Medicaid Formulary Updates
Date: 03/05/21
Dear Arizona Complete Health-Complete Care Plan (AzCH) Providers and Staff:
Effective April 1, 2021, AzCH will implement the AHCCCS formulary changes based on the recommendations from the January 26, 2021 AHCCCS Pharmacy & Therapeutics (P & T) Committee. Formulary changes are located on our website: https://www.azcompletehealth.com/providers/pharmacy.html.
AzCH encourages all prescribing clinicians to review the Arizona Complete Health-Medicaid Comprehensive Prescription Drug List (PDL) for preferred formulary alternatives prior to prescribing.
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) |
|---|---|---|---|---|
Androgenic Agents
| Testosterone transdermal solution (generic Axiron)
| Androgel Gel Packet*NEW Androgel Gel Pump Androderm Patches
| PA | N |
Antivirals, Topical - New Class
| X | Docosanol OTC Acyclovir Ointment
| Docosanol QL | N |
Colony Stimulating Factors
| X | Nivestym Syringe*New Nyvepria *New Neupogen, Fulphia, Udenyca
| PA | N |
Dipeptidyl Pepidase-4 Enzyme Inhibitors (DPP-4s)
| X | Trijardy XR *New Onglyza, Tradjenta, Janumet, Janumet XR, Januvia, Glyxambi, Jentadueto, Kombiglyze XR
| PA | N |
Glucagon-Like Peptied-1 Receptor Agonists (GLP-1s)
| X | Trulicity *New Victoza, Byetta, Bydureon Pen Bydureon Vials (discontinued)
| PA | N |
Sodium-Glucose co-transporter-2 (SGLT2s)
| X | Invokamet *New Synjardy * New Xigduo * New Farxiga, Invokana, Jardiance
| PA | N |
Immune Globulins
| Gamastan Vial | Gammaked (IV) *New Hizentra Syringe (SQ) *New Privigen (IV) *New
| PA | N |
Oral Oncology Oral - Hematologic
| Imatinib Melphalan
| Alkeran – Brand Only Gleevec – Brand Only
| PA | N |
Otic Antibiotics
| X | Ofloxacin (Otic) *New
| X | N |
Ulcerative Colitis Agents – New Class
| Balsalazide Mesalamine (Generic Lialda) Mesalamine (Generic Asacol HD)
| Apriso Canasa (Rectal) Delzicol Lialda Pentasa sfRowasa (Rectal) Sulfasalazine, Sulfasalazine DR
| QL apply, please review formulary | N |
*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). AG = Authorized Generic.
Contact the AzCH Pharmacy Team at 888-788-4408 x 6031278 if you have any questions.