Pharmacy

Finding your medication(s) on the Drug Lists

• You can search by the drug name.
• The lists include drugs that are generally covered

Arizona Complete Health-Complete Care Plan has three approved drug lists (formularies); Integrated, Behavioral and Crisis. You can view the drug lists using the following links:

• Arizona Complete Health Integrated Preferred Drug List (PDF) - Medicaid - (Revised 12/1/18)
• Arizona Complete Health Crisis Preferred Drug List (PDF) - Medicaid
• Arizona Complete Health Behavioral Health Preferred Drug List (PDF) - Medicaid -  (Revised 12/1/18)
  • Behavioral Health Drug List (BHDL) is ONLY for the following members:
    • Non-Title 19/21 persons determined to have a serious mental illness (SMI)
    • T19/21 Child/Adolescent, T19/21 CMDP and all T19/21 DDD members

Prescription Prior Authorization Requests

To submit a prior authorization electronically, use CoverMyMeds with Envolve Pharmacy Solutions.

• Pharmacy Prior Authorization Fax Form (PDF)

Ambetter from Arizona Complete Health pharmacy information is available using the following link:
Ambetter from Arizona Complete Health Pharmacy

Allwell from Arizona Complete Health Formularies

• HMO: 2019 Allwell Formulary (PDF)
• HMO DSNP: 2019 Allwell DNSP Formular (PDF)

Prior Authorization Criteria

• HMO: 2019 MAPD Prior Authorization Criteria (PDF)
• HMO DSNP: 2019 SNP Prior Authorization Criteria (PDF)

Step Therapy Criteria

• HMO: 2019 Step Therapy Criteria MA (PDF)
• HMO SNP: 2019 Step Therapy Criteria DSNP (PDF)

Quantity Limits

Refer to the List of Drugs (Formulary) for drug Requirements and Limits
2019 List of Drugs (Formulary)

Request for Medicare Coverage Determination Form

• HMO: 2019 Determination Form (PDF)
• HMO SNP: 2019 Determination Form DSNP (PDF)
• Medicare Part B: To submit a Medicare Part B prior authorization login to our Secure Provider Portal