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Formulary Updates Effective January 01, 2022

Date: 12/01/21

Effective 1/1/2022, Arizona Complete Health-Complete Care Plan (AzCH-CCP) will implement AHCCCS formulary changes based on the recommendations from the 10/18/2021 AHCCCS Pharmacy & Therapeutics (P & T) Committee.

Formulary changes are located on our website at: https://www.azcompletehealth.com/providers/pharmacy.html. We encourage all prescribing clinicians to review our Integrated Preferred Drug List (PDL) for preferred formulary alternatives prior to prescribing.

Highlights of the formulary changes effective 1/1/2022 are on the following page.

Please Contact Pharmacy Prior Authorization at 888-788-4408 x 6031278 if you have any questions.

 

Drug Class

Drug (s) Removed from Formulary

Preferred Alternative(s) on Formulary (NEW or current alternatives)

**Utilization Management (PA, STEP, QL, AGE)

*Grandfathering permitted (Y/N)

Antimigraine Agents - Triptans

 

Authorized Generic Zolmitriptan Tablet/ODT

Zomig Nasal Spray

Zolmitriptan ODT

Zolmitriptan Tablet

Sumatriptan (SQ Kit/Tablet/Vial)

Rizatriptan ODT/Tablet

Naratriptan Tablet

QL

N

Topical Steroids

       N/A

Betamethasone Dipropionate Cream (NEW)

Clobetasol Shampoo (NEW)

N/A

N

HIV-AIDS

 

 

Edurant (oral)

      

 

Delstrigo (NEW)

Dovato (NEW)

Efavirenz/Emtricitabine/

Tenofovir Disoproxil Fumarate (NEW)

Isentress HD (NEW)

Juluca (NEW)

Norvir Powder Pack (NEW)

Reyataz Powder Pack (NEW)

Symtuza (NEW)

Tivicay PD Suspension (NEW)

QL

Y

Movement Disorders

Tetrabenazine

Xenazine

Austedo (NEW)

Ingrezza (NEW)

PA

Y

Diabetic Meters,

Continuous Glucose Meter (CGM)

 

New Class

Dexcom G6 CGM System (ages 2 to < 4 years old)

Freestyle Libre System (ages 14 and up)

Freestyle Libre 2 System (ages 4 years old and up)

PA/

AGE

Patients on integrated systems only

Opioid Antagonists

N/A

Kloxxado (NEW)

Narcan

Naltrexone tabs

Vivitrol

N/A

N/A

*AHCCCS P&T determines whether or not to permit grandfathering (continued use of a non-formulary medication). If grandfathering is not permitted, members will need to switch to the preferred formulary alternative and a new prescription may be required (See AHCCCS Policy 310-V).

 

**Prior Authorization (PA), Step Therapy (STEP), Quantity Limit (QL), Age Restriction (AGE), Authorized Generic (AG)