April 2016

Title 19/21 SMI Drug List Updates: P. 19 Narcan nasal spray added to formulary P. 21 Benicar, Benicar HCT removed P. 22 Entresto added to formulary with PA P. 38 Advair HFA covered for ages 4-12, others require PA per AHCCCS PDL P. 38 Asmanex HFA removed per AHCCCS PDL P. 38 Asmanex Twisthaler added per AHCCCs PDL P. 38 Pulmicort Respules added with QLL #60/30 days per AHCCCS PDL P. 38 Budesonide Respules removed per AHCCCS PDL P. 38 Flovent Diskus removed per AHCCCS PDL P. 38 Pulmicort Flexhaler removed per AHCCCS PDL

GMH/SA & Non-Title 19/21 Drug List Updates: P. 10 Narcan nasal spray added to formulary

March 2016Title 19/21 SMI Drug List Updates: P. 7 Acyclovir QLL removed P. 9 Gleevec removed P. 9 Imatinib added with PA P. 14 Paroxetine 37.5mg QLL increased to #60/ 30 days P. 14 Escitalopram 10mg tablets QLL increased to #45/ 30days P. 14 Fluoxetine 10mg tablets QLL increased to #45/ 30 days

GMH/SA & Non-Title 19/21 Drug List Updates: P. 4 Paroxetine 37.5mg QLL increased to #60/ 30 days P. 4 Escitalopram 10mg tablets QLL increased to #45/ 30days P. 4 Fluoxetine 10mg tablets QLL increased to #45/ 30 days

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February 2016Title 19/21 SMI Drug List Updates: P. 6 Reyataz suspension added per AHCCCS P. 6 Evotaz added per AHCCCS P. 6 Prezista suspension added per AHCCCS P. 6 Prezcobix added per AHCCCS P. 6 Isentress chewable tablets and suspension added per AHCCCS P. 26 Prandimet P. 26 Repaglinide and metformin hydrochloride tablets added P. 33 Enoxaparin, Fragmin, fondaparinux QLL changed from 10 days w/o PA to

21 days P. 37 Patanol removed P. 37 Olopatadine ophthalmic added P. 42 Norgestimate/Ethinyl Estradiol 28-Day Tablet added P. 42 Ortho Tri Cyclen Lo removed P. 43 Tri-Lo-Estarylla 28-Day Tablet added P. 43 Tri-Lo-Sprintec 28-Day Tablet added P. 43 Trinessa Lo added

GMH/SA & Non-Title 19/21 Drug List Updates: No Updates

January 2016Title 19/21 SMI Drug List Updates: P. 9 Sandostatin LAR added with PA P. 9 Enbrel, Humira added w/ PA; preferred drugs with PA per AHCCCS PDL P. 9 Orencia, Kineret, Otezal, Ilaris, Cimzia, Simponi, Remicade, Arcalyst,

Cosentyx, Xeljanz, Actemra, Entyvio, Stelara removed from formulary; non-preferred drugs per AHCCCS PDL

P. 10 Hyalgan added with PA P. 10 Gel-One added with PA P. 10 Tasigna added with PA and QLL #60/30days P. 11 Diastat rectal Gel, QLL removed P. 14 Fluvoxamine ER, QLL changed #60/ 30 days P. 15 Ivega tablets removed from the formulary P. 15 Paliperidone tablets added to the formulary and PA removed P. 17 Aubagio added with PA and QLL #30/30days P. 17 Glatopa added with PA P. 17 Modafinil added with PA and QLL #30/30days P. 21 Candesartan, - HCT added P. 23 Crestor added with PA P. 26 Tradjenta added with STEP and QLL #30/30days P. 26 Jentadueto added with STEP and QLL #60/30days

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P. 26 Invokana added with STEP and QLL #30/30days P. 26 Invokamet added with STEP and QLL #60/30days P. 26 Farxiga added with STEP and QLL #30/30days P. 27 Trulicity added with STEP P. 27 Victoza removed P. 27 Genotropin, Norditropin, Nutropin preferred drug w/ PA per AHCCCS PDL P. 27 Humatrope, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive,

and Serostim removed from formulary; non-preferred drugs per AHCCCS PDL P. 27 Tev-Tropin removed from formulary, no longer marketed P. 27 Tacrolimus added, COVERED FOR AGE 2 THROUGH10; STEP FOR

ALL OTHERS QLL=30 gm/30 days P. 29 Esomeprazole OTC added with QLL #60/30days P. 29 Lansoprazole OTC added with QLL #60/30days P. 29 Omeprazole OTC QLL updated to #60/30days P. 30 Rectiv added with PA and QLL #30gm/30days P. 33 Fondaparinux added, 10 DAYS W/O PA(10 DAYS=10 SYRINGES) P. 37 ProAir removed from formulary P. 37 Proventil HFA removed from formulary P. 37 Foradil added changed from PA to STEP and QLL #60/30days P. 37 Striverdi Respimat added with QLL 1 inhaler per 30days P. 37 Arcapta Neohaler add with QLL 1 inhaler per 30days P. 37 Azelastine added with STEP P. 38 Incruse Ellipta added with QLL 1 inhaler per 30days P. 38 Kitabis and Bethkis added w/ PA; preferred drug per AHCCCS PDL P. 38 Tobi, Tobi podhaler, tobramycin ampules, Tobramycin PAK and Cayston

removed from formulary; non-preferred drugs per AHCCCS PDL P. 38 Epinephrine, EpiPen preferred drugs per AHCCCS PDL P. 38 Adrenaclick removed from formulary; non-preferred drug per AHCCCS

PDL P. 39 Epinastine added with STEP

GMH/SA & Non-Title 19/21 Drug List Updates: P. 3 Fluvoxamine ER, QLL changed #60/ 30 days P. 6 Ivega tablets removed from the formulary P. 6 Paliperidone tablets added to the formulary and PA removed

December

Title 19/21 SMI Drug List Updates: P. 5 Macrodantin 25mg removed from formulary P. 5 Nitrofurantion 25mg added to formulary P. 13 Bupropion XL 150mg tabs QLL changed to #90/30

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P. 14 Orap tablets removed from formulary P. 14 Pimozide tablets added to formulary P. 17 Namenda solution removed from formulary P. 17 Memantine solution added to formulary with PA P. 17 Methylphenidate ER 36mg QLL changed to #60/30 P. 32 Amicar tablets and solution added to formulary P. 37 Epi-Pen and Epi-Pen JR removed STEP

GMH/SA & Non-Title 19/21 Drug List Updates: P. 5 Orap tablets removed from formulary P. 5 Pimozide tablets added to formulary P. 9 Bupropion XL 150mg tabs QLL changed to #90/30 P. 9 Methylphenidate ER 36mg QLL changed to #60/30

November

Title 19/21 SMI Drug List Updates: P. 6 Epivir oral solution removed from formulary P. 6 Lamivudine oral solution added to formulary P. 7 Zyvox removed from formulary P. 7 linezolid added to formulary with PA P. 8 Valcyte removed from formulary P. 8 Valganciclovir added to formulary with PA P. 8 Daraprim added PA P. 20 Intuniv removed from formulary P. 20 Guanfacine ER added to formulary P. 22 Lescol XL removed from formulary P. 22 Fluvastatin ER added to formulary P. 29 HC w/pramoxine cream removed from formulary, DESI drug P. 34 Methergine tablets removed from formulary P. 34 methylergonovine maleate tablets added to formulary P. 42 Liletta added to formulary

GMH/SA & Non-Title 19/21 Drug List Updates: P. 9 Intuniv removed from formulary P. 9 Guanfacine ER added to formulary

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October 2015

Title 19/21 SMI Drug List Updates: P. 15 Abilify solution removed from formulary P. 15 Aripiprazole sol’n added to formulary, with PA and QLL of #480ml/30 days P. 17 Exelon Patch removed from formulary P. 17 Rivastigmine Patch added to formulary, with PA P. 20 Clonidine ER tabs QLL changed to #120/ 30 days P. 40 Peak Flow Meter added to formulary with QLL of #1/ 365 days P. 40 Pen Needles added to formulary with QLL of #100/ 30 days

GMH/SA & Non-Title 19/21 Drug List Updates: P. 9 Clonidine ER tabs QLL changed to #120/ 30 days P. 10 Abilify solution removed from formulary P. 10 Aripiprazole sol’n added to formulary, with PA and QLL of #480ml/30 days

September 2015

Title 19/21 SMI Drug List Updates: P. 18 Buprenorphine QLL changed to #90/ 30 days P. 37 Epi-Pen and Epi-Pen JR, added STEP P. 37 Epinephrine 0.3mg/0.3ml and 0.15mg/0.15ml added to the formulary P. 37 Budesonide Respules QLL added #60/ 30 days

GMH/SA & Non-Title 19/21 Drug List Updates: P. 9 Buprenorphine QLL changed to #90/ 30 days

August 2015

Title 19/21 SMI Drug List Updates: P. 8 Stromectol removed from formulary

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P. 8 Ivermectin added to the formulary P. 13 Lamotrigine QLL changed to #60/ 30 days P. 18 Namenda removed from fromulary P. 18 Memantine added to the formulary with no PA P. 40 Test strips QLL changed to #150/ 30 days

GMH/SA & Non-Title 19/21 Drug List Updates: No changes

July 2015

Title 19/21 SMI Drug List Updates: P. 15 aripiprazole removed from formulary per AHCCCS MRPDL P. 29 Antacids removed max dollar amount of $30/ month P. 34 Femhrt removed from formulary P. 34 Norethindrone Acetate/ Ethinyl Estradiol 0.5mg/2.5mcg added to formulary

GMH/SA & Non-Title 19/21 Drug List Updates: P. 5 aripiprazole removed from formulary per AHCCCS MRPDL

June 2015

Title 19/21 SMI Drug List Updates: P. 15 Abilify Maintenna PA added per DBHS P. 15 Invega Sustenna PA added per DBHS P. 35 Latanoprost QLL added #2 bottles/ 30 days P. 9 Cosentyx added with PA P. 32 Auryxia added with PA P. 16 Diclegis QLL changed to maximum 120 tabs P. 20 Clonidine ER QLL added #30/ 30 days

GMH/SA & Non-Title 19/21 Drug List Updates:

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P. 5 Abilify Maintenna PA added per DBHS P. 6 Invega Sustenna PA added per DBHS P. 9 Clonidine ER QLL added #30/ 30 days

May 2015

Title 19/21 SMI Drug List Updates: P. 7 Olysio removed from formulary per AHCCCS MRPDL P. 7 Harvoni added to formulary with PA per AHCCCS MRPDL P. 10 Fentanyl QLL changed to #15/30days P. 10 oxymorphone IR added to formulary with STEP and QL of #240/ 30days P. 10 oxymorphone ER added to formulary with STEP and QL of #60/ 30days P. 15 aripiprazole added to the formulary with QL of #30/ 30 days P. 24 fluticasone OTC added to formulary Zymar removed from formulary, drug no longer marketed Ultrase removed from formulary, drug no longer marketed

GMH/SA & Non-Title 19/21 Drug List Updates: P. 5 aripiprazole added to the formulary with QL of #30/ 30 days

April 2015

Title 19/21 SMI Drug List Updates: P. 14 Abilify Maintenna PA removed P. 15 Invega Sustenna PA removed P. 20 valsartan STEP removed P. 20 valsartan HCT STEP removed P. 21 amlodipine/valsartan added to formulary P. 21 amlodipine/valsartan w/hctz added to formulary P. 30 Colcrys removed from formulary P. 30 colchicine 0.6mg added to formulary

GMH/SA & Non-Title 19/21 Drug List Updates: P. 5 Abilify Maintenna PA removed P. 5 Invega Sustenna PA removed

March 2015

Title 19/21 SMI Drug List Updates: P.5 Terbinafine QL updated to #90/365days

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P.37 Spiriva Respimat added to formulary P.37 Esbriet added to formulary with PA P.7 Tybost added to formulary with PA P.7 Triumeq added to formulary P.7 Vitekta added to formulary P.37 Allegra 30mg/ml suspension removed from formulary P.37 Fexofenadine Suspension added to formulary

GMH/SA & Non-Title 19/21 Drug List Updates: none

February 2015

Title 19/21 SMI Drug List Updates: P. 18 phentermine added to formulary with PA required P. 28 Celebrex removed from formulary P. 28 celecoxib added to formulary with STEP P. 25 Orapred ODT removed from formulary P. 25 prednisolone sodium phosphate ODT added to formulary P. 32 Vivelle dot removed from formulary P. 32 Estradiol Dis (twice weekly) patch added to formulary P. 25 Victoza added to formulary with STEP P. 16 Focalin XR removed from formulary P. 16 dexmethylphenidate ER added to formulary

GMH/SA & Non-Title 19/21 Drug List Updates: none

January 2015

Title 19/21 SMI Drug List Updates: P. 65 Accu-Chek test strips removed from formulary P. 40 OTC Nasacort Allergy 24 hour spray added to formulary P. 15 Rapamune 1mg removed from formulary P. 15 sirolimus 1mg added to formulary P. 15 tramadol ER QLL #30/30days added to formulary P. 7 Cipro oral suspension removed from formulary P. 7 ciprofloxacin oral suspension added to formulary P. 39 Drysol 20% removed from formulary P. 39 aluminum chloride 20% added to formulary P. 7 Grifulvin V removed from formulary

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P. 7 griseofulvin microsize added to formulary P. 8 Gris-Peg removed from formulary P. 8 griseofulvin ultramicrosize added to formulary P. 17 Migranal removed from formulary P. 17 dihydroergotamine nasal spray added to formulary P. 53 Renvela removed from formulary P. 6 Furadantin suspension removed from formulary P. 6 nitrofurantoin suspension added to formulary P. 45 Reclast removed from formulary P. 45 zoledronic solution added to formulary with PA P. 19 Phenytek removed from formulary P. 19 phenytoin extended release capsules added to formulary P. 36 Slo Niacin OTC removed from formulary P. 36 Niacin tab CR added to formulary P. 59 Zaditor OTC removed from formulary P. 59 ketotifen fumarate ophthalmic solution added to formulary P. 27 Methylin Suspension removed from formulary P. 27 methylphenidate suspension added to formulary P. 38 OXSORALEN ULTRA removed from formulary P. 38 METHOXSALEN RAPID CAP 10 MG added to formulary P. 39 Natroba Suspension removed from formulary P. 39 spinosad suspension added to formulary P. 12 vistide removed from formulary P. 12 cidofovir added to formulary with PA P. 29 Campral removed from formulary P. 29 acamprosate added to formulary P. 32 Kapvay removed from formulary P. 32 clonidine ER added to formulary P. 24 Diclegis added to formulary QL = maximum 60 tablets P. 47 Asacol removed from formulary, drug no longer marketed P. 39 malathion 0.5% lotion added QLL = 1 pkg per 180days P. 39 permethrin 5% cream added QLL = 2pkg per 180days P. 39 piperonyl butoxide/pyrethrins OTC shampoo added QLL = 1 pkg/ 180days P. 39 pyrethrin 0.33% OTC shampoo added QLL = 1 pkg per 180days P. 39 SKLICE added QLL = 1 pkg per 180days P. 39 ULESFIA 5% LOTION added QLL = 2pkg per 180days

GMH/SA & Non-Title 19/21 Drug List Updates: none

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