Pharmacy Policies
| Policy Name | Policy Number | Reviewed |
|---|---|---|
| Abaloparatide (Tymlos) | AZ.CP.PHAR.345 | 02/22 |
| Acetylcholinesterase Inhibitors (Aricept, Aricept ODT, Razadyne, Razadyne ER, Exelon, Exelon Patch) | AZ.CP.PHAR.1018 | 02/22 |
| ADHD Medications in Children Under 6 Years Old | AZ.CP.PMN.07 | 09/20 |
| Agents for Insomnia | AZ.CP.PMN.1016 | 10/21 |
| Alpha1-Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) | AZ.CP.PHAR.94 | 02/22 |
| Amisulpride (Barhemsys) | AZ.CP.PMN.236 | 07/21 |
| Anthelmintics (albendazole ivermectin) | AZ.CP.PHAR.403 | 07/21 |
| Antipsychotic Medications in Children Under 18 | AZ.CP.PMN.08 | 07/20 |
| Atogepart (Qulipta) | AZ.CP.PHAR.566 | 02/22 |
| Bevacizumab (Avastin, Mvasi, Zirabev) | AZ.CP.PHAR.93 | 11/21 |
| Budesonide/Glycopyrrolate/Formoterol Fumarate (Breztri Aerosphere) and Fluticasone/Umeclidinium/Vilanterol (Trelegy Ellipta) | AZ.CP.PMN.1005 | 02/22 |
| Buprenorphine (Subutex) SL tablets | AZ.CP.PMN.82 | 02/22 |
| Buprenorphine Implant/Injection (Probuphine, Sublocade) | AZ.CP.PHAR.289 | 02/22 |
| Concomitant Antidepressant | AZ.CP.PMN.11 | 12/19 |
| Concomitant Antipsychotic Treatment | AZ.CP.PMN.10 | 07/20 |
| Cytokine and CAM antagonists | AZ.CP.PHAR.06 | 10/21 |
| Dipeptidyl Peptidase-4 (DPP-4) Inhibitors | AZ.CP.PMN.43 | 02/22 |
| Dronedarone (Multaq) | AZ.CP.PMN.1024 | 02/20 |
| Edoxaban (Savaysa) | AZ.CP.PMN.227 | 02/22 |
| Elexacaftor-Ivacaftor-Tezacaftor (Trikafta) | AZ.CP.PHAR.440 | 02/22 |
| Endothelin Receptor Antagonists-ETRA (Letairis, Opsumit, Tracleer) | AZ.CP.PHAR.1012 | 02/22 |
| Esketamine (Spravato) | AZ.CP.PMN.199 | 04/21 |
| Eteplirsen (Exondys 51) | AZ.CP.PHAR.288 | 02/22 |
| Filgrastim (Neupogen Zarxio Granix Nivestym) | AZ.CP.PHAR.297 | 07/21 |
| Glecaprevir/Pibrentasvir (Mavyret) and Sofosbuvir/Velpatasvir (Epclusa Approved Generic) | AZ.CP.PHAR.44 | 11/21 |
| Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists | AZ.CP.PMN.183 | 04/21 |
| Hepatitis B Drugs- Entecavir (Baraclude) and Adefovir (Hepsera) | AZ.CP.PMN.03 | 11/21 |
| Herceptin Biosimilars Trastuzumab-Hyaluronidase | AZ.CP.PHAR.228 | 04/21 |
| Human Growth Hormone (Somapacitan Somatropin) | AZ.CP.PHAR.517 | 02/22 |
| Imatinib (Gleevec) | AZ.CP.PHAR.65 | 04/21 |
| Istradefylline (Nourianz) | AZ.CP.PMN.217 | 02/22 |
| Ivacaftor (Kalydeco) | AZ.CP.PHAR.210 | 02/22 |
| Lactitol (Pizensy) | AZ.CP.PMN.241 | 08/21 |
| LAMA/LABA Combination Inhalers | AZ.CP.PMN.1021 | 07/20 |
| Leuprolide Acetate (Eligard, Fensolvi, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped) | AZ.CP.PHAR.173 | 02/22 |
| Long-Acting Opioid Analgesics | AZ.CP.PMN.97b | 02/22 |
| Lumacaftor-Ivacaftor (Orkambi) | AZ.CP.PHAR.213 | 02/22 |
| Maraviroc (Selzentry) | AZ.CP.PHAR.32 | 08/20 |
| Melphalan (Pepaxto, Alkeran) | AZ.CP.PHAR.535 | 08/21 |
| Methylnaltrexone Bromide (Relistor) | AZ.CP.PMN.169 | 10/20 |
| Migraine Products – Monoclonal Antibodies (Aimovig, Ajovy, Emgality, Vyepti) | AZ.CP.PHAR.1010 | 02/22 |
| Multiple Sclerosis Drugs | AZ.CP.PHAR.1020 | 02/22 |
| Naldemedine (Symproic) | AZ.CP.PMN.112 | 10/20 |
| Naloxegol (Movantik) | AZ.CP.PMN.171 | 10/20 |
| No Coverage Criteria/Off-Label Use Policy | AZ.CP.PMN.53 | 10/20 |
| Non-Calcium Phosphate Binders (Auryxia, Fosrenol, Renvela, Renagel, Velphoro) | AZ.CP.PMN.04 | 02/22 |
| Non-Preferred drugs and Brand Name Override | AZ.CP.PMN.16 | 11/21 |
| Non-Preferred Hepatitis C Treatments | AZ.CP.PHAR.400 | 08/21 |
| Non-Preferred Second-Generation Antipsychotics | AZ.CP.PMN.1025 | 02/22 |
| Nusinersen (Spinraza) | AZ.CP.PHAR.327 | 02/22 |
| Ophthalmics – Anti-inflammatory/Immunomodulators (Cequa, Restasis, Restasis Multidose, Xiidra) | AZ.CP.PMN.1014 | 02/22 |
| Pegfilgrastim (Neulasta), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo), Pegfilgrastin-apgf (Nyvepria) | AZ.CP.PHAR.296 | 08/21 |
| Phosphodiesterase-5 Inhibitors (PDE-5) (Adcirca, Alyq, Revatio) | AZ.CP.PHAR.1013 | 02/22 |
| Plecanatide (Trulance) | AZ.CP.PMN.87 | 10/20 |
| Posaconazole (Noxafil) | AZ.CP.PMN.1000 | 09/20 |
| Proton Pump Inhibitors | AZ.CP.PMN.1002 | 02/21 |
| Prucalopride (Motegrity) | AZ.CP.PMN.194 | 10/20 |
| Rifapentine (Priftin) | AZ.CP.PMN.05 | 02/22 |
| Rimegepant (Nurtec ODT) | AZ.CP.PHAR.490 | 02/22 |
| Rituximab (Rituxan), Rituximab-arrx (Riabni), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) | AZ.CP.PHAR.260 | 05/21 |
| SABG Drug List Exception Requests | AZ.CP.PMN.1009 | 09/19 |
| Short-Acting Opioid Analgesics | AZ.CP.PMN.97a | 02/22 |
| Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors | AZ.CP.PMN.14 | 02/22 |
| Step Therapy | AZ.CP.PST.01 | 02/22 |
| Tenapanor (Ibsrela) | AZ.CP.PMN.224 | 02/21 |
| Teriparatide (Forteo) | AZ.CP.PHAR.188 | 02/21 |
| Testosterone (Injectable; Nasal; Transdermal) | AZ.CP.PMN.02 | 04/21 |
| Thrombopoiesis Stimulating Agents- Doptelet, Nplate, Mulpleta, Promacta, Tavalisse | AZ.CP.PHAR.1019 | 02/22 |
| Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) | AZ.CP.PHAR.211 | 02/22 |
| Treprostinil (Orenitram, Remodulin, Tyvaso) | AZ.CP.PHAR.199 | 08/21 |
| Trintellix and Viibryd | AZ.CP.PMN.20 | 07/21 |
| Vancomycin Oral (Vancocin) | AZ.CP.PMN.166 | 02/21 |
| VMAT2 inhibitors (Ingrezza Austedo Xenazine) | AZ.CP.PHAR.340 | 02/22 |
| Voriconazole (Vfend) | AZ.CP.PMN.1003 | 11/20 |
| Weight Loss Medications | AZ.CP.PMN.1004 | 07/20 |
Medicaid (Arizona Complete Health-Complete Care Plan, Care1st Health Plan Arizona)
Medicaid and Marketplace (Ambetter)
AzCH-CCP Provider Resources
Further Arizona Complete Health-Complete Care Plan resources can be located on the Arizona Complete Health website.
Learn MoreCare1st Health Plan Arizona
Further Care1st Health Plan Arizona provider resources can be located on the Care1st Health Plan website.
Learn More