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Medicaid PDL Updates

FORMULARY UPDATES

Effective 4/1/2021

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

Effective April 1, 2021, AZCH will implement the AHCCCS formulary changes based on the recommendations from the January 26, 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- Medicaid Comprehensive Prescription Drug List (PDL) for preferred formulary alternatives prior to prescribing.

Below are some highlights of the Formulary changes:

 

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