Medicaid Formulary Changes Effective 10.1.24

Date: 09/04/24

FORMULARY UPDATES

Effective 10/01/2024

Effective October 1, 2024, Arizona Complete Health-Complete Care Plan (AzCH-CCP) will implement AHCCCS formulary changes based on the recommendations from the June 18, 2024, AHCCCS Pharmacy & Therapeutics (P & T) Committee.

To review the AzCH-CCP Preferred Drug Lists including the recent updates, visit our website at: www.azcompletehealth.com > For Providers > Pharmacy > Preferred Drug Lists.

We encourage all prescribing clinicians to review our Preferred Drug Lists (PDL) for preferred formulary alternatives prior to prescribing. The table below highlights some of the upcoming Formulary changes.

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-Other

Ajovy

1. Aimovig (NEW)

2. Dihydroergotamine mesylate nasal (AG) (NEW)

3. Cafergot

4. Emgality Syringe 120 mg

5. Emgality Pen

6. Ubrelvy

Cytokine and

CAM Antagonists

N/A

1. Xeljanz XR (NEW)

2. Xeljanz

3. Adalimumab biosimilar products

a. Simlandi

b. Hadlima

c. Unbranded Adalimumab-adbm (Boehringer Ingelheim)

4. Enbrel Kit, Enbrel Syringe, Enbrel Pen, Enbrel Mini Cartridge, Enbrel vial

5. Infliximab

6. Orencia Clickject, Orencia Syringe

7. Otezla

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)
Glucocorticoids, inhaled- Combination Products	N/A	1. Airduo Respiclick (NEW) 2. Advair Diskus (Brand Preferred) 3. Advair HFA (Brand Preferred) 4. Dulera 5. Symbicort (Brand Preferred)	N/A	N
Growth Hormones	· Genotropin Cartridge · Omnitrope Cartridge · Omnitrope Vial · Zomacton Vial	1. Genotropin Disposable Syringe 2. Norditropin Pen	PA	N
Hypoglycemics, Incretin Mimetics- Enhancers	· Kombiglyze XR · Nesina · Onglyza	1. alogliptin (AG) 2. alogliptin/metformin (AG) 3. alogliptin/pioglitazone (AG) 4. Janumet 5. Jentadueto 6. Jentadueto XR 7. Kazano 8. Kombiglyze XR 9. Tradjenta 10. Trijardi XR 11. Bydureon Pen 12. Byetta Pen 13. Trulicity 14. Victoza 15. Symlin Pen	PA	N
Hypoglycemics, Insulin and Related Agents	· Levemir Pen · Levemir Vial	1. Insulin degludec Pen 100U/ ml (NEW) 2. Insulin degludec Pen 200U/ ml (NEW) 3. Insulin degludec Vial (NEW) 4. Lantus Vial 5. Lantus Solostar Pen	N/A	N

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)
Immunologics Atopic Dermatitis and Asthma	· Dupixent Pen · Dupixent Syringe	1. Elidel (NEW) 2. Opzelura (NEW) 3. Eucrisa 4. Pimecrolimus (AG) 5. Tacrolimus (AG)	PA	N
Opioid Dependence Treatments	N/A	1. Brixadi (NEW) – Medical claim- Buy and Bill only 2. Sublocade 3. Buprenorphine sublingual tablet (PA required unless member is pregnant)	PA	N
Stimulants And Related Agents	Adderall XR	1. Amphetamine salt combination ER (AG) (NEW) 2. Amphetamine salt combo ER (Oral) (NEW) 3. Amphetamine salt combo 4. Atomoxetine (AG) 5. Clonidine ER 6. Concerta (Brand Preferred) 7. Daytrana 8. Dexmethylphenidate (AG) 9. Dexmethylphenidate ER 10. Guanfacine ER 11. Methylin Solution (Brand Preferred) 12. Methylphenidate 13. Methylphenidate CD (AG) 14. Ritalin LA 10 mg Capsule 15. Vyvanse Capsule	PA for ages less than 6 years old	N

*AHCCCS P&T determines whether 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).

Questions: Contact the pharmacy team (888) 788-4408 (Options 3, 7).

Thank you!