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AHCCCS Pharmacy and Therapeutics Committee Recommendations July 17, 2018 Committee Recommendations PDL Recommendation Key: • Products currently preferred and remaining preferred are listed in Black • Products currently new, not previously reviewed or non-preferred and recommended to be preferred are listed in Blue • Products currently new, not previously reviewed or preferred and recommended to be non- preferred are listed in Red • Products currently included on the AHCCCS approved drug list are noted with an asterisk (*) • Classes where grandfathering is recommended will have a notation on the preferred recommendations page

Reaching across Arizona to provide comprehensive 2 quality health care for those in need

P&T Public Class Vote: Antipsychotics, Oral

Reaching across Arizona to provide comprehensive 3 quality health care for those in need Antipsychotics PDL Recommendations (preferred products):

• Oral Agents

o aripiprazole ODT*, * & tablets* o clozapine ODT*, clozapine ODT* (AG) & tablets* o Latuda* o olanzapine ODT* & tablets* o quetiapine tablets* o risperdone ODT*, solution* & tablets* o Saphris* o capsules*

Reaching across Arizona to provide comprehensive 4 quality health care for those in need P&T Public Class Vote: Antipsychotics, Long-Acting Injectable

Reaching across Arizona to provide comprehensive 5 quality health care for those in need Antipsychotics PDL Recommendations (preferred products):

• Long-Acting Injectable Agents

o Abilify Maintena* o Aristada* o Aristada Initio – quantity of limit of 2 per year o Invega Sustenna* o Invega Trinza* o Risperdal Consta*

Reaching across Arizona to provide comprehensive 6 quality health care for those in need P&T Public Class Vote: Stimulants & Related Agents

Reaching across Arizona to provide comprehensive 7 quality health care for those in need Stimulants & Related Agents PDL Recommendations (preferred products): • guanfacine ER* • Adderall XR* • Kapvay* • amphetamine salt combination* • Methylin Solution* • Aptensio XR* • Methylphenidate* • , atomoxetine (AG) • methylphenidate CD*, methylphenidate • Concerta* CD (AG)* • Daytrana* • methylphenidate ER (gen. Ritalin LA)* • dextroamphetamine capsule ER* • Quillichew ER* • dextroamphetamine * • Quillivant XR* • Focalin* • Ritalin LA 10mg capsule* • Focalin XR* • Vyvanse Capsule*, Chewable Tablet Reaching across Arizona to provide comprehensive 8 quality health care for those in need

Stimulants & Related Agents (continued) PDL Recommendations (products moving to non- preferred): • methylphenidate chewable tablets* • methylphenidate ER (gen. Concerta)* • Strattera*

Reaching across Arizona to provide comprehensive 9 quality health care for those in need P&T Public Class Vote: Pancreatic

Reaching across Arizona to provide comprehensive 10 quality health care for those in need Pancreatic Enzymes PDL Recommendations (preferred products): • Creon* • Zenpep*

Reaching across Arizona to provide comprehensive 11 quality health care for those in need P&T Public Class Vote: Anticoagulants

Reaching across Arizona to provide comprehensive 12 quality health care for those in need Anticoagulants PDL Recommendations (preferred products):

• Oral Agents

o Eliquis*, Eliquis Dose Pack o Pradaxa* o Xarelto*, Xarelto Dose Pack* o Warfarin* • Injectable Agents o enoxaparin syringe*, enoxaparin syringe* (AG) o enoxaparin vial* (AG)

Reaching across Arizona to provide comprehensive 13 quality health care for those in need P&T Public Class Vote: , Oral

Reaching across Arizona to provide comprehensive 14 quality health care for those in need Antifungals, Oral PDL Recommendations (preferred products): • troche • suspension*, tablets* • griseofluvin suspension* • griseofluvin tablets microsized* • suspension, tablets* • tablets*

Reaching across Arizona to provide comprehensive 15 quality health care for those in need Antifungals, Oral (continued) PDL Recommendations (products moving to non-

preferred): • Cresemba • nystatin oral powder* • diflucan suspension*, tablets* • Onmel* • * • Oravig (buccal) • tablets ultramicrosized* • Sporanox Capsule*, Suspension* • Gris-Peg* • Vfend Suspension* • * • suspension*, tablets* • * • Lamisil Tablets* • Noxafil Suspension*, Tablets*

Reaching across Arizona to provide comprehensive 16 quality health care for those in need

P&T Public Class Vote: Antifungals, Topical

Reaching across Arizona to provide comprehensive 17 quality health care for those in need Antifungals, Topical PDL Recommendations (preferred products): • , suspension • ciclopirox solution • clotrimazole cream OTC*, cream Rx*, solution OTC*, solution Rx* • clotrimazole/ cream* • ketoconazole cream*, * • Lotrimin Ultra OTC • cream OTC*, ointment OTC*, powder OTC*, spray OTC • nystatin cream*, ointment*, powder* • Aero powder OTC, cream OTC, powder OTC, spray OTC • terbinafine cream OTC Reaching across Arizona to provide comprehensive 18 quality health care for those in need

Antifungals, Topical (continued)

PDL Recommendations (products moving to non-

preferred): • Ertaczo • Alevazol OTC • Exelderm Cream, Solution • Azolen Tincture • Extina* • Bensal HP • Fungoid Kit OTC* • ciclopirox gel, kit, shampoo • Fungoid OTC* • clotrimazole/betamethasone lotion* • Jublia • DermacinRx Therazole Pak • Kerydin • Desenex Aero Powder OTC • ketoconazole foam • • Lamisil AT Cream OTC, Gel OTC • Ecoza

Reaching across Arizona to provide comprehensive 19 quality health care for those in need

Antifungals, Topical (continued)

PDL Recommendations (products moving to non-

preferred): • Nizoral A-D Shampoo OTC* • Lamisil Spray OTC • Nizoral Shampoo* • Loprox Cream, Kit, Shampoo, Solution • nystatin/ cream, • Lotrimin AF Cream OTC* ointment • Lotrimin AF OTC* • cream • Lotrisone Cream* • Oxistat Cream, Lotion • Luzu • Penlac • Mentax • tolnaftate solution OTC • cream, cream (AG) • Vusion • Naftin Cream, Gel • Xolegel*

Reaching across Arizona to provide comprehensive 20 quality health care for those in need

P&T Public Class Vote: Beta Blockers

Reaching across Arizona to provide comprehensive 21 quality health care for those in need Beta Blockers PDL Recommendations (preferred products): • atenolol* • nadolol* • atenolol/chlorthalidone* • nadolol/bendroflumethazide • bisoprolol • solution*, tablets* • bisoprolol/HCTZ • propranolol ER* • * • propranolol/HCTZ • labetalol* • * • metoprolol* • metoprolol/HCTZ ***Grandfathering will apply in this class*** • metoprolol XL*

Reaching across Arizona to provide comprehensive 22 quality health care for those in need

Beta Blockers (continued) PDL Recommendations (products moving to non- preferred): • acebutolol • Hemangeol • Sotylize* • Betapace*, Betapace AF* • Inderal LA* • Tenoretic* • betaxolol • Inderal XL • Tenormin* • Bystolic • InnoPran XL • Timolol • carvedilol ER • Levatol • Toprol XL* • Coreg* • Lopressor* • Coreg CR • metoprolol XL/HCTZ (AG)* • Corgard* • pindolol* • Dutoprol • propranolol ER (AG)*

Reaching across Arizona to provide comprehensive 23 quality health care for those in need

P&T Public Class Vote: BPH Treatments

Reaching across Arizona to provide comprehensive 24 quality health care for those in need BPH Treatments PDL Recommendations (preferred products): • alfuzosin ER • doxazosin* • • * • tamsulosin* • terazosin*

Reaching across Arizona to provide comprehensive 25 quality health care for those in need BPH Treatments (continued) PDL Recommendations (products moving to non- preferred): • Avodart • Rapaflo • Cardura* • Uroxatral • Cardura XL* • Cialis • dutasteride/tamsulosin • Flomax* • Jalyn • Proscar*

Reaching across Arizona to provide comprehensive 26 quality health care for those in need

P&T Public Class Vote: Channel Blockers

Reaching across Arizona to provide comprehensive 27 quality health care for those in need Calcium Channel Blockers PDL Recommendations (preferred products): • * • capsule ER* • diltiazem tablet* • ER* ***Grandfathering will apply in this class*** • IR* • nifedipine ER* • capsule ER* • verapamil ER PM* • verapamil tablet* • verapamil tablet ER*

Reaching across Arizona to provide comprehensive 28 quality health care for those in need

Calcium Channel Blockers (continued) PDL Recommendations (products moving to non- preferred): • Adalat CC* • * • verapamil 360mg capsule • Calan SR* • * • Verelan PM* • Cardizem* • * • Cardizem CD* • Norvasc* • Cardizem CD 360mg • Nymalize* • Cardizem LA* • Procardia* • diltiazem LA (AG)* • Procardia XL • * • Tiazac • Matzim LA • Tiazac 420mg

Reaching across Arizona to provide comprehensive 29 quality health care for those in need

P&T Public Class Vote: , Topical

Reaching across Arizona to provide comprehensive 30 quality health care for those in need Steroids, Topical PDL Recommendations (preferred products):

• Low Potency Topical Agents

o cream*, gel, lotion* & ointment* o 0.01% oil*

Reaching across Arizona to provide comprehensive 31 quality health care for those in need Steroids, Topical (continued) PDL Recommendations (products moving to non- preferred): • Low Potency Agents o Ala-Scalp HP* o hydrocortisone/min oil/pet oi o dipropionate cr*, oi* o MiCort-HC* o Aqua Glycolic HC o Texacort* o Capex Shampoo* o Tridesilon* o Derma-Smoothe-FS* o Dermasorb HC Desonate Gel* o o lotion*, oi*

Reaching across Arizona to provide comprehensive 32 quality health care for those in need

Steroids, Topical PDL Recommendations (preferred products):

• Medium Potency Topical Steroid Agents

o propionate cream* & ointment* o furoate cream*, ointment* & solution*

Reaching across Arizona to provide comprehensive 33 quality health care for those in need Steroids, Topical (continued) PDL Recommendations (products moving to non-preferred): • Medium Potency Topical Steroid Agents

o foam o cr*, cr o cr (AG) (AG)*, lo*, oi*, oi (AG)*, so*, so (AG)* o Cloderm o hydrocortisone butyrate/emollient, o Cordran Tape emollient (AG) o Cutivate Cr*, Lo* o cr*, oi* o Elocon Cr*, Oi* o Luxiq* o cr*, oi*, so* o Pandel o flurandrenolide cr*, lo*, lo (AG)*, cr, oi oi* o Synalar Cream Kit, Oi*, Oi Kit, lo* o o So*, TS Kit Reaching across Arizona to provide comprehensive 34 quality health care for those in need

Steroids, Topical PDL Recommendations (preferred products):

• High Potency Topical Steroid Agents

o betamethasone dipropionate lotion o betamethasone dipropionate/propylene glyc cream* o betamethasone valerate cream*, lotion* & ointment* o cream*, ointment* & solution* o cream*, lotion* & ointment*

Reaching across Arizona to provide comprehensive 35 quality health care for those in need Steroids, Topical (continued) PDL Recommendations (products moving to non-preferred): • High Potency Topical Steroid Agents

o cr, lo o Ellzia Pak o betamethasone dipropionate/ o fluocinonide emollient*, gel* prop gly lotion*, ointment* o Halog C r, O i o betamethasone dipropionate gel* o Kenalog Aerosol* o DermacinRx Silapak o Sernivo Spray o DermacinRx Silazone o Silazone-II o Dermasorb TA o Topicort Ointment, Spray o cr, gel, oi o triamcinolone acetonide aerosol* o diacetate cr, oi o triamcinolone acetonide/dimethicone o Diprolene Oi* o Trianex Oi* Reaching across Arizona to provide comprehensive 36 quality health care for those in need

Steroids, Topical PDL Recommendations (preferred products):

• Very High Potency Topical Steroid Agents

o propionate cream*, emollient, gel*, ointment* & solution* o halobetasol propionate cream & ointment

***Grandfathering will apply for this class***

Reaching across Arizona to provide comprehensive 37 quality health care for those in need Steroids, Topical (continued) PDL Recommendations (products moving to non- preferred): • Very High Potency Topical Steroid Agents o Apexicon E o clobetasol lotion*, shampoo* o foam*, spray, spray (AG) o Clobex Lotion*, Shampoo*, Spray* o Clodan Kit o Olux* o Temovate Cream* o Ultravate Lotion o Ultravate X Pac Cream, Lotion

Reaching across Arizona to provide comprehensive 38 quality health care for those in need