AHCCCSTRBHAFormulary.Pdf Form

AHCCCS Fee-For-Service Program
T(RBHA) Drug List (BHDL) INTRODUCTION

AHCCCS is pleased to provide the AHCCCS FFS Program T(RBHA)Drug List (BHDL) to be used when prescribing behavioral health medications for AHCCCS FFS members. For clarification, this BHDL is only for the AHCCCS FFS members and it does not apply to AHCCCS members enrolled in any of the AHCCCS Managed Care Contractors’ Health Plans. This document provides general information regarding the AHCCCS pharmacy benefit for FFS members. The drugs listed on the BHDL are intended to provide clinically appropriate, cost-effective options for AHCCCS FFS members who require medically necessary behavioral health treatment. The drugs listed on the BHDL have been reviewed and approved by the Pharmacy and Therapeutics (P&T) Committee. However, the BHDL is not intended as a comprehensive listing of all drugs that may be reimbursed by AHCCCS. If a drug is not listed on the BHDL and is determined to be medically necessary, it may be requested through the prior authorization process.

OptumRx is the Pharmacy Benefit Manager (PBM) for the AHCCCS FFS Program. OptumRx will facilitate the administration of the pharmacy benefit for the following populations:  Acute FFS – Title XIX  Long Term Care FFS – Title XIX  KidsCare FFS – Title XXI  AHCCCS FFS Members who are enrolled in a TRBHA (Tribal/Regional Behavioral Health Authority)  Members who are Dual Eligibles (AHCCCS FFS members who are also eligible for Medicare)
 Federal Emergency Services (FES) Members whose coverage is limited to emergency dialysis service

Members may obtain additional pharmacy information on the OptumRx website at: https://ahcccs.rxportal.mycatamaranrx.com/rxclaim/portal/memberLogin

Members and prescribing clinicians may also contact the OptumRx Customer Service Center at 1 (855) 577-6310, 24 hours per day, 365 days per year.

For Prior Authorization Requests and Information:  Prescribing Clinicians may fax the completed prior authorization form to the OptumRx Prior Authorization Unit at 1 (866) 463-4830.  For telephonic requests for information, prescribing clinicians may call 1 (855) 577-6310 for assistance.  Prescribers preferring to send a written request via the US Mail, may send the request to the following address:

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Optum Rx Prior Authorization Department P.O. Box 5252 Lisle, IL 60532- 5252

With regard to federal legend drugs, medically necessary federally reimbursable outpatient prescription drugs are covered for eligible AHCCCS FFS members when prescribed by an AHCCCS registered clinician who is licensed to prescribe federal legend drugs in the State of Arizona. Some medications may require prior authorization approval prior to dispensing the medication to the member.

Pharmacy and Therapeutics (P&T) Committee
The P&T Committee, comprised of physicians and pharmacists, meets quarterly to discuss a variety of clinical issues, which pertain to drug selections, including formulary additions, deletions and changes as well as pharmacy program management.

The P&T Committee evaluates clinical information for newly marketed drugs within 180 days of market launch and current medications on an annual basis. The evaluation may include, but is not limited to the following review categories:

 Safety
 Efficacy  Comparative data and studies  FDA approved indications
 Treatment and consensus guidelines  Adverse events  Contraindications/Warnings/Precautions
 Pharmacokinetics  Dosage frequency and formulations  Patient administration/compliance considerations  Medical outcome and pharmacoeconomic studies

When a new drug is considered for inclusion on the ADL, it will be reviewed relative to similar drugs currently included on the ADL. The review process of a therapeutic class continually promotes the most clinically appropriate, useful, and cost-effective agents. All of the information in the ADL is provided as a reference for drug therapy selection. Specific drug selection for an individual member rests solely with the prescribing clinician.

Generic Drugs Generic substitution is a pharmacy action whereby a generic equivalent of a drug is dispensed rather than the brand name drug product. The AHCCCS pharmacy benefit requires mandatory generic substitution. This means that if a generic drug is equivalent to the brand reference drug and is available, the generic drug will be required for the filling and dispensing of the prescription for payment through the point-of-sale claims adjudication system. Generically available drugs are indicated on the ADL and are printed in lower case, for example, amoxacillin.

The ADL is organized by sections. Each section includes therapeutic groups identified by either a drug class or disease state. Products are listed with the generic name and the brand name is included as a reference to assist the prescribing clinicians in product recognition. Generics drugs are to be considered as the first line of prescribing. AHCCCS and its Contractors are required to use the most cost effective (least costly) clinically appropriate pharmaceutical treatment. The ADL also covers selected over-the-counter (OTC) products.
Prescribing clinicians are encouraged to prescribe OTC medications when clinically appropriate.

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Prior Authorization Procedures For Drugs Not Listed On The ADL
The drugs on the ADL have been selected to provide the most clinically appropriate and cost-effective medications for AHCCCS FFS members. When a drug not listed on the ADL is determined to be medically necessary for the appropriate medical management of a specific member, the prescriber must submit a prior authorization request specifying the reasons supporting the medical necessity of the particular drug for the AHCCCS member. Requests for these exceptions must be submitted in writing by the prescribing clinician on the OptumRx-AHCCCS Prior Authorization Form and faxed to:

OptumRx - Prior Authorization Department
Fax Number: 1 (866) 463-4830 Telephone Number: 1 (855) 577-6310

The OptumRx-AHCCCS Prior Authorization Request Form is available on the AHCCCS website at www.azahcccs.gov under the Pharmacy Information section on the right side of the website. Appropriate clinical documentation must be provided to support the medical necessity for the drug being requested.
Responses to requests will be provided within 2 business days of receipt unless the request is identified as urgent. If a request is identified as urgent, a response will be provided within 1 business day.

Prescribing clinicians are requested to adhere to the ADL when prescribing for AHCCCS FFS members. If a pharmacist receives a prescription for a drug not listed on the ADL, the pharmacist is expected to contact the prescribing clinician and request that the prescription be changed to a medication included on the ADL. If a medication on the ADL is not appropriate, the prescribing clinician is to be instructed to submit a prior authorization request form to OptumRx. Please contact the OptumRx Prior Authorization Department at 1 (855) 577-6310 with questions concerning the prior authorization process.

Dose Optimization Program – Quantity Limits (QL)
The ADL utilizes Quantity Limits for several drugs listed on the ADL. The intent of the quantity limits is to promote dose optimization and efficient medication dosing. Prescriptions for monthly quantities greater than the indicated limit require a prior authorization approval. For quantities greater than those listed on the ADL, the prescribing clinician must submit a prior authorization request with supporting documentation for the increased quantity of medication. The Dose Optimization Program is designed to consolidate medication dosage to the most efficient daily quantity to increase member adherence to therapy and also promote the efficient use of health care dollars. The limits for the program are established based on FDA approval for dosing and the availability of the total daily dose in the least amount of tablets or capsules daily.

Quantity limits are loaded in the prescription claims processing system to promote minimized dosing. The pharmacy claims processing system will prompt the pharmacist to request a new prescription order from the prescribing clinician for more efficient dosing.

Additions to the Dose Optimization Program are made from time to time and providers notified accordingly.
As always, we recognize that a number of member-specific variables must be taken into consideration when drug therapy is prescribed and therefore overrides will be available through the prior authorization process.
For any questions, please contact the OptumRx Customer Service Center at 1 (855) 577-6310.

Prescription Utilization Parameters AHCCCS members may reorder or refill a non-narcotic prescription when seventy-five percent (75%) of the medication has been used. Members may reorder or refill a narcotic prescription when eighty-five percent (85%) of the medication has been used. If a point-of-sale claim is submitted before 75% of the non-narcotic medication has been used, based on the original days supply submitted on the claim, the claim will reject with a "refill too soon" message. The same will happen with for narcotic prescription refills not meeting the 85% utilization. Please call the OptumRx 3

Customer Service Department at 1 (855) 577-6310 with questions or for help with dosage change authorization override.

Drug Efficacy Study Implementation (DESI) Drugs
Drugs that were initially marketed between the years of 1938 and 1962 were approved as safe but were not required to provide the effectiveness for FDA approval. Beginning in 1962 legislation required all new drugs to be both safe and effective before they could be approved to be available and marketed. This requirement also applied retroactively to all drugs approved as safe from the years 1938-1962. As a result, the FDA established the DESI program to review the labeled indications and the effectiveness of the pre-1962 drugs and to provide a determination of effectiveness. The “fully effective” determination was given for most of these products and they remain in the marketplace today. A few DESI products remain classified as “less than fully effective” and are awaiting final administrative disposition from the FDA. In addition, if a drug is classified as DESI, there are many products listed as identical, similar, or related to actual DESI products.
The AHCCCS FFS ADL does not pay for claims for DESI drugs that are considered “less than fully effective” drug products.

AHCCCS FFS Plan Exclusions The following drug categories are excluded from coverage under the outpatient pharmacy benefit and are not part of the ADL:

 DESI Drugs that are determined to be “less than fully effective”
 Anti obesity agents  Experimental / research drugs  Cosmetic drugs
 Cosmetic drugs for hair growth  Immunizations  Nutritional / diet supplements  Blood and blood plasma products  Products to promote fertility  Erectile dysfunction drugs  Drugs from manufacturers that do not participate in the FFS Medicaid Drug Rebate Program  Diagnostic products  Medical supplies except: o Syringes o Needles o Lancets o Alcohol Swabs o Spacers o Blood glucose meters and test strips  Intrauterine Devices

Notice AHCCCS and OptumRx provide the information contained in the ADL, solely for the convenience of prescribing clinicians. AHCCCS does not warrant or assure accuracy of such information nor is the ADL intended to be an all inclusive medication list. This ADL is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs.

AHCCCS assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider must consult the drug manufacturer’s product literature or standard references for more detailed information.
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Drug Class/Drug Name Brand Only PA Type  Quantity Limit  QL Days  ADHD/ANTI‐NARCOLEPSY/ANTI‐OBESITY/ANOREX AMPHETAMINES AMPHETAMINE SULFATE TABS PA Required for < 6 years of age 60 30 AMPHETAMINE‐DEXTROAMPHETAMINE CP24 PA Required for < 6 years of age 30 30 AMPHETAMINE‐DEXTROAMPHETAMINE TABS PA Required for < 6 years of age 60 30 DEXTROAMPHETAMINE SULFATE CP24 PA Required for < 6 years of age 60 30 DEXTROAMPHETAMINE SULFATE SOLN PA Required for < 6 years of age 600 30 DEXTROAMPHETAMINE SULFATE TABS PA Required for < 6 years of age 60 30 LISDEXAMFETAMINE DIMESYLATE CAPS PA Required for < 6 years of age 30 30 ATTENTION‐DEFICIT/HYPERACTIVITY DISORDER (ADHD) AG ATOMOXETINE HCL CAPS PA Required 60 30 CLONIDINE HCL (ADHD) MISC PA Required CLONIDINE HCL (ADHD) TB12 PA Required for < 6 years of age GUANFACINE HCL (ADHD) TB24 PA Required for < 6 years of age 30 30 STIMULANTS ‐ MISC. DEXMETHYLPHENIDATE HCL CP24 PA Required for < 6 years of age 30 30 DEXMETHYLPHENIDATE HCL TABS PA Required for < 6 years of age METHYLPHENIDATE HCL CHEW PA Required for < 6 years of age 60 30 METHYLPHENIDATE HCL CP24 PA Required for < 6 years of age 30 30 METHYLPHENIDATE HCL CPCR PA Required for < 6 years of age 30 30 METHYLPHENIDATE HCL SOLN PA Required for < 6 years of age 600 30 METHYLPHENIDATE HCL SUSR PA Required for < 6 years of age 180 30 METHYLPHENIDATE HCL TABS PA Required for < 6 years of age 90 30 METHYLPHENIDATE HCL TBCR PA Required for < 6 years of age 60 30 METHYLPHENIDATE PTCH PA Required 30 30 ANTIANXIETY AGENTS ANTIANXIETY AGENTS ‐ MISC.* BUSPIRONE HCL TABS 120 30        AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List •  Generic Preferred Over Brand, Unless Specified as Brand Only                                                                                              5

Drug Class/Drug Name Brand Only PA Type  Quantity Limit  QL Days         AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List •  Generic Preferred Over Brand, Unless Specified as Brand Only                                                                                              HYDROXYZINE HCL SYRP HYDROXYZINE HCL TABS HYDROXYZINE PAMOATE CAPS MEPROBAMATE TABS BENZODIAZEPINES ALPRAZOLAM CONC 120 30 ALPRAZOLAM TABS 120 30 ALPRAZOLAM TB24 120 30 ALPRAZOLAM TBDP 120 30 CHLORDIAZEPOXIDE HCL CAPS 120 30 CLORAZEPATE DIPOTASSIUM TABS 120 30 CLORAZEPATE DIPOTASSIUM TB24 60 30 DIAZEPAM CONC 120 30 DIAZEPAM SOLN 120 30 DIAZEPAM TABS 120 30 LORAZEPAM CONC 120 30 LORAZEPAM TABS 120 30 OXAZEPAM CAPS 120 30 ANTICONVULSANTS* ANTICONVULSANTS ‐ BENZODIAZEPINES CLONAZEPAM TABS 120 30 CLONAZEPAM TBDP 120 30 ANTICONVULSANTS ‐ MISC.** CARBAMAZEPINE CHEW CARBAMAZEPINE CP12 CARBAMAZEPINE POWD CARBAMAZEPINE SUSP CARBAMAZEPINE TABS 6

Drug Class/Drug Name Brand Only PA Type  Quantity Limit  QL Days         AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List •  Generic Preferred Over Brand, Unless Specified as Brand Only                                                                                              CARBAMAZEPINE TB12 GABAPENTIN CAPS GABAPENTIN SOLN GABAPENTIN TABS LAMOTRIGINE CHEW LAMOTRIGINE KIT LAMOTRIGINE TABS LAMOTRIGINE TB24 LAMOTRIGINE TBDP OXCARBAZEPINE SUSP OXCARBAZEPINE TABS TOPIRAMATE TABS VALPROIC ACID DIVALPROEX SODIUM CPSP DIVALPROEX SODIUM TB24 DIVALPROEX SODIUM TBEC VALPROATE SODIUM SYRP VALPROIC ACID CAPS ANTIDEPRESSANTS* ALPHA‐2 RECEPTOR ANTAGONISTS (TETRACYCLICS) MIRTAZAPINE TABS PA Required for < 6 years of age 45 30 MIRTAZAPINE TBDP PA Required for < 6 years of age 45 30 ANTIDEPRESSANTS ‐ MISC. BUPROPION HCL TABS PA Required for < 6 years of age 60 30 BUPROPION HCL TB12 PA Required for < 6 years of age 60 30 BUPROPION HCL TB24 PA Required for < 6 years of age 60 30 BUPROPION HYDROBROMIDE TB24 PA Required MONOAMINE OXIDASE INHIBITORS (MAOIS) 7

Drug Class/Drug Name Brand Only PA Type  Quantity Limit  QL Days         AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List •  Generic Preferred Over Brand, Unless Specified as Brand Only                                                                                              ISOCARBOXAZID TABS PA Required for < 6 years of age PHENELZINE SULFATE TABS PA Required for < 6 years of age SELEGILINE PT24 PA Required TRANYLCYPROMINE SULFATE TABS PA Required for < 6 years of age SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) CITALOPRAM HYDROBROMIDE SOLN PA Required for < 6 years of age 600 30 CITALOPRAM HYDROBROMIDE TABS PA Required for < 6 years of age 60 30 ESCITALOPRAM OXALATE SOLN PA Required for < 6 years of age 300 30 ESCITALOPRAM OXALATE TABS PA Required for < 6 years of age 60 30 FLUOXETINE HCL CAPS PA Required for < 6 years of age 120 30 FLUOXETINE HCL CPDR PA Required for < 6 years of age 120 30 FLUOXETINE HCL LIQD PA Required for < 6 years of age 120 30 FLUOXETINE HCL SOLN PA Required for < 6 years of age 120 30 FLUOXETINE HCL TABS PA Required for < 6 years of age 120 30 FLUVOXAMINE MALEATE CP24 PA Required for < 6 years of age 90 30 FLUVOXAMINE MALEATE TABS PA Required for < 6 years of age 120 30 PAROXETINE HCL SUSP PA Required for < 6 years of age 300 30 PAROXETINE HCL TABS PA Required for < 6 years of age 30 30 PAROXETINE HCL TB24 PA Required for < 6 years of age 30 30 PAROXETINE MESYLATE TABS PA Required SERTRALINE HCL CONC PA Required for < 6 years of age SERTRALINE HCL TABS PA Required for < 6 years of age 60 30 SEROTONIN MODULATORS NEFAZODONE HCL TABS PA Required for < 6 years of age TRAZODONE HCL POWD PA Required for < 6 years of age TRAZODONE HCL TABS PA Required for < 6 years of age VILAZODONE HCL KIT PA Required VILAZODONE HCL TABS PA Required 8

Drug Class/Drug Name Brand Only PA Type  Quantity Limit  QL Days         AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List •  Generic Preferred Over Brand, Unless Specified as Brand Only                                                                                              SEROTONIN‐NOREPINEPHRINE REUPTAKE INHIBITORS (SNRI) DESVENLAFAXINE FUMARATE TB24 PA Required for < 6 years of age 30 30 DESVENLAFAXINE SUCCINATE TB24 PA Required for < 6 years of age 30 30 DESVENLAFAXINE TB24 PA Required for < 6 years of age 30 30 DULOXETINE HCL CPEP PA Required for < 6 years of age 60 30 VENLAFAXINE HCL CP24 PA Required for < 6 years of age 60 30 VENLAFAXINE HCL TABS PA Required for < 6 years of age 120 30 VENLAFAXINE HCL TB24 PA Required for < 6 years of age 60 30 TRICYCLIC AGENTS* AMITRIPTYLINE HCL POWD PA Required for < 6 years of age AMITRIPTYLINE HCL SOLN PA Required for < 6 years of age AMITRIPTYLINE HCL TABS PA Required for < 6 years of age AMOXAPINE TABS PA Required for < 6 years of age CLOMIPRAMINE HCL CAPS PA Required for < 6 years of age DESIPRAMINE HCL POWD PA Required for < 6 years of age DESIPRAMINE HCL TABS PA Required for < 6 years of age DOXEPIN HCL CAPS PA Required for < 6 years of age 90 30 DOXEPIN HCL CONC PA Required for < 6 years of age 180 30 IMIPRAMINE HCL POWD PA Required for < 6 years of age IMIPRAMINE HCL TABS PA Required for < 6 years of age IMIPRAMINE PAMOATE CAPS PA Required for < 6 years of age NORTRIPTYLINE HCL CAPS PA Required for < 6 years of age NORTRIPTYLINE HCL POWD PA Required for < 6 years of age NORTRIPTYLINE HCL SOLN PA Required for < 6 years of age PROTRIPTYLINE HCL TABS PA Required for < 6 years of age TRIMIPRAMINE MALEATE CAPS PA Required for < 6 years of age TRIMIPRAMINE MALEATE POWD PA Required for < 6 years of age ANTIHISTAMINES 9

Drug Class/Drug Name Brand Only PA Type  Quantity Limit  QL Days         AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List •  Generic Preferred Over Brand, Unless Specified as Brand Only                                                                                              ANTIHISTAMINES ‐ ETHANOLAMINES DIPHENHYDRAMINE CITRATE TBDP DIPHENHYDRAMINE HCL CAPS DIPHENHYDRAMINE HCL CHEW DIPHENHYDRAMINE HCL ELIX DIPHENHYDRAMINE HCL LIQD DIPHENHYDRAMINE HCL STRP DIPHENHYDRAMINE HCL SUSR DIPHENHYDRAMINE HCL SYRP DIPHENHYDRAMINE HCL TABS DIPHENHYDRAMINE HCL TBDP ANTIHISTAMINES ‐ PIPERIDINES CYPROHEPTADINE HCL SYRP CYPROHEPTADINE HCL TABS ANTIHYPERTENSIVES ANTIADRENERGIC ANTIHYPERTENSIVES* CLONIDINE HCL PTWK CLONIDINE HCL TABS GUANFACINE HCL TABS 60 30 PRAZOSIN HCL CAPS PRAZOSIN HCL POWD ANTIPARKINSON AGENTS ANTIPARKINSON ANTICHOLINERGICS* BENZTROPINE MESYLATE SOLN BENZTROPINE MESYLATE TABS TRIHEXYPHENIDYL HCL ELIX TRIHEXYPHENIDYL HCL TABS ANTIPARKINSON DOPAMINERGICS** 10

Drug Class/Drug Name Brand Only PA Type  Quantity Limit  QL Days         AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List •  Generic Preferred Over Brand, Unless Specified as Brand Only                                                                                              AMANTADINE HCL CAPS AMANTADINE HCL SYRP AMANTADINE HCL TABS ANTIPSYCHOTICS/ANTIMANIC AGENTS ANTIMANIC AGENTS* LITHIUM CARBONATE CAPS LITHIUM CARBONATE POWD LITHIUM CARBONATE TABS LITHIUM CARBONATE TBCR LITHIUM CITRATE SYRP LITHIUM SOLN ANTIPSYCHOTICS ‐ MISC. CARBAMAZEPINE (ANTIPSYCHOTIC) CP12 LURASIDONE HCL TABS PA Required ZIPRASIDONE HCL CAPS PA Required for < 6 years of age 60 30 BENZISOXAZOLES ILOPERIDONE TABS PA Required PALIPERIDONE PALMITATE SUSP PA Required PALIPERIDONE TB24 PA Required RISPERIDONE MICROSPHERES SUSR PA Required for < 6 years of age RISPERIDONE SOLN PA Required for < 6 years of age 240 30 RISPERIDONE TABS PA Required for < 6 years of age 60 30 RISPERIDONE TBDP PA Required for < 6 years of age 60 30 BUTYROPHENONES** HALOPERIDOL DECANOATE SOLN PA Required for < 6 years of age HALOPERIDOL LACTATE CONC PA Required for < 6 years of age HALOPERIDOL LACTATE SOLN PA Required for < 6 years of age HALOPERIDOL POWD PA Required for < 6 years of age 11

Drug Class/Drug Name Brand Only PA Type  Quantity Limit  QL Days         AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List •  Generic Preferred Over Brand, Unless Specified as Brand Only                                                                                              HALOPERIDOL TABS PA Required for < 6 years of age DIBENZAPINES ASENAPINE MALEATE SUBL PA Required CLOZAPINE SUSP PA Required for < 6 years of age CLOZAPINE TABS PA Required for < 6 years of age 150 30 CLOZAPINE TBDP PA Required for < 6 years of age 150 30 LOXAPINE HCL CONC PA Required for < 6 years of age LOXAPINE HCL SOLN PA Required for < 6 years of age LOXAPINE SUCCINATE CAPS PA Required for < 6 years of age OLANZAPINE PAMOATE SUSR PA Required OLANZAPINE TABS PA Required for < 6 years of age 30 30 OLANZAPINE TBDP PA Required for < 6 years of age 30 30 QUETIAPINE FUMARATE TABS PA Required for < 6 years of age 60 30 QUETIAPINE FUMARATE TB24 PA Required PHENOTHIAZINES CHLORPROMAZINE HCL CONC PA Required for < 6 years of age CHLORPROMAZINE HCL CPCR PA Required for < 6 years of age CHLORPROMAZINE HCL SOLN PA Required for < 6 years of age CHLORPROMAZINE HCL SYRP PA Required for < 6 years of age CHLORPROMAZINE HCL TABS PA Required for < 6 years of age CHLORPROMAZINE SUPP PA Required for < 6 years of age FLUPHENAZINE DECANOATE SOLN PA Required for < 6 years of age FLUPHENAZINE ENANTHATE SOLN PA Required for < 6 years of age FLUPHENAZINE HCL CONC PA Required for < 6 years of age FLUPHENAZINE HCL ELIX PA Required for < 6 years of age FLUPHENAZINE HCL SOLN PA Required for < 6 years of age FLUPHENAZINE HCL TABS PA Required for < 6 years of age MESORIDAZINE BESYLATE CONC PA Required for < 6 years of age 12

Drug Class/Drug Name Brand Only PA Type  Quantity Limit  QL Days         AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List •  Generic Preferred Over Brand, Unless Specified as Brand Only                                                                                              MESORIDAZINE BESYLATE SOLN PA Required for < 6 years of age MESORIDAZINE BESYLATE TABS PA Required for < 6 years of age PERPHENAZINE CONC PA Required for < 6 years of age PERPHENAZINE TABS PA Required for < 6 years of age THIORIDAZINE HCL CONC PA Required for < 6 years of age THIORIDAZINE HCL SUSP PA Required for < 6 years of age THIORIDAZINE HCL TABS PA Required for < 6 years of age TRIFLUOPERAZINE HCL CONC PA Required for < 6 years of age TRIFLUOPERAZINE HCL POWD PA Required for < 6 years of age TRIFLUOPERAZINE HCL SOLN PA Required for < 6 years of age TRIFLUOPERAZINE HCL TABS PA Required for < 6 years of age QUINOLINONE DERIVATIVES ARIPIPRAZOLE SOLN Brand Only PA Required 150 30 ARIPIPRAZOLE SUSR Brand Only PA Required ARIPIPRAZOLE TABS Brand Only PA Required for < 6 years of age 30 30 ARIPIPRAZOLE TBDP Brand Only PA Required for < 6 years of age 30 30 THIOXANTHENES THIOTHIXENE CAPS PA Required for < 6 years of age THIOTHIXENE HCL CONC PA Required for < 6 years of age BETA BLOCKERS BETA BLOCKERS NON‐SELECTIVE* NADOLOL TABS PROPRANOLOL HCL CONC PROPRANOLOL HCL CP24 30 30 PROPRANOLOL HCL CPCR PROPRANOLOL HCL POWD PROPRANOLOL HCL SOLN PROPRANOLOL HCL SUSTAINED‐RELEASE BEADS CP24 30 30 13

Drug Class/Drug Name Brand Only PA Type  Quantity Limit  QL Days         AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List •  Generic Preferred Over Brand, Unless Specified as Brand Only                                                                                              PROPRANOLOL HCL TABS HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENT ANTIHISTAMINE HYPNOTICS DIPHENHYDRAMINE HCL (SLEEP) CAPS DIPHENHYDRAMINE HCL (SLEEP) LIQD DIPHENHYDRAMINE HCL (SLEEP) TABS DIPHENHYDRAMINE HCL (SLEEP) TBDP HYPNOTICS ‐ TRICYCLIC AGENTS DOXEPIN HCL (SLEEP) TABS PA Required NON‐BARBITURATE HYPNOTICS CHLORAL HYDRATE CAPS 60 30 CHLORAL HYDRATE SUPP 30 30 CHLORAL HYDRATE SYRP 150 30 ESTAZOLAM TABS 30 30 ESZOPICLONE TABS 30 30 FLURAZEPAM HCL CAPS 30 30 TEMAZEPAM CAPS 30 30 TRIAZOLAM TABS 30 30 ZALEPLON CAPS 30 30 ZOLPIDEM TARTRATE SOLN PA Required ZOLPIDEM TARTRATE SUBL PA Required ZOLPIDEM TARTRATE TABS 60 30 ZOLPIDEM TARTRATE TBCR 30 30 SELECTIVE MELATONIN RECEPTOR AGONISTS RAMELTEON TABS LAXATIVES BULK LAXATIVES* FIBER CAPS 14

Drug Class/Drug Name Brand Only PA Type  Quantity Limit  QL Days         AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List •  Generic Preferred Over Brand, Unless Specified as Brand Only                                                                                              FIBER CHEW FIBER LIQD FIBER POWD FIBER TABS METHYLCELLULOSE (LAXATIVE) PACK METHYLCELLULOSE (LAXATIVE) POWD METHYLCELLULOSE (LAXATIVE) TABS PSYLLIUM CAPS PSYLLIUM GRAN PSYLLIUM PACK PSYLLIUM POWD PSYLLIUM WAFR LAXATIVES ‐ MISCELLANEOUS LACTULOSE PACK LACTULOSE SOLN LACTULOSE SYRP SALINE LAXATIVES MAGNESIUM CITRATE SOLN MAGNESIUM OXIDE (LAXATIVE) TABS MAGNESIUM SULFATE (LAXATIVE) LIQD STIMULANT LAXATIVES** BISACODYL ENEM BISACODYL KIT BISACODYL POWD BISACODYL SUPP BISACODYL TBEC CASCARA SAGRADA CAPS CASCARA SAGRADA EXTR 15

Drug Class/Drug Name Brand Only PA Type  Quantity Limit  QL Days         AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List •  Generic Preferred Over Brand, Unless Specified as Brand Only                                                                                              CASCARA SAGRADA LIQD CASCARA SAGRADA TABS SENNA KIT SENNA LEAV SENNA LIQD SENNA MISC SENNA POWD SENNA SYRP SENNA TABS SENNOSIDES CAPS SENNOSIDES CHEW SENNOSIDES GRAN SENNOSIDES LIQD SENNOSIDES STRP SENNOSIDES TABS SURFACTANT LAXATIVES DOCUSATE SODIUM CAPS DOCUSATE SODIUM ENEM DOCUSATE SODIUM LIQD DOCUSATE SODIUM POWD DOCUSATE SODIUM SYRP DOCUSATE SODIUM TABS MOUTH/THROAT/DENTAL AGENTS* THROAT PRODUCTS ‐ MISC. ARTIFICIAL SALIVA AERS ARTIFICIAL SALIVA GEL ARTIFICIAL SALIVA GUM ARTIFICIAL SALIVA KIT 16

Drug Class/Drug Name Brand Only PA Type  Quantity Limit  QL Days         AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List •  Generic Preferred Over Brand, Unless Specified as Brand Only                                                                                              ARTIFICIAL SALIVA LOZG ARTIFICIAL SALIVA PACK ARTIFICIAL SALIVA SOLN PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENT AGENTS FOR CHEMICAL DEPENDENCY ACAMPROSATE CALCIUM TBEC 180 30 DISULFIRAM TABS PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS ‐ MISC. PIMOZIDE TABS THYROID AGENTS THYROID HORMONES LEVOTHYROXINE SODIUM TABS 30 30 LIOTHYRONINE SODIUM TABS 30 30 URINARY ANTISPASMODICS URINARY ANTISPASMODICS* BETHANECHOL CHLORIDE TABS VITAMINS OIL SOLUBLE VITAMINS* VITAMIN E CAPS VITAMIN E CHEW VITAMIN E LIQD VITAMIN E TABS WATER SOLUBLE VITAMINS** NIACIN CPCR NIACIN ELIX NIACIN POWD NIACIN TABS NIACIN TBCR 17

Drug Class/Drug Name Brand Only PA Type  Quantity Limit  QL Days         AHCCCS Fee‐For‐Service TRBHA Members Behavioral Health Drug List •  Generic Preferred Over Brand, Unless Specified as Brand Only                                                                                              NIACINAMIDE POWD NIACINAMIDE TABS NIACINAMIDE TBCR PYRIDOXINE HCL CAPS PYRIDOXINE HCL CPCR PYRIDOXINE HCL LOZG PYRIDOXINE HCL LPOP PYRIDOXINE HCL POWD PYRIDOXINE HCL SOLN PYRIDOXINE HCL TABS PYRIDOXINE HCL TBCR RIBOFLAVIN CAPS RIBOFLAVIN POWD RIBOFLAVIN TABS THIAMINE HCL CAPS THIAMINE HCL POWD THIAMINE HCL SOLN THIAMINE HCL TABS THIAMINE MONONITRATE POWD THIAMINE MONONITRATE TABS 18