(GPI) National Drug Code

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

Current Preferred Drug List Status Recommended Preferred MediSpan Generic National Drug First PDL = Preferred Drug List Status Therapeutic Class / Market National Drug Code Product Indicator Code (NDC) (First DataBank NPD = Non-Preferred PDL = Preferred Basket (NDC) MediSpan (GPI) DataBank GCN Generic Name Brand Name / Label Name NR= Not Previously Reviewed NPD = Non-Preferred ANTIDEPRESSANTS, OTHER 50458002800 46077 esketamine HCl SPRAVATO NR NPD ANTIDEPRESSANTS, OTHER 65862003230 16734 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00008083321 58180090107030 00008083321 16817 venlafaxine HCl EFFEXOR XR NR NPD ANTIDEPRESSANTS, OTHER 00008083322 58180090107030 00008083322 16817 venlafaxine HCl EFFEXOR XR NR NPD ANTIDEPRESSANTS, OTHER 00008083621 58180090107050 00008083621 16818 venlafaxine HCl EFFEXOR XR NR NPD ANTIDEPRESSANTS, OTHER 00008083622 58180090107050 00008083622 16818 venlafaxine HCl EFFEXOR XR NR NPD ANTIDEPRESSANTS, OTHER 00008083721 58180090107020 00008083721 16816 venlafaxine HCl EFFEXOR XR NR NPD ANTIDEPRESSANTS, OTHER 00008083722 58180090107020 00008083722 16816 venlafaxine HCl EFFEXOR XR NR NPD ANTIDEPRESSANTS, OTHER 00008121030 58180020207510 00008121030 38222 desvenlafaxine succinate PRISTIQ NR NPD ANTIDEPRESSANTS, OTHER 00008121101 58180020207520 00008121101 99451 desvenlafaxine succinate PRISTIQ NR NPD ANTIDEPRESSANTS, OTHER 00008121114 58180020207520 00008121114 99451 desvenlafaxine succinate PRISTIQ NR NPD ANTIDEPRESSANTS, OTHER 00008121130 58180020207520 00008121130 99451 desvenlafaxine succinate PRISTIQ NR NPD ANTIDEPRESSANTS, OTHER 00008121150 58180020207520 00008121150 99451 desvenlafaxine succinate PRISTIQ NR NPD ANTIDEPRESSANTS, OTHER 00008122201 58180020207540 00008122201 99452 desvenlafaxine succinate PRISTIQ NR NPD ANTIDEPRESSANTS, OTHER 00008122214 58180020207540 00008122214 99452 desvenlafaxine succinate PRISTIQ NR NPD ANTIDEPRESSANTS, OTHER 00008122230 58180020207540 00008122230 99452 desvenlafaxine succinate PRISTIQ NR NPD ANTIDEPRESSANTS, OTHER 00052010530 58030050000315 00052010530 16732 mirtazapine REMERON NR NPD ANTIDEPRESSANTS, OTHER 00052010606 58030050007215 00052010606 12529 mirtazapine REMERON NR NPD ANTIDEPRESSANTS, OTHER 00052010630 58030050007215 00052010630 12529 mirtazapine REMERON NR NPD ANTIDEPRESSANTS, OTHER 00052010730 58030050000330 00052010730 16733 mirtazapine REMERON NR NPD ANTIDEPRESSANTS, OTHER 00052010806 58030050007230 00052010806 12531 mirtazapine REMERON NR NPD ANTIDEPRESSANTS, OTHER 00052010830 58030050007230 00052010830 12531 mirtazapine REMERON NR NPD ANTIDEPRESSANTS, OTHER 00052011006 58030050007245 00052011006 13041 mirtazapine REMERON NR NPD ANTIDEPRESSANTS, OTHER 00052011030 58030050007245 00052011030 13041 mirtazapine REMERON NR NPD ANTIDEPRESSANTS, OTHER 00054040013 58180020207520 00054040013 99451 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 00054040022 58180020207520 00054040022 99451 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 00054040113 58180020207540 00054040113 99452 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 00054040122 58180020207540 00054040122 99452 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 00054060313 58180020207510 00054060313 38222 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 00071035060 58100020100305 00071035060 16417 phenelzine sulfate NARDIL NR NPD ANTIDEPRESSANTS, OTHER 00093019901 58180090100320 00093019901 16811 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 00093102406 58120050100310 00093102406 16406 nefazodone HCl NEFAZODONE HCL NR NPD ANTIDEPRESSANTS, OTHER 00093102506 58120050100330 00093102506 16408 nefazodone HCl NEFAZODONE HCL NR NPD ANTIDEPRESSANTS, OTHER 00093102606 58120050100340 00093102606 16409 nefazodone HCl NEFAZODONE HCL NR NPD ANTIDEPRESSANTS, OTHER 00093711306 58120050100320 00093711306 16407 nefazodone HCl NEFAZODONE HCL NR NPD ANTIDEPRESSANTS, OTHER 00093717801 58120050100305 00093717801 16404 nefazodone HCl NEFAZODONE HCL NR NPD ANTIDEPRESSANTS, OTHER 00093720656 58030050000315 00093720656 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00093720756 58030050000330 00093720756 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00093720856 58030050000345 00093720856 16734 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00093730365 58030050007215 00093730365 12529 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00093730465 58030050007230 00093730465 12531 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00093738001 58180090100340 00093738001 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 00093738101 58180090100350 00093738101 16813 venlafaxine HCl VENLAFAXINE HCL NR PDL

5/17/2019 1 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, OTHER 00093738201 58180090100360 00093738201 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 00093738301 58180090100370 00093738301 16815 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 00093738405 58180090107020 00093738405 16816 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 00093738456 58180090107020 00093738456 16816 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 00093738498 58180090107020 00093738498 16816 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 00093738505 58180090107030 00093738505 16817 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 00093738556 58180090107030 00093738556 16817 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 00093738598 58180090107030 00093738598 16817 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 00093738605 58180090107050 00093738605 16818 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 00093738656 58180090107050 00093738656 16818 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 00093738698 58180090107050 00093738698 16818 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 00115165308 58030050007215 00115165308 12529 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00115165408 58030050007230 00115165408 12531 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00115165608 58030050007245 00115165608 13041 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00115544513 58300040107440 00115544513 17573 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00115681108 58300040107520 00115681108 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 00115681110 58300040107520 00115681110 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 00131326546 58180090107510 00131326546 14349 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 00131326632 58180090107520 00131326632 14352 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 00131326732 58180090107530 00131326732 14353 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 00131326832 58180090107540 00131326832 14354 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 00173013555 58300040107430 00173013555 16386 bupropion HCl WELLBUTRIN SR NR NPD ANTIDEPRESSANTS, OTHER 00173072200 58300040107440 00173072200 17573 bupropion HCl WELLBUTRIN SR NR NPD ANTIDEPRESSANTS, OTHER 00173094755 58300040107420 00173094755 16387 bupropion HCl WELLBUTRIN SR NR NPD ANTIDEPRESSANTS, OTHER 00185041001 58300040107420 00185041001 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00185041005 58300040107420 00185041005 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00185041060 58300040107420 00185041060 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00185041501 58300040107430 00185041501 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00185041505 58300040107430 00185041505 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00185041552 58300040107430 00185041552 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00185041560 58300040107430 00185041560 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00185111160 58300040107440 00185111160 17573 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00187073030 58300040107520 00187073030 20317 bupropion HCl WELLBUTRIN XL NR NPD ANTIDEPRESSANTS, OTHER 00187073090 58300040107520 00187073090 20317 bupropion HCl WELLBUTRIN XL NR NPD ANTIDEPRESSANTS, OTHER 00187073130 58300040107530 00187073130 20318 bupropion HCl WELLBUTRIN XL NR NPD ANTIDEPRESSANTS, OTHER 00187581030 58300040207520 00187581030 26198 bupropion HBr APLENZIN NR NPD ANTIDEPRESSANTS, OTHER 00187581130 58300040207530 00187581130 16996 bupropion HBr APLENZIN NR NPD ANTIDEPRESSANTS, OTHER 00187581230 58300040207540 00187581230 17050 bupropion HBr APLENZIN NR NPD ANTIDEPRESSANTS, OTHER 00378043301 58300040100305 00378043301 16384 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 00378043305 58300040100305 00378043305 16384 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 00378043501 58300040100310 00378043501 16385 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 00378043505 58300040100310 00378043505 16385 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 00378200877 58300040107520 00378200877 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 00378200905 58300040107530 00378200905 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 00378341101 58300040107420 00378341101 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00378341105 58300040107420 00378341105 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00378341201 58300040107430 00378341201 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00378341205 58300040107430 00378341205 16386 bupropion HCl BUPROPION HCL SR NR PDL

5/17/2019 2 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, OTHER 00378341301 58300040107440 00378341301 17573 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00378351501 58030050000315 00378351501 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00378351510 58030050000315 00378351510 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00378351570 58030050000315 00378351570 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00378351593 58030050000315 00378351593 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00378353001 58030050000330 00378353001 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00378353005 58030050000330 00378353005 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00378353070 58030050000330 00378353070 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00378353093 58030050000330 00378353093 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00378354501 58030050000345 00378354501 16734 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00378354505 58030050000345 00378354505 16734 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00378354593 58030050000345 00378354593 16734 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00378423077 58180020207520 00378423077 99451 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 00378423093 58180020207520 00378423093 99451 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 00378423177 58180020207540 00378423177 99452 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 00378423193 58180020207540 00378423193 99452 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 00378488101 58180090100320 00378488101 16811 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 00378488201 58180090100340 00378488201 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 00378488301 58180090100350 00378488301 16813 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 00378488401 58180090100360 00378488401 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 00378488501 58180090100370 00378488501 16815 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 00456110130 58120088106410 00456110130 38253 vilazodone HCl VIIBRYD NR NPD ANTIDEPRESSANTS, OTHER 00456111030 58120088100310 00456111030 29916 vilazodone HCl VIIBRYD NR NPD ANTIDEPRESSANTS, OTHER 00456112030 58120088100320 00456112030 29917 vilazodone HCl VIIBRYD NR NPD ANTIDEPRESSANTS, OTHER 00456114030 58120088100340 00456114030 29918 vilazodone HCl VIIBRYD NR NPD ANTIDEPRESSANTS, OTHER 00456220228 5818005010B620 00456220228 35335 levomilnacipran HCl FETZIMA NR NPD ANTIDEPRESSANTS, OTHER 00456221230 58180050107080 00456221230 35334 levomilnacipran HCl FETZIMA NR NPD ANTIDEPRESSANTS, OTHER 00456222030 58180050107020 00456222030 35327 levomilnacipran HCl FETZIMA NR NPD ANTIDEPRESSANTS, OTHER 00456224030 58180050107040 00456224030 35328 levomilnacipran HCl FETZIMA NR NPD ANTIDEPRESSANTS, OTHER 00456228030 58180050107060 00456228030 35329 levomilnacipran HCl FETZIMA NR NPD ANTIDEPRESSANTS, OTHER 00555073302 58120080100325 00555073302 16394 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 00591111710 58030050000315 00591111710 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00591111730 58030050000315 00591111730 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00591111810 58030050000330 00591111810 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00591111830 58030050000330 00591111830 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00591111930 58030050000345 00591111930 16734 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00591246915 58030050007215 00591246915 12529 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00591247015 58030050007230 00591247015 12531 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00591247115 58030050007245 00591247115 13041 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00591333105 58300040107520 00591333105 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 00591333119 58300040107520 00591333119 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 00591333130 58300040107520 00591333130 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 00591354005 58300040107420 00591354005 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00591354060 58300040107420 00591354060 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00591354105 58300040107430 00591354105 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00591354125 58300040107430 00591354125 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00591354160 58300040107430 00591354160 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00591354260 58300040107440 00591354260 17573 bupropion HCl BUPROPION HCL SR NR PDL

5/17/2019 3 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, OTHER 00591365930 58180020207520 00591365930 99451 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 00591366030 58180020207540 00591366030 99452 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 00591406030 58180020207510 00591406030 38222 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 00591559001 58100030100305 00591559001 16418 tranylcypromine sulfate TRANYLCYPROMINE SULFATE NR NPD ANTIDEPRESSANTS, OTHER 00603616021 58120080100305 00603616021 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 00603616028 58120080100305 00603616028 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 00603616032 58120080100305 00603616032 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 00603616121 58120080100310 00603616121 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 00603616128 58120080100310 00603616128 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 00603616132 58120080100310 00603616132 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 00781105301 58300040100305 00781105301 16384 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 00781105310 58300040100305 00781105310 16384 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 00781106401 58300040100310 00781106401 16385 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 00781106410 58300040100310 00781106410 16385 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 00781552810 58300040107520 00781552810 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 00781552831 58300040107520 00781552831 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 00781552910 58300040107530 00781552910 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 00781552931 58300040107530 00781552931 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 00904399161 58120080100310 00904399161 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 00904646861 58180090107020 00904646861 16816 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 00904646961 58180090107030 00904646961 16817 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 00904647061 58180090107050 00904647061 16818 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 00904651961 58030050000315 00904651961 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 00904655461 58120080100305 00904655461 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 00904655561 58120080100310 00904655561 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 00904657304 58300040107530 00904657304 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 00904658561 58300040107430 00904658561 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 00904663661 58300040100310 00904663661 16385 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 10370010103 58300040107520 10370010103 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 10370010150 58300040107520 10370010150 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 10370010203 58300040107530 10370010203 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 10370010250 58300040107530 10370010250 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 13107000105 58030050000308 13107000105 21817 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 13107000130 58030050000308 13107000130 21817 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 13107000305 58030050000330 13107000305 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 13107000330 58030050000330 13107000330 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 13107000334 58030050000330 13107000334 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 13107003105 58030050000315 13107003105 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 13107003130 58030050000315 13107003130 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 13107003134 58030050000315 13107003134 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 13107003205 58030050000345 13107003205 16734 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 13107003234 58030050000345 13107003234 16734 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 13668001830 58180090107020 13668001830 16816 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 13668001890 58180090107020 13668001890 16816 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 13668001930 58180090107030 13668001930 16817 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 13668001990 58180090107030 13668001990 16817 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 13668002030 58180090107050 13668002030 16818 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 13668002090 58180090107050 13668002090 16818 venlafaxine HCl VENLAFAXINE HCL ER NR PDL

5/17/2019 4 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, OTHER 13668033001 58120080100305 13668033001 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 13668033005 58120080100305 13668033005 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 13668033101 58120080100310 13668033101 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 13668033105 58120080100310 13668033105 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 13668033201 58120080100315 13668033201 16393 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 13668033205 58120080100315 13668033205 16393 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 13668033301 58120080100325 13668033301 16394 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 13668043060 58300040107420 13668043060 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 13668043160 58300040107430 13668043160 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 13668043260 58300040107440 13668043260 17573 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 13811071230 58180090107510 13811071230 14349 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 13811071290 58180090107510 13811071290 14349 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 13811071330 58180090107520 13811071330 14352 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 13811071390 58180090107520 13811071390 14352 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 13811071430 58180090107530 13811071430 14353 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 13811071490 58180090107530 13811071490 14353 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 13811071530 58180090107540 13811071530 14354 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 13811071590 58180090107540 13811071590 14354 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 16714031101 58180090100320 16714031101 16811 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 16714031201 58180090100340 16714031201 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 16714031301 58180090100350 16714031301 16813 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 16714031401 58180090100360 16714031401 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 16714065501 58180090100320 16714065501 16811 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 16714065601 58180090100340 16714065601 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 16714065701 58180090100350 16714065701 16813 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 16714065801 58180090100360 16714065801 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 16714065901 58180090100370 16714065901 16815 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 16714070601 58030050000308 16714070601 21817 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 16714070701 58030050000315 16714070701 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 16714070801 58030050000330 16714070801 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 16714070901 58030050000345 16714070901 16734 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 16729029901 58120080100305 16729029901 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 16729029917 58120080100305 16729029917 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 16729030001 58120080100310 16729030001 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 16729030017 58120080100310 16729030017 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 16729030101 58120080100315 16729030101 16393 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 16729030116 58120080100315 16729030116 16393 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 16729030201 58120080100325 16729030201 16394 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 16729044310 58300040107520 16729044310 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 16729044315 58300040107520 16729044315 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 16729044316 58300040107520 16729044316 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 23155019101 58300040100305 23155019101 16384 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 23155019201 58300040100310 23155019201 16385 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 23155024601 58180090100320 23155024601 16811 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 23155024701 58180090100340 23155024701 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 23155024709 58180090100340 23155024709 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 23155024801 58180090100350 23155024801 16813 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 23155024901 58180090100360 23155024901 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL

5/17/2019 5 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, OTHER 23155025001 58180090100370 23155025001 16815 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 24979010102 58300040107520 24979010102 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 24979010106 58300040107520 24979010106 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 24979010107 58300040107520 24979010107 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 24979010202 58300040107530 24979010202 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 24979010206 58300040107530 24979010206 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 24979010207 58300040107530 24979010207 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 29033004530 58180090107530 29033004530 14353 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 29033004590 58180090107530 29033004590 14353 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 29033004630 58180090107540 29033004630 14354 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 29033004690 58180090107540 29033004690 14354 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 30698003201 58100010000305 30698003201 16416 isocarboxazid MARPLAN NR NPD ANTIDEPRESSANTS, OTHER 41616075881 58180090107530 41616075881 14353 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 41616075981 58180090107520 41616075981 14352 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 41616075983 58180090107520 41616075983 14352 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 41616076081 58180090107510 41616076081 14349 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 41616076083 58180090107510 41616076083 14349 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 42806034805 58300040107520 42806034805 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 42806034809 58300040107520 42806034809 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 42806034830 58300040107520 42806034830 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 42806034905 58300040107530 42806034905 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 42806034909 58300040107530 42806034909 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 43386036021 58100020100305 43386036021 16417 phenelzine sulfate PHENELZINE SULFATE NR NPD ANTIDEPRESSANTS, OTHER 43547028809 58300040107420 43547028809 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43547028810 58300040107420 43547028810 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43547028850 58300040107420 43547028850 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43547028909 58300040107430 43547028909 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43547028910 58300040107430 43547028910 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43547028950 58300040107430 43547028950 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43547029009 58300040107440 43547029009 17573 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43547029010 58300040107440 43547029010 17573 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43598053601 58300040107420 43598053601 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43598053605 58300040107420 43598053605 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43598053660 58300040107420 43598053660 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43598053701 58300040107430 43598053701 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43598053705 58300040107430 43598053705 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43598053760 58300040107430 43598053760 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43598053860 58300040107440 43598053860 17573 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43598065505 58300040107520 43598065505 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 43598065530 58300040107520 43598065530 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 43598065605 58300040107530 43598065605 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 43598065630 58300040107530 43598065630 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 43598075101 58300040107420 43598075101 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43598075160 58300040107420 43598075160 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43598075201 58300040107430 43598075201 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43598075205 58300040107430 43598075205 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43598075260 58300040107430 43598075260 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 43598075360 58300040107440 43598075360 17573 bupropion HCl BUPROPION HCL SR NR PDL

5/17/2019 6 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, OTHER 44183088031 58180020007520 44183088031 35582 desvenlafaxine DESVENLAFAXINE ER NR NPD ANTIDEPRESSANTS, OTHER 44183089031 58180020007540 44183089031 35584 desvenlafaxine DESVENLAFAXINE ER NR NPD ANTIDEPRESSANTS, OTHER 45963014130 58300040107520 45963014130 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 45963014190 58300040107520 45963014190 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 45963014205 58300040107530 45963014205 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 45963014230 58300040107530 45963014230 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 45963014290 58300040107530 45963014290 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 47335073613 58300040107420 47335073613 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 47335073686 58300040107420 47335073686 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 47335073688 58300040107420 47335073688 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 47335073713 58300040107430 47335073713 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 47335073786 58300040107430 47335073786 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 47335073788 58300040107430 47335073788 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 47335073886 58300040107440 47335073886 17573 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 47335075883 58180090107530 47335075883 14353 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 47335075983 58180090107520 47335075983 14352 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 47335076083 58180090107510 47335076083 14349 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 47781063730 58300040107545 47781063730 33081 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 49502090030 58100027008520 49502090030 26612 selegiline EMSAM NR NPD ANTIDEPRESSANTS, OTHER 49502090130 58100027008530 49502090130 26613 selegiline EMSAM NR NPD ANTIDEPRESSANTS, OTHER 49502090230 58100027008540 49502090230 26614 selegiline EMSAM NR NPD ANTIDEPRESSANTS, OTHER 49884003201 58100030100305 49884003201 16418 tranylcypromine sulfate TRANYLCYPROMINE SULFATE NR NPD ANTIDEPRESSANTS, OTHER 49909001030 58300040107545 49909001030 33081 bupropion HCl FORFIVO XL NR NPD ANTIDEPRESSANTS, OTHER 50111043301 58120080100305 50111043301 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 50111043302 58120080100305 50111043302 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 50111043303 58120080100305 50111043303 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 50111043401 58120080100310 50111043401 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 50111043402 58120080100310 50111043402 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 50111043403 58120080100310 50111043403 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 50111044101 58120080100315 50111044101 16393 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 50111044102 58120080100315 50111044102 16393 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 50458002802 5811002010C520 50458002802 46078 esketamine HCl SPRAVATO NR NPD ANTIDEPRESSANTS, OTHER 50458002803 5811002010C530 50458002803 46079 esketamine HCl SPRAVATO NR NPD ANTIDEPRESSANTS, OTHER 51079004720 58300040107520 51079004720 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 51079008620 58030050000315 51079008620 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 51079008720 58030050000330 51079008720 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 51079008756 58030050000330 51079008756 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 51079008820 58030050000345 51079008820 16734 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 51079010903 58300040107530 51079010903 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 51079039120 58300040107420 51079039120 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 51079039220 58300040107430 51079039220 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 51079048020 58180090100340 51079048020 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 51079048220 58180090100360 51079048220 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 51079094320 58300040100305 51079094320 16384 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 51079094356 58300040100305 51079094356 16384 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 51079094420 58300040100310 51079094420 16385 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 51991000633 58180020207510 51991000633 38222 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 51991031110 58180020207520 51991031110 99451 desvenlafaxine succinate ER NR NPD

5/17/2019 7 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, OTHER 51991031133 58180020207520 51991031133 99451 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 51991031190 58180020207520 51991031190 99451 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 51991031210 58180020207540 51991031210 99452 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 51991031233 58180020207540 51991031233 99452 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 51991031290 58180020207540 51991031290 99452 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 52427057530 58300040107545 52427057530 33081 bupropion HCl FORFIVO XL NR NPD ANTIDEPRESSANTS, OTHER 52817013010 58180090100320 52817013010 16811 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 52817013110 58180090100340 52817013110 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 52817013210 58180090100350 52817013210 16813 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 52817013310 58180090100360 52817013310 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 52817013410 58180090100370 52817013410 16815 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 53489051001 58120080100305 53489051001 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 53489051101 58120080100310 53489051101 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 53489051701 58120080100315 53489051701 16393 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 57237000705 58030050000308 57237000705 21817 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 57237000730 58030050000308 57237000730 21817 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 57237000805 58030050000315 57237000805 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 57237000830 58030050000315 57237000830 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 57237000905 58030050000330 57237000905 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 57237000930 58030050000330 57237000930 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 57237001005 58030050000345 57237001005 16734 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 57237001030 58030050000345 57237001030 16734 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 57237001106 58030050007215 57237001106 12529 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 57237001206 58030050007230 57237001206 12531 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 57237001306 58030050007245 57237001306 13041 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 57237017201 58180090100320 57237017201 16811 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 57237017290 58180090100320 57237017290 16811 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 57237017301 58180090100340 57237017301 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 57237017390 58180090100340 57237017390 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 57237017401 58180090100350 57237017401 16813 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 57237017490 58180090100350 57237017490 16813 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 57237017501 58180090100360 57237017501 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 57237017590 58180090100360 57237017590 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 57237017601 58180090100370 57237017601 16815 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 57237017690 58180090100370 57237017690 16815 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 57664039288 58180090100320 57664039288 16811 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 57664039388 58180090100340 57664039388 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 57664039488 58180090100350 57664039488 16813 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 57664039588 58180090100360 57664039588 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 57664039688 58180090100370 57664039688 16815 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 57664049918 58030050000315 57664049918 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 57664049983 58030050000315 57664049983 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 57664050018 58030050000330 57664050018 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 57664050083 58030050000330 57664050083 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 57664050183 58030050000345 57664050183 16734 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 57664051083 58030050000308 57664051083 21817 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 59746075830 58300040107520 59746075830 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 59746075890 58300040107520 59746075890 20317 bupropion HCl BUPROPION XL NR PDL

5/17/2019 8 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, OTHER 59762011901 58100020100305 59762011901 16417 phenelzine sulfate PHENELZINE SULFATE NR NPD ANTIDEPRESSANTS, OTHER 59762018001 58180090107020 59762018001 16816 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 59762018002 58180090107020 59762018002 16816 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 59762018101 58180090107030 59762018101 16817 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 59762018102 58180090107030 59762018102 16817 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 59762018201 58180090107050 59762018201 16818 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 59762018202 58180090107050 59762018202 16818 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 59762121003 58180020207510 59762121003 38222 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 59762121103 58180020207520 59762121103 99451 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 59762122203 58180020207540 59762122203 99452 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 60505015701 58300040100310 60505015701 16385 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 60505015801 58300040100305 60505015801 16384 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 60505024701 58030050000315 60505024701 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 60505024708 58030050000315 60505024708 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 60505024801 58030050000330 60505024801 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 60505024808 58030050000330 60505024808 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 60505024901 58030050000345 60505024901 16734 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 60505024908 58030050000345 60505024908 16734 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 60505265300 58120080100305 60505265300 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 60505265301 58120080100305 60505265301 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 60505265305 58120080100305 60505265305 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 60505265307 58120080100305 60505265307 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 60505265400 58120080100310 60505265400 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 60505265401 58120080100310 60505265401 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 60505265405 58120080100310 60505265405 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 60505265407 58120080100310 60505265407 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 60505265501 58120080100315 60505265501 16393 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 60505265505 58120080100315 60505265505 16393 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 60505265507 58120080100315 60505265507 16393 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 60505265901 58120080100325 60505265901 16394 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 60505408903 58120080100315 60505408903 16393 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 62332000831 58180090100320 62332000831 16811 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 62332000931 58180090100340 62332000931 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 62332001031 58180090100350 62332001031 16813 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 62332001131 58180090100360 62332001131 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 62332001231 58180090100370 62332001231 16815 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 63304019130 58180020007520 63304019130 34470 desvenlafaxine DESVENLAFAXINE ER NR NPD ANTIDEPRESSANTS, OTHER 63304019230 58180020007540 63304019230 34482 desvenlafaxine DESVENLAFAXINE ER NR NPD ANTIDEPRESSANTS, OTHER 63739035510 58030050000315 63739035510 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 63739035610 58030050000330 63739035610 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 63739071410 58300040107430 63739071410 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 64679083001 58300040107545 64679083001 33081 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 64764055030 58120093100310 64764055030 35346 vortioxetine hydrobromide BRINTELLIX NR NPD ANTIDEPRESSANTS, OTHER 64764058030 58120093100340 64764058030 35349 vortioxetine hydrobromide BRINTELLIX NR NPD ANTIDEPRESSANTS, OTHER 64764072030 58120093100310 64764072030 35346 vortioxetine hydrobromide TRINTELLIX NR NPD ANTIDEPRESSANTS, OTHER 64764073030 58120093100320 64764073030 35347 vortioxetine hydrobromide TRINTELLIX NR NPD ANTIDEPRESSANTS, OTHER 64764075030 58120093100340 64764075030 35349 vortioxetine hydrobromide TRINTELLIX NR NPD ANTIDEPRESSANTS, OTHER 64980020101 58300040100305 64980020101 16384 bupropion HCl BUPROPION HCL NR PDL

5/17/2019 9 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, OTHER 64980020201 58300040100310 64980020201 16385 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 65162030009 58180090100320 65162030009 16811 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 65162030209 58180090100340 65162030209 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 65162030509 58180090100370 65162030509 16815 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 65162030609 58180090100350 65162030609 16813 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 65162030709 58180090100360 65162030709 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 65224088031 58180020007520 65224088031 35582 desvenlafaxine KHEDEZLA NR NPD ANTIDEPRESSANTS, OTHER 65224089031 58180020007540 65224089031 35584 desvenlafaxine KHEDEZLA NR NPD ANTIDEPRESSANTS, OTHER 65580030409 58180090107540 65580030409 14354 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 65862000330 58030050000330 65862000330 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 65862002106 58030050007215 65862002106 12529 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 65862002206 58030050007230 65862002206 12531 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 65862002306 58030050007245 65862002306 13041 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 65862003130 58030050000315 65862003130 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 65862040501 58180090100340 65862040501 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 65862040701 58180090100360 65862040701 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 65862040801 58180090100370 65862040801 16815 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 65862052701 58180090107020 65862052701 16816 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 65862052730 58180090107020 65862052730 16816 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 65862052790 58180090107020 65862052790 16816 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 65862052799 58180090107020 65862052799 16816 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 65862052801 58180090107030 65862052801 16817 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 65862052830 58180090107030 65862052830 16817 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 65862052890 58180090107030 65862052890 16817 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 65862052899 58180090107030 65862052899 16817 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 65862069701 58180090107050 65862069701 16818 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 65862069705 58180090107050 65862069705 16818 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 65862069730 58180090107050 65862069730 16818 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 65862069790 58180090107050 65862069790 16818 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 66993070930 58030050007215 66993070930 12529 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 66993071130 58030050007230 66993071130 12531 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 68001015600 58180090100370 68001015600 16815 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 68001015700 58180090100320 68001015700 16811 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 68001015800 58180090100340 68001015800 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 68001015900 58180090100350 68001015900 16813 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 68001016000 58180090100360 68001016000 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 68001019800 58300040100310 68001019800 16385 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 68001019900 58300040100305 68001019900 16384 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 68001026405 58300040107530 68001026405 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68001028703 58300040107520 68001028703 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68001028704 58300040107520 68001028704 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68001030800 58300040100305 68001030800 16384 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 68001030900 58300040100310 68001030900 16385 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 68001032103 58300040107530 68001032103 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68001032104 58300040107530 68001032104 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68001032105 58300040107530 68001032105 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68001032203 58300040107520 68001032203 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68001032204 58300040107520 68001032204 20317 bupropion HCl BUPROPION XL NR PDL

5/17/2019 10 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, OTHER 68001032205 58300040107520 68001032205 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68025007930 58180090107510 68025007930 14349 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68025008030 58180090107520 68025008030 14352 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68025008090 58180090107520 68025008090 14352 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68025008130 58180090107530 68025008130 14353 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68025008190 58180090107530 68025008190 14353 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68025008230 58180090107540 68025008230 14354 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68025008290 58180090107540 68025008290 14354 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68084011901 58030050000315 68084011901 16732 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 68084012001 58030050000330 68084012001 16733 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 68084012101 58030050000345 68084012101 16734 mirtazapine MIRTAZAPINE NR PDL ANTIDEPRESSANTS, OTHER 68084012501 58120080100310 68084012501 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 68084025221 58300040107530 68084025221 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68084060801 58120080100315 68084060801 16393 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 68084069801 58180090107020 68084069801 16816 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68084070901 58180090107030 68084070901 16817 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68084071301 58180090107050 68084071301 16818 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68084084401 58180090100340 68084084401 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 68084085601 58180090100360 68084085601 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 68084085611 58180090100360 68084085611 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 68084089625 58180090100320 68084089625 16811 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 68180031902 58300040107520 68180031902 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68180031906 58300040107520 68180031906 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68180031909 58300040107520 68180031909 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68180032002 58300040107530 68180032002 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68180032006 58300040107530 68180032006 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68180032009 58300040107530 68180032009 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68180059206 58180020207520 68180059206 99451 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 68180059209 58180020207520 68180059209 99451 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 68180059306 58180020207540 68180059306 99452 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 68180059309 58180020207540 68180059309 99452 desvenlafaxine succinate ER NR NPD ANTIDEPRESSANTS, OTHER 68382001801 58180090100320 68382001801 16811 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 68382001901 58180090100340 68382001901 16812 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 68382002001 58180090100350 68382002001 16813 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 68382002101 58180090100360 68382002101 16814 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 68382003406 58180090107020 68382003406 16816 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68382003410 58180090107020 68382003410 16816 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68382003416 58180090107020 68382003416 16816 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68382003506 58180090107030 68382003506 16817 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68382003510 58180090107030 68382003510 16817 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68382003516 58180090107030 68382003516 16817 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68382003606 58180090107050 68382003606 16818 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68382003610 58180090107050 68382003610 16818 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68382003616 58180090107050 68382003616 16818 venlafaxine HCl VENLAFAXINE HCL ER NR PDL ANTIDEPRESSANTS, OTHER 68382010101 58180090100370 68382010101 16815 venlafaxine HCl VENLAFAXINE HCL NR PDL ANTIDEPRESSANTS, OTHER 68382035316 58300040107520 68382035316 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68382035405 58300040107530 68382035405 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 68382035406 58300040107530 68382035406 20318 bupropion HCl BUPROPION XL NR PDL

5/17/2019 11 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, OTHER 68382080501 58120080100305 68382080501 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 68382080505 58120080100305 68382080505 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 68382080510 58120080100305 68382080510 16391 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 68382080601 58120080100310 68382080601 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 68382080605 58120080100310 68382080605 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 68382080610 58120080100310 68382080610 16392 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 68382080701 58120080100315 68382080701 16393 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 68382080705 58120080100315 68382080705 16393 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 68382080801 58120080100325 68382080801 16394 trazodone HCl TRAZODONE HCL NR PDL ANTIDEPRESSANTS, OTHER 69097087502 58300040107520 69097087502 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 69097087505 58300040107520 69097087505 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 69097087512 58300040107520 69097087512 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 69097087602 58300040107530 69097087602 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 69097087612 58300040107530 69097087612 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 69097087703 58300040107420 69097087703 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 69097087712 58300040107420 69097087712 16387 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 69097087803 58300040107430 69097087803 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 69097087807 58300040107430 69097087807 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 69097087812 58300040107430 69097087812 16386 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 69097087903 58300040107440 69097087903 17573 bupropion HCl BUPROPION HCL SR NR PDL ANTIDEPRESSANTS, OTHER 69097091707 58300040100305 69097091707 16384 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 69097091807 58300040100310 69097091807 16385 bupropion HCl BUPROPION HCL NR PDL ANTIDEPRESSANTS, OTHER 70436001002 58300040107520 70436001002 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 70436001004 58300040107520 70436001004 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 70436001006 58300040107520 70436001006 20317 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 70436001102 58300040107530 70436001102 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 70436001104 58300040107530 70436001104 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, OTHER 72604003201 58100010000305 72604003201 16416 isocarboxazid MARPLAN NR NPD ANTIDEPRESSANTS, OTHER 76282048130 58300040107530 76282048130 20318 bupropion HCl BUPROPION XL NR PDL ANTIDEPRESSANTS, SSRIs 16714035203 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862015630 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862015730 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00049490030 58160070100310 00049490030 16374 sertraline HCl ZOLOFT NR NPD ANTIDEPRESSANTS, SSRIs 00049490041 58160070100310 00049490041 16374 sertraline HCl ZOLOFT NR NPD ANTIDEPRESSANTS, SSRIs 00049491030 58160070100320 00049491030 16375 sertraline HCl ZOLOFT NR NPD ANTIDEPRESSANTS, SSRIs 00049491041 58160070100320 00049491041 16375 sertraline HCl ZOLOFT NR NPD ANTIDEPRESSANTS, SSRIs 00049496030 58160070100305 00049496030 16373 sertraline HCl ZOLOFT NR NPD ANTIDEPRESSANTS, SSRIs 00054006258 58160020102020 00054006258 16344 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00093434656 58160040000140 00093434656 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00093474010 58160020100310 00093474010 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00093474150 58160020100320 00093474150 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00093526256 58160040000360 00093526256 30817 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00093585001 58160034100310 00093585001 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 00093585005 58160034100310 00093585005 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 00093585101 58160034100320 00093585101 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 00093585105 58160034100320 00093585105 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 00093585201 58160034100330 00093585201 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 00093585205 58160034100330 00093585205 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL

5/17/2019 12 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, SSRIs 00093610812 58160040002020 00093610812 16357 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00093711498 58160060000310 00093711498 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00093711598 58160060000320 00093711598 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00093712198 58160060000340 00093712198 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00093718810 58160040000310 00093718810 16356 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00093718856 58160040000310 00093718856 16356 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00093719801 58160040000140 00093719801 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00093719805 58160040000140 00093719805 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00093719856 58160040000140 00093719856 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00121072104 58160040002020 00121072104 16357 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00121472105 58160040002020 00121472105 16357 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00143965430 58160070100320 00143965430 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00143965530 58160070100310 00143965530 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00143965609 58160070100305 00143965609 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00143980701 58160034100330 00143980701 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 00143980705 58160034100330 00143980705 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 00143980801 58160034100320 00143980801 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 00143980901 58160034100310 00143980901 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 00185001701 58160045100310 00185001701 16347 fluvoxamine maleate FLUVOXAMINE MALEATE NR PDL ANTIDEPRESSANTS, SSRIs 00185002701 58160045100320 00185002701 16348 fluvoxamine maleate FLUVOXAMINE MALEATE NR PDL ANTIDEPRESSANTS, SSRIs 00185002705 58160045100320 00185002705 16348 fluvoxamine maleate FLUVOXAMINE MALEATE NR PDL ANTIDEPRESSANTS, SSRIs 00185015701 58160045100330 00185015701 16349 fluvoxamine maleate FLUVOXAMINE MALEATE NR PDL ANTIDEPRESSANTS, SSRIs 00185015705 58160045100330 00185015705 16349 fluvoxamine maleate FLUVOXAMINE MALEATE NR PDL ANTIDEPRESSANTS, SSRIs 00185037101 58160020100310 00185037101 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00185037201 58160020100320 00185037201 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00185037301 58160020100340 00185037301 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00228284803 58160045107020 00228284803 99481 fluvoxamine maleate FLUVOXAMINE MALEATE ER NR NPD ANTIDEPRESSANTS, SSRIs 00228284903 58160045107030 00228284903 99482 fluvoxamine maleate FLUVOXAMINE MALEATE ER NR NPD ANTIDEPRESSANTS, SSRIs 00378040701 58160045100310 00378040701 16347 fluvoxamine maleate FLUVOXAMINE MALEATE NR PDL ANTIDEPRESSANTS, SSRIs 00378041201 58160045100320 00378041201 16348 fluvoxamine maleate FLUVOXAMINE MALEATE NR PDL ANTIDEPRESSANTS, SSRIs 00378041401 58160045100330 00378041401 16349 fluvoxamine maleate FLUVOXAMINE MALEATE NR PDL ANTIDEPRESSANTS, SSRIs 00378073401 58160040000310 00378073401 16356 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378073493 58160040000310 00378073493 16356 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378073501 58160040000320 00378073501 16359 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378073593 58160040000320 00378073593 16359 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378200305 58160060007520 00378200305 17078 paroxetine HCl PAROXETINE ER NR NPD ANTIDEPRESSANTS, SSRIs 00378200393 58160060007520 00378200393 17078 paroxetine HCl PAROXETINE ER NR NPD ANTIDEPRESSANTS, SSRIs 00378200405 58160060007530 00378200405 17077 paroxetine HCl PAROXETINE ER NR NPD ANTIDEPRESSANTS, SSRIs 00378200493 58160060007530 00378200493 17077 paroxetine HCl PAROXETINE ER NR NPD ANTIDEPRESSANTS, SSRIs 00378200593 58160060007540 00378200593 17079 paroxetine HCl PAROXETINE ER NR NPD ANTIDEPRESSANTS, SSRIs 00378385577 58160034100310 00378385577 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 00378385610 58160034100320 00378385610 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 00378385677 58160034100320 00378385677 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 00378385710 58160034100330 00378385710 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 00378385777 58160034100330 00378385777 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 00378541028 62206040000110 00378541028 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378542028 62206040000120 00378542028 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378623101 58160020100310 00378623101 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL

5/17/2019 13 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, SSRIs 00378623105 58160020100310 00378623105 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00378623201 58160020100320 00378623201 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00378623205 58160020100320 00378623205 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00378623301 58160020100340 00378623301 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00378623305 58160020100340 00378623305 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00378700110 58160060000310 00378700110 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378700193 58160060000310 00378700193 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378700210 58160060000320 00378700210 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378700293 58160060000320 00378700293 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378700310 58160060000330 00378700310 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378700393 58160060000330 00378700393 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378700410 58160060000340 00378700410 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378700493 58160060000340 00378700493 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378801101 58160070100305 00378801101 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378812101 58160070100310 00378812101 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378812701 58160070100320 00378812701 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00378812705 58160070100320 00378812705 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00430021014 62206040000310 00430021014 16356 fluoxetine HCl SARAFEM NR NPD ANTIDEPRESSANTS, SSRIs 00430022014 62206040000320 00430022014 16359 fluoxetine HCl SARAFEM NR NPD ANTIDEPRESSANTS, SSRIs 00456200501 58160034100310 00456200501 18975 escitalopram oxalate LEXAPRO NR NPD ANTIDEPRESSANTS, SSRIs 00456201001 58160034100320 00456201001 17851 escitalopram oxalate LEXAPRO NR NPD ANTIDEPRESSANTS, SSRIs 00456202001 58160034100330 00456202001 17987 escitalopram oxalate LEXAPRO NR NPD ANTIDEPRESSANTS, SSRIs 00456401001 58160020100310 00456401001 16345 citalopram hydrobromide CELEXA NR NPD ANTIDEPRESSANTS, SSRIs 00456402001 58160020100320 00456402001 16342 citalopram hydrobromide CELEXA NR NPD ANTIDEPRESSANTS, SSRIs 00456404001 58160020100340 00456404001 16343 citalopram hydrobromide CELEXA NR NPD ANTIDEPRESSANTS, SSRIs 00574027930 62226060300110 00574027930 34876 paroxetine mesylate PAROXETINE MESYLATE NR NPD ANTIDEPRESSANTS, SSRIs 00713474001 58160020100310 00713474001 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00713474005 58160020100310 00713474005 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00713474101 58160020100320 00713474101 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00713474105 58160020100320 00713474105 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00713474201 58160020100340 00713474201 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00713474205 58160020100340 00713474205 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00777310402 58160040000110 00777310402 16353 fluoxetine HCl PROZAC NR NPD ANTIDEPRESSANTS, SSRIs 00777310502 58160040000120 00777310502 16354 fluoxetine HCl PROZAC NR NPD ANTIDEPRESSANTS, SSRIs 00777310507 58160040000120 00777310507 16354 fluoxetine HCl PROZAC NR NPD ANTIDEPRESSANTS, SSRIs 00777310530 58160040000120 00777310530 16354 fluoxetine HCl PROZAC NR NPD ANTIDEPRESSANTS, SSRIs 00777310730 58160040000140 00777310730 16355 fluoxetine HCl PROZAC NR NPD ANTIDEPRESSANTS, SSRIs 00781282201 58160040000120 00781282201 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00781282210 58160040000120 00781282210 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00781282301 58160040000110 00781282301 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00781282310 58160040000110 00781282310 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00781282401 58160040000140 00781282401 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00781282410 58160040000140 00781282410 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00781282431 58160040000140 00781282431 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00904567661 58160060000310 00904567661 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00904567761 58160060000320 00904567761 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00904567961 58160060000340 00904567961 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00904578461 58160040000110 00904578461 16353 fluoxetine HCl FLUOXETINE HCL NR PDL

5/17/2019 14 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, SSRIs 00904578561 58160040000120 00904578561 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 00904608461 58160020100310 00904608461 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00904608561 58160020100320 00904608561 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00904608661 58160020100340 00904608661 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 00904642661 58160034100320 00904642661 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 00904642761 58160034100330 00904642761 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 10370017511 58160045107020 10370017511 99481 fluvoxamine maleate FLUVOXAMINE MALEATE ER NR NPD ANTIDEPRESSANTS, SSRIs 10370017611 58160045107030 10370017611 99482 fluvoxamine maleate FLUVOXAMINE MALEATE ER NR NPD ANTIDEPRESSANTS, SSRIs 13107000501 58160020100310 13107000501 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13107000505 58160020100310 13107000505 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13107000601 58160020100320 13107000601 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13107000605 58160020100320 13107000605 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13107000701 58160020100340 13107000701 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13107000705 58160020100340 13107000705 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13107015405 58160060000310 13107015405 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13107015430 58160060000310 13107015430 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13107015490 58160060000310 13107015490 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13107015505 58160060000320 13107015505 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13107015530 58160060000320 13107015530 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13107015590 58160060000320 13107015590 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13107015599 58160060000320 13107015599 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13107015605 58160060000330 13107015605 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13107015630 58160060000330 13107015630 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13107015690 58160060000330 13107015690 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13107015699 58160060000330 13107015699 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13107015705 58160060000340 13107015705 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13107015730 58160060000340 13107015730 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13107015790 58160060000340 13107015790 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13107015799 58160060000340 13107015799 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13668000901 58160020100310 13668000901 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13668000905 58160020100310 13668000905 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13668000909 58160020100310 13668000909 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13668000930 58160020100310 13668000930 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13668001001 58160020100320 13668001001 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13668001005 58160020100320 13668001005 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13668001006 58160020100320 13668001006 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13668001030 58160020100320 13668001030 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13668001101 58160020100340 13668001101 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13668001105 58160020100340 13668001105 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13668001108 58160020100340 13668001108 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13668001130 58160020100340 13668001130 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 13668013501 58160034100310 13668013501 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 13668013505 58160034100310 13668013505 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 13668013510 58160034100310 13668013510 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 13668013601 58160034100320 13668013601 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 13668013605 58160034100320 13668013605 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 13668013610 58160034100320 13668013610 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 13668013701 58160034100330 13668013701 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL

5/17/2019 15 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, SSRIs 13668013705 58160034100330 13668013705 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 13668013710 58160034100330 13668013710 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 13668044330 62206040000310 13668044330 16356 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13668047330 62206040000320 13668047330 16359 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 13668047391 62206040000320 13668047391 16359 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714035101 58160040000110 16714035101 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714035201 58160040000120 16714035201 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714035301 58160040000140 16714035301 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714060101 58160070101320 16714060101 16376 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714060102 58160070101320 16714060102 16376 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714061101 58160070100305 16714061101 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714061104 58160070100305 16714061104 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714061105 58160070100305 16714061105 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714061106 58160070100305 16714061106 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714061201 58160070100310 16714061201 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714061204 58160070100310 16714061204 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714061205 58160070100310 16714061205 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714061206 58160070100310 16714061206 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714061301 58160070100320 16714061301 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714061304 58160070100320 16714061304 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714061305 58160070100320 16714061305 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16714061306 58160070100320 16714061306 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16729016801 58160034100310 16729016801 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 16729016817 58160034100310 16729016817 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 16729016901 58160034100320 16729016901 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 16729016917 58160034100320 16729016917 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 16729017001 58160034100330 16729017001 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 16729017017 58160034100330 16729017017 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 16729021510 58160070100305 16729021510 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16729021515 58160070100305 16729021515 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16729021516 58160070100305 16729021516 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16729021615 58160070100310 16729021615 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16729021616 58160070100310 16729021616 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16729021715 58160070100320 16729021715 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 16729021716 58160070100320 16729021716 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 31722020601 58160020100310 31722020601 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 31722020605 58160020100310 31722020605 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 31722020701 58160020100320 31722020701 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 31722020705 58160020100320 31722020705 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 31722020710 58160020100320 31722020710 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 31722020801 58160020100340 31722020801 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 31722020805 58160020100340 31722020805 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 31722021205 58160070100305 31722021205 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 31722021230 58160070100305 31722021230 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 31722021290 58160070100305 31722021290 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 31722021305 58160070100310 31722021305 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 31722021330 58160070100310 31722021330 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 31722021390 58160070100310 31722021390 16374 sertraline HCl SERTRALINE HCL NR PDL

5/17/2019 16 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, SSRIs 31722021405 58160070100320 31722021405 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 31722021430 58160070100320 31722021430 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 31722024990 58160034100310 31722024990 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 31722025090 58160034100320 31722025090 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 31722025190 58160034100330 31722025190 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 31722056424 58160020102020 31722056424 16344 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 31722056924 58160034102020 31722056924 19035 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 31722090301 58160040000110 31722090301 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 31722090305 58160040000110 31722090305 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 31722090330 58160040000110 31722090330 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 31722090401 58160040000120 31722090401 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 31722090405 58160040000120 31722090405 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 31722090410 58160040000120 31722090410 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 31722090501 58160040000140 31722090501 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 33342003611 58160034100310 33342003611 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 33342003711 58160034100320 33342003711 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 33342003811 58160034100330 33342003811 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 33342005328 58160034102020 33342005328 19035 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 42543072501 58160040000110 42543072501 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 42543072510 58160040000110 42543072510 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 42543072530 58160040000110 42543072530 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 42543072601 58160040000120 42543072601 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 42543072605 58160040000120 42543072605 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 42543072610 58160040000120 42543072610 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 42543072701 58160040000140 42543072701 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 42543072705 58160040000140 42543072705 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 42543072730 58160040000140 42543072730 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 42806001901 58160020100310 42806001901 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 42806001910 58160020100310 42806001910 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 42806002001 58160020100320 42806002001 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 42806002010 58160020100320 42806002010 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 42806002101 58160020100340 42806002101 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 42806002110 58160020100340 42806002110 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 42858070303 58160060007520 42858070303 17078 paroxetine HCl PAROXETINE ER NR NPD ANTIDEPRESSANTS, SSRIs 42858070503 58160060007530 42858070503 17077 paroxetine HCl PAROXETINE ER NR NPD ANTIDEPRESSANTS, SSRIs 42858070703 58160060007540 42858070703 17079 paroxetine HCl PAROXETINE ER NR NPD ANTIDEPRESSANTS, SSRIs 43547028010 58160034100310 43547028010 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 43547028011 58160034100310 43547028011 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 43547028110 58160034100320 43547028110 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 43547028111 58160034100320 43547028111 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 43547028210 58160034100330 43547028210 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 43547028211 58160034100330 43547028211 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 43547034703 58160060000310 43547034703 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43547034709 58160060000310 43547034709 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43547034711 58160060000310 43547034711 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43547034750 58160060000310 43547034750 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43547034803 58160060000320 43547034803 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43547034809 58160060000320 43547034809 16366 paroxetine HCl PAROXETINE HCL NR PDL

5/17/2019 17 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, SSRIs 43547034811 58160060000320 43547034811 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43547034850 58160060000320 43547034850 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43547034903 58160060000330 43547034903 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43547034909 58160060000330 43547034909 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43547034911 58160060000330 43547034911 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43547034950 58160060000330 43547034950 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43547035003 58160060000340 43547035003 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43547035009 58160060000340 43547035009 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43547035011 58160060000340 43547035011 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43547035050 58160060000340 43547035050 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43547040903 62226060300110 43547040903 34876 paroxetine mesylate PAROXETINE MESYLATE NR NPD ANTIDEPRESSANTS, SSRIs 43598056601 58160040000320 43598056601 16359 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43598056630 58160040000320 43598056630 16359 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 43598063230 58160040000360 43598063230 30817 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 47781060030 58160040000360 47781060030 30817 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 49884033501 58160040000310 49884033501 16356 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 49884033511 58160040000310 49884033511 16356 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 49884033601 58160040000320 49884033601 16359 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 49884033611 58160040000320 49884033611 16359 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 49884046811 58160040000360 49884046811 30817 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 49884087201 58160040000140 49884087201 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 49884087205 58160040000140 49884087205 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 49884087211 58160040000140 49884087211 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 49909000530 58160040000360 49909000530 30817 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 50111064701 58160040000110 50111064701 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 50111064702 58160040000110 50111064702 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 50111064703 58160040000110 50111064703 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 50111064801 58160040000120 50111064801 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 50111064802 58160040000120 50111064802 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 50111064803 58160040000120 50111064803 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 50111064844 58160040000120 50111064844 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 51079054320 58160034100320 51079054320 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 51079054420 58160034100330 51079054420 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 51079077420 58160060000320 51079077420 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 51079099220 58160045100320 51079099220 16348 fluvoxamine maleate FLUVOXAMINE MALEATE NR PDL ANTIDEPRESSANTS, SSRIs 51079099320 58160045100330 51079099320 16349 fluvoxamine maleate FLUVOXAMINE MALEATE NR PDL ANTIDEPRESSANTS, SSRIs 52427057630 58160040000360 52427057630 30817 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 52817014050 58160060000310 52817014050 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 52817014090 58160060000310 52817014090 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 52817014190 58160060000320 52817014190 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 52817014250 58160060000330 52817014250 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 52817014290 58160060000330 52817014290 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 52817014390 58160060000340 52817014390 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 54458088910 58160020100340 54458088910 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 54458088916 58160020100340 54458088916 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 54458089110 58160034100330 54458089110 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 54458089116 58160034100330 54458089116 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 54458089210 58160034100320 54458089210 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL

5/17/2019 18 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, SSRIs 54458089216 58160034100320 54458089216 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 54458098010 58160020100320 54458098010 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 54458098016 58160020100320 54458098016 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 54458098112 58160020100310 54458098112 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 54458098116 58160020100310 54458098116 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 54458098810 58160060000330 54458098810 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 54458098816 58160060000330 54458098816 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 54458098910 58160060000320 54458098910 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 54458098916 58160060000320 54458098916 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 54458099010 58160060000310 54458099010 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 54458099016 58160060000310 54458099016 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 54766020101 58160060300310 54766020101 20854 paroxetine mesylate PEXEVA NR NPD ANTIDEPRESSANTS, SSRIs 54766020201 58160060300320 54766020201 20855 paroxetine mesylate PEXEVA NR NPD ANTIDEPRESSANTS, SSRIs 54766020301 58160060300330 54766020301 20856 paroxetine mesylate PEXEVA NR NPD ANTIDEPRESSANTS, SSRIs 54766020401 58160060300340 54766020401 20857 paroxetine mesylate PEXEVA NR NPD ANTIDEPRESSANTS, SSRIs 54766090753 62226060300110 54766090753 34876 paroxetine mesylate BRISDELLE NR NPD ANTIDEPRESSANTS, SSRIs 54838052340 58160040002020 54838052340 16357 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 54838054070 58160020102020 54838054070 16344 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 54838055170 58160034102020 54838055170 19035 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 54879001101 58160034100330 54879001101 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 55111014901 58160040000140 55111014901 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 55111015001 58160040000310 55111015001 16356 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 55111015010 58160040000310 55111015010 16356 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 55111015030 58160040000310 55111015030 16356 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 55111028448 58160040006530 55111028448 12929 fluoxetine HCl FLUOXETINE DR NR NPD ANTIDEPRESSANTS, SSRIs 55111034201 58160020100310 55111034201 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 55111034301 58160020100320 55111034301 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 55111034305 58160020100320 55111034305 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 57664050818 58160020100320 57664050818 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 57664050913 58160020100340 57664050913 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 57664050918 58160020100340 57664050918 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 57664050988 58160020100340 57664050988 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 59746027901 58160034100310 59746027901 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 59746028001 58160034100320 59746028001 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 59746028101 58160034100330 59746028101 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 59746045710 58160060000310 59746045710 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59746045730 58160060000310 59746045730 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59746045790 58160060000310 59746045790 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59746045810 58160060000320 59746045810 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59746045830 58160060000320 59746045830 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59746045890 58160060000320 59746045890 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59746045910 58160060000330 59746045910 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59746045930 58160060000330 59746045930 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59746046010 58160060000340 59746046010 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59746046030 58160060000340 59746046030 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59746046090 58160060000340 59746046090 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59746054301 58160020100310 59746054301 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 59746054305 58160020100310 59746054305 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL

5/17/2019 19 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, SSRIs 59746054401 58160020100320 59746054401 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 59746054405 58160020100320 59746054405 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 59746054601 58160020100340 59746054601 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 59746054605 58160020100340 59746054605 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 59762006701 58160070101320 59762006701 16376 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59762490001 58160070100310 59762490001 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59762490002 58160070100310 59762490002 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59762490003 58160070100310 59762490003 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59762490004 58160070100310 59762490004 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59762490005 58160070100310 59762490005 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59762491001 58160070100320 59762491001 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59762491002 58160070100320 59762491002 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59762491003 58160070100320 59762491003 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59762491004 58160070100320 59762491004 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59762491005 58160070100320 59762491005 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59762494001 58160070101320 59762494001 16376 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 59762496001 58160070100305 59762496001 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 60505008301 58160060000320 60505008301 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 60505008302 58160060000320 60505008302 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 60505008304 58160060000320 60505008304 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 60505008401 58160060000330 60505008401 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 60505008402 58160060000330 60505008402 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 60505008404 58160060000330 60505008404 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 60505009701 58160060000310 60505009701 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 60505009702 58160060000310 60505009702 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 60505009704 58160060000310 60505009704 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 60505010101 58160060000340 60505010101 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 60505010102 58160060000340 60505010102 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 60505010104 58160060000340 60505010104 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 60505016401 58160045100310 60505016401 16347 fluvoxamine maleate FLUVOXAMINE MALEATE NR PDL ANTIDEPRESSANTS, SSRIs 60505016501 58160045100320 60505016501 16348 fluvoxamine maleate FLUVOXAMINE MALEATE NR PDL ANTIDEPRESSANTS, SSRIs 60505016601 58160045100330 60505016601 16349 fluvoxamine maleate FLUVOXAMINE MALEATE NR PDL ANTIDEPRESSANTS, SSRIs 60505040205 58160060001820 60505040205 16369 paroxetine HCl PAXIL NR NPD ANTIDEPRESSANTS, SSRIs 60505251801 58160020100310 60505251801 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 60505251804 58160020100310 60505251804 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 60505251901 58160020100320 60505251901 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 60505251903 58160020100320 60505251903 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 60505251904 58160020100320 60505251904 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 60505251908 58160020100320 60505251908 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 60505252001 58160020100340 60505252001 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 60505252004 58160020100340 60505252004 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 60505278001 58160034100310 60505278001 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 60505278008 58160034100310 60505278008 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 60505278101 58160034100320 60505278101 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 60505278201 58160034100330 60505278201 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 60505278208 58160034100330 60505278208 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 60505366303 58160060000310 60505366303 16364 paroxetine HCl PAXIL NR NPD ANTIDEPRESSANTS, SSRIs 60505366403 58160060000320 60505366403 16366 paroxetine HCl PAXIL NR NPD

5/17/2019 20 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, SSRIs 60505366503 58160060000330 60505366503 16367 paroxetine HCl PAXIL NR NPD ANTIDEPRESSANTS, SSRIs 60505366603 58160060000340 60505366603 16368 paroxetine HCl PAXIL NR NPD ANTIDEPRESSANTS, SSRIs 60505366803 58160060007520 60505366803 17078 paroxetine HCl PAXIL CR NR NPD ANTIDEPRESSANTS, SSRIs 60505366903 58160060007530 60505366903 17077 paroxetine HCl PAXIL CR NR NPD ANTIDEPRESSANTS, SSRIs 60505367003 58160060007540 60505367003 17079 paroxetine HCl PAXIL CR NR NPD ANTIDEPRESSANTS, SSRIs 60505367303 58160060007520 60505367303 17078 paroxetine HCl PAROXETINE CR NR NPD ANTIDEPRESSANTS, SSRIs 60505367403 58160060007530 60505367403 17077 paroxetine HCl PAROXETINE CR NR NPD ANTIDEPRESSANTS, SSRIs 60505367503 58160060007540 60505367503 17079 paroxetine HCl PAROXETINE CR NR NPD ANTIDEPRESSANTS, SSRIs 62175047032 58160060007520 62175047032 17078 paroxetine HCl PAROXETINE ER NR NPD ANTIDEPRESSANTS, SSRIs 62175047132 58160060007530 62175047132 17077 paroxetine HCl PAROXETINE ER NR NPD ANTIDEPRESSANTS, SSRIs 62175047232 58160060007540 62175047232 17079 paroxetine HCl PAROXETINE ER NR NPD ANTIDEPRESSANTS, SSRIs 62332002231 58160040000110 62332002231 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 62332002291 58160040000110 62332002291 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 62332002331 58160040000120 62332002331 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 62332002391 58160040000120 62332002391 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 62332002430 58160040000140 62332002430 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 62332002431 58160040000140 62332002431 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 62332002491 58160040000140 62332002491 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 62332024230 58160040000310 62332024230 16356 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 62332024231 58160040000310 62332024231 16356 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 62332024330 58160040000320 62332024330 16359 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 62332024331 58160040000320 62332024331 16359 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 62559015801 58160045100310 62559015801 16347 fluvoxamine maleate FLUVOXAMINE MALEATE NR PDL ANTIDEPRESSANTS, SSRIs 62559015901 58160045100320 62559015901 16348 fluvoxamine maleate FLUVOXAMINE MALEATE NR PDL ANTIDEPRESSANTS, SSRIs 62559016001 58160045100330 62559016001 16349 fluvoxamine maleate FLUVOXAMINE MALEATE NR PDL ANTIDEPRESSANTS, SSRIs 63304063201 58160040000140 63304063201 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 63304063230 58160040000140 63304063230 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 63739096310 58160060000320 63739096310 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 64980040906 58160070101320 64980040906 16376 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65162005203 58160020100310 65162005203 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 65162005210 58160020100310 65162005210 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 65162005250 58160020100310 65162005250 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 65162005303 58160020100320 65162005303 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 65162005310 58160020100320 65162005310 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 65162005350 58160020100320 65162005350 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 65162005403 58160020100340 65162005403 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 65162005410 58160020100340 65162005410 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 65162005450 58160020100340 65162005450 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 65162070588 58160034102020 65162070588 19035 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 65862000501 58160020100310 65862000501 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 65862000505 58160020100310 65862000505 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 65862000601 58160020100320 65862000601 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 65862000605 58160020100320 65862000605 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 65862000701 58160020100340 65862000701 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 65862000705 58160020100340 65862000705 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 65862001101 58160070100305 65862001101 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862001105 58160070100305 65862001105 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862001130 58160070100305 65862001130 16373 sertraline HCl SERTRALINE HCL NR PDL

5/17/2019 21 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, SSRIs 65862001201 58160070100310 65862001201 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862001205 58160070100310 65862001205 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862001230 58160070100310 65862001230 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862001301 58160070100320 65862001301 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862001305 58160070100320 65862001305 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862001330 58160070100320 65862001330 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862007424 58160020102020 65862007424 16344 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 65862015505 58160060000320 65862015505 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862015530 58160060000320 65862015530 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862015599 58160060000320 65862015599 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862019201 58160040000110 65862019201 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862019205 58160040000110 65862019205 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862019299 58160040000110 65862019299 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862019301 58160040000120 65862019301 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862019305 58160040000120 65862019305 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862019399 58160040000120 65862019399 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862019401 58160040000140 65862019401 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862019405 58160040000140 65862019405 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862019430 58160040000140 65862019430 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862019499 58160040000140 65862019499 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 65862037301 58160034100310 65862037301 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 65862037305 58160034100310 65862037305 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 65862037401 58160034100320 65862037401 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 65862037405 58160034100320 65862037405 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 65862037501 58160034100330 65862037501 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 65862037505 58160034100330 65862037505 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 68001012900 58160040000140 68001012900 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68001012903 58160040000140 68001012903 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68001012904 58160040000140 68001012904 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68001019500 58160034100310 68001019500 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 68001019600 58160034100320 68001019600 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 68001019603 58160034100320 68001019603 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 68001019700 58160034100330 68001019700 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 68001019703 58160034100330 68001019703 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 68084010101 58160040000140 68084010101 16355 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68084018001 58160070100305 68084018001 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68084018101 58160070100310 68084018101 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68084018201 58160070100320 68084018201 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68084060501 58160040000120 68084060501 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68084060511 58160040000120 68084060511 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68084061701 58160034100320 68084061701 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 68084061801 58160034100330 68084061801 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 68084074401 58160020100320 68084074401 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 68180013501 58160034100320 68180013501 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 68180013601 58160034100330 68180013601 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 68180013701 58160034100310 68180013701 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 68180035103 58160070100305 68180035103 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68180035106 58160070100305 68180035106 16373 sertraline HCl SERTRALINE HCL NR PDL

5/17/2019 22 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, SSRIs 68180035109 58160070100305 68180035109 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68180035202 58160070100310 68180035202 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68180035205 58160070100310 68180035205 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68180035206 58160070100310 68180035206 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68180035209 58160070100310 68180035209 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68180035302 58160070100320 68180035302 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68180035305 58160070100320 68180035305 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68180035306 58160070100320 68180035306 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68180035309 58160070100320 68180035309 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68180064506 58160060007540 68180064506 17079 paroxetine HCl PAROXETINE ER NR NPD ANTIDEPRESSANTS, SSRIs 68180064606 58160060007530 68180064606 17077 paroxetine HCl PAROXETINE ER NR NPD ANTIDEPRESSANTS, SSRIs 68180064706 58160060007520 68180064706 17078 paroxetine HCl PAROXETINE ER NR NPD ANTIDEPRESSANTS, SSRIs 68382000105 58160060000340 68382000105 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68382000106 58160060000340 68382000106 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68382000116 58160060000340 68382000116 16368 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68382009705 58160060000310 68382009705 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68382009706 58160060000310 68382009706 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68382009710 58160060000310 68382009710 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68382009716 58160060000310 68382009716 16364 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68382009801 58160060000320 68382009801 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68382009805 58160060000320 68382009805 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68382009806 58160060000320 68382009806 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68382009810 58160060000320 68382009810 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68382009816 58160060000320 68382009816 16366 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68382009905 58160060000330 68382009905 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68382009906 58160060000330 68382009906 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68382009910 58160060000330 68382009910 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68382009916 58160060000330 68382009916 16367 paroxetine HCl PAROXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68645013054 58160040000120 68645013054 16354 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68645013154 58160040000110 68645013154 16353 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68645048870 58160070100310 68645048870 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68645048970 58160070100320 68645048970 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68645051454 58160020100340 68645051454 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 68645051954 58160034100320 68645051954 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 68645052054 58160034100330 68645052054 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 68645052154 58160070100305 68645052154 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68645052254 58160070100310 68645052254 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68645052354 58160070100320 68645052354 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 68645055954 58160020100340 68645055954 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 68645056954 58160020100310 68645056954 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 68645057054 58160020100320 68645057054 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 68645057154 58160020100340 68645057154 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 68968202001 58160060300320 68968202001 20855 paroxetine mesylate PEXEVA NR NPD ANTIDEPRESSANTS, SSRIs 68968203001 58160060300330 68968203001 20856 paroxetine mesylate PEXEVA NR NPD ANTIDEPRESSANTS, SSRIs 68968907503 62226060300110 68968907503 34876 paroxetine mesylate BRISDELLE NR NPD ANTIDEPRESSANTS, SSRIs 69097082207 58160020100310 69097082207 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 69097082212 58160020100310 69097082212 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 69097082307 58160020100320 69097082307 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL

5/17/2019 23 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ANTIDEPRESSANTS, SSRIs 69097082312 58160020100320 69097082312 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 69097082407 58160020100340 69097082407 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 69097082412 58160020100340 69097082412 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 69097083302 58160070100305 69097083302 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 69097083305 58160070100305 69097083305 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 69097083312 58160070100305 69097083312 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 69097083402 58160070100310 69097083402 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 69097083412 58160070100310 69097083412 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 69097083502 58160070100320 69097083502 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 69097083512 58160070100320 69097083512 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 69097084705 58160034100310 69097084705 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 69097084805 58160034100320 69097084805 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 69097084905 58160034100330 69097084905 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 75834014830 58160040000360 75834014830 30817 fluoxetine HCl FLUOXETINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282020610 58160020100310 76282020610 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 76282020690 58160020100310 76282020690 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 76282020710 58160020100320 76282020710 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 76282020790 58160020100320 76282020790 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 76282020810 58160020100340 76282020810 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 76282020890 58160020100340 76282020890 16343 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 76282021201 58160070100305 76282021201 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282021205 58160070100305 76282021205 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282021218 58160070100305 76282021218 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282021230 58160070100305 76282021230 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282021260 58160070100305 76282021260 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282021290 58160070100305 76282021290 16373 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282021301 58160070100310 76282021301 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282021305 58160070100310 76282021305 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282021318 58160070100310 76282021318 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282021330 58160070100310 76282021330 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282021390 58160070100310 76282021390 16374 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282021401 58160070100320 76282021401 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282021405 58160070100320 76282021405 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282021418 58160070100320 76282021418 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282021430 58160070100320 76282021430 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282021460 58160070100320 76282021460 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282021490 58160070100320 76282021490 16375 sertraline HCl SERTRALINE HCL NR PDL ANTIDEPRESSANTS, SSRIs 76282024910 58160034100310 76282024910 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 76282024930 58160034100310 76282024930 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 76282024990 58160034100310 76282024990 18975 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 76282025010 58160034100320 76282025010 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 76282025030 58160034100320 76282025030 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 76282025090 58160034100320 76282025090 17851 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 76282025110 58160034100330 76282025110 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 76282025130 58160034100330 76282025130 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 76282025190 58160034100330 76282025190 17987 escitalopram oxalate ESCITALOPRAM OXALATE NR PDL ANTIDEPRESSANTS, SSRIs 76282062810 58160020100310 76282062810 16345 citalopram hydrobromide CITALOPRAM HBR NR PDL ANTIDEPRESSANTS, SSRIs 76282062910 58160020100320 76282062910 16342 citalopram hydrobromide CITALOPRAM HBR NR PDL

5/17/2019 24 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00002418402 30053060100320 00002418402 59011 raloxifene HCl EVISTA NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00002418407 30053060100320 00002418407 59011 raloxifene HCl EVISTA NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00002418430 30053060100320 00002418430 59011 raloxifene HCl EVISTA NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00002840001 30044070002020 00002840001 14404 teriparatide FORTEO NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00004018682 30042048100360 00004018682 24444 ibandronate sodium BONIVA NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00004018683 30042048100360 00004018683 24444 ibandronate sodium BONIVA NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00006003144 30042010100370 00006003144 85361 alendronate sodium FOSAMAX NR NPD BONE RESORPTION SUPPRESSION alendronate sodium/vitamin AND RELATED AGENTS 00006027044 30042010200380 00006027044 98437 D3 FOSAMAX PLUS D NR NPD BONE RESORPTION SUPPRESSION alendronate sodium/vitamin AND RELATED AGENTS 00006071044 30042010200370 00006071044 24481 D3 FOSAMAX PLUS D NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00093309829 30042065100330 00093309829 17378 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00093309844 30042065100330 00093309844 17378 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00093309956 30042065100305 00093309956 92238 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00093514056 30042010100305 00093514056 21682 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00093514101 30042010100310 00093514101 21680 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00093514156 30042010100310 00093514156 21680 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00093517129 30042010100370 00093517129 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00093517144 30042010100370 00093517144 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00093517244 30042010100335 00093517244 12389 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00093729001 30053060100320 00093729001 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00093729056 30053060100320 00093729056 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00093777179 30042065100380 00093777179 99637 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00115167601 30042010100305 00115167601 21682 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00115167608 30042010100305 00115167608 21682 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00115167801 30042010100310 00115167801 21680 alendronate sodium ALENDRONATE SODIUM NR PDL

5/17/2019 25 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00115167808 30042010100310 00115167808 21680 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00115167926 30042010100335 00115167926 12389 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00115167934 30042010100335 00115167934 12389 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00115168008 30042010100340 00115168008 21681 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00115168126 30042010100370 00115168126 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00115168134 30042010100370 00115168134 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00178010102 30042010100870 00178010102 33019 alendronate sodium BINOSTO NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00378328691 30042040100305 00378328691 26420 etidronate disodium ETIDRONATE DISODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00378328891 30042040100310 00378328891 26421 etidronate disodium ETIDRONATE DISODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00378356601 30042010100305 00378356601 21682 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00378356701 30042010100310 00378356701 21680 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00378356899 30042010100335 00378356899 12389 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00378356999 30042010100370 00378356999 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00378521553 30042048100360 00378521553 24444 ibandronate sodium IBANDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00430047015 30042065100320 00430047015 60511 risedronate sodium ACTONEL NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00430047115 30042065100305 00430047115 92238 risedronate sodium ACTONEL NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00430047203 30042065100330 00430047203 17378 risedronate sodium ACTONEL NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00430047207 30042065100330 00430047207 17378 risedronate sodium ACTONEL NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00430047801 30042065100380 00430047801 99637 risedronate sodium ACTONEL NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00430047802 30042065100380 00430047802 99637 risedronate sodium ACTONEL NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00430097903 30042065100635 00430097903 29223 risedronate sodium ATELVIA NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00591204403 30042065100380 00591204403 99637 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00591204454 30042065100380 00591204454 99637 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00591207504 30042065100330 00591207504 17378 risedronate sodium RISEDRONATE SODIUM NR NPD

5/17/2019 26 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00591207539 30042065100330 00591207539 17378 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00591210230 30042065100305 00591210230 92238 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00591210930 30042065100320 00591210930 60511 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00591236701 30053060100320 00591236701 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00591236730 30053060100320 00591236730 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00591377031 30042048100360 00591377031 24444 ibandronate sodium IBANDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 00591387604 30042065100635 00591387604 29223 risedronate sodium RISEDRONATE SODIUM DR NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 16252059902 30042010100335 16252059902 12389 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 16252059944 30042010100335 16252059944 12389 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 16252060102 30042010100370 16252060102 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 16252060144 30042010100370 16252060144 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 16714063101 30042010100310 16714063101 21680 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 16714063102 30042010100310 16714063102 21680 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 16714063201 30042010100335 16714063201 12389 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 16714063202 30042010100335 16714063202 12389 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 16714063301 30042010100370 16714063301 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 16714063302 30042010100370 16714063302 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 31722025630 30053060100320 31722025630 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 33342010707 30042065100305 33342010707 92238 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 33342010937 30042065100330 33342010937 17378 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 33342010950 30042065100330 33342010950 17378 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 43598050501 30053060100320 43598050501 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 43598050510 30053060100320 43598050510 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 43598050530 30053060100320 43598050530 59011 raloxifene HCl RALOXIFENE HCL NR PDL

5/17/2019 27 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

BONE RESORPTION SUPPRESSION AND RELATED AGENTS 47335063768 30042010100335 47335063768 12389 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 47335063868 30042010100370 47335063868 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 47335066862 30042065100330 47335066862 17378 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 47335066868 30042065100330 47335066868 17378 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 47335092860 30042065100380 47335092860 99637 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 47781010307 30042048100360 47781010307 24444 ibandronate sodium IBANDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 47781010333 30042048100360 47781010333 24444 ibandronate sodium IBANDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 49884016111 30043020002080 49884016111 23281 calcitonin,salmon,synthetic CALCITONIN-SALMON NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 51079094201 30042010100370 51079094201 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 51079094205 30042010100370 51079094205 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 51224030110 30042010102020 51224030110 21109 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 55111057503 30042048100360 55111057503 24444 ibandronate sodium IBANDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 55111057511 30042048100360 55111057511 24444 ibandronate sodium IBANDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 55513071001 3004453000E520 55513071001 28656 denosumab PROLIA NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 59746024202 30042010100335 59746024202 12389 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 59746024402 30042010100370 59746024402 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 59762040704 30042065100635 59762040704 29223 risedronate sodium RISEDRONATE SODIUM DR NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 60505082306 30043020002080 60505082306 23281 calcitonin,salmon,synthetic CALCITONIN-SALMON NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 60505279500 30042048100360 60505279500 24444 ibandronate sodium IBANDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 60505309702 30042065100380 60505309702 99637 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 60505309704 30042065100380 60505309704 99637 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 60505316500 30042065100330 60505316500 17378 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 64980034001 30042010100310 64980034001 21680 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 64980034114 30042010100335 64980034114 12389 alendronate sodium ALENDRONATE SODIUM NR PDL

5/17/2019 28 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

BONE RESORPTION SUPPRESSION AND RELATED AGENTS 64980034214 30042010100370 64980034214 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 65162005703 30053060100320 65162005703 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 65162005709 30053060100320 65162005709 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 65162005710 30053060100320 65162005710 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 65162005711 30053060100320 65162005711 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 65862023703 30042048100360 65862023703 24444 ibandronate sodium IBANDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 65862032804 30042010100335 65862032804 12389 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 65862032904 30042010100370 65862032904 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 65862087003 30042065100380 65862087003 99637 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 65862087011 30042065100380 65862087011 99637 risedronate sodium RISEDRONATE SODIUM NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 66993041702 30053060100320 66993041702 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 66993041730 30053060100320 66993041730 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 66993066102 30053060100320 66993066102 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 66993066130 30053060100320 66993066130 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 68462039301 30053060100320 68462039301 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 68462039330 30053060100320 68462039330 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 69097022316 30042010100335 69097022316 12389 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 69097022376 30042010100335 69097022376 12389 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 69097022416 30042010100370 69097022416 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 69097022476 30042010100370 69097022476 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 69097082502 30053060100320 69097082502 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 69097082507 30053060100320 69097082507 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 69097082515 30053060100320 69097082515 59011 raloxifene HCl RALOXIFENE HCL NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 69543013004 30042010100335 69543013004 12389 alendronate sodium ALENDRONATE SODIUM NR PDL

5/17/2019 29 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

BONE RESORPTION SUPPRESSION AND RELATED AGENTS 69543013012 30042010100335 69543013012 12389 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 69543013104 30042010100370 69543013104 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 69543013112 30042010100370 69543013112 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 69543013120 30042010100370 69543013120 85361 alendronate sodium ALENDRONATE SODIUM NR PDL BONE RESORPTION SUPPRESSION AND RELATED AGENTS 70539000102 3004400500D230 70539000102 43334 abaloparatide TYMLOS NR NPD BONE RESORPTION SUPPRESSION AND RELATED AGENTS 76439013004 30042010100335 76439013004 12389 alendronate sodium ALENDRONATE SODIUM NR PDL BRONCHODILATORS, BETA AGONIST 00378699052 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00378827064 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00591291923 24540 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 16252009722 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00078061915 44201042200120 00078061915 30184 indacaterol maleate ARCAPTA NEOHALER NPD NPD BRONCHODILATORS, BETA AGONIST 00085113201 44201010103410 00085113201 22913 albuterol sulfate PROVENTIL HFA PDL PDL BRONCHODILATORS, BETA AGONIST 00085113204 44201010103410 00085113204 22913 albuterol sulfate PROVENTIL HFA PDL PDL BRONCHODILATORS, BETA AGONIST 00093066116 44201010101205 00093066116 22780 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00093317431 44201010103410 00093317431 22913 albuterol sulfate ALBUTEROL SULFATE HFA NPD NPD BRONCHODILATORS, BETA AGONIST 00093414556 44201045102510 00093414556 15665 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00093414564 44201045102510 00093414564 15665 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00093414604 44201045102520 00093414604 24540 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00093414664 44201045102520 00093414664 24540 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00093414756 44201045102560 00093414756 23146 levalbuterol HCl LEVALBUTEROL CONCENTRATE NPD NPD BRONCHODILATORS, BETA AGONIST 00093414804 44201045102530 00093414804 24541 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00093414856 44201045102530 00093414856 24541 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00093414864 44201045102530 00093414864 24541 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00115261101 44201060200305 00115261101 20072 terbutaline sulfate TERBUTALINE SULFATE NPD NPD BRONCHODILATORS, BETA AGONIST 00115262201 44201060200310 00115262201 20071 terbutaline sulfate TERBUTALINE SULFATE NPD NPD BRONCHODILATORS, BETA AGONIST 00115993078 44201045102510 00115993078 15665 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00115993178 44201045102520 00115993178 24540 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00115993278 44201045102530 00115993278 24541 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00173052000 44201058108020 00173052000 64012 salmeterol xinafoate SEREVENT DISKUS PDL PDL BRONCHODILATORS, BETA AGONIST 00173052100 44201058108020 00173052100 64012 salmeterol xinafoate SEREVENT DISKUS PDL PDL BRONCHODILATORS, BETA AGONIST 00173068220 44201010103410 00173068220 22913 albuterol sulfate VENTOLIN HFA PDL PDL BRONCHODILATORS, BETA AGONIST 00173068221 44201010103410 00173068221 22913 albuterol sulfate VENTOLIN HFA PDL PDL BRONCHODILATORS, BETA AGONIST 00173068224 44201010103410 00173068224 22913 albuterol sulfate VENTOLIN HFA PDL PDL BRONCHODILATORS, BETA AGONIST 00378025501 44201010100305 00378025501 20100 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00378057201 44201010100310 00378057201 20101 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00378412201 44201010107410 00378412201 24858 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00378412401 44201010107420 00378412401 24859 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00378699152 44201010102555 00378699152 14633 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00378699252 44201010102560 00378699252 14634 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00378699298 44201010102560 00378699298 14634 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00378699393 44201045102560 00378699393 23146 levalbuterol HCl LEVALBUTEROL CONCENTRATE NPD NPD BRONCHODILATORS, BETA AGONIST 00378827052 44201010102515 00378827052 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL

5/17/2019 30 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

BRONCHODILATORS, BETA AGONIST 00378827055 44201010102515 00378827055 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00378827091 44201010102515 00378827091 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00378827093 44201010102515 00378827093 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00378968044 44201045102510 00378968044 15665 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00378968144 44201045102520 00378968144 24540 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00378968244 44201045102530 00378968244 24541 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00378969052 44201045102510 00378969052 15665 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00378969152 44201045102520 00378969152 24540 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00378969252 44201045102530 00378969252 24541 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00472082516 44201010101205 00472082516 22780 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00487030101 44201010102555 00487030101 14633 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00487950101 44201010102515 00487950101 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00487950102 44201010102515 00487950102 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00487950103 44201010102515 00487950103 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00487950125 44201010102515 00487950125 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00487950160 44201010102515 00487950160 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00487990102 44201010102520 00487990102 22697 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00487990130 44201010102520 00487990130 22697 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00487990401 44201010102560 00487990401 14634 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00487990425 44201010102560 00487990425 14634 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00527131101 44201060200310 00527131101 20071 terbutaline sulfate TERBUTALINE SULFATE NPD NPD BRONCHODILATORS, BETA AGONIST 00527131801 44201060200305 00527131801 20072 terbutaline sulfate TERBUTALINE SULFATE NPD NPD BRONCHODILATORS, BETA AGONIST 00591273623 44201045102510 00591273623 15665 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00591273723 44201045102520 00591273723 24540 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00591273823 44201045102530 00591273823 24541 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 00591292754 44201045503220 00591292754 24422 levalbuterol tartrate LEVALBUTEROL TARTRATE HFA NPD NPD BRONCHODILATORS, BETA AGONIST 00591346753 44201010102555 00591346753 14633 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00591346853 44201010102560 00591346853 14634 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00591379730 44201010102515 00591379730 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00591379760 44201010102515 00591379760 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00591379783 44201010102515 00591379783 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00597019261 44201052203410 00597019261 36174 olodaterol HCl STRIVERDI RESPIMAT NPD NPD BRONCHODILATORS, BETA AGONIST 00781715529 44201010102515 00781715529 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00781715564 44201010102515 00781715564 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 00781715586 44201010102515 00781715586 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 17478017101 44201045102560 17478017101 23146 levalbuterol HCl XOPENEX CONCENTRATE NPD NPD BRONCHODILATORS, BETA AGONIST 17478017130 44201045102560 17478017130 23146 levalbuterol HCl XOPENEX CONCENTRATE NPD NPD BRONCHODILATORS, BETA AGONIST 17478017224 44201045102510 17478017224 15665 levalbuterol HCl XOPENEX NPD NPD BRONCHODILATORS, BETA AGONIST 17478017324 44201045102520 17478017324 24540 levalbuterol HCl XOPENEX NPD NPD BRONCHODILATORS, BETA AGONIST 17478017424 44201045102530 17478017424 24541 levalbuterol HCl XOPENEX NPD NPD BRONCHODILATORS, BETA AGONIST 24208034720 44201010102520 24208034720 41680 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 43598041025 44201045102520 43598041025 24540 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 49502060530 44201027102520 49502060530 98776 formoterol fumarate PERFOROMIST NPD NPD BRONCHODILATORS, BETA AGONIST 49502060561 44201027102520 49502060561 98776 formoterol fumarate PERFOROMIST NPD NPD BRONCHODILATORS, BETA AGONIST 49884025801 44201050200305 49884025801 19730 metaproterenol sulfate METAPROTERENOL SULFATE NPD NPD BRONCHODILATORS, BETA AGONIST 49884025901 44201050200310 49884025901 19731 metaproterenol sulfate METAPROTERENOL SULFATE NPD NPD BRONCHODILATORS, BETA AGONIST 50383074016 44201010101205 50383074016 22780 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 50383074120 44201010102520 50383074120 41680 albuterol sulfate ALBUTEROL SULFATE PDL PDL

5/17/2019 31 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

BRONCHODILATORS, BETA AGONIST 53489017601 44201010100305 53489017601 20100 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 53489017701 44201010100310 53489017701 20101 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 54838050780 44201050201205 54838050780 19720 metaproterenol sulfate METAPROTERENOL SULFATE NPD NPD BRONCHODILATORS, BETA AGONIST 59310057922 44201010103410 59310057922 22913 albuterol sulfate PROAIR HFA PDL PDL BRONCHODILATORS, BETA AGONIST 59310058020 44201010108020 59310058020 38212 albuterol sulfate PROAIR RESPICLICK NPD NPD BRONCHODILATORS, BETA AGONIST 60687039583 44201010102515 60687039583 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 62559072101 44201060200305 62559072101 20072 terbutaline sulfate TERBUTALINE SULFATE NPD NPD BRONCHODILATORS, BETA AGONIST 62559072201 44201060200310 62559072201 20071 terbutaline sulfate TERBUTALINE SULFATE NPD NPD BRONCHODILATORS, BETA AGONIST 63402051001 44201045503220 63402051001 24422 levalbuterol tartrate XOPENEX HFA NPD NPD BRONCHODILATORS, BETA AGONIST 63402067530 44201042200120 63402067530 30184 indacaterol maleate ARCAPTA NEOHALER NPD NPD BRONCHODILATORS, BETA AGONIST 63402091130 44201012102520 63402091130 97366 arformoterol tartrate BROVANA NPD NPD BRONCHODILATORS, BETA AGONIST 63402091164 44201012102520 63402091164 97366 arformoterol tartrate BROVANA NPD NPD BRONCHODILATORS, BETA AGONIST 64980044201 44201010100305 64980044201 20100 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 64980044301 44201010100310 64980044301 20101 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 65862094424 44201045102520 65862094424 24540 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 65862094524 44201045102530 65862094524 24541 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 66689010016 44201010101205 66689010016 22780 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 66993001968 44201010103410 66993001968 22913 albuterol sulfate ALBUTEROL SULFATE HFA NPD NPD BRONCHODILATORS, BETA AGONIST 66993002127 44201045102510 66993002127 15665 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 66993002227 44201045102520 66993002227 24540 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 66993002327 44201045102530 66993002327 24541 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 69238134401 44201010100305 69238134401 20100 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 69238134501 44201010100310 69238134501 20101 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 69543029010 44201010100305 69543029010 20100 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 69543029110 44201010100310 69543029110 20101 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 76204020001 44201010102515 76204020001 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 76204020025 44201010102515 76204020025 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 76204020030 44201010102515 76204020030 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 76204020060 44201010102515 76204020060 41681 albuterol sulfate ALBUTEROL SULFATE PDL PDL BRONCHODILATORS, BETA AGONIST 76204070001 44201045102510 76204070001 15665 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 76204070025 44201045102510 76204070025 15665 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 76204080001 44201045102520 76204080001 24540 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 76204080024 44201045102520 76204080024 24540 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 76204080025 44201045102520 76204080025 24540 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 76204090001 44201045102530 76204090001 24541 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 76204090012 44201045102530 76204090012 24541 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 76204090024 44201045102530 76204090024 24541 levalbuterol HCl LEVALBUTEROL HCL PDL PDL BRONCHODILATORS, BETA AGONIST 76204090025 44201045102530 76204090025 24541 levalbuterol HCl LEVALBUTEROL HCL PDL PDL COLONY STIMULATING FACTORS 63459091001 35575 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 63459091012 35575 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 63459091018 35575 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 63459091201 35576 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 63459091218 35576 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 00069029101 8240152010E520 00069029101 45103 filgrastim-aafi NIVESTYM NPD NPD COLONY STIMULATING FACTORS 00069029110 8240152010E520 00069029110 45103 filgrastim-aafi NIVESTYM NPD NPD COLONY STIMULATING FACTORS 00069029201 8240152010E530 00069029201 45104 filgrastim-aafi NIVESTYM NPD NPD COLONY STIMULATING FACTORS 00069029210 8240152010E530 00069029210 45104 filgrastim-aafi NIVESTYM NPD NPD COLONY STIMULATING FACTORS 00069029301 82401520102020 00069029301 45098 filgrastim-aafi NIVESTYM NPD NPD

5/17/2019 32 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

COLONY STIMULATING FACTORS 00069029310 82401520102020 00069029310 45098 filgrastim-aafi NIVESTYM NPD NPD COLONY STIMULATING FACTORS 00069029401 82401520102030 00069029401 45099 filgrastim-aafi NIVESTYM NPD NPD COLONY STIMULATING FACTORS 00069029410 82401520102030 00069029410 45099 filgrastim-aafi NIVESTYM NPD NPD COLONY STIMULATING FACTORS 55513019001 8240157000E520 55513019001 15666 pegfilgrastim NEULASTA PDL NPD COLONY STIMULATING FACTORS 55513019201 8240157000F820 55513019201 37706 pegfilgrastim NEULASTA PDL NPD COLONY STIMULATING FACTORS 55513020901 8240152000E550 55513020901 13308 filgrastim NEUPOGEN PDL PDL COLONY STIMULATING FACTORS 55513020910 8240152000E550 55513020910 13308 filgrastim NEUPOGEN PDL PDL COLONY STIMULATING FACTORS 55513020991 8240152000E550 55513020991 13308 filgrastim NEUPOGEN PDL PDL COLONY STIMULATING FACTORS 55513053001 82401520002010 55513053001 26001 filgrastim NEUPOGEN PDL PDL COLONY STIMULATING FACTORS 55513053010 82401520002010 55513053010 26001 filgrastim NEUPOGEN PDL PDL COLONY STIMULATING FACTORS 55513054601 82401520002012 55513054601 13206 filgrastim NEUPOGEN PDL PDL COLONY STIMULATING FACTORS 55513054610 82401520002012 55513054610 13206 filgrastim NEUPOGEN PDL PDL COLONY STIMULATING FACTORS 55513092401 8240152000E545 55513092401 13309 filgrastim NEUPOGEN PDL PDL COLONY STIMULATING FACTORS 55513092410 8240152000E545 55513092410 13309 filgrastim NEUPOGEN PDL PDL COLONY STIMULATING FACTORS 55513092491 8240152000E545 55513092491 13309 filgrastim NEUPOGEN PDL PDL COLONY STIMULATING FACTORS 61314030410 8240152060E530 61314030410 38083 filgrastim-sndz ZARXIO NPD NPD COLONY STIMULATING FACTORS 61314031201 8240152060E540 61314031201 38082 filgrastim-sndz ZARXIO NPD NPD COLONY STIMULATING FACTORS 61314031210 8240152060E540 61314031210 38082 filgrastim-sndz ZARXIO NPD NPD COLONY STIMULATING FACTORS 61314031801 8240152060E530 61314031801 38083 filgrastim-sndz ZARXIO NPD NPD COLONY STIMULATING FACTORS 61314031810 8240152060E530 61314031810 38083 filgrastim-sndz ZARXIO NPD NPD COLONY STIMULATING FACTORS 61314032601 8240152060E540 61314032601 38082 filgrastim-sndz ZARXIO NPD NPD COLONY STIMULATING FACTORS 61314032605 8240152060E540 61314032605 38082 filgrastim-sndz ZARXIO NPD NPD COLONY STIMULATING FACTORS 61314032610 8240152060E540 61314032610 38082 filgrastim-sndz ZARXIO NPD NPD COLONY STIMULATING FACTORS 63459091011 8240152070E530 63459091011 35575 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 63459091015 8240152070E530 63459091015 35575 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 63459091017 8240152070E530 63459091017 35575 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 63459091036 8240152070E530 63459091036 35575 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 63459091211 8240152070E540 63459091211 35576 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 63459091212 8240152070E540 63459091212 35576 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 63459091215 8240152070E540 63459091215 35576 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 63459091217 8240152070E540 63459091217 35576 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 63459091236 8240152070E540 63459091236 35576 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 63459091853 82401520702020 63459091853 45674 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 63459091859 82401520702020 63459091859 45674 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 63459092053 82401520702030 63459092053 45673 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 63459092059 82401520702030 63459092059 45673 tbo-filgrastim GRANIX NPD NPD COLONY STIMULATING FACTORS 67457083306 8240157020E520 67457083306 44881 pegfilgrastim-jmdb FULPHILA NPD PDL COLONY STIMULATING FACTORS 70114010101 8240157010E520 70114010101 45679 pegfilgrastim-cbqv UDENYCA NPD PDL ENZYME REPLACEMENT, GAUCHERS DISEASE 00069010601 82700080102120 00069010601 32078 taliglucerase alfa ELELYSO NR PDL ENZYME REPLACEMENT, GAUCHERS DISEASE 10148020115 82700070000120 10148020115 19453 miglustat MIGLUSTAT NR PDL ENZYME REPLACEMENT, GAUCHERS DISEASE 10148020190 82700070000120 10148020190 19453 miglustat MIGLUSTAT NR PDL ENZYME REPLACEMENT, GAUCHERS DISEASE 43975031083 82700070000120 43975031083 19453 miglustat MIGLUSTAT NR PDL ENZYME REPLACEMENT, GAUCHERS DISEASE 54092070104 82700085102120 54092070104 28299 velaglucerase alfa VPRIV NR PDL

5/17/2019 33 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ENZYME REPLACEMENT, GAUCHERS DISEASE 58468022001 82700040600120 58468022001 36988 eliglustat tartrate CERDELGA NR PDL ENZYME REPLACEMENT, GAUCHERS DISEASE 58468466301 82700050002120 58468466301 62531 imiglucerase CEREZYME NR PDL ENZYME REPLACEMENT, GAUCHERS DISEASE 66215020118 82700070000120 66215020118 19453 miglustat ZAVESCA NR NPD ENZYME REPLACEMENT, GAUCHERS DISEASE 66215020190 82700070000120 66215020190 19453 miglustat ZAVESCA NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 00004040109 8240104010E515 00004040109 98874 methoxy peg-epoetin beta MIRCERA NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 00004040209 8240104010E520 00004040209 98890 methoxy peg-epoetin beta MIRCERA NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 00004040309 8240104010E525 00004040309 98891 methoxy peg-epoetin beta MIRCERA NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 00004040509 8240104010E545 00004040509 98893 methoxy peg-epoetin beta MIRCERA NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 00069130501 82401020042010 00069130501 44764 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 00069130510 82401020042010 00069130510 44764 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 00069130601 82401020042015 00069130601 44765 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 00069130610 82401020042015 00069130610 44765 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 00069130701 82401020042020 00069130701 44766 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 00069130710 82401020042020 00069130710 44766 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 00069130801 82401020042040 00069130801 44767 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 00069130810 82401020042040 00069130810 44767 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 00069130901 82401020042060 00069130901 44768 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 00069130904 82401020042060 00069130904 44768 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 55513000204 82401015102010 55513000204 14049 darbepoetin alfa in polysorbat ARANESP NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513000304 82401015102020 55513000304 14053 darbepoetin alfa in polysorbat ARANESP NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513000404 82401015102030 55513000404 14054 darbepoetin alfa in polysorbat ARANESP NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513000504 82401015102040 55513000504 14055 darbepoetin alfa in polysorbat ARANESP NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513000601 82401015102060 55513000601 14056 darbepoetin alfa in polysorbat ARANESP NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513002104 8240101510E543 55513002104 14891 darbepoetin alfa in polysorbat ARANESP NR NPD

5/17/2019 34 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ERYTHROPOIESIS STIMULATING PROTEINS 55513002304 8240101510E552 55513002304 14893 darbepoetin alfa in polysorbat ARANESP NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513002504 8240101510E560 55513002504 14894 darbepoetin alfa in polysorbat ARANESP NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513002704 8240101510E575 55513002704 15202 darbepoetin alfa in polysorbat ARANESP NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513002801 8240101510E582 55513002801 97063 darbepoetin alfa in polysorbat ARANESP NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513003201 8240101510E590 55513003201 27164 darbepoetin alfa in polysorbat ARANESP NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513005704 8240101510E528 55513005704 97064 darbepoetin alfa in polysorbat ARANESP NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513009804 8240101510E510 55513009804 14877 darbepoetin alfa in polysorbat ARANESP NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513011001 82401015102070 55513011001 97066 darbepoetin alfa in polysorbat ARANESP NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513011101 8240101510E588 55513011101 97065 darbepoetin alfa in polysorbat ARANESP NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513012601 82401020002010 55513012601 25110 epoetin alfa EPOGEN PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513012610 82401020002010 55513012610 25110 epoetin alfa EPOGEN PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513014401 82401020002040 55513014401 25112 epoetin alfa EPOGEN PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513014410 82401020002040 55513014410 25112 epoetin alfa EPOGEN PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513014801 82401020002020 55513014801 25111 epoetin alfa EPOGEN PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513014810 82401020002020 55513014810 25111 epoetin alfa EPOGEN PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513026710 82401020002015 55513026710 25113 epoetin alfa EPOGEN PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513028301 82401020002040 55513028301 24059 epoetin alfa EPOGEN PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513028310 82401020002040 55513028310 24059 epoetin alfa EPOGEN PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513047801 82401020002050 55513047801 25114 epoetin alfa EPOGEN PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 55513047810 82401020002050 55513047810 25114 epoetin alfa EPOGEN PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 59353000201 82401020042010 59353000201 44764 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 59353000210 82401020042010 59353000210 44764 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 59353000301 82401020042015 59353000301 44765 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 59353000310 82401020042015 59353000310 44765 epoetin alfa-epbx RETACRIT NPD PDL

5/17/2019 35 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ERYTHROPOIESIS STIMULATING PROTEINS 59353000401 82401020042020 59353000401 44766 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 59353000410 82401020042020 59353000410 44766 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 59353001001 82401020042040 59353001001 44767 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 59353001010 82401020042040 59353001010 44767 epoetin alfa-epbx RETACRIT NPD PDL ERYTHROPOIESIS STIMULATING PROTEINS 59353040009 8240104010E510 59353040009 16207 methoxy peg-epoetin beta MIRCERA NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 59353040109 8240104010E515 59353040109 98874 methoxy peg-epoetin beta MIRCERA NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 59353040209 8240104010E520 59353040209 98890 methoxy peg-epoetin beta MIRCERA NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 59353040309 8240104010E525 59353040309 98891 methoxy peg-epoetin beta MIRCERA NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 59353040409 8240104010E535 59353040409 98892 methoxy peg-epoetin beta MIRCERA NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 59353040509 8240104010E545 59353040509 98893 methoxy peg-epoetin beta MIRCERA NR NPD ERYTHROPOIESIS STIMULATING PROTEINS 59676030201 82401020002010 59676030201 25110 epoetin alfa PROCRIT PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 59676030301 82401020002015 59676030301 25113 epoetin alfa PROCRIT PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 59676030401 82401020002020 59676030401 25111 epoetin alfa PROCRIT PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 59676031000 82401020002040 59676031000 25112 epoetin alfa PROCRIT PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 59676031001 82401020002040 59676031001 25112 epoetin alfa PROCRIT PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 59676031002 82401020002040 59676031002 25112 epoetin alfa PROCRIT PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 59676031204 82401020002040 59676031204 24059 epoetin alfa PROCRIT PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 59676032000 82401020002050 59676032000 25114 epoetin alfa PROCRIT PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 59676032004 82401020002050 59676032004 25114 epoetin alfa PROCRIT PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 59676034000 82401020002060 59676034000 25115 epoetin alfa PROCRIT PDL NPD ERYTHROPOIESIS STIMULATING PROTEINS 59676034001 82401020002060 59676034001 25115 epoetin alfa PROCRIT PDL NPD HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 00009501201 27500050000310 00009501201 95252 miglitol GLYSET NR NPD HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 00009501301 27500050000320 00009501301 95253 miglitol GLYSET NR NPD HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 00009501401 27500050000340 00009501401 95254 miglitol GLYSET NR NPD

5/17/2019 36 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 00054014025 27500010000310 00054014025 8070 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 00054014125 27500010000320 00054014125 2319 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 00054014225 27500010000340 00054014225 2318 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 00115115101 27500010000320 00115115101 2319 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 00115115201 27500010000340 00115115201 2318 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 00378282177 27500010000320 00378282177 2319 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 16252052301 27500010000310 16252052301 8070 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 16252052401 27500010000320 16252052401 2319 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 16252052501 27500010000340 16252052501 2318 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 23155014701 27500010000310 23155014701 8070 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 23155014801 27500010000320 23155014801 2319 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 23155014901 27500010000340 23155014901 2318 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 47781034001 27500010000310 47781034001 8070 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 47781034101 27500010000320 47781034101 2319 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 47781034201 27500010000340 47781034201 2318 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 57664068488 27500050000310 57664068488 95252 miglitol MIGLITOL NR NPD HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 57664068588 27500050000320 57664068588 95253 miglitol MIGLITOL NR NPD HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 57664068688 27500050000340 57664068688 95254 miglitol MIGLITOL NR NPD HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 64380075806 27500010000310 64380075806 8070 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 64380075906 27500010000320 64380075906 2319 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 64380076006 27500010000340 64380076006 2318 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 69543012010 27500010000310 69543012010 8070 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 69543012011 27500010000310 69543012011 8070 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 69543012110 27500010000320 69543012110 2319 acarbose ACARBOSE NR PDL

5/17/2019 37 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 69543012111 27500010000320 69543012111 2319 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 69543012210 27500010000340 69543012210 2318 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, ALPHA- GLUCOSIDASE INHIBITORS 69543012211 27500010000340 69543012211 2318 acarbose ACARBOSE NR PDL HYPOGLYCEMICS, METFORMINS 60505026007 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 00087606005 27250050000320 00087606005 10810 metformin HCl GLUCOPHAGE NR NPD HYPOGLYCEMICS, METFORMINS 00087606313 27250050007520 00087606313 89863 metformin HCl GLUCOPHAGE XR NR NPD HYPOGLYCEMICS, METFORMINS 00087606413 27250050007530 00087606413 19578 metformin HCl GLUCOPHAGE XR NR NPD HYPOGLYCEMICS, METFORMINS 00087607005 27250050000340 00087607005 10811 metformin HCl GLUCOPHAGE NR NPD HYPOGLYCEMICS, METFORMINS 00087607111 27250050000350 00087607111 10857 metformin HCl GLUCOPHAGE NR NPD HYPOGLYCEMICS, METFORMINS 00093104801 27250050000320 00093104801 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00093104810 27250050000320 00093104810 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00093104898 27250050000320 00093104898 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00093104901 27250050000340 00093104901 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00093104910 27250050000340 00093104910 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00093571205 27997002400330 00093571205 89879 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00093721201 27250050007530 00093721201 19578 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 00093721401 27250050000350 00093721401 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00093721410 27250050000350 00093721410 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00093721498 27250050000350 00093721498 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00093726701 27250050007520 00093726701 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 00093726710 27250050007520 00093726710 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 00093745501 27997002350320 00093745501 18366 glipizide/metformin HCl GLIPIZIDE-METFORMIN NR NPD HYPOGLYCEMICS, METFORMINS 00093745601 27997002350325 00093745601 18367 glipizide/metformin HCl GLIPIZIDE-METFORMIN NR NPD HYPOGLYCEMICS, METFORMINS 00093745701 27997002350340 00093745701 18368 glipizide/metformin HCl GLIPIZIDE-METFORMIN NR NPD HYPOGLYCEMICS, METFORMINS 00115165001 27997002400330 00115165001 89879 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00185441601 27250050007520 00185441601 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 00228275111 27997002400310 00228275111 89878 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00228275211 27997002400320 00228275211 92889 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00228275250 27997002400320 00228275250 92889 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00228275311 27997002400330 00228275311 89879 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00228275350 27997002400330 00228275350 89879 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00378313201 27997002350325 00378313201 18367 glipizide/metformin HCl GLIPIZIDE-METFORMIN NR NPD HYPOGLYCEMICS, METFORMINS 00378313301 27997002350340 00378313301 18368 glipizide/metformin HCl GLIPIZIDE-METFORMIN NR NPD HYPOGLYCEMICS, METFORMINS 00378600191 27250050007570 00378600191 21831 metformin HCl METFORMIN ER OSMOTIC NR NPD HYPOGLYCEMICS, METFORMINS 00378600291 27250050007560 00378600291 21832 metformin HCl METFORMIN ER OSMOTIC NR NPD HYPOGLYCEMICS, METFORMINS 00378718505 27250050000320 00378718505 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00378718605 27250050000340 00378718605 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00378718705 27250050000350 00378718705 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00591241101 27250050007580 00591241101 97061 metformin HCl METFORMIN ER GASTRIC NR NPD HYPOGLYCEMICS, METFORMINS 00591241219 27250050007590 00591241219 97067 metformin HCl METFORMIN ER GASTRIC NR NPD HYPOGLYCEMICS, METFORMINS 00591271960 27250050007560 00591271960 21832 metformin HCl METFORMIN ER OSMOTIC NR NPD HYPOGLYCEMICS, METFORMINS 00591272060 27250050007570 00591272060 21831 metformin HCl METFORMIN ER OSMOTIC NR NPD HYPOGLYCEMICS, METFORMINS 00781550301 27250050007520 00781550301 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 00904579461 27250050007520 00904579461 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 00904632661 27250050000320 00904632661 10810 metformin HCl METFORMIN HCL NR PDL

5/17/2019 38 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

HYPOGLYCEMICS, METFORMINS 00904632761 27250050000340 00904632761 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00904632861 27250050000350 00904632861 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 00904668961 27250050000320 00904668961 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 10631020601 27250050002020 10631020601 20808 metformin HCl RIOMET NR NPD HYPOGLYCEMICS, METFORMINS 10631020602 27250050002020 10631020602 20808 metformin HCl RIOMET NR NPD HYPOGLYCEMICS, METFORMINS 10631023801 27250050002020 10631023801 20808 metformin HCl RIOMET NR NPD HYPOGLYCEMICS, METFORMINS 10631023802 27250050002020 10631023802 20808 metformin HCl RIOMET NR NPD HYPOGLYCEMICS, METFORMINS 23155010201 27250050000320 23155010201 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 23155010205 27250050000320 23155010205 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 23155010206 27250050000320 23155010206 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 23155010210 27250050000320 23155010210 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 23155010301 27250050000340 23155010301 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 23155010305 27250050000340 23155010305 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 23155010310 27250050000340 23155010310 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 23155010401 27250050000350 23155010401 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 23155010405 27250050000350 23155010405 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 23155010406 27250050000350 23155010406 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 23155010410 27250050000350 23155010410 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 23155011501 27997002350320 23155011501 18366 glipizide/metformin HCl GLIPIZIDE-METFORMIN NR NPD HYPOGLYCEMICS, METFORMINS 23155011601 27997002350325 23155011601 18367 glipizide/metformin HCl GLIPIZIDE-METFORMIN NR NPD HYPOGLYCEMICS, METFORMINS 23155011701 27997002350340 23155011701 18368 glipizide/metformin HCl GLIPIZIDE-METFORMIN NR NPD HYPOGLYCEMICS, METFORMINS 23155023401 27997002400320 23155023401 92889 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 23155023505 27997002400330 23155023505 89879 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 29033003106 27250050007560 29033003106 21832 metformin HCl METFORMIN ER OSMOTIC NR NPD HYPOGLYCEMICS, METFORMINS 29033003206 27250050007570 29033003206 21831 metformin HCl METFORMIN ER OSMOTIC NR NPD HYPOGLYCEMICS, METFORMINS 33342023911 27250050007520 33342023911 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 33342024011 27250050007530 33342024011 19578 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 42806021305 27250050000320 42806021305 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 42806021310 27250050000320 42806021310 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 42806021501 27250050000340 42806021501 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 42806021505 27250050000340 42806021505 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 42806022105 27250050000350 42806022105 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 42806031305 27250050000320 42806031305 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 42806031401 27250050000340 42806031401 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 42806031505 27250050000350 42806031505 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 43547035710 27250050000320 43547035710 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 43547035711 27250050000320 43547035711 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 43547035750 27250050000320 43547035750 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 43547035810 27250050000340 43547035810 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 43547035850 27250050000340 43547035850 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 43547035910 27250050000350 43547035910 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 43547035950 27250050000350 43547035950 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 47335030588 27250050007580 47335030588 97061 metformin HCl METFORMIN ER GASTRIC NR NPD HYPOGLYCEMICS, METFORMINS 47335030688 27250050007590 47335030688 97067 metformin HCl METFORMIN ER GASTRIC NR NPD HYPOGLYCEMICS, METFORMINS 49483062010 27250050000350 49483062010 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 49483062081 27250050000350 49483062081 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 49483062110 27250050000340 49483062110 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 49483062281 27250050000320 49483062281 10810 metformin HCl METFORMIN HCL NR PDL

5/17/2019 39 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

HYPOGLYCEMICS, METFORMINS 49483062301 27250050007520 49483062301 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 49483062309 27250050007520 49483062309 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 49483062310 27250050007520 49483062310 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 49483062350 27250050007520 49483062350 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 49483062401 27250050007530 49483062401 19578 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 49483062450 27250050007530 49483062450 19578 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 50742015401 27250050000320 50742015401 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 50742015405 27250050000320 50742015405 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 50742015410 27250050000320 50742015410 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 50742015490 27250050000320 50742015490 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 50742015501 27250050000340 50742015501 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 50742015505 27250050000340 50742015505 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 50742015510 27250050000340 50742015510 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 50742015590 27250050000340 50742015590 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 50742015601 27250050000350 50742015601 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 50742015605 27250050000350 50742015605 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 50742015610 27250050000350 50742015610 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 50742063460 27250050007570 50742063460 21831 metformin HCl METFORMIN ER OSMOTIC NR NPD HYPOGLYCEMICS, METFORMINS 51079017201 27250050000320 51079017201 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 51079017220 27250050000320 51079017220 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 51079017420 27250050000350 51079017420 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 51224000750 27250050007520 51224000750 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 51224000760 27250050007520 51224000760 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 51224010750 27250050007530 51224010750 19578 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 51224010760 27250050007530 51224010760 19578 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 51991080505 27250050000320 51991080505 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 51991080510 27250050000320 51991080510 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 51991080601 27250050000340 51991080601 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 51991080605 27250050000340 51991080605 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 51991080705 27250050000350 51991080705 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 51991080710 27250050000350 51991080710 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 53746017801 27250050007520 53746017801 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 53746017805 27250050007520 53746017805 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 53746017810 27250050007520 53746017810 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 53746017890 27250050007520 53746017890 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 53746017901 27250050007530 53746017901 19578 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 53746017905 27250050007530 53746017905 19578 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 53746021801 27250050000320 53746021801 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 53746021805 27250050000320 53746021805 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 53746021810 27250050000320 53746021810 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 53746021901 27250050000340 53746021901 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 53746021905 27250050000340 53746021905 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 53746021910 27250050000340 53746021910 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 53746022001 27250050000350 53746022001 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 53746022005 27250050000350 53746022005 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 53746022010 27250050000350 53746022010 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 57237002301 27997002400310 57237002301 89878 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 57237002401 27997002400320 57237002401 92889 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL

5/17/2019 40 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

HYPOGLYCEMICS, METFORMINS 57237002405 27997002400320 57237002405 92889 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 57237002501 27997002400330 57237002501 89879 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 57237002505 27997002400330 57237002505 89879 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 57664039751 27250050000320 57664039751 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 57664039753 27250050000320 57664039753 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 57664039758 27250050000320 57664039758 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 57664043551 27250050000340 57664043551 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 57664043553 27250050000340 57664043553 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 57664043558 27250050000340 57664043558 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 57664047451 27250050000350 57664047451 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 57664047453 27250050000350 57664047453 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 57664047458 27250050000350 57664047458 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 57664047488 27250050000350 57664047488 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 58657064001 27250050000320 58657064001 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 58657064010 27250050000320 58657064010 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 58657064050 27250050000320 58657064050 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 58657064101 27250050000340 58657064101 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 58657064110 27250050000340 58657064110 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 58657064150 27250050000340 58657064150 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 58657064201 27250050000350 58657064201 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 58657064210 27250050000350 58657064210 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 58657064250 27250050000350 58657064250 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 59630057460 27250050007560 59630057460 21832 metformin HCl FORTAMET NR NPD HYPOGLYCEMICS, METFORMINS 59630057560 27250050007570 59630057560 21831 metformin HCl FORTAMET NR NPD HYPOGLYCEMICS, METFORMINS 60505019000 27250050000320 60505019000 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 60505019001 27250050000320 60505019001 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 60505019100 27250050000340 60505019100 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 60505019101 27250050000340 60505019101 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 60505019200 27250050000350 60505019200 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 60505019201 27250050000350 60505019201 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 60505026001 27250050007520 60505026001 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 60505026002 27250050007520 60505026002 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 60505132901 27250050007530 60505132901 19578 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 61442036101 27250050000320 61442036101 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 61442036105 27250050000320 61442036105 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 61442036110 27250050000320 61442036110 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 61442036205 27250050000340 61442036205 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 61442036301 27250050000350 61442036301 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 61442036305 27250050000350 61442036305 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 62037057101 27250050007520 62037057101 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 62037057110 27250050007520 62037057110 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 62037057701 27250050007530 62037057701 19578 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 62037057710 27250050007530 62037057710 19578 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 62756014201 27250050007520 62756014201 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 62756014202 27250050007520 62756014202 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 62756014301 27250050007530 62756014301 19578 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 63739064010 27250050000320 63739064010 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65162017850 27250050007520 65162017850 89863 metformin HCl METFORMIN HCL ER NR PDL

5/17/2019 41 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

HYPOGLYCEMICS, METFORMINS 65162017910 27250050007530 65162017910 19578 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 65162021810 27250050000320 65162021810 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65162021811 27250050000320 65162021811 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65162021850 27250050000320 65162021850 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65162021910 27250050000340 65162021910 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65162021911 27250050000340 65162021911 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65162021950 27250050000340 65162021950 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65162022010 27250050000350 65162022010 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65162022050 27250050000350 65162022050 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65862000801 27250050000320 65862000801 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65862000805 27250050000320 65862000805 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65862000899 27250050000320 65862000899 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65862000901 27250050000340 65862000901 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65862000905 27250050000340 65862000905 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65862001001 27250050000350 65862001001 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65862001005 27250050000350 65862001005 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65862001046 27250050000350 65862001046 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65862001099 27250050000350 65862001099 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65862008001 27997002400310 65862008001 89878 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65862008005 27997002400310 65862008005 89878 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65862008101 27997002400320 65862008101 92889 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65862008105 27997002400320 65862008105 92889 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65862008201 27997002400330 65862008201 89879 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 65862008205 27997002400330 65862008205 89879 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877015901 27250050007520 67877015901 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 67877015905 27250050007520 67877015905 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 67877021701 27250050000320 67877021701 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877021705 27250050000320 67877021705 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877021710 27250050000320 67877021710 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877021801 27250050000340 67877021801 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877021805 27250050000340 67877021805 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877022101 27250050000350 67877022101 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877022105 27250050000350 67877022105 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877022110 27250050000350 67877022110 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877056101 27250050000320 67877056101 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877056105 27250050000320 67877056105 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877056110 27250050000320 67877056110 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877056201 27250050000340 67877056201 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877056205 27250050000340 67877056205 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877056210 27250050000340 67877056210 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877056301 27250050000350 67877056301 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877056305 27250050000350 67877056305 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 67877056310 27250050000350 67877056310 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68012000213 27250050007580 68012000213 97061 metformin HCl GLUMETZA NR NPD HYPOGLYCEMICS, METFORMINS 68012000316 27250050007590 68012000316 97067 metformin HCl GLUMETZA NR NPD HYPOGLYCEMICS, METFORMINS 68012000450 27250050007580 68012000450 97061 metformin HCl GLUMETZA NR NPD HYPOGLYCEMICS, METFORMINS 68180033607 27250050007560 68180033607 21832 metformin HCl METFORMIN ER OSMOTIC NR NPD HYPOGLYCEMICS, METFORMINS 68180033707 27250050007570 68180033707 21831 metformin HCl METFORMIN ER OSMOTIC NR NPD

5/17/2019 42 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

HYPOGLYCEMICS, METFORMINS 68180033801 27250050007580 68180033801 97061 metformin HCl METFORMIN ER GASTRIC NR NPD HYPOGLYCEMICS, METFORMINS 68180033909 27250050007590 68180033909 97067 metformin HCl METFORMIN ER GASTRIC NR NPD HYPOGLYCEMICS, METFORMINS 68382002801 27250050000320 68382002801 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382002805 27250050000320 68382002805 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382002810 27250050000320 68382002810 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382002901 27250050000340 68382002901 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382002905 27250050000340 68382002905 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382002910 27250050000340 68382002910 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382003001 27250050000350 68382003001 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382003005 27250050000350 68382003005 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382003010 27250050000350 68382003010 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382018401 27997002350320 68382018401 18366 glipizide/metformin HCl GLIPIZIDE-METFORMIN NR NPD HYPOGLYCEMICS, METFORMINS 68382018501 27997002350325 68382018501 18367 glipizide/metformin HCl GLIPIZIDE-METFORMIN NR NPD HYPOGLYCEMICS, METFORMINS 68382018601 27997002350340 68382018601 18368 glipizide/metformin HCl GLIPIZIDE-METFORMIN NR NPD HYPOGLYCEMICS, METFORMINS 68382065505 27997002400330 68382065505 89879 glyburide/metformin HCl GLYBURIDE-METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382075801 27250050000320 68382075801 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382075805 27250050000320 68382075805 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382075810 27250050000320 68382075810 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382075901 27250050000340 68382075901 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382075905 27250050000340 68382075905 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382075910 27250050000340 68382075910 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382076001 27250050000350 68382076001 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382076005 27250050000350 68382076005 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68382076010 27250050000350 68382076010 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68462015901 27250050000320 68462015901 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68462015905 27250050000320 68462015905 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68462015910 27250050000320 68462015910 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68462016001 27250050000340 68462016001 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68462016005 27250050000340 68462016005 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68462016010 27250050000340 68462016010 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68462016101 27250050000350 68462016101 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68462016105 27250050000350 68462016105 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68462016110 27250050000350 68462016110 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68645030059 27250050000350 68645030059 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68645053959 27250050000320 68645053959 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68645054459 27250050000320 68645054459 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68645054559 27250050000350 68645054559 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68645054659 27250050000350 68645054659 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68645054759 27250050000340 68645054759 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68645054859 27250050000340 68645054859 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68645054959 27250050000340 68645054959 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 68682001710 27250050007580 68682001710 97061 metformin HCl METFORMIN ER GASTRIC NR NPD HYPOGLYCEMICS, METFORMINS 68682001890 27250050007590 68682001890 97067 metformin HCl METFORMIN ER GASTRIC NR NPD HYPOGLYCEMICS, METFORMINS 68682002150 27250050007580 68682002150 97061 metformin HCl METFORMIN ER GASTRIC NR NPD HYPOGLYCEMICS, METFORMINS 69367018001 27250050000320 69367018001 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 69367018005 27250050000320 69367018005 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 69367018101 27250050000340 69367018101 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 69367018105 27250050000340 69367018105 10811 metformin HCl METFORMIN HCL NR PDL

5/17/2019 43 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

HYPOGLYCEMICS, METFORMINS 69367018201 27250050000350 69367018201 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 69367018205 27250050000350 69367018205 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 70010049110 27250050007520 70010049110 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 71093013204 27250050000320 71093013204 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 71093013205 27250050000320 71093013205 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 71093013206 27250050000320 71093013206 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 71093013304 27250050000340 71093013304 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 71093013305 27250050000340 71093013305 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 71093013404 27250050000350 71093013404 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 71093013405 27250050000350 71093013405 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 71717010411 27250050000320 71717010411 10810 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 71717010510 27250050000340 71717010510 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 71717010550 27250050000340 71717010550 10811 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 71717010611 27250050000350 71717010611 10857 metformin HCl METFORMIN HCL NR PDL HYPOGLYCEMICS, METFORMINS 76385012810 27250050007520 76385012810 89863 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, METFORMINS 76385012901 27250050007530 76385012901 19578 metformin HCl METFORMIN HCL ER NR PDL HYPOGLYCEMICS, SGLT2 00006536303 27700055200320 00006536303 44248 ertugliflozin pidolate STEGLATRO NR NPD HYPOGLYCEMICS, SGLT2 00006536306 27700055200320 00006536306 44248 ertugliflozin pidolate STEGLATRO NR NPD HYPOGLYCEMICS, SGLT2 00006536307 27700055200320 00006536307 44248 ertugliflozin pidolate STEGLATRO NR NPD HYPOGLYCEMICS, SGLT2 00006536403 27700055200340 00006536403 44259 ertugliflozin pidolate STEGLATRO NR NPD HYPOGLYCEMICS, SGLT2 00006536406 27700055200340 00006536406 44259 ertugliflozin pidolate STEGLATRO NR NPD HYPOGLYCEMICS, SGLT2 00006536407 27700055200340 00006536407 44259 ertugliflozin pidolate STEGLATRO NR NPD HYPOGLYCEMICS, SGLT2 00006536903 27996002450310 00006536903 44284 ertugliflozin/metformin SEGLUROMET NR NPD HYPOGLYCEMICS, SGLT2 00006537003 27996002450330 00006537003 44286 ertugliflozin/metformin SEGLUROMET NR NPD HYPOGLYCEMICS, SGLT2 00006537303 27996002450320 00006537303 44285 ertugliflozin/metformin SEGLUROMET NR NPD HYPOGLYCEMICS, SGLT2 00006537306 27996002450320 00006537306 44285 ertugliflozin/metformin SEGLUROMET NR NPD HYPOGLYCEMICS, SGLT2 00006537403 27996002450340 00006537403 44287 ertugliflozin/metformin SEGLUROMET NR NPD HYPOGLYCEMICS, SGLT2 00310620530 27700040200310 00310620530 35698 dapagliflozin propanediol FARXIGA NR PDL HYPOGLYCEMICS, SGLT2 00310621030 27700040200320 00310621030 34394 dapagliflozin propanediol FARXIGA NR PDL HYPOGLYCEMICS, SGLT2 00310622560 27996002307507 00310622560 44304 dapagliflozin/metformin HCl XIGDUO XR NR NPD HYPOGLYCEMICS, SGLT2 00310625030 27996002307510 00310625030 37339 dapagliflozin/metformin HCl XIGDUO XR NR NPD HYPOGLYCEMICS, SGLT2 00310626060 27996002307515 00310626060 37343 dapagliflozin/metformin HCl XIGDUO XR NR NPD HYPOGLYCEMICS, SGLT2 00310627030 27996002307520 00310627030 37342 dapagliflozin/metformin HCl XIGDUO XR NR NPD HYPOGLYCEMICS, SGLT2 00310628030 27996002307525 00310628030 37344 dapagliflozin/metformin HCl XIGDUO XR NR NPD HYPOGLYCEMICS, SGLT2 00597015230 27700050000310 00597015230 36716 empagliflozin JARDIANCE NR PDL HYPOGLYCEMICS, SGLT2 00597015237 27700050000310 00597015237 36716 empagliflozin JARDIANCE NR PDL HYPOGLYCEMICS, SGLT2 00597015290 27700050000310 00597015290 36716 empagliflozin JARDIANCE NR PDL HYPOGLYCEMICS, SGLT2 00597015330 27700050000320 00597015330 36723 empagliflozin JARDIANCE NR PDL HYPOGLYCEMICS, SGLT2 00597015337 27700050000320 00597015337 36723 empagliflozin JARDIANCE NR PDL HYPOGLYCEMICS, SGLT2 00597015390 27700050000320 00597015390 36723 empagliflozin JARDIANCE NR PDL HYPOGLYCEMICS, SGLT2 00597015960 27996002400310 00597015960 39377 empagliflozin/metformin HCl SYNJARDY NR NPD HYPOGLYCEMICS, SGLT2 00597016818 27996002400325 00597016818 38932 empagliflozin/metformin HCl SYNJARDY NR NPD HYPOGLYCEMICS, SGLT2 00597016860 27996002400325 00597016860 38932 empagliflozin/metformin HCl SYNJARDY NR NPD HYPOGLYCEMICS, SGLT2 00597017518 27996002400315 00597017518 38929 empagliflozin/metformin HCl SYNJARDY NR NPD HYPOGLYCEMICS, SGLT2 00597017560 27996002400315 00597017560 38929 empagliflozin/metformin HCl SYNJARDY NR NPD HYPOGLYCEMICS, SGLT2 00597018018 27996002400320 00597018018 39378 empagliflozin/metformin HCl SYNJARDY NR NPD HYPOGLYCEMICS, SGLT2 00597018060 27996002400320 00597018060 39378 empagliflozin/metformin HCl SYNJARDY NR NPD HYPOGLYCEMICS, SGLT2 00597028073 27996002407540 00597028073 42788 empagliflozin/metformin HCl SYNJARDY XR NR NPD

5/17/2019 44 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

HYPOGLYCEMICS, SGLT2 00597028090 27996002407540 00597028090 42788 empagliflozin/metformin HCl SYNJARDY XR NR NPD HYPOGLYCEMICS, SGLT2 00597029074 27996002407530 00597029074 42786 empagliflozin/metformin HCl SYNJARDY XR NR NPD HYPOGLYCEMICS, SGLT2 00597029578 27996002407560 00597029578 42789 empagliflozin/metformin HCl SYNJARDY XR NR NPD HYPOGLYCEMICS, SGLT2 00597029588 27996002407560 00597029588 42789 empagliflozin/metformin HCl SYNJARDY XR NR NPD HYPOGLYCEMICS, SGLT2 00597030045 27996002407550 00597030045 42787 empagliflozin/metformin HCl SYNJARDY XR NR NPD HYPOGLYCEMICS, SGLT2 00597030093 27996002407550 00597030093 42787 empagliflozin/metformin HCl SYNJARDY XR NR NPD HYPOGLYCEMICS, SGLT2 50458014030 27700020000320 50458014030 34439 canagliflozin INVOKANA NR PDL HYPOGLYCEMICS, SGLT2 50458014090 27700020000320 50458014090 34439 canagliflozin INVOKANA NR PDL HYPOGLYCEMICS, SGLT2 50458014130 27700020000330 50458014130 34441 canagliflozin INVOKANA NR PDL HYPOGLYCEMICS, SGLT2 50458014190 27700020000330 50458014190 34441 canagliflozin INVOKANA NR PDL HYPOGLYCEMICS, SGLT2 50458054060 27996002200320 50458054060 36954 canagliflozin/metformin HCl INVOKAMET NR NPD HYPOGLYCEMICS, SGLT2 50458054160 27996002200330 50458054160 36857 canagliflozin/metformin HCl INVOKAMET NR NPD HYPOGLYCEMICS, SGLT2 50458054260 27996002200340 50458054260 36953 canagliflozin/metformin HCl INVOKAMET NR NPD HYPOGLYCEMICS, SGLT2 50458054360 27996002200350 50458054360 36859 canagliflozin/metformin HCl INVOKAMET NR NPD HYPOGLYCEMICS, SGLT2 50458094001 27996002207520 50458094001 42312 canagliflozin/metformin HCl INVOKAMET XR NR NPD HYPOGLYCEMICS, SGLT2 50458094101 27996002207530 50458094101 42313 canagliflozin/metformin HCl INVOKAMET XR NR NPD HYPOGLYCEMICS, SGLT2 50458094201 27996002207540 50458094201 42314 canagliflozin/metformin HCl INVOKAMET XR NR NPD HYPOGLYCEMICS, SGLT2 50458094301 27996002207550 50458094301 42315 canagliflozin/metformin HCl INVOKAMET XR NR NPD IgG/hyaluronidase,recombinan IMMUNE GLOBULINS 00944251002 19990002356420 00944251002 37095 t HYQVIA NR NPD IgG/hyaluronidase,recombinan IMMUNE GLOBULINS 00944251102 19990002356425 00944251102 37104 t HYQVIA NR NPD IgG/hyaluronidase,recombinan IMMUNE GLOBULINS 00944251202 19990002356430 00944251202 37105 t HYQVIA NR NPD IgG/hyaluronidase,recombinan IMMUNE GLOBULINS 00944251302 19990002356440 00944251302 37106 t HYQVIA NR NPD IgG/hyaluronidase,recombinan IMMUNE GLOBULINS 00944251402 19990002356450 00944251402 37107 t HYQVIA NR NPD immun glob G/gly/gluc/IgA 0- IMMUNE GLOBULINS 00944265603 19100020102120 00944265603 6951 50 GAMMAGARD S-D NR PDL immun glob G/gly/gluc/IgA 0- IMMUNE GLOBULINS 00944265804 19100020102130 00944265804 7392 50 GAMMAGARD S-D NR PDL immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944270002 19100020302060 00944270002 38016 ov50 GAMMAGARD LIQUID NR PDL immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944270003 19100020302064 00944270003 38016 ov50 GAMMAGARD LIQUID NR PDL immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944270004 19100020302068 00944270004 38016 ov50 GAMMAGARD LIQUID NR PDL immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944270005 19100020302072 00944270005 38016 ov50 GAMMAGARD LIQUID NR PDL immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944270006 19100020302076 00944270006 38016 ov50 GAMMAGARD LIQUID NR PDL immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944270007 19100020302080 00944270007 38016 ov50 GAMMAGARD LIQUID NR PDL immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944270010 19100020302068 00944270010 38016 ov50 GAMMAGARD LIQUID NR PDL immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944270011 19100020302072 00944270011 38016 ov50 GAMMAGARD LIQUID NR PDL

5/17/2019 45 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944270012 19100020302076 00944270012 38016 ov50 GAMMAGARD LIQUID NR PDL immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944270013 19100020302080 00944270013 38016 ov50 GAMMAGARD LIQUID NR PDL immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944285001 19100020202050 00944285001 42328 ov50 CUVITRU NR NPD immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944285002 19100020202050 00944285002 42328 ov50 CUVITRU NR NPD immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944285003 19100020202054 00944285003 42329 ov50 CUVITRU NR NPD immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944285004 19100020202054 00944285004 42329 ov50 CUVITRU NR NPD immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944285005 19100020202058 00944285005 42335 ov50 CUVITRU NR NPD immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944285007 19100020202062 00944285007 42277 ov50 CUVITRU NR NPD immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 00944285008 19100020202062 00944285008 42277 ov50 CUVITRU NR NPD IMMUNE GLOBULINS 13533033504 19100020002200 13533033504 43712 immune globul G (IgG)/glycine GAMASTAN NR NPD IMMUNE GLOBULINS 13533033512 19100020002200 13533033512 43712 immune globul G (IgG)/glycine GAMASTAN NR NPD IMMUNE GLOBULINS 13533033513 19100020002200 13533033513 43712 immune globul G (IgG)/glycine GAMASTAN NR NPD IMMUNE GLOBULINS 13533033540 19100020002200 13533033540 43712 immune globul G (IgG)/glycine GAMASTAN NR NPD IMMUNE GLOBULINS 13533063504 19100020002200 13533063504 43712 immune globul G (IgG)/glycine GAMASTAN S-D NR PDL IMMUNE GLOBULINS 13533063512 19100020002200 13533063512 43712 immune globul G (IgG)/glycine GAMASTAN S-D NR PDL IMMUNE GLOBULINS 13533063513 19100020002200 13533063513 43712 immune globul G (IgG)/glycine GAMASTAN S-D NR PDL IMMUNE GLOBULINS 13533063540 19100020002200 13533063540 43712 immune globul G (IgG)/glycine GAMASTAN S-D NR PDL immune globul G/gly/IgA avg IMMUNE GLOBULINS 13533080012 19100020302060 13533080012 29305 46 GAMUNEX-C NR PDL immune globul G/gly/IgA avg IMMUNE GLOBULINS 13533080015 19100020302064 13533080015 29306 46 GAMUNEX-C NR PDL immune globul G/gly/IgA avg IMMUNE GLOBULINS 13533080020 19100020302068 13533080020 29307 46 GAMUNEX-C NR PDL immune globul G/gly/IgA avg IMMUNE GLOBULINS 13533080021 19100020302068 13533080021 29307 46 GAMUNEX-C NR PDL immune globul G/gly/IgA avg IMMUNE GLOBULINS 13533080024 19100020302076 13533080024 29309 46 GAMUNEX-C NR PDL immune globul G/gly/IgA avg IMMUNE GLOBULINS 13533080025 19100020302076 13533080025 29309 46 GAMUNEX-C NR PDL immune globul G/gly/IgA avg IMMUNE GLOBULINS 13533080040 19100020302084 13533080040 37322 46 GAMUNEX-C NR PDL immune globul G/gly/IgA avg IMMUNE GLOBULINS 13533080071 19100020302072 13533080071 29308 46 GAMUNEX-C NR PDL immune globul G/gly/IgA avg IMMUNE GLOBULINS 13533080072 19100020302072 13533080072 29308 46 GAMUNEX-C NR PDL immun globG(IgG)/sucr/IgA IMMUNE GLOBULINS 44206041706 19100020102125 44206041706 38203 ov50 CARIMUNE NF NANOFILTERED NR PDL immun globG(IgG)/sucr/IgA IMMUNE GLOBULINS 44206041812 19100020102135 44206041812 38204 ov50 CARIMUNE NF NANOFILTERED NR PDL

5/17/2019 46 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

immun glob G(IgG)/pro/IgA 0- IMMUNE GLOBULINS 44206043605 19100020102068 44206043605 38017 50 PRIVIGEN NR NPD immun glob G(IgG)/pro/IgA 0- IMMUNE GLOBULINS 44206043710 19100020102072 44206043710 38017 50 PRIVIGEN NR NPD immun glob G(IgG)/pro/IgA 0- IMMUNE GLOBULINS 44206043820 19100020102076 44206043820 38017 50 PRIVIGEN NR NPD immun glob G(IgG)/pro/IgA 0- IMMUNE GLOBULINS 44206043940 19100020102090 44206043940 38017 50 PRIVIGEN NR NPD immun glob G(IgG)/pro/IgA 0- IMMUNE GLOBULINS 44206045101 19100020202050 44206045101 28385 50 HIZENTRA NR PDL immun glob G(IgG)/pro/IgA 0- IMMUNE GLOBULINS 44206045202 19100020202054 44206045202 28386 50 HIZENTRA NR PDL immun glob G(IgG)/pro/IgA 0- IMMUNE GLOBULINS 44206045404 19100020202058 44206045404 28387 50 HIZENTRA NR PDL immun glob G(IgG)/pro/IgA 0- IMMUNE GLOBULINS 44206045510 19100020202065 44206045510 35316 50 HIZENTRA NR PDL immun glob G(IgG)/gly/IgA IMMUNE GLOBULINS 59730650201 19100020102068 59730650201 38014 ov50 BIVIGAM NR PDL IMMUNE GLOBULINS 61953000405 19100020102044 61953000405 37917 50 FLEBOGAMMA DIF NR PDL IMMUNE GLOBULINS 61953000501 19100020102068 61953000501 42386 50 FLEBOGAMMA DIF NR PDL IMMUNE GLOBULINS 61953000502 19100020102072 61953000502 42386 50 FLEBOGAMMA DIF NR PDL IMMUNE GLOBULINS 61953000503 19100020102076 61953000503 42386 50 FLEBOGAMMA DIF NR PDL immun glob G/sorb/gly/IgA 0- IMMUNE GLOBULINS 64208823402 19100020102038 64208823402 37918 50 GAMMAPLEX NR NPD immun glob G/sorb/gly/IgA 0- IMMUNE GLOBULINS 64208823403 19100020102042 64208823403 37918 50 GAMMAPLEX NR NPD immun glob G/sorb/gly/IgA 0- IMMUNE GLOBULINS 64208823404 19100020102044 64208823404 37918 50 GAMMAPLEX NR NPD immun glob G/sorb/gly/IgA 0- IMMUNE GLOBULINS 64208823406 19100020102038 64208823406 37918 50 GAMMAPLEX NR NPD immun glob G/sorb/gly/IgA 0- IMMUNE GLOBULINS 64208823407 19100020102042 64208823407 37918 50 GAMMAPLEX NR NPD immun glob G/sorb/gly/IgA 0- IMMUNE GLOBULINS 64208823408 19100020102044 64208823408 37918 50 GAMMAPLEX NR NPD immun glob G(IgG)/gly/IgA 0- IMMUNE GLOBULINS 64208823501 19100020102068 64208823501 43214 50 GAMMAPLEX NR NPD immun glob G(IgG)/gly/IgA 0- IMMUNE GLOBULINS 64208823502 19100020102072 64208823502 43214 50 GAMMAPLEX NR NPD immun glob G(IgG)/gly/IgA 0- IMMUNE GLOBULINS 64208823503 19100020102076 64208823503 43214 50 GAMMAPLEX NR NPD immun glob G(IgG)/gly/IgA 0- IMMUNE GLOBULINS 64208823505 19100020102068 64208823505 43214 50 GAMMAPLEX NR NPD immun glob G(IgG)/gly/IgA 0- IMMUNE GLOBULINS 64208823506 19100020102072 64208823506 43214 50 GAMMAPLEX NR NPD immun glob G(IgG)/gly/IgA 0- IMMUNE GLOBULINS 64208823507 19100020102076 64208823507 43214 50 GAMMAPLEX NR NPD immun globG(IgG)/malt/IgA IMMUNE GLOBULINS 67467084304 19100020102042 67467084304 37919 ov50 OCTAGAM NR NPD

5/17/2019 47 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

IMMUNE GLOBULINS 68982082001 19100020602020 68982082001 45566 ifas/glycine PANZYGA NR NPD IMMUNE GLOBULINS 68982082002 19100020602025 68982082002 45566 ifas/glycine PANZYGA NR NPD IMMUNE GLOBULINS 68982082003 19100020602030 68982082003 45566 ifas/glycine PANZYGA NR NPD IMMUNE GLOBULINS 68982082004 19100020602035 68982082004 45566 ifas/glycine PANZYGA NR NPD IMMUNE GLOBULINS 68982082005 19100020602040 68982082005 45566 ifas/glycine PANZYGA NR NPD IMMUNE GLOBULINS 68982082006 19100020602045 68982082006 45566 ifas/glycine PANZYGA NR NPD IMMUNE GLOBULINS 68982082081 19100020602020 68982082081 45566 ifas/glycine PANZYGA NR NPD IMMUNE GLOBULINS 68982082082 19100020602025 68982082082 45566 ifas/glycine PANZYGA NR NPD IMMUNE GLOBULINS 68982082083 19100020602030 68982082083 45566 ifas/glycine PANZYGA NR NPD IMMUNE GLOBULINS 68982082084 19100020602035 68982082084 45566 ifas/glycine PANZYGA NR NPD IMMUNE GLOBULINS 68982082085 19100020602040 68982082085 45566 ifas/glycine PANZYGA NR NPD IMMUNE GLOBULINS 68982082086 19100020602045 68982082086 45566 ifas/glycine PANZYGA NR NPD immun globG(IgG)/malt/IgA IMMUNE GLOBULINS 68982084002 19100020102034 68982084002 37919 ov50 OCTAGAM NR NPD immun globG(IgG)/malt/IgA IMMUNE GLOBULINS 68982084003 19100020102038 68982084003 37919 ov50 OCTAGAM NR NPD immun globG(IgG)/malt/IgA IMMUNE GLOBULINS 68982084004 19100020102042 68982084004 37919 ov50 OCTAGAM NR NPD immun globG(IgG)/malt/IgA IMMUNE GLOBULINS 68982085001 19100020102063 68982085001 27457 ov50 OCTAGAM NR NPD immun globG(IgG)/malt/IgA IMMUNE GLOBULINS 68982085002 19100020102068 68982085002 27457 ov50 OCTAGAM NR NPD immun globG(IgG)/malt/IgA IMMUNE GLOBULINS 68982085003 19100020102072 68982085003 27457 ov50 OCTAGAM NR NPD immun globG(IgG)/malt/IgA IMMUNE GLOBULINS 68982085004 19100020102076 68982085004 27457 ov50 OCTAGAM NR NPD immune globul G/gly/IgA avg IMMUNE GLOBULINS 76125090010 19100020302072 76125090010 29308 46 GAMMAKED NR NPD immune globul G/gly/IgA avg IMMUNE GLOBULINS 76125090020 19100020302076 76125090020 29309 46 GAMMAKED NR NPD immune globul G/gly/IgA avg IMMUNE GLOBULINS 76125090050 19100020302068 76125090050 29307 46 GAMMAKED NR NPD NEUROPATHIC PAIN 00093754206 58180025106720 00093754206 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 00093754356 58180025106730 00093754356 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 00093754456 58180025106750 00093754456 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 00228289006 58180025106720 00228289006 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 00228289103 58180025106730 00228289103 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 00228289150 58180025106730 00228289150 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 00228289203 58180025106750 00228289203 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 00228289296 58180025106750 00228289296 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 00904636761 58180025106730 00904636761 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 00904636861 58180025106750 00904636861 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 00904645261 58180025106720 00904645261 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 00904645361 58180025106730 00904645361 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 00904645461 58180025106750 00904645461 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 13668010960 58180025106720 13668010960 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 13668011005 58180025106730 13668011005 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 13668011030 58180025106730 13668011030 23162 duloxetine HCl DULOXETINE HCL NR NR

5/17/2019 48 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

NEUROPATHIC PAIN 13668011105 58180025106750 13668011105 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 13668011130 58180025106750 13668011130 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 13811066260 58180025106720 13811066260 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 23155065406 58180025106720 23155065406 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 23155065503 58180025106730 23155065503 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 23155065509 58180025106730 23155065509 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 23155065603 58180025106750 23155065603 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 23155065609 58180025106750 23155065609 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 23155065610 58180025106750 23155065610 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 27241009706 58180025106720 27241009706 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 27241009803 58180025106730 27241009803 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 27241009809 58180025106730 27241009809 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 27241009903 58180025106750 27241009903 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 27241009990 58180025106750 27241009990 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 31722058160 58180025106720 31722058160 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 31722058230 58180025106730 31722058230 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 31722058330 58180025106750 31722058330 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 33342016009 58180025106720 33342016009 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 33342016207 58180025106750 33342016207 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 42292002101 58180025106750 42292002101 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 43547037906 58180025106720 43547037906 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 43547038003 58180025106730 43547038003 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 43547038009 58180025106730 43547038009 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 43547038011 58180025106730 43547038011 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 43547038103 58180025106750 43547038103 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 43547038111 58180025106750 43547038111 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 47335038186 58180025106720 47335038186 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 47335038188 58180025106720 47335038188 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 47335038281 58180025106730 47335038281 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 47335038283 58180025106730 47335038283 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 47335038318 58180025106750 47335038318 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 47335038383 58180025106750 47335038383 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 51991074605 58180025106720 51991074605 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 51991074690 58180025106720 51991074690 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 51991074710 58180025106730 51991074710 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 51991074790 58180025106730 51991074790 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 51991074810 58180025106750 51991074810 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 51991074890 58180025106750 51991074890 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 57237001760 58180025106720 57237001760 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 57237001830 58180025106730 57237001830 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 57237001890 58180025106730 57237001890 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 57237001899 58180025106730 57237001899 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 57237001930 58180025106750 57237001930 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 57237001990 58180025106750 57237001990 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 57237001999 58180025106750 57237001999 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 60505299506 58180025106720 60505299506 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 60505299603 58180025106730 60505299603 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 60505299703 58180025106750 60505299703 23164 duloxetine HCl DULOXETINE HCL NR NR

5/17/2019 49 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

NEUROPATHIC PAIN 60505299708 58180025106750 60505299708 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 66993066260 58180025106720 66993066260 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 66993066305 58180025106730 66993066305 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 66993066330 58180025106730 66993066330 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 66993066405 58180025106750 66993066405 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 66993066430 58180025106750 66993066430 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68001025506 58180025106720 68001025506 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68001025604 58180025106730 68001025604 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68001025605 58180025106730 68001025605 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68001025608 58180025106730 68001025608 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68001025704 58180025106750 68001025704 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68001025708 58180025106750 68001025708 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68084067521 58180025106720 68084067521 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68084068301 58180025106730 68084068301 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68084068311 58180025106730 68084068311 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68084069201 58180025106750 68084069201 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68180029407 58180025106720 68180029407 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68180029503 58180025106730 68180029503 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68180029506 58180025106730 68180029506 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68180029509 58180025106730 68180029509 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68180029603 58180025106750 68180029603 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68180029606 58180025106750 68180029606 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68180029609 58180025106750 68180029609 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68382038514 58180025106720 68382038514 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68382038606 58180025106730 68382038606 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68382038616 58180025106730 68382038616 23162 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 68382038706 58180025106750 68382038706 23164 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 69097029703 58180025106720 69097029703 23161 duloxetine HCl DULOXETINE HCL NR NR NEUROPATHIC PAIN 69097029902 58180025106750 69097029902 23164 duloxetine HCl DULOXETINE HCL NR NR ONCOLOGY, ORAL - HEMATOLOGIC 00003052411 21534020000350 00003052411 27259 dasatinib SPRYCEL NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 00003052711 21534020000320 00003052711 27257 dasatinib SPRYCEL NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 00003052811 21534020000340 00003052811 27258 dasatinib SPRYCEL NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 00003083050 21700030000105 00003083050 38400 hydroxyurea HYDREA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00003085222 21534020000360 00003085222 99867 dasatinib SPRYCEL NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 00003085522 21534020000354 00003085522 29405 dasatinib SPRYCEL NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 00003085722 21534020000380 00003085722 29406 dasatinib SPRYCEL NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 00006056840 21531575000120 00006056840 97345 vorinostat ZOLINZA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00054024913 21534035100340 00054024913 19907 imatinib mesylate IMATINIB MESYLATE NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00054458111 21300040000305 00054458111 38520 mercaptopurine MERCAPTOPURINE NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 00054458127 21300040000305 00054458127 38520 mercaptopurine MERCAPTOPURINE NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 00069013501 21534012000320 00069013501 33199 bosutinib BOSULIF NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00069013601 21534012000340 00069013601 33202 bosutinib BOSULIF NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00069019301 21534012000327 00069019301 44162 bosutinib BOSULIF NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00069029860 21370030300320 00069029860 45797 glasdegib maleate DAURISMO NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00069153130 21370030300335 00069153130 45798 glasdegib maleate DAURISMO NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00074056111 21470080000320 00074056111 41049 venetoclax VENCLEXTA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00074056114 21470080000320 00074056114 41049 venetoclax VENCLEXTA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00074056607 21470080000340 00074056607 41051 venetoclax VENCLEXTA NR NPD

5/17/2019 50 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ONCOLOGY, ORAL - HEMATOLOGIC 00074056611 21470080000340 00074056611 41051 venetoclax VENCLEXTA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00074057611 21470080000360 00074057611 41052 venetoclax VENCLEXTA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00074057622 21470080000360 00074057622 41052 venetoclax VENCLEXTA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00074057634 21470080000360 00074057634 41052 venetoclax VENCLEXTA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00074057928 2147008000B720 00074057928 41048 venetoclax VENCLEXTA STARTING PACK NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00078040134 21534035100320 00078040134 19908 imatinib mesylate GLEEVEC NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 00078052651 21534060200125 00078052651 99070 nilotinib HCl TASIGNA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00078052687 21534060200125 00078052687 99070 nilotinib HCl TASIGNA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00078059251 21534060200115 00078059251 28737 nilotinib HCl TASIGNA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00078059287 21534060200115 00078059287 28737 nilotinib HCl TASIGNA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00078064930 21534035100340 00078064930 19907 imatinib mesylate GLEEVEC NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 00078065006 21531550100120 00078065006 38008 panobinostat lactate FARYDAK NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00078065106 21531550100130 00078065106 38009 panobinostat lactate FARYDAK NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00078065206 21531550100140 00078065206 38011 panobinostat lactate FARYDAK NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00078069802 21533030000130 00078069802 43327 midostaurin RYDAPT NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00078069819 21533030000130 00078069819 43327 midostaurin RYDAPT NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00078069851 21533030000130 00078069851 43327 midostaurin RYDAPT NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00078069899 21533030000130 00078069899 43327 midostaurin RYDAPT NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00078095166 21534060200110 00078095166 44546 nilotinib HCl TASIGNA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00093762998 21534035100320 00093762998 19908 imatinib mesylate IMATINIB MESYLATE NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00093763056 21534035100340 00093763056 19907 imatinib mesylate IMATINIB MESYLATE NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00310051260 21534003000120 00310051260 44011 acalabrutinib CALQUENCE NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00378224577 21534035100320 00378224577 19908 imatinib mesylate IMATINIB MESYLATE NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00378224693 21534035100340 00378224693 19907 imatinib mesylate IMATINIB MESYLATE NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00378354725 21300040000305 00378354725 38520 mercaptopurine MERCAPTOPURINE NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 00378354752 21300040000305 00378354752 38520 mercaptopurine MERCAPTOPURINE NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 00469142590 21534031200320 00469142590 45803 gilteritinib fumarate XOSPATA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 00555080802 21708080000110 00555080802 48590 tretinoin TRETINOIN NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 00555088202 21700030000105 00555088202 38400 hydroxyurea HYDROXYUREA NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 10370026801 21708080000110 10370026801 48590 tretinoin TRETINOIN NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 16714070401 21534035100320 16714070401 19908 imatinib mesylate IMATINIB MESYLATE NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 16714070501 21534035100340 16714070501 19907 imatinib mesylate IMATINIB MESYLATE NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 43598034490 21534035100320 43598034490 19908 imatinib mesylate IMATINIB MESYLATE NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 43598034530 21534035100340 43598034530 19907 imatinib mesylate IMATINIB MESYLATE NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 47335047281 21534035100320 47335047281 19908 imatinib mesylate IMATINIB MESYLATE NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 47335047583 21534035100340 47335047583 19907 imatinib mesylate IMATINIB MESYLATE NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 47781020050 21101040000305 47781020050 38380 melphalan MELPHALAN NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 49884072401 21700030000105 49884072401 38400 hydroxyurea HYDROXYUREA NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 50881000560 21537560200310 50881000560 30892 ruxolitinib phosphate JAKAFI NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 50881001060 21537560200320 50881001060 30893 ruxolitinib phosphate JAKAFI NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 50881001560 21537560200325 50881001560 30894 ruxolitinib phosphate JAKAFI NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 50881002060 21537560200330 50881002060 30895 ruxolitinib phosphate JAKAFI NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 50881002560 21537560200335 50881002560 30896 ruxolitinib phosphate JAKAFI NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 54482005301 21700050100105 54482005301 38740 procarbazine HCl MATULANE NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 54482005401 21700050100105 54482005401 38740 procarbazine HCl MATULANE NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 57962001428 21534033000320 57962001428 44465 ibrutinib IMBRUVICA NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 57962007028 21534033000110 57962007028 44475 ibrutinib IMBRUVICA NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 57962014009 21534033000120 57962014009 35599 ibrutinib IMBRUVICA NR PDL

5/17/2019 51 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ONCOLOGY, ORAL - HEMATOLOGIC 57962014012 21534033000120 57962014012 35599 ibrutinib IMBRUVICA NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 57962028028 21534033000330 57962028028 44466 ibrutinib IMBRUVICA NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 57962042028 21534033000340 57962042028 44467 ibrutinib IMBRUVICA NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 57962056028 21534033000350 57962056028 44468 ibrutinib IMBRUVICA NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 59572020514 99392070000120 59572020514 28301 thalidomide THALOMID NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 59572021015 99392070000130 59572021015 95392 thalidomide THALOMID NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 59572021513 99392070000135 59572021513 98220 thalidomide THALOMID NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 59572022016 99392070000140 59572022016 19321 thalidomide THALOMID NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 59572040200 99394050000110 59572040200 31911 lenalidomide REVLIMID NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 59572040228 99394050000110 59572040228 31911 lenalidomide REVLIMID NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 59572040500 99394050000120 59572040500 26314 lenalidomide REVLIMID NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 59572040528 99394050000120 59572040528 26314 lenalidomide REVLIMID NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 59572041000 99394050000130 59572041000 26315 lenalidomide REVLIMID NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 59572041028 99394050000130 59572041028 26315 lenalidomide REVLIMID NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 59572041500 99394050000140 59572041500 27276 lenalidomide REVLIMID NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 59572041521 99394050000140 59572041521 27276 lenalidomide REVLIMID NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 59572042000 99394050000145 59572042000 34743 lenalidomide REVLIMID NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 59572042021 99394050000145 59572042021 34743 lenalidomide REVLIMID NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 59572042500 99394050000150 59572042500 27277 lenalidomide REVLIMID NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 59572042521 99394050000150 59572042521 27277 lenalidomide REVLIMID NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 59572050121 21450080000110 59572050121 34147 pomalidomide POMALYST NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 59572050200 21450080000115 59572050200 34148 pomalidomide POMALYST NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 59572050221 21450080000115 59572050221 34148 pomalidomide POMALYST NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 59572050300 21450080000120 59572050300 34149 pomalidomide POMALYST NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 59572050321 21450080000120 59572050321 34149 pomalidomide POMALYST NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 59572050400 21450080000125 59572050400 34150 pomalidomide POMALYST NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 59572050421 21450080000125 59572050421 34150 pomalidomide POMALYST NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 59572070530 21535030200320 59572070530 43688 enasidenib mesylate IDHIFA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 59572071030 21535030200340 59572071030 43689 enasidenib mesylate IDHIFA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 60505290009 21534035100320 60505290009 19908 imatinib mesylate IMATINIB MESYLATE NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 60505290103 21534035100340 60505290103 19907 imatinib mesylate IMATINIB MESYLATE NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 61958170101 21538040000320 61958170101 36884 idelalisib ZYDELIG NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 61958170201 21538040000330 61958170201 36885 idelalisib ZYDELIG NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 62484002001 21300040001830 62484002001 33277 mercaptopurine PURIXAN NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 62484002002 21300040001830 62484002002 33277 mercaptopurine PURIXAN NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 63020007902 21536045100130 63020007902 40193 ixazomib citrate NINLARO NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 63020008002 21536045100140 63020008002 40194 ixazomib citrate NINLARO NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 63020053430 21534075100340 63020053430 33874 ponatinib HCl ICLUSIG NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 63020053530 21534075100320 63020053530 33873 ponatinib HCl ICLUSIG NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 68084028401 21700030000105 68084028401 38400 hydroxyurea HYDROXYUREA NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 68462079201 21708080000110 68462079201 48590 tretinoin TRETINOIN NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 69076091302 21300040000305 69076091302 38520 mercaptopurine MERCAPTOPURINE NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 69076091325 21300040000305 69076091325 38520 mercaptopurine MERCAPTOPURINE NR PDL ONCOLOGY, ORAL - HEMATOLOGIC 71334010001 21534940000320 71334010001 45016 ivosidenib TIBSOVO NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 71779011502 21538030000120 71779011502 45424 duvelisib COPIKTRA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 71779012502 21538030000130 71779012502 45425 duvelisib COPIKTRA NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 76189053430 21534075100340 76189053430 33874 ponatinib HCl ICLUSIG NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 76388063525 21101010000305 76388063525 38370 chlorambucil LEUKERAN NR PDL

5/17/2019 52 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

ONCOLOGY, ORAL - HEMATOLOGIC 76388071325 21100010000305 76388071325 38420 busulfan MYLERAN NR NPD ONCOLOGY, ORAL - HEMATOLOGIC 76388088025 21300060000305 76388088025 10290 thioguanine TABLOID NR PDL OPHTHALMICS, ANTI- INFLAMMATORY/IMMUNOMODUL ATOR 47335050797 45144 cyclosporine CEQUA NR NPD OPHTHALMICS, ANTI- INFLAMMATORY/IMMUNOMODUL ATOR 00023530105 86720020001620 00023530105 42588 cyclosporine RESTASIS MULTIDOSE NR NPD OPHTHALMICS, ANTI- INFLAMMATORY/IMMUNOMODUL ATOR 00023916330 86720020001620 00023916330 19216 cyclosporine RESTASIS NR PDL OPHTHALMICS, ANTI- INFLAMMATORY/IMMUNOMODUL ATOR 00023916360 86720020001620 00023916360 19216 cyclosporine RESTASIS NR PDL OPHTHALMICS, ANTI- INFLAMMATORY/IMMUNOMODUL ATOR 47335050696 86720020002040 47335050696 45144 cyclosporine CEQUA NR NPD OPHTHALMICS, ANTI- INFLAMMATORY/IMMUNOMODUL ATOR 54092060601 86734050002020 54092060601 41847 lifitegrast XIIDRA NR NPD OTIC ANTIBIOTICS 00065853110 87991002401820 00065853110 82031 ciprofloxacin/hydrocortisone CIPRO HC NR NPD OTIC ANTIBIOTICS 00065853302 87991002361820 00065853302 20188 ciprofloxacin HCl/dexameth CIPRODEX NR PDL OTIC ANTIBIOTICS 24208041005 87100060002010 24208041005 13880 ofloxacin OFLOXACIN NR NPD OTIC ANTIBIOTICS 24208041010 87100060002010 24208041010 13880 ofloxacin OFLOXACIN NR NPD neomycin/polymyxin NEOMYCIN-POLYMYXIN- OTIC ANTIBIOTICS 24208063110 87991003102010 24208063110 14023 B/hydrocort HYDROCORT NR PDL neomycin/polymyxin OTIC ANTIBIOTICS 24208063562 87991003101807 24208063562 14025 B/hydrocort NEOMYCIN-POLYMYXIN-HC NR PDL OTIC ANTIBIOTICS 24338008014 87991002382025 24338008014 41358 ciprofloxacin HCl/fluocinolone OTOVEL NR NPD OTIC ANTIBIOTICS 42195055014 87100012102020 42195055014 24946 ciprofloxacin HCl CIPROFLOXACIN HCL NR PDL OTIC ANTIBIOTICS 50383002505 87100060002010 50383002505 13880 ofloxacin OFLOXACIN NR NPD OTIC ANTIBIOTICS 50383002510 87100060002010 50383002510 13880 ofloxacin OFLOXACIN NR NPD OTIC ANTIBIOTICS 60505036301 87100060002010 60505036301 13880 ofloxacin OFLOXACIN NR NPD OTIC ANTIBIOTICS 60505036302 87100060002010 60505036302 13880 ofloxacin OFLOXACIN NR NPD neomycin/polymyxin OTIC ANTIBIOTICS 61314064511 87991003101807 61314064511 14025 B/hydrocort NEOMYCIN-POLYMYXIN-HC NR PDL neomycin/polymyxin NEOMYCIN-POLYMYXIN- OTIC ANTIBIOTICS 61314064610 87991003102010 61314064610 14023 B/hydrocort HYDROCORT NR PDL neomyc/colist/hydrocort/thon OTIC ANTIBIOTICS 63481042105 87991004201820 63481042105 14106 zn COLY-MYCIN S NR NPD OTIC ANTIBIOTICS 69251020101 87100012001830 69251020101 40328 ciprofloxacin OTIPRIO NR NPD PAH AGENTS, ORAL AND INHALED 00069033621 40143060101920 00069033621 33186 sildenafil citrate REVATIO NR NPD PAH AGENTS, ORAL AND INHALED 00069419068 40143060100320 00069419068 24758 sildenafil citrate REVATIO NR NPD PAH AGENTS, ORAL AND INHALED 00093551798 40143060100320 00093551798 24758 sildenafil citrate SILDENAFIL NR PDL PAH AGENTS, ORAL AND INHALED 00378165777 40143060100320 00378165777 24758 sildenafil citrate SILDENAFIL NR PDL PAH AGENTS, ORAL AND INHALED 00378697693 40143080000320 00378697693 26587 tadalafil TADALAFIL NR NPD PAH AGENTS, ORAL AND INHALED 00904667104 40143060100320 00904667104 24758 sildenafil citrate SILDENAFIL NR PDL PAH AGENTS, ORAL AND INHALED 13668018590 40143060100320 13668018590 24758 sildenafil citrate SILDENAFIL NR PDL

5/17/2019 53 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

PAH AGENTS, ORAL AND INHALED 27241012302 40143080000320 27241012302 26587 tadalafil TADALAFIL NR NPD PAH AGENTS, ORAL AND INHALED 27241012403 40143060100320 27241012403 24758 sildenafil citrate SILDENAFIL NR PDL PAH AGENTS, ORAL AND INHALED 31722064730 40143080000320 31722064730 26587 tadalafil TADALAFIL NR NPD PAH AGENTS, ORAL AND INHALED 31722077690 40143060100320 31722077690 24758 sildenafil citrate SILDENAFIL NR PDL PAH AGENTS, ORAL AND INHALED 33342012110 40143060100320 33342012110 24758 sildenafil citrate SILDENAFIL NR PDL PAH AGENTS, ORAL AND INHALED 42543000510 40143060100320 42543000510 24758 sildenafil citrate SILDENAFIL NR PDL PAH AGENTS, ORAL AND INHALED 42543000590 40143060100320 42543000590 24758 sildenafil citrate SILDENAFIL NR PDL PAH AGENTS, ORAL AND INHALED 43598057860 40143080000320 43598057860 26587 tadalafil TADALAFIL NR NPD PAH AGENTS, ORAL AND INHALED 50419025001 40134050000310 50419025001 35376 riociguat ADEMPAS NR NPD PAH AGENTS, ORAL AND INHALED 50419025101 40134050000320 50419025101 35377 riociguat ADEMPAS NR NPD PAH AGENTS, ORAL AND INHALED 50419025201 40134050000330 50419025201 35383 riociguat ADEMPAS NR NPD PAH AGENTS, ORAL AND INHALED 50419025301 40134050000340 50419025301 35384 riociguat ADEMPAS NR NPD PAH AGENTS, ORAL AND INHALED 50419025401 40134050000350 50419025401 35385 riociguat ADEMPAS NR NPD PAH AGENTS, ORAL AND INHALED 55111037290 40143060100320 55111037290 24758 sildenafil citrate SILDENAFIL NR PDL PAH AGENTS, ORAL AND INHALED 59762003301 40143060100320 59762003301 24758 sildenafil citrate SILDENAFIL NR PDL PAH AGENTS, ORAL AND INHALED 60505340409 40143060100320 60505340409 24758 sildenafil citrate SILDENAFIL NR PDL PAH AGENTS, ORAL AND INHALED 61958080101 40160007000310 61958080101 98566 ambrisentan LETAIRIS NR PDL PAH AGENTS, ORAL AND INHALED 61958080201 40160007000320 61958080201 98567 ambrisentan LETAIRIS NR PDL PAH AGENTS, ORAL AND INHALED 65162035109 40143060100320 65162035109 24758 sildenafil citrate SILDENAFIL NR PDL PAH AGENTS, ORAL AND INHALED 65862068890 40143060100320 65862068890 24758 sildenafil citrate SILDENAFIL NR PDL PAH AGENTS, ORAL AND INHALED 66215010103 40160015000320 66215010103 14979 bosentan TRACLEER NR PDL PAH AGENTS, ORAL AND INHALED 66215010106 40160015000320 66215010106 14979 bosentan TRACLEER NR PDL PAH AGENTS, ORAL AND INHALED 66215010206 40160015000330 66215010206 14978 bosentan TRACLEER NR PDL PAH AGENTS, ORAL AND INHALED 66215010314 40160015007320 66215010314 43819 bosentan TRACLEER NR PDL PAH AGENTS, ORAL AND INHALED 66215010356 40160015007320 66215010356 43819 bosentan TRACLEER NR PDL PAH AGENTS, ORAL AND INHALED 66215030200 40170060002020 66215030200 26415 iloprost tromethamine VENTAVIS NR NPD PAH AGENTS, ORAL AND INHALED 66215030230 40170060002020 66215030230 26415 iloprost tromethamine VENTAVIS NR NPD PAH AGENTS, ORAL AND INHALED 66215030300 40170060002040 66215030300 21597 iloprost tromethamine VENTAVIS NR NPD PAH AGENTS, ORAL AND INHALED 66215030330 40170060002040 66215030330 21597 iloprost tromethamine VENTAVIS NR NPD PAH AGENTS, ORAL AND INHALED 66215050130 40160050000320 66215050130 35443 macitentan OPSUMIT NR NPD PAH AGENTS, ORAL AND INHALED 66215060206 40120070000310 66215060206 40355 selexipag UPTRAVI NR NPD PAH AGENTS, ORAL AND INHALED 66215060214 40120070000310 66215060214 40355 selexipag UPTRAVI NR NPD PAH AGENTS, ORAL AND INHALED 66215060406 40120070000315 66215060406 40356 selexipag UPTRAVI NR NPD PAH AGENTS, ORAL AND INHALED 66215060606 40120070000320 66215060606 40357 selexipag UPTRAVI NR NPD PAH AGENTS, ORAL AND INHALED 66215060806 40120070000325 66215060806 40358 selexipag UPTRAVI NR NPD PAH AGENTS, ORAL AND INHALED 66215061006 40120070000330 66215061006 40359 selexipag UPTRAVI NR NPD PAH AGENTS, ORAL AND INHALED 66215061206 40120070000335 66215061206 40374 selexipag UPTRAVI NR NPD PAH AGENTS, ORAL AND INHALED 66215061406 40120070000340 66215061406 40375 selexipag UPTRAVI NR NPD PAH AGENTS, ORAL AND INHALED 66215061606 40120070000345 66215061606 40376 selexipag UPTRAVI NR NPD PAH AGENTS, ORAL AND INHALED 66215062820 4012007000B720 66215062820 40378 selexipag UPTRAVI NR NPD PAH AGENTS, ORAL AND INHALED 66302020601 40170080002020 66302020601 27489 treprostinil/nebulizer/accesor TYVASO STARTER KIT NR NPD PAH AGENTS, ORAL AND INHALED 66302020602 40170080002020 66302020602 27491 treprostinil/neb accessories TYVASO REFILL KIT NR NPD PAH AGENTS, ORAL AND INHALED 66302020603 40170080002020 66302020603 27492 treprostinil TYVASO NR NPD PAH AGENTS, ORAL AND INHALED 66302030001 40170080050410 66302030001 35799 treprostinil diolamine ORENITRAM ER NR NPD PAH AGENTS, ORAL AND INHALED 66302030201 40170080050415 66302030201 35798 treprostinil diolamine ORENITRAM ER NR NPD PAH AGENTS, ORAL AND INHALED 66302031001 40170080050420 66302031001 35803 treprostinil diolamine ORENITRAM ER NR NPD PAH AGENTS, ORAL AND INHALED 66302032501 40170080050425 66302032501 35804 treprostinil diolamine ORENITRAM ER NR NPD PAH AGENTS, ORAL AND INHALED 66302035001 40170080050435 66302035001 43521 treprostinil diolamine ORENITRAM ER NR NPD

5/17/2019 54 AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE AUGUST 1, 2019

PAH AGENTS, ORAL AND INHALED 66302046760 40143080000320 66302046760 26587 tadalafil ADCIRCA NR PDL PAH AGENTS, ORAL AND INHALED 68001017605 40143060100320 68001017605 24758 sildenafil citrate SILDENAFIL NR PDL PAH AGENTS, ORAL AND INHALED 68001036305 40143060100320 68001036305 24758 sildenafil citrate SILDENAFIL NR PDL PAH AGENTS, ORAL AND INHALED 68084086921 40143060100320 68084086921 24758 sildenafil citrate SILDENAFIL NR PDL THROMBOPOIESIS STIMULATING PROTEINS 00007464113 82405030100330 00007464113 15995 eltrombopag olamine PROMACTA NR PDL THROMBOPOIESIS STIMULATING PROTEINS 00007464213 82405030100340 00007464213 28344 eltrombopag olamine PROMACTA NR PDL THROMBOPOIESIS STIMULATING PROTEINS 00078068415 82405030100310 00078068415 31176 eltrombopag olamine PROMACTA NR PDL THROMBOPOIESIS STIMULATING PROTEINS 00078068515 82405030100320 00078068515 15994 eltrombopag olamine PROMACTA NR PDL THROMBOPOIESIS STIMULATING PROTEINS 00078068615 82405030100330 00078068615 15995 eltrombopag olamine PROMACTA NR PDL THROMBOPOIESIS STIMULATING PROTEINS 00078068715 82405030100340 00078068715 28344 eltrombopag olamine PROMACTA NR PDL THROMBOPOIESIS STIMULATING PROTEINS 00078097219 82405030103030 00078097219 45875 eltrombopag olamine PROMACTA NR PDL THROMBOPOIESIS STIMULATING PROTEINS 00078097223 82405030103030 00078097223 45875 eltrombopag olamine PROMACTA NR PDL THROMBOPOIESIS STIMULATING PROTEINS 00078097261 82405030103030 00078097261 45875 eltrombopag olamine PROMACTA NR PDL THROMBOPOIESIS STIMULATING PROTEINS 55513022101 82405060002120 55513022101 13289 romiplostim NPLATE NR PDL THROMBOPOIESIS STIMULATING PROTEINS 55513022201 82405060002130 55513022201 13288 romiplostim NPLATE NR PDL THROMBOPOIESIS STIMULATING PROTEINS 59630055107 82405045000320 59630055107 45056 lusutrombopag MULPLETA NR NPD THROMBOPOIESIS STIMULATING PROTEINS 71332000101 85756040100310 71332000101 44702 fostamatinib disodium TAVALISSE NR NPD THROMBOPOIESIS STIMULATING PROTEINS 71332000201 85756040100320 71332000201 44703 fostamatinib disodium TAVALISSE NR NPD THROMBOPOIESIS STIMULATING PROTEINS 71369002010 82405010200320 71369002010 44787 avatrombopag maleate DOPTELET NR NPD THROMBOPOIESIS STIMULATING PROTEINS 71369002015 82405010200320 71369002015 44787 avatrombopag maleate DOPTELET NR NPD

5/17/2019 55