10 MG MM MELATONIN TR MELATONIN SL TAB 3 MG MELATONIN MELATONIN SL TAB 5 MG MELATONIN MELATONIN SL TAB 10 MG CVS MELATONIN QUICK DISSOLVE MELATONIN LIQUID 1 MG/4ML (2.5 MG/10ML) MELATONIN MELATONIN LIQUID 1 MG/ML MELATONIN MELATONIN TABLET DISINTEGRATING 3 MG SV MELATONIN MELATONIN TABLET DISINTEGRATING 5 MG MELATONIN MELATONIN TABLET DISINTEGRATING 10 MG HM MELATONIN QUICK DISSOLVE ALTERNATIVE MEDICINE COMBINATIONS MELATONIN-PYRIDOXINE TABLETS 1-10 MG MELATONIN MELATONIN-PYRIDOXINE TABLETS 3-10 MG MELATONIN MELATONIN-PYRIDOXINE TABLETS 5-1 MG EQL MELATONIN/VITAMIN B-6 MELATONIN-PYRIDOXINE TABLETS 5-10 MG MELATONIN MELATONIN-PYRIDOXINE TABLETS ER 3-10 MG MELATONIN TR/VITAMIN B-6 MELATONIN-PYRIDOXINE TABLETS ER 5-10 MG MELATONIN TR/VITAMIN B6 ANALGESICS - ANTI-INFLAMMATORY NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) NAPROXEN SODIUM CAPSULES 220 MG EQL NAPROXEN SODIUM ANTHELMINTICS ANTHELMINTICS PYRANTEL PAMOATE SUSPENSION 144 MG/ML (50 MG/ML BASE EQUIV) REESES PINWORM MEDICINE ANTIDIARRHEAL/PROBIOTIC AGENTS ANTIDIARRHEAL/PROBIOTIC COMBINATIONS BACILLUS COAGULANS-INULIN CAPSULES PROBIOTIC FORMULA LACTOBACILLUS-INULIN CAPSULES CULTURELLE DIGESTIVE HEALTH ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC. BISMUTH SUBSALICYLATE CHEWABLE TABLETS 262 MG PX STOMACH RELIEF LACTOBACILLUS CAPSULES CVS PROBIOTIC ACIDOPHILUS LACTOBACILLUS CHEWABLE TABLETS PROBIOTIC CHEWABLE CHILDRENS LACTOBACILLUS REUTERI LIQUID BIOGAIA PROTECTIS BABY LACTOBACILLUS RHAMNOSUS (GG) CHEWABLE TABLETS CULTURELLE KIDS LACTOBACILLUS RHAMNOSUS (GG) PACKET MOMMYS BLISS PROBIOTIC PROBIOTIC PRODUCT - CAPSULES CVS ADULT 50+ PROBIOTIC ANTIHYPERTENSIVES ACE INHIBITORS ENALAPRIL MALEATE ORAL SOLUTION 1 MG/ML EPANED ANTISEPTICS & DISINFECTANTS CHLORINE ANTISEPTICS CHLORHEXIDINE GLUCONATE LIQUID 2% CHLORHEXIDINE GLUCONATE CHLORHEXIDINE GLUCONATE LIQUID 4% OPERAND CHLORHEXIDINE GLUCONATE CMDP Additional Preferred Drug List • Generic Drugs Are Preferred Drugs Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 11/2/2018 Preferred Drug Quantity Drug Class/Drug Name Reference Brand Name Brand Only Status PA Type Step Therapy Requirements Limit QL Days CHLORHEXIDINE GLUCONATE SOLUTION 4% HM ANTISEPTIC SKIN CLEANSER CONTRACEPTIVES COMBINATION CONTRACEPTIVES - ORAL NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TABLETS 1 MG-20 MCG GILDESS FE 1/20 NORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TABLETS 1 MG-20 MCG (24) MIBELAS 24 FE NORETHIN-ETH ESTRADIOL-FE TABLETS 1 MG-10 MCG (24)/10 MCG (2) LO LOESTRIN FE COMBINATION CONTRACEPTIVES - TRANSDERMAL NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR XULANE COUGH/COLD/ALLERGY MISC. RESPIRATORY INHALANTS SODIUM CHLORIDE AERO SOLUTION 0.9% SIMPLY SALINE BABY MUCOLYTICS ACETYLCYSTEINE INHAL SOLUTION 10% ACETYLCYSTEINE ACETYLCYSTEINE INHAL SOLUTION 20% ACETYLCYSTEINE DERMATOLOGICALS ANTIFUNGALS - TOPICAL TERBINAFINE HCL CREAM 1% TERBINAFINE HCL ANTIBIOTICS - TOPICAL NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINTMENT 1% GNP TRIPLE ANTIBIOTIC PLUS ANTISEBORRHEIC PRODUCTS SELENIUM SULFIDE SHAMPOO 2.25% SELENIUM SULFIDE SHAMPOO CORTICOSTEROIDS - TOPICAL BETAMETHASONE DIPROPIONATE CREAM 0.05% BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE OINT 0.05% BETAMETHASONE DIPROPIONATE DIAPER RASH PRODUCTS DIAPER RASH PRODUCTS - OINTMENT CVS PEDIATRIC OINTMENT EMOLLIENTS EMOLLIENT CREAM MOISTURIZING CREAM EMOLLIENT OINTMENT DAILY CONDITIONING TREATMENT KERATOLYTIC/ANTIMITOTIC AGENTS SALICYLIC ACID PAD 40% CORN REMOVERS MISC. TOPICAL CALAMINE-ZINC OXIDE LOTION HM CALAMINE DIMETHICONE-ZINC OXIDE-VITAMIN A-VITAMIN D CREAM 1-10% CVS ZINC OXIDE DIAPER CREAM SKIN PROTECTANTS MISC - CREAM EUCERIN ZINC OXIDE CREAM 13% DESITIN RAPID RELIEF SCABICIDES & PEDICULICIDES PERMETHRIN CR RINSE 1% & NIT REMOVER GEL & PERMETH SPR KIT NIX COMPLETE LICE TREATMENT KIT BENZYL ALCOHOL LOTION 5% ULESFIA PYRETH-PIPERONYL BUTOX SHAM-PERMETH AERO-NIT REMOVER GEL KIT LICE SOLUTION COMPLETE TAR PRODUCTS COAL TAR SHAMPOO 0.5% THERAPEUTIC SHAMPOO DIAGNOSTIC PRODUCTS DIAGNOSTIC TESTS ACETONE (URINE) TEST STRIP KETONE TEST STRIPS DIGESTIVE AIDS DIGESTIVE ENZYMES LACTASE TABLETS 3000 UNIT CVS LACTASE LACTASE TABLETS 9000 UNIT DAIRY DIGESTIVE SUPPLEMENT FAST ACTING GASTROINTMENTESTINAL AGENTS - MISC. ANTIFLATULENTS CMDP Additional Preferred Drug List • Generic Drugs Are Preferred Drugs Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 11/2/2018 Preferred Drug Quantity Drug Class/Drug Name Reference Brand Name Brand Only Status PA Type Step Therapy Requirements Limit QL Days SIMETHICONE CHEWABLE TABLETS 80 MG RA GAS RELIEF SIMETHICONE LIQUID 40 MG/0.6ML CVS GAS RELIEF DROPS EXTRA STRENGTH SIMETHICONE SUSPENSION 40 MG/0.6ML HM GAS RELIEF INFANTS DROPS HEMATOPOIETIC AGENTS IRON CARBONYL IRON CHEWABLE TABLETS 15 MG (ELEMENTAL IRON) IRON CHEWS PEDIATRIC LAXATIVES BULK LAXATIVES CALCIUM POLYCARBOPHIL TABLETS 625 MG CVS FIBER LAXATIVE CORN DEXTRIN ORAL POWDER CVS EASY FIBER INULIN CHEWABLE TABLETS 1.5 GM FIBER CHOICE FRUITY BITES LUBRICANT LAXATIVES MINERAL OIL QC MINERAL OIL HEAVY LAXATIVES - MISCELLANEOUS GLYCERIN ENEMA ADULT 5.4 GM/AVERAGE DELIVERED DOSE FLEET LIQUID GLYCERIN SUPPOSITORIES GLYCERIN LIQUID SUPPOSITORIES 2.8 GM (2.7 ML) PEDIA-LAX GLYCERIN SUPPOSITORIES 1 GM GLYCERIN INFANTS & CHILDREN GLYCERIN SUPPOSITORIES 1.2 GM GLYCERIN CHILDREN GLYCERIN SUPPOSITORIES 2 GM GLYCERIN ADULT LAXATIVE COMBINATIONS SENNOSIDES-DOCUSATE SODIUM TABLETS 8.6-50 MG GNP STOOL SOFTENER/STIMULANT LAXATIVE SALINE LAXATIVES MAGNESIUM HYDROXIDE SUSPENSION 400 MG/5ML SM MILK OF MAGNESIA SODIUM PHOSPHATES - ENEMA EQ ENEMA MACROLIDES ERYTHROMYCINS ERYTHROMYCIN TABLETS 250 MG ERYTHROMYCIN BASE ERYTHROMYCIN TABLETS DELAYED RELEASE 250 MG ERY-TAB ERYTHROMYCIN ETHYLSUCCINATE FOR SUSPENSION 200 MG/5ML ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ETHYLSUCCINATE FOR SUSPENSION 400 MG/5ML ERYPED 400 MEDICAL DEVICES AND SUPPLIES RESPIRATORY THERAPY SUPPLIES PEAK FLOW METER PERSONAL BEST FULL RANGE MINERALS & ELECTROLYTES CALCIUM CALCIUM CARBONATE-CHOLECALCIFEROL TABLETS 600 MG-400 UNIT CALCIUM 600+D3 CALCIUM CARBONATE-CHOLECALCIFEROL CHEWABLE TABLETS 500 MG-400 UNIT CALCIUM 500/D ELECTROLYTE MIXTURES ORAL ELECTROLYTE SOLUTION RA PEDIATRIC ELECTROLYTE MOUTH/THROAT/DENTAL AGENTS DENTAL PRODUCTS SF 5000 PLUS CREAM 1.1% SF 5000 PLUS FLUORIDEX PASTE 1.1% FLUORIDEX MULTIVITAMINS MULTIVITAMINS MULTIPLE VITAMIN TABLETS ONE DAILY PEDIATRIC MULTIPLE VITAMINS PEDIATRIC MULTIPLE VITAMIN W/ C SOLUTION 35 MG/ML POLY-VITA DROPS PEDIATRIC MULTIPLE VITAMIN W/ C & FA CHEWABLE TABLETS GNP ANIMAL SHAPES PED MULTIPLE VITAMINS W/ MINERALS PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEWABLE TABLETS MVW COMPLETE FORMULATION CMDP Additional Preferred Drug List • Generic Drugs Are Preferred Drugs Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 11/2/2018 Preferred Drug Quantity Drug Class/Drug Name Reference Brand Name Brand Only Status PA Type Step Therapy Requirements Limit QL Days PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEWABLE TABLETS 60 MG POLYVITAMIN/IRON PED MV W/ IRON PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEWABLE TABLETS 15 MG RA CHILDRENS CHEWABLE VITAMINS/IRON PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEWABLE TABLETS 18 MG MULTIVITAMIN PLUS IRON CHILDRENS PEDIATRIC MULTIPLE VITAMINS W/ IRON DROPS 10 MG/ML POLY-VITAMIN/IRON DROPS PRENATAL VITAMINS PRENATAL VIT W/ FE FUMARATE-FA TABLETS 27-0.8 MG PRENATAL VITAMIN PRENATAL VIT W/ FE FUMARATE-FA TABLETS 28-0.8 MG PRENATAL PRENATAL VIT W/ FE FUM-FA-OMEGA 3 CAPSULES 27-0.8-228 MG PRENATAL MULTI +DHA PRENATAL VIT & MIN W/ FA-FISH OIL CHEWABLE TABLETS 0.4-113.5 MG CVS PRENATAL GUMMY/DHA/FOLIC ACID PRENATAL MV & MIN W/FE FUM-FA-DHA CAPSULES 27-0.8-250 MG PRENATAL MULTI + DHA PRENATAL W/FE FUM-FA TABLETS 28-0.975 MG & DHA CAPSULES 200 MG PACK WEGMANS COMPLETE PRENATAL+DHA NASAL AGENTS - SYSTEMIC AND TOPICAL NASAL ANTI-INFECTIVES MUPIROCIN CALCIUM NASAL OINTMENT 2% BACTROBAN NASAL TRIAMCINOLONE ACETONIDE NASAL AEROSOL SUSPENSION 55 MCG/ACT TRIAMCINOLONE ACETONIDE NASAL AGENTS - MISC. SALINE NASAL SOLUTION 0.65% AYR NASAL DROPS SALINE NASAL SPRAY 0.65% LITTLE NOSES SALINE NUTRIENTS MISC. NUTRITIONAL SUBSTANCES OMEGA-3 FATTY ACIDS CAPSULES 500 MG FISH OIL BURP-LESS OMEGA-3 FATTY ACIDS CAPSULES 1000 MG THEROMEGA OMEGA-3 FATTY ACIDS CAPSULES 1200 MG SM OMEGA-3 FISH OIL OPHTHALMIC AGENTS ARTIFICIAL TEARS AND LUBRICANTS CARBOXYMETHYLCELLULOSE SODIUM OPHTH SOLUTION 0.25% CVS LUBRICANT EYE DROPS CARBOXYMETHYLCELLULOSE SODIUM OPHTH SOLUTION 0.5% ULTRA FRESH CARBOXYMETHYLCELLULOSE SODIUM (PF) OPHTH SOLUTION 0.5% RETAINE CMC CARBOXYMETHYLCELLULOSE
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