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
• Arizona Complete Health Crisis Preferred Drug List (PDF) - Medicaid
• Arizona Complete Health Behavioral Health Preferred Drug List (PDF) - Medicaid
  • Behavioral Health Drug List (BHDL) is ONLY for the following members:
    • Non-Title 19/21 persons determined to have a serious mental illness (SMI)
    • Non-Title 19/21 children/adolescents determined to have a serious emotional disturbance (SED)
    • Non-Title 19/21 children/adolescents determined to have a serious emotional disturbance (SED)
• Substance Abuse Block Grant (SABG) Medication List (PDF)

The AHCCCS Pharmaceutical and Therapeutics Committee recently adopted the following changes to the state’s PDL, effective October 1st, 2020.

October 2020 Medicaid PDL Updates (PDF)

Prescription Prior Authorization Requests

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

Pharmacy Prior Authorization Fax Form (PDF)

Oncology Prior Authorization Requests

Pre-approval Process

The requesting physician must complete an authorization request using one of the following methods:

• Logging into the NCH Provider Web Portal: https://my.newcenturyhealth.com
• Calling 1-877-624-8601 (Monday – Friday 5 a.m. to 5 p.m. PST)
• Faxing the authorization form to 1-877-624-8602

Please note:

Inpatient requests for chemotherapy should continue to be submitted via the Arizona Complete Health’s Secure Provider Portal.

Pharmacy dispensed chemotherapeutic and supportive agents that were previously submitted to Envolve Pharmacy Solutions or CoverMyMeds should be submitted directly to NCH.

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

Updated 01/01/20:

• Allwell Medicare, Essentials, Essentials II and Premier (HMO); Allwell CHF/Diabetes Medicare (HMO C-SNP) List of Drugs - English (PDF)
• Allwell Medicare, Essentials, Essentials II and Premier (HMO); Allwell CHF/Diabetes Medicare (HMO C-SNP) List of Drugs - Spanish (PDF)

• Allwell Dual Medicare (HMO D-SNP) and Allwell Medicare Essentials I (HMO) - English (PDF)
• Allwell Dual Medicare (HMO D-SNP) and Allwell Medicare Essentials I (HMO) - Spanish (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