As a result of AHCCCS Prescription Drug List Changes, there are several changes to Mercy Care's Formulary that will be made effective, July 1, 2018.
Opioid Dependence Treatment
Prior authorization is not required for buprenorphine, without naloxone, for MAT use by women who are pregnant and/or nursing when the prescriber indicates one of the following ICD-10 Codes on the prescription:
- O09.91 - Supervision of high risk pregnancy, 1st trimester
- O09.92 - Supervision of high risk pregnancy, 2nd trimester
- O09.93 - Supervision of high risk pregnancy, 3rd trimester
- O09.90 - Supervision of high risk pregnancy - use for post-partum nursing mothers.
Hypoglycemics - Incretin Mimetics
Glyxambi was added as a preferred agent to the AHCCCS Acute/LTC Drug List and will require a Prior Authorization.
Bevespi Aerosphere and Stiolto Respimat were added as preferred agents to the AHCCCS Acute/LTC Drug List and will require a Prior Authorization.
Previously formoterol was listed as PA required but will be removed from formulary.
- Albuterol Syrup
- Ventolin HFA
- Albuterol Nebulized Solution
- Levalbuterol Nebulizer Solution is preferred on the AHCCCS Acute/LTC Drug List for children under the age of 4 years old and available without authorization. A prior authorization is required for ages 4 years and older.
- Serevent Diskus will now require a Prior Authorization.
- Arcapta, Striverdi, and metaproterenol will be removed from formulary.
- Montelukast chewable and oral tablets are preferred.
- Montelukast Granules are preferred on the AHCCCS Acute/LTC Drug List for children under the age of 4 years old and available without prior authorization.
- Zafirlukast will be removed from formulary.
- Calcium Acetate capsules and tablets
- Renagel Tablets
- Renvela Tablets - BRAND ONLY
- Renvela Powder Packets
Note: Grandfathering was not approved for the phosphate binders. Please transition your members to a preferred agent or submit a prior authorization request to continue with non preferred agent.
- Temazepam 15mg & 30 mg
- Zolpidem tablets
- Rozerem will require step therapy through Temazepam and Zolpidem.
Non-Preferred Agents to be removed from the formulary
Note: Grandfathering was approved for all current members utilizing non-preferred sedative hypnotics.
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