OTC Drug List for Dual Eligibles - English Form

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Arizona Complete Health-Complete Care Plan Dual Eligible Member Preferred Drug List
AzCH-CCP covers select drugs for AHCCCS recipients who are eligible for Medicare. These include drugs that are:
• Over-the-counter (OTC)
• Excluded from coverage under Medicare Part D Drugs must also be safe and cost effective. This is not a complete list of all covered drugs.
If you need a drug that is not on the drug list, your doctor may request prior authorization at https://www.covermymeds.com/epa/envolverx/ or your doctor may fax a prior authorization form located at https://www.azcompletehealth.com/providers/pharmacy.html
• Generic Preferred Over Brand, Unless Specified as Brand Only AHCCCS DUAL Program Drug List Effective Date: 12/1/2022 Drug Class/Drug Name Reference Brand Name PA Type Quantity Limit QL Days ALTERNATIVE MEDICINES

ALTERNATIVE MEDICINE – M’s

MELATONIN TABLETS MELATONIN

ANALGESICS - ANTI-INFLAMMATORY

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)

IBUPROFEN CAPSULES ADVIL

IBUPROFEN CHEWABLE CHILDRENS MOTRIN

IBUPROFEN SUSPENSION CHILDRENS MOTRIN

IBUPROFEN TABLETS ADVIL JUNIOR STRENGTH

ANALGESICS - NONNARCOTIC

ANALGESICS OTHER

ACETAMINOPHEN CAPSULES VARIOUS

ACETAMINOPHEN CHEWABLE VARIOUS

ACETAMINOPHEN ELIXIR VARIOUS

ACETAMINOPHEN LIQUID VARIOUS

ACETAMINOPHEN PACK VARIOUS

ACETAMINOPHEN SOLUTION VARIOUS

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• Generic Preferred Over Brand, Unless Specified as Brand Only AHCCCS DUAL Program Drug List Effective Date: 12/1/2022 Drug Class/Drug Name Reference Brand Name PA Type Quantity Limit QL Days ACETAMINOPHEN SUPPOSITORY VARIOUS

ACETAMINOPHEN SUSPENSION VARIOUS

ACETAMINOPHEN SYRUP VARIOUS

ACETAMINOPHEN TABLETS VARIOUS

ACETAMINOPHEN TABLET CONTROLLED RELEASE VARIOUS

ACETAMINOPHEN ORALLY DISPERSABLE TABLET VARIOUS

SALICYLATES

ASPIRIN CHEWABLE ST JOSEPH ADULT

ASPIRIN SUPPOSITORY ASPIRIN

ASPIRIN TABLETS ASPIRIN

ASPIRIN ORALLY DISPERSABLE TABLET ADULT ASPIRIN LOW STRENGTH

ASPIRIN TABLET ENTERIC COATED 1/2HALFPRIN

ASPIRIN TABLET EFFERVESCENT MEDI-SELTZER

ANTACIDS

ANTACIDS - CALCIUM SALTS

CALCIUM CARBONATE (ANTACID) CHEWABLE CHILDRENS MYLANTA UPSET STOMACH RELIEF

CALCIUM CARBONATE (ANTACID) TABLETS CALCIUM CARBONATE

ANTACID COMBINATIONS

ALUM & MAG HYDROX-SIMETHICONE SUSPENSION ANTACID FAST ACTING

ANTACIDS - MAGNESIUM SALTS

MAGNESIUM OXIDE TABLETS MAGNESIUM OXIDE

ANTACIDS - BICARBONATE

SODIUM BICARBONATE TABLETS SODIUM BICARBONATE

ANTICOAGULANTS

HEPARINS AND HEPARINOID-LIKE AGENTS

HEPARIN SODIUM (PORCINE) LOCK FLUSH & NACL LOCK FLUSH KIT HEPARIN SODIUM LOCK FLUSH

HEPARIN SODIUM (PORCINE) LOCK FLUSH SOLUTION HEPARIN LOCK FLUSH

ANTIDIARRHEALS

ANTIPERISTALTIC AGENTS

LOPERAMIDE HCL CAPSULES LOPERAMIDE HCL

LOPERAMIDE HCL CHEWABLE IMODIUM A-D

LOPERAMIDE HCL LIQUID LOPERAMIDE HCL

LOPERAMIDE HCL SUSPENSION IMODIUM A-D

LOPERAMIDE HCL TABLETS IMODIUM A-D

ANTIEMETICS

ANTIEMETICS - ANTICHOLINERGIC**

MECLIZINE HCL CHEWABLE MECLIZINE HCL

MECLIZINE HCL TABLETS MECLIZINE HCL

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• Generic Preferred Over Brand, Unless Specified as Brand Only AHCCCS DUAL Program Drug List Effective Date: 12/1/2022 Drug Class/Drug Name Reference Brand Name PA Type Quantity Limit QL Days ANTIHISTAMINES

ANTIHISTAMINES - ALKYLAMINES

CHLORPHENIRAMINE MALEATE TABLETS CHLORPHENIRAMINE MALEATE

ANTIHISTAMINES - ETHANOLAMINES

DIPHENHYDRAMINE HCL CAPSULES BANOPHEN

DIPHENHYDRAMINE HCL CHEWABLE BENADRYL ALLERGY CHILDRENS

DIPHENHYDRAMINE HCL ELIXIR MEDI-PHEDRYL

DIPHENHYDRAMINE HCL LIQUID BANOPHEN

DIPHENHYDRAMINE HCL STRP TRIAMINIC COUGH & RUNNY NOSE

DIPHENHYDRAMINE HCL SYRUP ALTARYL

DIPHENHYDRAMINE HCL TABLETS ALKA-SELTZER PLUS ALLERGY FAST RELIEF FORMULA

DIPHENHYDRAMINE HCL ORALLY DISPERSABLE TABLET WAL-DRYL ALLERGY RELIEF CHILDRENS

ANTIHISTAMINES - NON-SEDATING

CETIRIZINE HCL CAPSULES ZYRTEC ALLERGY

30 30 CETIRIZINE HCL CHEWABLE WAL-ZYR CHILDRENS

30 30 CETIRIZINE HCL SYRUP ALL DAY ALLERGY CHILDRENS

150 30 CETIRIZINE HCL TABLETS CETIRIZINE HCL

30 30 CETIRIZINE HCL ORALLY DISPERSABLE TABLET ZYRTEC ALLERGY

30 30 FEXOFENADINE HCL SUSPENSION ALLEGRA ALLERGY CHILDRENS

150 30 FEXOFENADINE HCL TABLETS ALLEGRA ALLERGY CHILDRENS

30 30 FEXOFENADINE HCL ORALLY DISPERSABLE TABLET ALLEGRA ALLERGY CHILDRENS

30 30 LORATADINE CAPSULES CLARITIN

30 30 LORATADINE CHEWABLE CLARITIN

30 30 LORATADINE SYRUP CLARITIN

150 30 LORATADINE TABLETS ALAVERT

30 30 LORATADINE ORALLY DISPERSABLE TABLET CLARITIN REDITABLETS

30 30 CONTRACEPTIVES

EMERGENCY CONTRACEPTIVES**

LEVONORGESTREL (EMERGENCY OC) TABLETS PLAN B

COUGH/COLD/ALLERGY

COUGH/COLD/ALLERGY COMBINATIONS**

CETIRIZINE-PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUS

30 30 CHLORPHENIRAMINE & PSEUDOEPH CHEWABLE VARIOUS

CHLORPHENIRAMINE & PSEUDOEPH LIQUID VARIOUS

CHLORPHENIRAMINE & PSEUDOEPH SOLUTION VARIOUS

CHLORPHENIRAMINE & PSEUDOEPH SYRUP VARIOUS

CHLORPHENIRAMINE & PSEUDOEPH TABLETS VARIOUS

DIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN LIQUID VARIOUS

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• Generic Preferred Over Brand, Unless Specified as Brand Only AHCCCS DUAL Program Drug List Effective Date: 12/1/2022 Drug Class/Drug Name Reference Brand Name PA Type Quantity Limit QL Days DIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN PACK VARIOUS

DIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN SUSPENSION VARIOUS

DIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN TABLETS VARIOUS

FEXOFENADINE-PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUS

30 30 FEXOFENADINE-PSEUDOEPHEDRINE TABLET 24-HOUR VARIOUS

30 30 LORATADINE & PSEUDOEPHEDRINE TABLET 12-HOUR VARIOUS

30 30 LORATADINE & PSEUDOEPHEDRINE TABLET 24-HOUR VARIOUS

30 30 PHENYLEPHRINE W/ DM-GG CAPSULES VARIOUS

PHENYLEPHRINE W/ DM-GG LIQUID VARIOUS

PHENYLEPHRINE W/ DM-GG SUSPENSION VARIOUS

PHENYLEPHRINE W/ DM-GG SYRUP VARIOUS

PHENYLEPHRINE W/ DM-GG TABLETS VARIOUS

PHENYLEPHRINE-BROMPHENIRAMINE-DM ELIXIR VARIOUS

480 30 PHENYLEPHRINE-BROMPHENIRAMINE-DM LIQUID VARIOUS

480 30 PHENYLEPHRINE-BROMPHENIRAMINE-DM SYRUP VARIOUS

480 30 PHENYLEPHRINE-CHLORPHEN-DM LIQUID VARIOUS PA Required

PHENYLEPHRINE-CHLORPHEN-DM SOLUTION VARIOUS PA Required

PHENYLEPHRINE-CHLORPHEN-DM SYRUP VARIOUS PA Required

PHENYLEPHRINE-CHLORPHEN-DM TABLETS VARIOUS PA Required

PHENYLEPHRINE-GUAIFENESIN CAPSULES VARIOUS

PHENYLEPHRINE-GUAIFENESIN LIQUID VARIOUS

PHENYLEPHRINE-GUAIFENESIN SYRUP VARIOUS

PHENYLEPHRINE-GUAIFENESIN TABLETS VARIOUS

PSEUDOEPHEDRINE-GUAIFENESIN CAPSULES VARIOUS

PSEUDOEPHEDRINE-GUAIFENESIN LIQUID VARIOUS

PSEUDOEPHEDRINE-GUAIFENESIN SYRUP VARIOUS

PSEUDOEPHEDRINE-GUAIFENESIN TABLETS VARIOUS

PSEUDOEPHEDRINE-GUAIFENESIN TABLET 12-HOUR VARIOUS

EXPECTORANTS

GUAIFENESIN LIQUID HERBAL EXPEC

GUAIFENESIN PACK MUCINEX FOR KIDS

GUAIFENESIN SOLUTION TRIACTIN CHEST CONGESTION

GUAIFENESIN SYRUP DIABETIC TUSSIN EX

GUAIFENESIN TABLETS GUAIFENESIN

GUAIFENESIN TABLET 12-HOUR EQ MUCUS ER

DERMATOLOGICALS

ACNE PRODUCTS

BENZOYL PEROXIDE BAR ACNE TREATMENT CLEANSING BAR

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• Generic Preferred Over Brand, Unless Specified as Brand Only AHCCCS DUAL Program Drug List Effective Date: 12/1/2022 Drug Class/Drug Name Reference Brand Name PA Type Quantity Limit QL Days BENZOYL PEROXIDE CREAM NEUTROGENA ON-THE-SPOT ACNE TREATMENT

BENZOYL PEROXIDE GEL BENZOYL PEROXIDE

BENZOYL PEROXIDE LIQUID PANOXYL

BENZOYL PEROXIDE LOTION BP CLEANSING LOTION

BENZOYL PEROXIDE WASH VARIOUS

ANTI-INFLAMMATORY AGENTS - TOPICAL

DICLOFENAC GEL VOLTAREN GEL

200 30 ANTIBIOTICS - TOPICAL

BACITRACIN (TOPICAL) OINTMENT BACITRACIN

BACITRACIN ZINC OINTMENT BACIGUENT

NEOMYCIN SULFATE (TOPICAL) OINTMENT BACITRACIN

ANTIFUNGALS - TOPICAL

BUTENAFINE CREAM MENTAX

CLOTRIMAZOLE (TOPICAL) CREAM FUNGICURE INTENSIVE WITH NAILGUARD

CLOTRIMAZOLE (TOPICAL) LOTION CLOTRIMAZOLE GRX

CLOTRIMAZOLE SOLUTION (OTC) VARIOUS

MICONAZOLE NITRATE (TOPICAL) CREAM PODACTIN

MICONAZOLE NITRATE (TOPICAL) OINTMENT TETTERINE

TOLNAFTATE AERO POWDER VARIOUS

TOLNAFTATE CREAM VARIOUS

TOLNAFTATE POWDER VARIOUS

TERBINAFINE CREAM VARIOUS

ANTIHISTAMINES-TOPICAL

DIPHENHYDRAMINE HCL (TOPICAL) GEL ANTI-ITCH MAXIMUM STRENGTH

DIPHENHYDRAMINE HCL (TOPICAL) LOTION BENADRYL ITCH STOPPING

DIPHENHYDRAMINE HCL (TOPICAL) SOLUTION DESENEX SHAKE POWDERER

CORTICOSTEROIDS - TOPICAL

HYDROCORTISONE (TOPICAL) CREAM HYDROCORTISONE

HYDROCORTISONE (TOPICAL) GEL CORTIZONE-10

HYDROCORTISONE (TOPICAL) OINTMENT HYDROCORTISONE

EMOLLIENT/KERATOLYTIC AGENTS

UREA CREAM REA-LO

EMOLLIENTS

LACTIC ACID (AMMONIUM LACTATE) CREAM LAC-HYDRIN

LACTIC ACID (AMMONIUM LACTATE) LOTION GERI-HYDROLAC 12

LOCAL ANESTHETICS – TOPICAL

LIDOCAINE HCL GEL 2% REGENECARE GEL

60 30 LIDOCAINE HCL CREAM 2% XOLIDO

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• Generic Preferred Over Brand, Unless Specified as Brand Only AHCCCS DUAL Program Drug List Effective Date: 12/1/2022 Drug Class/Drug Name Reference Brand Name PA Type Quantity Limit QL Days LIDOCAINE HCL CREAM 4% ASPERCREME W/LIDOCAINE

230 30 MISC. TOPICAL

ZINC OXIDE (TOPICAL) OINTMENT MEIJER ZINC OXIDE

ZINC OXIDE (TOPICAL) CREAM DESITIN

SCABICIDES & PEDICULICIDES

IVERMECTIN LOTION 0.5% IVERMECTIN PA Required

PYRETHRINS-PIPERONYL BUTOXIDE FOAM A-200 MAXIMUM STRENGTH

PYRETHRINS-PIPERONYL BUTOXIDE KIT PRONTO

PYRETHRINS-PIPERONYL BUTOXIDE LIQUID AL12

GASTROINTESTINAL AGENTS - MISCELLANEOUS

ANTIFLATULENTS

SIMETHICONE SUSPENSION CVS INFANTS GAS RELIEF

HEMATOPOIETIC AGENTS

FOLIC ACID/FOLATES

FOLIC ACID CAPSULES FA-8

FOLIC ACID TABLETS FOLIC ACID

IRON

FERROUS FUMARATE CAPSULES HIGH POTENCY IRON

FERROUS FUMARATE TABLETS FEMIRON

FERROUS FUMARATE TABLET CONTROLLED RELEASE IRON

FERROUS GLUCONATE TABLETS FERATE

FERROUS SULFATE DRIED TABLETS FEOSOL

FERROUS SULFATE DRIED TABLET CONTROLLED RELEASE EQ SLOW-RELEASE IRON

FERROUS SULFATE ELIXIR FEROSUL

FERROUS SULFATE LIQUID SPATONE PUR-ABSORB IRON

FERROUS SULFATE SOLUTION BPROTECTED PEDIA IRON

FERROUS SULFATE SYRUP FERROUS SULFATE

FERROUS SULFATE TABLETS FERROUS SULFATE

FERROUS SULFATE TABLET CONTROLLED RELEASE FERROUS SULFATE

FERROUS SULFATE TABLET ENTERIC COATED FERROUS SULFATE

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENT

ANTIHISTAMINE HYPNOTICS

DOXYLAMINE SUCCINATE (SLEEP) TABLETS RA NIGHT SLEEP AID

LAXATIVES

BULK LAXATIVES

PSYLLIUM CAPSULES NAT-RUL PSYLLIUM SEED HUSKS

PSYLLIUM PACK METAMUCIL SMOOTH TEXTURE

PSYLLIUM POWDER KONSYL

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• Generic Preferred Over Brand, Unless Specified as Brand Only AHCCCS DUAL Program Drug List Effective Date: 12/1/2022 Drug Class/Drug Name Reference Brand Name PA Type Quantity Limit QL Days PSYLLIUM WAFR METAMUCIL

LAXATIVE COMBINATION

SENNOSIDES-DOCUSATE SODIUM TABLETS SENNA-S

LAXATIVES - MISCELLANEOUS

POLYETHYLENE GLYCOL 3350 PACK CLEARLAX

POLYETHYLENE GLYCOL 3350 POWDER CLEARLAX

GLYCERIN (LAXATIVE) SUPPOSITORIES GLYCERIN CHILDREN

SALINE LAXATIVES

SODIUM PHOSPHATES ENEMA GNP ENEMA

STIMULANT LAXATIVES

BISACODYL ENEMA FLEET BISACODYL

BISACODYL SUPPOSITORY BISAC-EVAC

BISACODYL TABLET ENTERIC COATED ALOPHEN

SENNOSIDES TABLETS QC SENNA

SURFACTANT LAXATIVES

DOCUSATE SODIUM CAPSULES COLACE

DOCUSATE SODIUM ENEMA DOCUSOL KIDS

DOCUSATE SODIUM LIQUID PEDIA-LAX

DOCUSATE SODIUM SYRUP DIOCTO

MEDICAL DEVICES AND SUPPLIES

CONTRACEPTIVES

CONDOMS - FEMALE MISC TROJAN NATURALAMB

CONDOMS - MALE MISC ZINC OXIDE

CONDOMS LATEX LUBRICATED - MALE MISC LIFESTYLES ASSORTED COLORS

CONDOMS LATEX NON-LUBRICATED - MALE MISC ATLAS COLORED LUBRICATED CONDOM

CONDOMS NON-LATEX NON-LUBRICATED - MALE MISC ATLAS COLORED CONDOM/SPERMICIDE

MISC. DEVICES

ALCOHOL SWABS PADS ALCOHOL SWABS PADS

PARENTERAL THERAPY SUPPLIES

SYRINGE/NEEDLE (DISP) VARIOUS

MINERALS & ELECTROLYTES

CALCIUM

CALCIUM ACETATE TABLETS CALCIUM ACETATE

CALCIUM LACTATE CAPSULES CAL-LAC

CALCIUM LACTATE TABLETS CALCIUM LACTATE

CALCIUM COMBINATIONS

CALCIUM CARBONATE-CHOLECALCIFEROL TABLETS CALCIUM CARBONATE/VITAMIN D

FLUORIDE

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• Generic Preferred Over Brand, Unless Specified as Brand Only AHCCCS DUAL Program Drug List Effective Date: 12/1/2022 Drug Class/Drug Name Reference Brand Name PA Type Quantity Limit QL Days SODIUM FLUORIDE ORAL SOLUTION 0.5MG/ML SODIUM FLUORIDE

MAGNESIUM

MAGNESIUM OXIDE (MG SUPPOSITORYLEMENT) CAPSULES MAGNESIUM

MAGNESIUM OXIDE (MG SUPPOSITORYLEMENT) TABLETS MAG-200

POTASSIUM

POTASSIUM CHRLORIDE GRANULES POTASSIUM CHLORIDE

MOUTH/THROAT/DENTAL AGENTS

THROAT PRODUCTS – MISC

ARTIFICIAL SALIVA VARIOUS

MULTIVITAMINS

MULTIPLE VITAMINS W/ MINERALS

MULTIPLE VITAMINS W/ MINERALS TABLETS ABC PLUS SENIOR

30 30 PEDIATRIC MULTIPLE VITAMINS

PEDIATRIC MULTIPLE VITAMIN DROPS POLY-VI-SOL

PED MV W/ IRON

PEDIATRIC MULTIPLE VITAMINS W/ IRON SOULTION POLY-VITE SOL /IRON

PRENATAL VITAMINS

PRENATAL VIT W/ FERROUS FUMARATE-FOLIC ACID CLASSIC PRENATAL

NASAL AGENTS - SYSTEMIC AND TOPICAL

NASAL AGENTS - MISCELLANEOUS

SALINE NASAL SPRAY SALINE NASAL SPRAY

NASAL STEROIDS

FLUTICASONE PROPIONATE (NASAL) FLONASE ALLERGY RELIEF

SYMPATHOMIMETIC DECONGESTANTS

PSEUDOEPHEDRINE HCL LIQUID SUDAFED CHILDRENS

PSEUDOEPHEDRINE HCL SYRUP PSEUDOEPHEDRINE

PSEUDOEPHEDRINE HCL TABLETS SHOPKO NASAL DECONGESTANTMAXIMUM STRENGTH

PSEUDOEPHEDRINE HCL TABLET 12-HOUR SHOPKO NASAL DECONGESTANT

PSEUDOEPHEDRINE HCL TABLET 24-HOUR SUDAFED 24 HOUR

OPHTHALMIC AGENTS

ARTIFICIAL TEARS AND LUBRICANTS

ARTIFICIAL TEAR GEL VARIOUS

ARTIFICIAL TEAR OINTMENT VARIOUS

ARTIFICIAL TEAR SOLUTION VARIOUS

CARBOXYMETHYLCELLULOSE-GLYCERIN SOLUTION VARIOUS

CARBOXYMETHYLCELLULOSE-HYPROMELLOSE GEL VARIOUS

CARBOXYMETHYLCELLULOSE SODIUM (OPHTH) SOUTION VARIOUS

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• Generic Preferred Over Brand, Unless Specified as Brand Only AHCCCS DUAL Program Drug List Effective Date: 12/1/2022 Drug Class/Drug Name Reference Brand Name PA Type Quantity Limit QL Days CARBOXYMETHYLCELLULOSE SODIUM (OPHTH) GEL VARIOUS

METHYLCELLULOSE (OPHTH) SOLUTION VARIOUS

POLYETHYLENE GLYCOL-PROPYLENE GLYCOL (OPHTH) SOLUTION VARIOUS

POLYVINYL ALCOHOL SOLUTION VARIOUS

PROPYLENE GLYCOL (OPHTH) SOLUTION VARIOUS

OPHTHALMIC DECONGESTANTS

NAPHAZOLINE HCL SOLUTION GENTEAL

NAPHAZOLINE W/ PHENIRAMINE SOLUTION NAPHCON-A

NAPHAZOLINE W/ ZINC SULFATE SOLUTION CVS REDNESS RELIEF

NAPHAZOLINE-GLYCERIN SOLUTION CLEAR EYES REDNESS RELIEF

NAPHAZOLINE-GLYCERIN-ZINC SULFATE SOLUTION CLEAR EYES TRIPLE ACTION RELIEF

NAPHAZOLINE-POLYETHYLENE GLYCOL 300 SOLUTION CLEAR EYES COOLING COMFORT REDNESS RELIEF

PHENYLEPHRINE HCL (OPHTH) SOLUTION VISINE-LR

PHENYLEPHRINE W/ ZINC SULFATE SOLUTION VISINE-AC

TETRAHYDROZOLINE W/ POLYETHYLENE GLYCOL SOLUTION OPCON-A

TETRAHYDROZOLINE W/ ZINC SULFATE SOLUTION ADVANCED LUBRICANT

TETRAHYDROZOLINE-DEXTRAN-POLYETHYLENE GLYCOL-POVIDONE SOLUTION CLEAR EYES COMPLETE 7 SYMPTOM RELIEF

TETRAHYDROZOLINE-GLYCERIN-HYPROMELLOSE-PEG 400 SOLUTION VISINE ADVANCED RELIEF

TETRAHYDROZOLINE-GLYCERIN-HYPROMELLOSE-PEG 400-ZINC SULFATE SOLUTION VISINE MAXIMUM REDNESS RELIEF

TETRAHYDROZOLINE-POLYVINYL ALCOHOL-POVIDONE SOLUTION CLEAR EYES FOR DRY EYES PLUS REDNESS RELIEF

OPHTHALMICS - MISC.

KETOTIFEN FUMARATE (OPHTH) SOLUTION VISINE TOTALITY MULTI-SYMPTOM/HYDROBLEND

SODIUM CHLORIDE HYPERTONIC SOLUTION ALTACHLORE

NUTRIENTS

MISC. NUTRITIONAL SUBSTANCES

OMEGA-3 FATTY ACIDS CAPSULES FISH OIL

OMEGA-3 FATTY ACIDS CAPSULE DELAYED RELEASE FISH OIL

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENT

SMOKING DETERRENTS

NICOTINE KIT NICOTINE TRANSDERMAL SYSTEM

84 180 NICOTINE POLACRILEX GUM KLS QUIT2

540 180 NICOTINE POLACRILEX LOZENGE COMMIT

540 180 NICOTINE PATCH 24-HOUR NICODERM CQ

84 180 ULCER DRUGS

H-2 ANTAGONISTS

FAMOTIDINE CHEWABLE PEPCID AC

FAMOTIDINE TABLETS PEPCID AC

RANITIDINE HCL TABLETS WAL-ZAN 75

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• Generic Preferred Over Brand, Unless Specified as Brand Only AHCCCS DUAL Program Drug List Effective Date: 12/1/2022 Drug Class/Drug Name Reference Brand Name PA Type Quantity Limit QL Days PROTON PUMP INHIBITORS

ESOMEPRAZOLE MAGNESIUM CAPSULE DELAYED RELEASE? NEXIUM

60 30 LANSOPRAZOLE CAPSULE DELAYED RELEASE HEARTBURN RELIEF 24 HOUR

60 30 OMEPRAZOLE MAGNESIUM CAPSULE DELAYED RELEASE OMEPRAZOLE MAGNESIUM

60 30 VAGINAL PRODUCTS

SPERMICIDES

NONOXYNOL-9 FILM VCF VAGINAL CONTRACEPTIVE FILM

NONOXYNOL-9 FOAM VCF VAGINAL CONTRACEPTIVE FOAM

NONOXYNOL-9 GEL SHUR-SEAL

NONOXYNOL-9 MISC TODAY SPONGE

NONOXYNOL-9 SUPPOSITORY ENCARE

VAGINAL ANTI-INFECTIVES

CLOTRIMAZOLE VAGINAL CREAM GYNE-LOTRIMIN

MICONAZOLE NITRATE VAGINAL SUPPOSITORY SM MICONAZOLE 7

MICONAZOLE NITRATE VAGINAL KIT MICONAZOLE 3 COMBO PACK

VITAMINS

OIL SOLUBLE VITAMINS

VITAMIN E CAPSULES VITAMIN E

VITAMIN E LIQUID LIQUI-E

VITAMIN E OIL VITAMIN E

VITAMIN E TABLETS VITAMIN E

WATER SOLUBLE VITAMINS

NIACIN CAPSULE CONTROLLED RELEASE NIACIN

NIACIN TABLET CONTROLLED RELEASE ENDUR-ACIN

PYRIDOXINE HCL CAPSULES NEURO-K-250 T.D.

PYRIDOXINE HCL TABLETS PYRIDOXINE HCL

PYRIDOXINE HCL TABLET CONTROLLED RELEASE VITAMIN B-6

THIAMINE HCL CAPSULES THIAMINE

THIAMINE HCL TABLETS VITAMIN B-1