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Notification of AHCCCS Preferred Insulin Formulary Changes

Date: 07/01/21

Effective 8/1/2021

Dear Arizona Complete Health-Complete Care Plan Providers and Staff:

Effective August 1, 2021, Arizona Complete Health (AzCH) will implement the AHCCCS formulary changes based on the recommendations from the May 19, 2021 AHCCS Pharmacy & Therapeutics (P & T) Committee. Formulary changes are located on our website.

AzCH encourages all prescribing clinicians to review the Arizona Complete Health Integrated Preferred Drug List (PDL) for preferred formulary alternatives prior to prescribing.

Below are some highlights of the Formulary changes effective August 1, 2021:

 

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)

Hypoglycemics

Insulin and

Related Agents: Rapid-Acting Insulins

Humalog Pens

 

Humalog Junior KwikPen

 

 

Humalog Vials

 

 

 

Insulin Lispro Pen (AG)

  • NDC: 00002822201
  • NDC: 00002822259
  • NDC: 66733082201
  • NDC: 66733082259

 

Insulin Lispro Junior Kwikpen (AG)

  • NDC: 00002775201
  • NDC: 00002775205

 

Insulin Lispro Vial (AG)

  • NDC: 00002773701
  • NDC: 66733077301

 

 

 

N

Hypoglycemics

Insulin and

Related Agents: Rapid-Acting Insulins

 

Novolog Cartridge

 

Novolog Pens

 

 

Novolog Vials

Insulin Aspart Cartridge (AG)

  • NDC: 73070010210
  • NDC: 73070010215

 

Insulin Aspart Pen (AG)

  • NDC: 73070010310
  • NDC: 73070010315

 

Insulin Aspart Vial (AG)

  • NDC: 73070010011

 

 

N

Hypoglycemics

Insulin and

Related Agents:

Rapid-Intermediate-Acting Combination Insulins

 

 

Humalog Mix Pens

 

Insulin Aspart/Insulin Aspart Protamine Insulin Pen (AG)

  • NDC: 73070020310
  • NDC: 73070020315

 

Insulin Aspart/Insulin Aspart Protamine Vial (AG)

NDC: 73070020011

 

N

Hypoglycemics

Insulin and

Related Agents:

Rapid-Intermediate-Acting Combination Insulins

 

Novolog Mix Pens

 

Novolog Mix Vials

 

 

Insulin Lispro Protamine Mix FlexPen (AG)

  • NDC: 00002823301
  • NDC: 00002823305

 

 

 

 

 

 

 

 

 

 

 

N

Hypoglycemics

Insulin and

Related Agents:

Intermediate-Acting Insulin

 

Humulin Pen OTCHumulin vials OTC
  • NDC: 00002831501
  • NDC: 00002831517

 

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 Pharmacy Prior Authorization at 888-788-4408 x6031278 if you have any questions.