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Drug Name Drug Tier Requirements/ Limits ADHD/ANTI-NARCOLEPSY Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- Attention-Deficit/Hyperactivity Disorder (ADHD) OBESITY/ANOREXIANTS - Drugs to Treat QL(2 ea daily); ADHD, Sleep and Eating Disorders atomoxetine hcl caps 10 F mg AL(At least 6 Amphetamines yrs old) ADDERALL TABS QL(2 ea daily); atomoxetine hcl caps 18 QL(1 ea daily); (Amphetamine- F AL(At least 6 mg, 25 mg, 40 mg, 60 mg, F AL(At least 6 Dextroamphetamine) yrs old) 80 mg, 100 mg yrs old) ADDERALL XR CP24 QL(1 ea daily); QL(1 ea daily); 2.5MG-2.5MG-2.5MG- AL(At least 6 guanfacine hcl (adhd) tb24 F AL(At least 6 2.5MG, 7.5MG-7.5MG- yrs old) yrs old) 7.5MG-7.5MG, 1.25MG- QL(1 ea daily); 1.25MG-1.25MG-1.25MG, INTUNIV TB24 NF F )) AL(At least 6 3.75MG-3.75MG-3.75MG- (Guanfacine HCl (ADHD yrs old) 3.75MG, 6.25MG-6.25MG- QL(4 ea daily); 6.25MG-6.25MG KAPVAY TB12 0.1 MG F )) AL(At least 6 (Amphetamine- (Clonidine HCl (ADHD yrs old) Dextroamphetamine) QL(2 ea daily); ADDERALL XR CP24 QL(2 ea daily); STRATTERA CAPS 10 MG NF (Atomoxetine HCl) AL(At least 6 5MG-5MG-5MG-5MG F AL(At least 6 yrs old) (Amphetamine- yrs old) Dextroamphetamine) STRATTERA CAPS 18 QL(1 ea daily); MG, 25 MG, 40 MG, 60 NF AL(At least 6 amphetamine- QL(2 ea daily); MG, 80 MG, 100 MG yrs old) dextroamphetamine tabs AL(At least 6 (Atomoxetine HCl) 5mg-5mg-5mg-5mg, yrs old) 2.5mg-2.5mg-2.5mg- Stimulants - Misc. 2.5mg, 7.5mg-7.5mg- QL(1 ea daily); 7.5mg-7.5mg, 1.25mg- APTENSIO XR CP24 F AL(At least 6 1.25mg-1.25mg-1.25mg, F yrs old) 3.75mg-3.75mg-3.75mg- QL(2 ea daily); 3.75mg, 1.875mg- CONCERTA TBCR NF ) AL(At least 6 1.875mg-1.875mg- (Methylphenidate HCl yrs old) 1.875mg, 3.125mg- 3.125mg-3.125mg- QL(1 ea daily); 3.125mg DAYTRANA PTCH F AL(At least 6 yrs old) DEXEDRINE CP24 QL(2 ea daily); (Dextroamphetamine NF AL(At least 6 QL(2 ea daily); FOCALIN TABS F Sulfate) yrs old) ) AL(At least 6 (Dexmethylphenidate HCl yrs old) QL(2 ea daily); dextroamphetamine sulfate F AL(At least 6 QL(2 ea daily); cp24 5 mg, 10 mg, 15 mg FOCALIN XR CP24 F yrs old) ) AL(At least 6 (Dexmethylphenidate HCl yrs old) QL(2 ea daily); dextroamphetamine sulfate F AL(At least 6 QL(1 ea daily); tabs 5 mg, 10 mg METADATE CD CPCR NF yrs old) ) AL(At least 6 (Methylphenidate HCl yrs old) QL(1 ea daily); VYVANSE CAPS F AL(At least 6 METHYLIN CHEW 5 MG, AL(At least 6 yrs old) 10 MG, 2.5 MG NF yrs old) (Methylphenidate HCl) QL(1 ea daily); VYVANSE CHEW F AL(At least 6 yrs old) Arizona Complete Health-Complete Care Plan Effective October 1, 2018 1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METHYLIN SOLN 5 QL(10 ml TOBI NEBU (Tobramycin) NF MG/5ML, 10 MG/5ML F daily); AL(At (Methylphenidate HCl) least 6 yrs old) ANALGESICS - ANTI-INFLAMMATORY - Drugs methylphenidate hcl chew F AL(At least 6 to Treat Pain, Swelling, Muscle and Joint or 5 mg, 10 mg, 2.5 mg yrs old) Conditions methylphenidate hcl cp24 QL(2 ea daily); Anti-TNF-alpha - Monoclonal Antibodies or 10 mg, 20 mg, 30 mg, F AL(At least 6 40 mg yrs old) HUMIRA PEDIATRIC PA; SP CROHNS DISEASE F methylphenidate hcl cpcr or QL(1 ea daily); STARTER PACK PSKT 10 mg, 20 mg, 30 mg, 40 F AL(At least 6 mg, 50 mg, 60 mg yrs old) HUMIRA PEN PNKT F PA; SP QL(2 ea daily); HUMIRA PEN-CD/UC/HS PA; SP METHYLPHENIDATE HCL F ER TBCR AL(At least 6 STARTER PNKT 40 F yrs old) MG/0.8ML QL(3 ea daily); methylphenidate hcl tabs or HUMIRA PEN-PS/UV F PA; SP F AL(At least 6 STARTER PNKT 5 mg, 10 mg, 20 mg yrs old) PA; SP methylphenidate hcl tbcr or QL(2 ea daily); HUMIRA PSKT F 18 mg, 27 mg, 36 mg, 54 F AL(At least 6 mg yrs old) Nonsteroidal Anti-inflammatory Agents (NSAIDs) METHYLPHENIDATE QL(2 ea daily); ADVIL CAPS (Ibuprofen) NF HYDROCHLORIDE ER F AL(At least 6 TB24 yrs old) ADVIL MIGRAINE CAPS NF (Ibuprofen) QL(1 ea daily); QUILLICHEW ER CHER F AL(At least 6 ALEVE CAPS (Naproxen NF yrs old) Sodium) QL(5 ml daily); ANAPROX DS TABS NF QUILLIVANT XR SUSR F AL(At least 6 (Naproxen Sodium) yrs old) ARTHROTEC 50 TBEC NF QL(2 ea daily); (Diclofenac w/ Misoprostol) RITALIN LA CP24 10 MG F AL(At least 6 (Methylphenidate HCl) ARTHROTEC 75 TBEC NF yrs old) (Diclofenac w/ Misoprostol) RITALIN LA CP24 20 MG, QL(2 ea daily); CELEBREX CAPS NF PA; QL(2 ea 30 MG, 40 MG NF AL(At least 6 (Celecoxib) daily) (Methylphenidate HCl) yrs old) celecoxib caps or 50 mg, F PA; QL(2 ea QL(3 ea daily); 100 mg, 200 mg, 400 mg daily) RITALIN TABS NF AL(At least 6 (Methylphenidate HCl) CHILDRENS ADVIL SUSP NF RX/OTC yrs old) (Ibuprofen) AMINOGLYCOSIDES - Drugs to Treat Bacterial CHILDRENS MOTRIN NF RX/OTC Infections SUSP (Ibuprofen) Aminoglycosides DAYPRO TABS NF (Oxaprozin) BETHKIS NEBU F PA; SP diclofenac potassium tabs F 50 mg KITABIS PAK NEBU F PA diclofenac sodium tb24 or F neomycin sulfate tabs or F 100 mg Arizona Complete Health-Complete Care Plan Effective October 1, 2018 2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits diclofenac sodium tbec or F LODINE TABS (Etodolac) NF 25 mg, 50 mg, 75 mg MECLOFENAMATE diclofenac w/ misoprostol F tbec SODIUM CAPS OR 50 F MG, 100 MG EC-NAPROSYN TBEC NF (Naproxen) mefenamic acid caps or F 250 mg etodolac caps F meloxicam tabs or 15 mg, F 7.5 mg etodolac tabs F MOBIC TABS (Meloxicam) NF etodolac tb24 F nabumetone tabs or 500 F mg, 750 mg FELDENE CAPS NF (Piroxicam) NALFON CAPS F FENOPROFEN CALCIUM F CAPS OR 400 MG NAPROSYN SUSP NF (Naproxen) fenoprofen calcium tabs or F 600 mg NAPROSYN TABS NF (Naproxen) FENORTHO CAPS 400 F MG naproxen sodium caps or F 220 mg flurbiprofen tabs or 50 mg, F 100 mg naproxen sodium tabs or F 275 mg, 550 mg ibuprofen caps or 200 mg F naproxen susp or 125 F ibuprofen chew or 100 mg F mg/5ml naproxen tabs or 250 mg, F ibuprofen susp or 100 F RX/OTC 375 mg, 500 mg mg/5ml naproxen tbec or 375 mg, F ibuprofen tabs or 400 mg, F 500 mg 600 mg, 800 mg oxaprozin tabs 600 mg F INDOCIN SUPP F piroxicam caps or 10 mg, F INDOCIN SUSP F 20 mg PONSTEL CAPS NF indomethacin caps or 25 F (Mefenamic Acid) mg, 50 mg sulindac tabs or 150 mg, F indomethacin cpcr or 75 F 200 mg mg TOLMETIN SODIUM F ketoprofen caps or 50 mg, F CAPS 400 MG 75 mg tolmetin sodium caps 400 F KETOPROFEN CAPS OR F mg 50 MG, 75 MG TOLMETIN SODIUM TABS F KETOPROFEN ER CP24 F 200 MG, 600 MG Pyrimidine Synthesis Inhibitors ketorolac tromethamine F QL(20 ea per tabs or 10 mg 30 days retail) ARAVA TABS NF (Leflunomide) Arizona Complete Health-Complete Care Plan Effective October 1, 2018 3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits leflunomide tabs or 10 mg, F TYLENOL EXTRA 20 mg STRENGTH TABS NF (Acetaminophen) Soluble Tumor Necrosis Factor Receptor Agents TYLENOL INFANTS ENBREL SOSY 50 MG/ML, F PA; SP PAIN+FEVER SUSP NF 25 MG/0.5ML (Acetaminophen) ENBREL SURECLICK PA; SP F TYLENOL INFANTS SUSP NF SOAJ (Acetaminophen) ANALGESICS - NonNarcotic - Drugs to Treat TYLENOL TABS NF Pain, Muscle and Joint Conditions (Acetaminophen) Analgesic Combinations Salicylates butalbital-acetaminophen- QL(6 ea daily) F aspirin buffered (cal carb- F caffeine caps mag carb-mag oxide) tabs butalbital-acetaminophen- F QL(6 ea daily) caffeine tabs aspirin chew or 81 mg F butalbital-aspirin-caffeine F QL(6 ea daily) ASPIRIN SUPP RE 120 caps 50mg-40mg-325mg MG, 200 MG, 300 MG, 600 F BUTALBITAL/ASPIRIN/CA QL(6 ea daily) MG FFEINE TABS 50MG- F aspirin supp re 300 mg, F 40MG-325MG 600 mg ESGIC TABS (Butalbital- NF QL(6 ea daily) aspirin tabs or 325 mg F Acetaminophen-Caffeine) FIORICET CAPS QL(6 ea daily) aspirin tbec or 81 mg, 324 F (Butalbital-Acetaminophen- NF mg, 325 mg, 500 mg Caffeine) BUFFERIN TABS (Aspirin Buffered (Cal Carb-Mag NF FIORINAL CAPS NF QL(6 ea daily) (Butalbital-Aspirin-Caffeine) Carb-Mag Oxide)) Analgesics Other choline & mag salicylate F liqd acetaminophen caps or F 500 mg diflunisal tabs F acetaminophen chew or 80 F DISALCID TABS NF mg (Salsalate) acetaminophen elix or 160 F ECOTRIN MAXIMUM mg/5ml, 80 mg/2.5ml STRENGTH TBEC NF acetaminophen liqd or 160 F (Aspirin) mg/5ml ECOTRIN REGULAR acetaminophen supp re F STRENGTH TBEC NF 120 mg, 325 mg, 650 mg (Aspirin) acetaminophen susp or F salsalate tabs or 500 mg, F 160 mg/5ml, 80 mg/2.5ml 750 mg acetaminophen tabs or 325 F ANALGESICS - OPIOID - Drugs to Treat Pain, mg, 500 mg Muscle and Joint Conditions TYLENOL CHILDRENS NF SUSP (Acetaminophen) Opioid Agonists DEMEROL TABS OR 100 NF MG (Meperidine HCl) Arizona Complete Health-Complete Care Plan Effective October 1, 2018 4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DILAUDID LIQD OR 1 QL(16 ml daily) tramadol hcl tabs or 50 mg F QL(6 ea daily) MG/ML (Hydromorphone NF HCl) tramadol hcl tb24 or 100 F PA DILAUDID TABS OR 2 QL(6 ea daily) mg, 200 mg, 300 mg MG, 4 MG, 8 MG NF ULTRAM TABS (Tramadol NF QL(6 ea daily) (Hydromorphone HCl) HCl) DURAGESIC PT72 NF PA XTAMPZA ER C12A F PA (Fentanyl) EMBEDA CPCR F PA Opioid Combinations acetaminophen w/ codeine F QL(16 ml daily) fentanyl pt72 12 mcg/hr, 25 PA soln 120mg/5ml-12mg/5ml mcg/hr, 50 mcg/hr, 75 F mcg/hr, 100 mcg/hr acetaminophen w/ codeine QL(6 ea daily) tabs 300mg-15mg, 300mg- F hydromorphone hcl liqd or F QL(16 ml daily) 30mg, 300mg-60mg 1 mg/ml butalbital-acetaminophen- F QL(6 ea daily) 12 per caffeine w/ codeine caps HYDROMORPHONE HCL F month;QL(0.4 SUPP RE 3 MG ea daily,12 ea butalbital-aspirin-caffeine QL(6 ea daily) per fill retail) w/cod caps 50mg-40mg- F 30mg-325mg hydromorphone hcl tabs or F QL(6 ea daily) 2 mg, 4 mg, 8 mg FIORICET/CODEINE QL(6 ea daily) CAPS (Butalbital- NF meperidine hcl tabs or 50 F Acetaminophen-Caffeine w/ mg, 100 mg Codeine) 500 per FIORINAL/CODEINE #3 QL(6
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