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CMDP Additional Preferred Drug List

• Generic Drugs Are Preferred Drugs Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2020 Preferred Drug Quantity Drug Class/Drug Name Reference Brand Name Brand Only Status PA Type Step Therapy Requirements Limit QL Days ALTERNATIVE MEDICINES ALTERNATIVE MEDICINE CAP 5 MG CVS MELATONIN MELATONIN CAP 10 MG MELATONIN MELATONIN TAB 300 MCG MELATONIN MELATONIN TAB 1 MG MELATONIN MELATONIN TAB 3 MG GNP MELATONIN MELATONIN TAB 5 MG CVS MELATONIN MELATONIN TAB ER 1 MG MELATONIN TIMED RELEASE MELATONIN TAB ER 5 MG MELATONIN MELATONIN TAB ER 10 MG MM MELATONIN TR MELATONIN SL TAB 3 MG MELATONIN MELATONIN SL TAB 5 MG MELATONIN MELATONIN SL TAB 10 MG CVS MELATONIN QUICK DISSOLVE MELATONIN LIQUID 1 MG/4ML (2.5 MG/10ML) MELATONIN MELATONIN LIQUID 1 MG/ML MELATONIN MELATONIN TABLET DISINTEGRATING 3 MG SV MELATONIN MELATONIN TABLET DISINTEGRATING 5 MG MELATONIN MELATONIN TABLET DISINTEGRATING 10 MG HM MELATONIN QUICK DISSOLVE ALTERNATIVE MEDICINE COMBINATIONS MELATONIN-PYRIDOXINE TABLETS 1-10 MG MELATONIN MELATONIN-PYRIDOXINE TABLETS 3-10 MG MELATONIN MELATONIN-PYRIDOXINE TABLETS 5-1 MG EQL MELATONIN/ B-6 MELATONIN-PYRIDOXINE TABLETS 5-10 MG MELATONIN MELATONIN-PYRIDOXINE TABLETS ER 3-10 MG MELATONIN TR/VITAMIN B-6 MELATONIN-PYRIDOXINE TABLETS ER 5-10 MG MELATONIN TR/VITAMIN B6 ANTHELMINTICS ANTHELMINTICS PYRANTEL PAMOATE SUSPENSION 144 MG/ML (50 MG/ML BASE EQUIV) REESES PINWORM MEDICINE ANTIDIARRHEAL/ AGENTS ANTIDIARRHEAL/PROBIOTIC COMBINATIONS COAGULANS-INULIN CAPSULES PROBIOTIC FORMULA -INULIN CAPSULES CULTURELLE DIGESTIVE HEALTH ANTIDIARRHEAL/PROBIOTIC AGENTS - MISC. BISMUTH SUBSALICYLATE CHEWABLE TABLETS 262 MG PX STOMACH RELIEF LACTOBACILLUS CAPSULES CVS PROBIOTIC ACIDOPHILUS LACTOBACILLUS CHEWABLE TABLETS PROBIOTIC CHEWABLE CHILDRENS LACTOBACILLUS REUTERI LIQUID BIOGAIA PROTECTIS BABY LACTOBACILLUS RHAMNOSUS (GG) CHEWABLE TABLETS CULTURELLE KIDS LACTOBACILLUS RHAMNOSUS (GG) PACKET MOMMYS BLISS PROBIOTIC PROBIOTIC PRODUCT - CAPSULES CVS ADULT 50+ PROBIOTIC ANTISEPTICS & DISINFECTANTS CHLORINE ANTISEPTICS CHLORHEXIDINE GLUCONATE LIQUID 2% CHLORHEXIDINE GLUCONATE CHLORHEXIDINE GLUCONATE LIQUID 4% OPERAND CHLORHEXIDINE GLUCONATE CHLORHEXIDINE GLUCONATE SOLUTION 4% HM ANTISEPTIC SKIN CLEANSER CONTRACEPTIVES COMBINATION CONTRACEPTIVES - ORAL NORETHINDRONE ACE & ETHINYL ESTRADIOL-FE TABLETS 1 MG-20 MCG GILDESS FE 1/20 NORETHINDRONE ACE-ETH ESTRADIOL-FE CHEW TABLETS 1 MG-20 MCG (24) MIBELAS 24 FE NORETHIN-ETH ESTRADIOL-FE TABLETS 1 MG-10 MCG (24)/10 MCG (2) LO LOESTRIN FE COMBINATION CONTRACEPTIVES - TRANSDERMAL NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-35 MCG/24HR XULANE CMDP Additional Preferred Drug List

• Generic Drugs Are Preferred Drugs Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2020 Preferred Drug Quantity Drug Class/Drug Name Reference Brand Name Brand Only Status PA Type Step Therapy Requirements Limit QL Days COUGH/COLD/ALLERGY MISC. RESPIRATORY INHALANTS CHLORIDE AERO SOLUTION 0.9% SIMPLY SALINE BABY DERMATOLOGICALS ANTIFUNGALS - TOPICAL TERBINAFINE HCL CREAM 1% TERBINAFINE HCL ANTIBIOTICS - TOPICAL NEOMYCIN-BACITRACIN-POLYMYXIN-PRAMOXINE OINTMENT 1% GNP TRIPLE ANTIBIOTIC PLUS ANTISEBORRHEIC PRODUCTS SULFIDE SHAMPOO 2.25% SELENIUM SULFIDE SHAMPOO CORTICOSTEROIDS - TOPICAL BETAMETHASONE DIPROPIONATE CREAM 0.05% BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE OINT 0.05% BETAMETHASONE DIPROPIONATE DIAPER RASH PRODUCTS DIAPER RASH PRODUCTS - OINTMENT CVS PEDIATRIC OINTMENT EMOLLIENTS EMOLLIENT CREAM MOISTURIZING CREAM EMOLLIENT OINTMENT DAILY CONDITIONING TREATMENT KERATOLYTIC/ANTIMITOTIC AGENTS SALICYLIC ACID PAD 40% CORN REMOVERS MISC. TOPICAL CALAMINE- OXIDE LOTION HM CALAMINE DIMETHICONE-ZINC OXIDE-- CREAM 1-10% CVS ZINC OXIDE DIAPER CREAM SKIN PROTECTANTS MISC - CREAM EUCERIN ZINC OXIDE CREAM 13% DESITIN RAPID RELIEF SCABICIDES & PEDICULICIDES PERMETHRIN CR RINSE 1% & NIT REMOVER GEL & PERMETH SPR KIT NIX COMPLETE LICE TREATMENT KIT BENZYL ALCOHOL LOTION 5% ULESFIA PYRETH-PIPERONYL BUTOX SHAM-PERMETH AERO-NIT REMOVER GEL KIT LICE SOLUTION COMPLETE TAR PRODUCTS COAL TAR SHAMPOO 0.5% THERAPEUTIC SHAMPOO DIAGNOSTIC PRODUCTS DIAGNOSTIC TESTS ACETONE (URINE) TEST STRIP KETONE TEST STRIPS DIGESTIVE AIDS DIGESTIVE ENZYMES LACTASE TABLETS 3000 UNIT CVS LACTASE LACTASE TABLETS 9000 UNIT DAIRY DIGESTIVE SUPPLEMENT FAST ACTING GASTROINTMENTESTINAL AGENTS - MISC. ANTIFLATULENTS SIMETHICONE CHEWABLE TABLETS 80 MG RA GAS RELIEF SIMETHICONE LIQUID 40 MG/0.6ML CVS GAS RELIEF DROPS EXTRA STRENGTH SIMETHICONE SUSPENSION 40 MG/0.6ML HM GAS RELIEF INFANTS DROPS HEMATOPOIETIC AGENTS CARBONYL IRON CHEWABLE TABLETS 15 MG (ELEMENTAL IRON) IRON CHEWS PEDIATRIC LAXATIVES BULK LAXATIVES CALCIUM POLYCARBOPHIL TABLETS 625 MG CVS FIBER LAXATIVE CORN DEXTRIN ORAL POWDER CVS EASY FIBER INULIN CHEWABLE TABLETS 1.5 GM FIBER CHOICE FRUITY BITES LUBRICANT LAXATIVES OIL QC MINERAL OIL HEAVY CMDP Additional Preferred Drug List

• Generic Drugs Are Preferred Drugs Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2020 Preferred Drug Quantity Drug Class/Drug Name Reference Brand Name Brand Only Status PA Type Step Therapy Requirements Limit QL Days LAXATIVES - MISCELLANEOUS GLYCERIN ENEMA ADULT 5.4 GM/AVERAGE DELIVERED DOSE FLEET LIQUID GLYCERIN SUPPOSITORIES GLYCERIN LIQUID SUPPOSITORIES 2.8 GM (2.7 ML) PEDIA-LAX GLYCERIN SUPPOSITORIES 1 GM GLYCERIN INFANTS & CHILDREN GLYCERIN SUPPOSITORIES 1.2 GM GLYCERIN CHILDREN GLYCERIN SUPPOSITORIES 2 GM GLYCERIN ADULT LAXATIVE COMBINATIONS SENNOSIDES-DOCUSATE SODIUM TABLETS 8.6-50 MG GNP STOOL SOFTENER/STIMULANT LAXATIVE SALINE LAXATIVES HYDROXIDE SUSPENSION 400 MG/5ML SM MILK OF MAGNESIA SODIUM PHOSPHATES - ENEMA EQ ENEMA MACROLIDES ERYTHROMYCINS ERYTHROMYCIN TABLETS 250 MG ERYTHROMYCIN BASE ERYTHROMYCIN TABLETS DELAYED RELEASE 250 MG ERY-TAB ERYTHROMYCIN ETHYLSUCCINATE FOR SUSPENSION 200 MG/5ML ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ETHYLSUCCINATE FOR SUSPENSION 400 MG/5ML ERYPED 400 MEDICAL DEVICES AND SUPPLIES DIABETIC SUPPLIES FREESTYLE METER FREESTYLE LIBRE MINERALS & ELECTROLYTES ELECTROLYTE MIXTURES ORAL ELECTROLYTE SOLUTION RA PEDIATRIC ELECTROLYTE MOUTH/THROAT/DENTAL AGENTS DENTAL PRODUCTS SF 5000 PLUS CREAM 1.1% SF 5000 PLUS FLUORIDEX PASTE 1.1% FLUORIDEX PED MULTIPLE W/ MINERALS PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEWABLE TABLETS MVW COMPLETE FORMULATION PEDIATRIC MULTIPLE VITAMIN W/ MINERALS & C CHEWABLE TABLETS 60 MG POLYVITAMIN/IRON PED MV W/ IRON PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEWABLE TABLETS 15 MG RA CHILDRENS CHEWABLE VITAMINS/IRON PEDIATRIC MULTIPLE VITAMINS W/ IRON CHEWABLE TABLETS 18 MG PLUS IRON CHILDRENS NASAL AGENTS - SYSTEMIC AND TOPICAL NASAL ANTI-INFECTIVES MUPIROCIN CALCIUM NASAL OINTMENT 2% BACTROBAN NASAL NASAL AGENTS - MISC. SALINE NASAL SOLUTION 0.65% AYR NASAL DROPS SALINE NASAL SPRAY 0.65% LITTLE NOSES SALINE NUTRIENTS MISC. NUTRITIONAL SUBSTANCES OMEGA-3 FATTY ACIDS CAPSULES 500 MG BURP-LESS OMEGA-3 FATTY ACIDS CAPSULES 1000 MG THEROMEGA OMEGA-3 FATTY ACIDS CAPSULES 1200 MG SM OMEGA-3 FISH OIL OPHTHALMIC AGENTS ARTIFICIAL TEARS AND LUBRICANTS DEXTRAN 70-HYPROMELLOSE OPHTH SOLUTION 0.1-0.3% NATURAL BALANCE TEARS DEXTRAN 70-HYPROMELLOSE (PF) OPHTH SOLUTION 0.1-0.3% BION TEARS WHITE PETROLATUM-MINERAL OIL OPHTH OINTMENT CVS EYE LUBRICANT NIGHTTIME OTIC AGENTS OTIC AGENTS - MISCELLANEOUS CARBAMIDE PEROXIDE 6.5% OTIC SOLUTION EARWAX REMOVAL CMDP Additional Preferred Drug List

• Generic Drugs Are Preferred Drugs Over Brand Name Drugs Unless Specified as Brand Only • Federally Reimbursable Drugs Not Listed On The AHCCCS Drug List Are Available Through Prior Authorization Effective Date: 10/1/2020 Preferred Drug Quantity Drug Class/Drug Name Reference Brand Name Brand Only Status PA Type Step Therapy Requirements Limit QL Days PHARMACEUTICAL ADJUVANTS INTERNAL VEHICLE INGREDIENTS/AGENTS STARCH-MALTODEXTRIN ORAL THICKENING POWDER THICK NOW XANTHAN GUM ORAL THICKENING GEL SIMPLYTHICK LIQUID VEHICLES DISTILLED WATER PURIFIED WATER ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERG MISC. ANTI-ULCER SUCRALFATE SUSPENSION 1 GM/10ML SUCRALFATE VAGINAL PRODUCTS VAGINAL ANTI-INFECTIVES MICONAZOLE NITRATE VAGINAL CREAM 2% QC MICONAZOLE 7 VITAMINS WATER SOLUBLE VITAMINS ASCORBIC ACID TABLETS 500 MG BIOTIN CAPSULES 5 MG PA BIOTIN BIOTIN TABLETS 1000 MCG BIOTIN OIL SOLUBLE VITAMINS CHOLECALCIFEROL CAPSULES 400 UNIT EQL VITAMIN D3 CHOLECALCIFEROL CAPSULES 1000 UNIT D3-1000 CHOLECALCIFEROL CAPSULES 2000 UNIT KP VITAMIN D CHOLECALCIFEROL CAPSULES 5000 UNIT CVS D3 CHOLECALCIFEROL CAPSULES 10000 UNIT VITAMIN D3 CHOLECALCIFEROL CAPSULES 50000 UNIT D3-50 CHOLECALCIFEROL TABLETS 400 UNIT VITAMIN D-400 CHOLECALCIFEROL TABLETS 1000 UNIT D 1000 CHOLECALCIFEROL TABLETS 2000 UNIT D 2000 CHOLECALCIFEROL TABLETS 5000 UNIT D-5000 CHOLECALCIFEROL CHEWABLE TABLETS 1000 UNIT CVS VITAMIN D CHILDRENS GUMMIES CHOLECALCIFEROL ORAL LIQUID 400 UNIT/ML VITAMIN D CHOLECALCIFEROL DROPS 400 UNIT/0.028ML (PER DROP) BABY SUPER DAILY D3