AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 1

Therapeutic Class / Market Basket

National Drug Code (NDC)MediSpan

MediSpan Generic Product Indicator

(GPI)

National Drug Code (NDC)

(First DataBank)

First DataBank

GCN Generic NameBrand Name / Label Name

Current Preferred Drug List Status PDL = Preferred

NPD = Non-Preferred NR = Not Previoiusly

Reviewed

Recommended PreferredDrug List Status PDL = Preferred

NPD = Non-Preferred

Product is Federally RebatedY= YesN = No

ANTIFUNGALS, ORAL 52343008722 11407015000325 52343008722 42193 fluconazole FLUCONAZOLE PDL NPD NANTIFUNGALS, TOPICAL 10939057433 30400 miconazole nitrate

MICONAZOLE NITRATE PDL NPD N

ANTIFUNGALS, TOPICAL 11017025030 30410 miconazole nitrate LOTRIMIN AF PDL NPD NANTIFUNGALS, TOPICAL 11017066317 30370 clotrimazole LOTRIMIN AF NPD NPD NANTIFUNGALS, TOPICAL 11523433804 37521 butenafine HCl LOTRIMIN ULTRA PDL NPD NANTIFUNGALS, TOPICAL 32953009907 30370 clotrimazole ATHLETE'S FOOT PDL NPD NANTIFUNGALS, TOPICAL 41100040788 27083 miconazole nitrate LOTRIMIN AF PDL NPD NANTIFUNGALS, TOPICAL 50428009980 62498 terbinafine HCl ATHLETE'S FOOT PDL NPD NANTIFUNGALS, TOPICAL 59779028046 30390 miconazole nitrate

ATHLETE'S FOOT SPRAY NPD NPD N

ANTIFUNGALS, TOPICAL 70030014723 99729 tolnaftate ATHLETE'S FOOT PDL NPD NANTIFUNGALS, TOPICAL 73462015013 30410 miconazole nitrate ZEASORB PDL NPD NANTIFUNGALS, TOPICAL 73462015065 30410 miconazole nitrate ZEASORB PDL NPD NANTIFUNGALS, TOPICAL 11917010473 90150085002005 11917010473 99729 tolnaftate ANTIFUNGAL PDL NPD NANTIFUNGALS, TOPICAL 57896019945 90150085002905 57896019945 30310 tolnaftate TOLNAFTATE PDL NPD N

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 2

ANTIFUNGALS, TOPICAL 11673044805 90150085003210 11673044805 99729 tolnaftate ANTIFUNGAL PDL NPD NANTIFUNGALS, TOPICAL 11822324000 90150085003210 11822324000 99729 tolnaftate ANTIFUNGAL PDL NPD NANTIFUNGALS, TOPICAL 00363069590 90150085003305 00363069590 30290 tolnaftate JOCK ITCH PDL NPD NANTIFUNGALS, TOPICAL 11917004865 90150085003305 11917004865 30290 tolnaftate TOLNAFTATE PDL NPD NANTIFUNGALS, TOPICAL 11917007846 90150085003305 11917007846 30290 tolnaftate

ODOR CONTROL FOOT-SNEAKER PDL NPD N

ANTIFUNGALS, TOPICAL 11917012990 90150085003705 11917012990 30300 tolnaftate TOLNAFTATE PDL NPD NANTIFUNGALS, TOPICAL 50428231738 90150085003705 50428231738 30300 tolnaftate ANTIFUNGAL CREAM PDL NPD NANTIFUNGALS, TOPICAL 50428521682 90150085003705 50428521682 30300 tolnaftate ANTIFUNGAL CREAM PDL NPD NANTIFUNGALS, TOPICAL 11917009374 90150087103710 11917009374 62498 terbinafine HCl TERBINAFINE PDL NPD NANTIFUNGALS, TOPICAL 59779008001 90150087103710 59779008001 62498 terbinafine HCl ATHLETE'S FOOT PDL NPD NANTIFUNGALS, TOPICAL 59779008002 90150087103710 59779008002 62498 terbinafine HCl ATHLETE'S FOOT PDL NPD NANTIFUNGALS, TOPICAL 59779052301 90150087103710 59779052301 62498 terbinafine HCl JOCK ITCH PDL NPD NANTIFUNGALS, TOPICAL 10135067181 90154020002005 10135067181 30380 clotrimazole CLOTRIMAZOLE PDL NPD NANTIFUNGALS, TOPICAL 69842086601 90154020002005 69842086601 30380 clotrimazole CLOTRIMAZOLE PDL NPD NANTIFUNGALS, TOPICAL 71399050001 90154020002005 71399050001 30380 clotrimazole CLOTRIMAZOLE PDL NPD NANTIFUNGALS, TOPICAL 00179801430 90154020003705 00179801430 30370 clotrimazole CLOTRIMAZOLE PDL NPD NANTIFUNGALS, TOPICAL 11017057136 90154020003705 11017057136 30370 clotrimazole LOTRIMIN AF NPD NPD N

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 3

ANTIFUNGALS, TOPICAL 11673091012 90154020003705 11673091012 30370 clotrimazole CLOTRIMAZOLE PDL NPD NANTIFUNGALS, TOPICAL 11822039260 90154020003705 11822039260 30370 clotrimazole JOCK ITCH RELIEF PDL NPD NANTIFUNGALS, TOPICAL 11822307820 90154020003705 11822307820 30370 clotrimazole CLOTRIMAZOLE AF PDL NPD NANTIFUNGALS, TOPICAL 11822471250 90154020003705 11822471250 30370 clotrimazole CLOTRIMAZOLE PDL NPD NANTIFUNGALS, TOPICAL 11917005426 90154020003705 11917005426 30370 clotrimazole CLOTRIMAZOLE PDL NPD NANTIFUNGALS, TOPICAL 11917005427 90154020003705 11917005427 30370 clotrimazole CLOTRIMAZOLE PDL NPD NANTIFUNGALS, TOPICAL 11917012991 90154020003705 11917012991 30370 clotrimazole CLOTRIMAZOLE PDL NPD NANTIFUNGALS, TOPICAL 11917012992 90154020003705 11917012992 30370 clotrimazole CLOTRIMAZOLE PDL NPD NANTIFUNGALS, TOPICAL 41415005675 90154020003705 41415005675 30370 clotrimazole

ATHLETIC FOOT CREAM PDL NPD N

ANTIFUNGALS, TOPICAL 49035012307 90154020003705 49035012307 30370 clotrimazole JOCK ITCH PDL NPD NANTIFUNGALS, TOPICAL 49035081227 90154020003705 49035081227 30370 clotrimazole ATHLETE'S FOOT PDL NPD NANTIFUNGALS, TOPICAL 50428008517 90154020003705 50428008517 30370 clotrimazole ITCH RELIEF PDL NPD NANTIFUNGALS, TOPICAL 50428211003 90154020003705 50428211003 30370 clotrimazole CLOTRIMAZOLE PDL NPD NANTIFUNGALS, TOPICAL 50428903693 90154020003705 50428903693 30370 clotrimazole RINGWORM PDL NPD NANTIFUNGALS, TOPICAL 59779030501 90154020003705 59779030501 30370 clotrimazole CLOTRIMAZOLE PDL NPD NANTIFUNGALS, TOPICAL 59779030502 90154020003705 59779030502 30370 clotrimazole CLOTRIMAZOLE PDL NPD NANTIFUNGALS, TOPICAL 69396000120 90154020003705 69396000120 30370 clotrimazole CLOTRIMAZOLE PDL NPD N

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 4

ANTIFUNGALS, TOPICAL 71085000860 90154045003710 71085000860 31850 ketoconazole KETOCONAZOLE PDL NPD NANTIFUNGALS, TOPICAL 11523091901 90154050102910 11523091901 30410 miconazole nitrate LOTRIMIN AF PDL NPD NANTIFUNGALS, TOPICAL 11701003816 90154050102910 11701003816 30410 miconazole nitrate MICRO-GUARD PDL NPD NANTIFUNGALS, TOPICAL 59779063571 90154050102910 59779063571 30410 miconazole nitrate

ANTI-FUNGAL POWDER PDL NPD N

ANTIFUNGALS, TOPICAL 11017041013 90154050103210 11017041013 27083 miconazole nitrate LOTRIMIN AF PDL NPD NANTIFUNGALS, TOPICAL 00363034190 90154050103310 00363034190 30390 miconazole nitrate

ATHLETE'S FOOT SPRAY NPD NPD N

ANTIFUNGALS, TOPICAL 11822546090 90154050103310 11822546090 30390 miconazole nitrate

ATHLETE'S FOOT SPRAY NPD NPD N

ANTIFUNGALS, TOPICAL 50428334067 90154050103310 50428334067 30390 miconazole nitrate

ATHLETE'S FOOT SPRAY NPD NPD N

ANTIFUNGALS, TOPICAL 11701004514 90154050103705 11701004514 30400 miconazole nitrate BAZA ANTIFUNGAL PDL NPD NANTIFUNGALS, TOPICAL 11701004523 90154050103705 11701004523 30400 miconazole nitrate BAZA ANTIFUNGAL PDL NPD NANTIFUNGALS, TOPICAL 65197010305 90154050103705 65197010305 30400 miconazole nitrate MICATIN PDL NPD NANTIFUNGALS, TOPICAL 69396001420 90154050103705 69396001420 30400 miconazole nitrate

MICONAZOLE NITRATE PDL NPD N

ANTIFUNGALS, TOPICAL 11086004002 90154050104210 11086004002 13394 miconazole nitrate TRIPLE PASTE AF PDL NPD NANTIFUNGALS, TOPICAL 11701006723 90154050104210 11701006723 13394 miconazole nitrate CRITIC-AID PDL NPD NANTIFUNGALS, TOPICAL 61924023404 90154050104210 61924023404 13394 miconazole nitrate DERMAFUNGAL PDL NPD NANTIFUNGALS, TOPICAL 70263033301 90154065003710 70263033301 46920 oxiconazole nitrate

OXICONAZOLE NITRATE NPD NPD N

ANTIFUNGALS, TOPICAL 69489072130 90154075002010 69489072130 46900 sulconazole nitrate EXELDERM NPD NPD N

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 5

ANTIFUNGALS, TOPICAL 69489071160 90154075003710 69489071160 46910 sulconazole nitrate EXELDERM NPD NPD NBETA-BLOCKERS 50419010710 39513 sotalol HCl BETAPACE NPD NPD NBETA-BLOCKERS 10135063405 33300007000310 10135063405 1554 carvedilol CARVEDILOL PDL NPD NBETA-BLOCKERS 10135063505 33300007000320 10135063505 1552 carvedilol CARVEDILOL PDL NPD NCALCIUM CHANNEL BLOCKERS 42582031418 34000003100330 42582031418 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL NPD N

CALCIUM CHANNEL BLOCKERS 42582031518 34000003100340 42582031518 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL NPD N

PHOSPHATE BINDERS 10135062902 52800020100120 10135062902 13675 calcium acetate CALCIUM ACETATE PDL NPD NSTEROIDS, TOPICAL HIGH 70512003160 90550050104205 70512003160 31480 diflorasone diacetate

DIFLORASONE DIACETATE NPD NPD N

STEROIDS, TOPICAL HIGH 71800000960 90550050104205 71800000960 31480 diflorasone diacetate

DIFLORASONE DIACETATE NPD NPD N

STEROIDS, TOPICAL HIGH 71800015631 90550085103400 71800015631 98339 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE NPD NPD N

STEROIDS, TOPICAL HIGH 69329029001 90559903906420 69329029001 38908

triamcinolone/dimeth/silicone DERMAWERX SDS NPD NPD N

STEROIDS, TOPICAL HIGH 69837000302 90559903906420 69837000302 38908

triamcinolone/dimeth/silicone

SURE RESULT TAC PAK NPD NPD N

STEROIDS, TOPICAL HIGH 70859000201 90559903906420 70859000201 38908

triamcinolone/dimeth/silicone NUTRIARX NPD NPD N

STEROIDS, TOPICAL HIGH 70859004701 90559903906420 70859004701 38908

triamcinolone/dimeth/silicone NUTRIARX NPD NPD N

STEROIDS, TOPICAL LOW 10939057033 92421 hydrocortisone/aloe vera

HYDROCORTISONE-ALOE PDL NPD N

STEROIDS, TOPICAL LOW 10939057333 92421 hydrocortisone/aloe vera

HYDROCORTISONE PLUS PDL NPD N

STEROIDS, TOPICAL LOW 11383018552 30942 hydrocortisone HYDROCORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 43072000406 30942 hydrocortisone HYDROCORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 59779030728 30942 hydrocortisone HYDROCORTISONE PDL NPD N

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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STEROIDS, TOPICAL LOW 59779031916 92421 hydrocortisone/aloe vera

CORTISONE WITH ALOE PDL NPD N

STEROIDS, TOPICAL LOW 59779031956 92421 hydrocortisone/aloe vera

CORTISONE WITH ALOE PDL NPD N

STEROIDS, TOPICAL LOW 59779084428 30942 hydrocortisone ANTI-ITCH PDL NPD NSTEROIDS, TOPICAL LOW 74300003396 30951 hydrocortisone CORTIZONE-10 PDL NPD NSTEROIDS, TOPICAL LOW 11917004954 90550075003715 11917004954 30941 hydrocortisone HYDROCORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 50428037924 90550075003715 50428037924 92420 hydrocortisone/aloe vera

HYDROCORTISONE-ALOE PDL NPD N

STEROIDS, TOPICAL LOW 00363036964 90550075003720 00363036964 30942 hydrocortisone HYDROCORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 00573283010 90550075003720 00573283010 30942 hydrocortisone PREPARATION H PDL NPD NSTEROIDS, TOPICAL LOW 11822358780 90550075003720 11822358780 30942 hydrocortisone HYDROCORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 11822372390 90550075003720 11822372390 30942 hydrocortisone ANTI-ITCH PDL NPD NSTEROIDS, TOPICAL LOW 11917004958 90550075003720 11917004958 30942 hydrocortisone HYDROCORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 11917004959 90550075003720 11917004959 30942 hydrocortisone HYDROCORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 11917013828 90550075003720 11917013828 30942 hydrocortisone HYDROCORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 41415004775 90550075003720 41415004775 30942 hydrocortisone HYDROCREAM PDL NPD NSTEROIDS, TOPICAL LOW 49035070764 90550075003720 49035070764 92421 hydrocortisone/aloe vera

HYDROCORTISONE-ALOE PDL NPD N

STEROIDS, TOPICAL LOW 50428030208 90550075003720 50428030208 30942 hydrocortisone HYDROCORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 50428373019 90550075003720 50428373019 30942 hydrocortisone HYDROCORTISONE PDL NPD N

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 7

STEROIDS, TOPICAL LOW 50428690242 90550075003720 50428690242 30942 hydrocortisone CORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 59779009902 90550075003720 59779009902 30942 hydrocortisone CORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 59779009903 90550075003720 59779009903 30942 hydrocortisone CORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 00096073204 90550075004115 00096073204 30974 hydrocortisone AQUANIL HC PDL NPD NSTEROIDS, TOPICAL LOW 00394085932 90550075004115 00394085932 29135 hydrocortisone HYDROCORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 41167003310 90550075004115 41167003310 29135 hydrocortisone CORTIZONE-10 PDL NPD NSTEROIDS, TOPICAL LOW 59779087825 90550075004115 59779087825 29135 hydrocortisone CORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 63736033942 90550075004115 63736033942 30974 hydrocortisone DERMAREST ECZEMA PDL NPD NSTEROIDS, TOPICAL LOW 11822314320 90550075004210 11822314320 30951 hydrocortisone ANTI-ITCH PDL NPD NSTEROIDS, TOPICAL LOW 11917004957 90550075004210 11917004957 30851 hydrocortisone acetate HYDROCORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 11917006914 90550075004210 11917006914 30951 hydrocortisone HYDROCORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 41167000393 90550075004210 41167000393 30951 hydrocortisone CORTIZONE-10 PDL NPD NSTEROIDS, TOPICAL LOW 41167003396 90550075004210 41167003396 30951 hydrocortisone CORTIZONE-10 PDL NPD NSTEROIDS, TOPICAL LOW 50428373092 90550075004210 50428373092 30951 hydrocortisone HYDROCORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 59390008017 90550075004210 59390008017 30951 hydrocortisone HYDROCORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 59779003456 90550075004210 59779003456 30951 hydrocortisone CORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 69396000320 90550075004210 69396000320 30951 hydrocortisone HYDROCORTISONE PDL NPD N

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 8

STEROIDS, TOPICAL LOW 11917006655 90559902503720 11917006655 30942 hydrocortisone HYDROCORTISONE PDL NPD NSTEROIDS, TOPICAL LOW 41167000350 90559902503720 41167000350 30942 hydrocortisone CORTIZONE-10 PDL NPD NSTEROIDS, TOPICAL LOW 41167000391 90559902503720 41167000391 30942 hydrocortisone CORTIZONE-10 PDL NPD NSTEROIDS, TOPICAL LOW 41167001056 90559902503720 41167001056 30942 hydrocortisone CORTIZONE-10 PLUS PDL NPD NSTEROIDS, TOPICAL LOW 49348043578 90559902503720 49348043578 30942 hydrocortisone HYDROCORTISONE PDL NPD NSTEROIDS, TOPICAL MEDIUM 24470091912 90550065003710 24470091912 28711 flurandrenolide FLURANDRENOLIDE NPD NPD NSTEROIDS, TOPICAL MEDIUM 24470091960 90550065003710 24470091960 28711 flurandrenolide FLURANDRENOLIDE NPD NPD NSTEROIDS, TOPICAL MEDIUM 24470092112 90550065004105 24470092112 31310 flurandrenolide FLURANDRENOLIDE NPD NPD NSTEROIDS, TOPICAL MEDIUM 57893031112 90550065004105 57893031112 31310 flurandrenolide NOLIX NPD NPD NSTEROIDS, TOPICAL MEDIUM 70512003204 90550075304120 70512003204 62480 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD N

ANTIFUNGALS, ORAL 00254101636 26502 posaconazole POSACONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 00254204502 35649 posaconazole POSACONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 00054042725 11000020000105 00054042725 42560 flucytosine FLUCYTOSINE NPD NPD Y

ANTIFUNGALS, ORAL 00187355410 11000020000105 00187355410 42560 flucytosine ANCOBON NPD NPD Y

ANTIFUNGALS, ORAL 42794000908 11000020000105 42794000908 42560 flucytosine FLUCYTOSINE NPD NPD Y

ANTIFUNGALS, ORAL 43386077101 11000020000105 43386077101 42560 flucytosine FLUCYTOSINE NPD NPD Y

ANTIFUNGALS, ORAL 00187355510 11000020000110 00187355510 42561 flucytosine ANCOBON NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 9

ANTIFUNGALS, ORAL 42494034001 11000020000110 42494034001 42561 flucytosine FLUCYTOSINE NPD NPD Y

ANTIFUNGALS, ORAL 42794001008 11000020000110 42794001008 42561 flucytosine FLUCYTOSINE NPD NPD Y

ANTIFUNGALS, ORAL 00781551501 11000030100315 00781551501 42402 griseofulvin, microsize GRISEOFULVIN PDL PDL Y

ANTIFUNGALS, ORAL 64980018601 11000030100315 64980018601 42402 griseofulvin, microsize GRISEOFULVIN PDL PDL Y

ANTIFUNGALS, ORAL 64980018603 11000030100315 64980018603 42402 griseofulvin, microsize GRISEOFULVIN PDL PDL Y

ANTIFUNGALS, ORAL 00472001304 11000030101805 00472001304 42390 griseofulvin, microsize GRISEOFULVIN PDL PDL Y

ANTIFUNGALS, ORAL 69097036108 11000030101805 69097036108 42390 griseofulvin, microsize GRISEOFULVIN PDL PDL Y

ANTIFUNGALS, ORAL 00115172401 11000030200305 00115172401 42410 griseofulvin ultramicrosizeGRISEOFULVIN

ULTRAMICROSIZE NPD NPD Y

ANTIFUNGALS, ORAL 64720029510 11000030200305 64720029510 42410 griseofulvin ultramicrosizeGRISEOFULVIN

ULTRAMICROSIZE NPD NPD Y

ANTIFUNGALS, ORAL 64980018403 11000030200305 64980018403 42410 griseofulvin ultramicrosizeGRISEOFULVIN

ULTRAMICROSIZE NPD NPD Y

ANTIFUNGALS, ORAL 68682051901 11000030200305 68682051901 42410 griseofulvin ultramicrosizeGRISEOFULVIN

ULTRAMICROSIZE NPD NPD Y

ANTIFUNGALS, ORAL 00115172501 11000030200315 00115172501 42412 griseofulvin ultramicrosizeGRISEOFULVIN

ULTRAMICROSIZE NPD NPD Y

ANTIFUNGALS, ORAL 64720029610 11000030200315 64720029610 42412 griseofulvin ultramicrosizeGRISEOFULVIN

ULTRAMICROSIZE NPD NPD Y

ANTIFUNGALS, ORAL 64980018501 11000030200315 64980018501 42412 griseofulvin ultramicrosizeGRISEOFULVIN

ULTRAMICROSIZE NPD NPD Y

ANTIFUNGALS, ORAL 64980018503 11000030200315 64980018503 42412 griseofulvin ultramicrosizeGRISEOFULVIN

ULTRAMICROSIZE NPD NPD Y

ANTIFUNGALS, ORAL 68682052001 11000030200315 68682052001 42412 griseofulvin ultramicrosizeGRISEOFULVIN

ULTRAMICROSIZE NPD NPD Y

ANTIFUNGALS, ORAL 00093098301 11000060000305 00093098301 42452 nystatin NYSTATIN PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 10

ANTIFUNGALS, ORAL 23155005101 11000060000305 23155005101 42452 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 53489040001 11000060000305 53489040001 42452 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 16714050101 11000080100310 16714050101 60823 terbinafine HCl TERBINAFINE HCL PDL PDL Y

ANTIFUNGALS, ORAL 16714050102 11000080100310 16714050102 60823 terbinafine HCl TERBINAFINE HCL PDL PDL Y

ANTIFUNGALS, ORAL 16714079501 11000080100310 16714079501 60823 terbinafine HCl TERBINAFINE HCL PDL PDL Y

ANTIFUNGALS, ORAL 16714079502 11000080100310 16714079502 60823 terbinafine HCl TERBINAFINE HCL PDL PDL Y

ANTIFUNGALS, ORAL 51991052601 11000080100310 51991052601 60823 terbinafine HCl TERBINAFINE HCL PDL PDL Y

ANTIFUNGALS, ORAL 51991052633 11000080100310 51991052633 60823 terbinafine HCl TERBINAFINE HCL PDL PDL Y

ANTIFUNGALS, ORAL 65862007930 11000080100310 65862007930 60823 terbinafine HCl TERBINAFINE HCL PDL PDL Y

ANTIFUNGALS, ORAL 67405050003 11000080100310 67405050003 60823 terbinafine HCl TERBINAFINE HCL PDL PDL Y

ANTIFUNGALS, ORAL 67405050010 11000080100310 67405050010 60823 terbinafine HCl TERBINAFINE HCL PDL PDL Y

ANTIFUNGALS, ORAL 69097085902 11000080100310 69097085902 60823 terbinafine HCl TERBINAFINE HCL PDL PDL Y

ANTIFUNGALS, ORAL 69097085907 11000080100310 69097085907 60823 terbinafine HCl TERBINAFINE HCL PDL PDL Y

ANTIFUNGALS, ORAL 00093090001 11404040000310 00093090001 42590 ketoconazole KETOCONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 00378026101 11404040000310 00378026101 42590 ketoconazole KETOCONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 51672402601 11404040000310 51672402601 42590 ketoconazole KETOCONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 51672402606 11404040000310 51672402606 42590 ketoconazole KETOCONAZOLE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 11

ANTIFUNGALS, ORAL 64380082706 11404040000310 64380082706 42590 ketoconazole KETOCONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 00049341030 11407015000310 00049341030 42192 fluconazole DIFLUCAN NPD NPD Y

ANTIFUNGALS, ORAL 00172541046 11407015000310 00172541046 42192 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 16714069401 11407015000310 16714069401 42192 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 55111014330 11407015000310 55111014330 42192 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 57237000330 11407015000310 57237000330 42192 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 67405060103 11407015000310 67405060103 42192 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 68001025104 11407015000310 68001025104 42192 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 68462010130 11407015000310 68462010130 42192 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 70710113703 11407015000310 70710113703 42192 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00049342030 11407015000320 00049342030 42190 fluconazole DIFLUCAN NPD NPD Y

ANTIFUNGALS, ORAL 00049342041 11407015000320 00049342041 42190 fluconazole DIFLUCAN NPD NPD Y

ANTIFUNGALS, ORAL 00172541146 11407015000320 00172541146 42190 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00172541160 11407015000320 00172541160 42190 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00378251693 11407015000320 00378251693 42190 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00904650061 11407015000320 00904650061 42190 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 16714069101 11407015000320 16714069101 42190 fluconazole FLUCONAZOLE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 12

ANTIFUNGALS, ORAL 16714069102 11407015000320 16714069102 42190 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 55111014401 11407015000320 55111014401 42190 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 55111014430 11407015000320 55111014430 42190 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 57237000430 11407015000320 57237000430 42190 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 59762501601 11407015000320 59762501601 42190 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 67405060203 11407015000320 67405060203 42190 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 68001025204 11407015000320 68001025204 42190 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 68462010230 11407015000320 68462010230 42190 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 70710113801 11407015000320 70710113801 42190 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 70710113803 11407015000320 70710113803 42190 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00049350079 11407015000325 00049350079 42193 fluconazole DIFLUCAN NPD NPD Y

ANTIFUNGALS, ORAL 00172541211 11407015000325 00172541211 42193 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00172541279 11407015000325 00172541279 42193 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 16714069210 11407015000325 16714069210 42193 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 16714069211 11407015000325 16714069211 42193 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 55111014512 11407015000325 55111014512 42193 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 55111014571 11407015000325 55111014571 42193 fluconazole FLUCONAZOLE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 13

ANTIFUNGALS, ORAL 57237000511 11407015000325 57237000511 42193 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 59762501701 11407015000325 59762501701 42193 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 67405060301 11407015000325 67405060301 42193 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 68001025320 11407015000325 68001025320 42193 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 68001025321 11407015000325 68001025321 42193 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 68462010340 11407015000325 68462010340 42193 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 70710113908 11407015000325 70710113908 42193 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00049343030 11407015000330 00049343030 42191 fluconazole DIFLUCAN NPD NPD Y

ANTIFUNGALS, ORAL 00049343041 11407015000330 00049343041 42191 fluconazole DIFLUCAN NPD NPD Y

ANTIFUNGALS, ORAL 00172541346 11407015000330 00172541346 42191 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00172541360 11407015000330 00172541360 42191 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00378252093 11407015000330 00378252093 42191 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00904650161 11407015000330 00904650161 42191 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 16714069301 11407015000330 16714069301 42191 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 16714069302 11407015000330 16714069302 42191 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 55111014601 11407015000330 55111014601 42191 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 55111014630 11407015000330 55111014630 42191 fluconazole FLUCONAZOLE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 14

ANTIFUNGALS, ORAL 57237000630 11407015000330 57237000630 42191 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 59762501801 11407015000330 59762501801 42191 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 67405060403 11407015000330 67405060403 42191 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 68001025404 11407015000330 68001025404 42191 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 68084073501 11407015000330 68084073501 42191 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 68462010430 11407015000330 68462010430 42191 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 70710114001 11407015000330 70710114001 42191 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 70710114003 11407015000330 70710114003 42191 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00049344019 11407015001910 00049344019 60822 fluconazole DIFLUCAN NPD NPD Y

ANTIFUNGALS, ORAL 00054000285 11407015001910 00054000285 60822 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 16714069501 11407015001910 16714069501 60822 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 57237014935 11407015001910 57237014935 60822 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 59762502901 11407015001910 59762502901 60822 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00049345019 11407015001940 00049345019 60821 fluconazole DIFLUCAN NPD NPD Y

ANTIFUNGALS, ORAL 00054000385 11407015001940 00054000385 60821 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 16714069601 11407015001940 16714069601 60821 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 57237015035 11407015001940 57237015035 60821 fluconazole FLUCONAZOLE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 15

ANTIFUNGALS, ORAL 59762503001 11407015001940 59762503001 60821 fluconazole FLUCONAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00469032014 11407030100120 00469032014 38095 isavuconazonium sulfate CRESEMBA NPD NPD Y

ANTIFUNGALS, ORAL 00469052014 11407030100120 00469052014 38095 isavuconazonium sulfate CRESEMBA NPD NPD Y

ANTIFUNGALS, ORAL 51862046260 11407035000113 51862046260 45848 itraconazole TOLSURA NPD NPD Y

ANTIFUNGALS, ORAL 00185055083 11407035000120 00185055083 49101 itraconazole ITRACONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 00378510093 11407035000120 00378510093 49101 itraconazole ITRACONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 10147170003 11407035000120 10147170003 49101 itraconazole ITRACONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 10147170007 11407035000120 10147170007 49101 itraconazole ITRACONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 13668046330 11407035000120 13668046330 49101 itraconazole ITRACONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 16714074302 11407035000120 16714074302 49101 itraconazole ITRACONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 49884023911 11407035000120 49884023911 49101 itraconazole ITRACONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 50458029001 11407035000120 50458029001 49101 itraconazole SPORANOX NPD NPD Y

ANTIFUNGALS, ORAL 50458029004 11407035000120 50458029004 49101 itraconazole SPORANOX NPD NPD Y

ANTIFUNGALS, ORAL 50458029028 11407035000120 50458029028 49101 itraconazole SPORANOX NPD NPD Y

ANTIFUNGALS, ORAL 59746028230 11407035000120 59746028230 49101 itraconazole ITRACONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 62332020430 11407035000120 62332020430 49101 itraconazole ITRACONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 65162063003 11407035000120 65162063003 49101 itraconazole ITRACONAZOLE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 16

ANTIFUNGALS, ORAL 67877045430 11407035000120 67877045430 49101 itraconazole ITRACONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 00259142014 11407035000330 00259142014 33787 itraconazole ONMEL NPD NPD Y

ANTIFUNGALS, ORAL 00259142028 11407035000330 00259142028 33787 itraconazole ONMEL NPD NPD Y

ANTIFUNGALS, ORAL 10147015001 11407035002020 10147015001 49100 itraconazole ITRACONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 50458029515 11407035002020 50458029515 49100 itraconazole SPORANOX NPD NPD Y

ANTIFUNGALS, ORAL 65162008774 11407035002020 65162008774 49100 itraconazole ITRACONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 00085432402 11407060000620 00085432402 35649 posaconazole NOXAFIL NPD NPD Y

ANTIFUNGALS, ORAL 00085132801 11407060001820 00085132801 26502 posaconazole NOXAFIL NPD NPD Y

ANTIFUNGALS, ORAL 00049317030 11407080000320 00049317030 17497 voriconazole VFEND NPD NPD Y

ANTIFUNGALS, ORAL 00093528956 11407080000320 00093528956 17497 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 00781566731 11407080000320 00781566731 17497 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 00904659604 11407080000320 00904659604 17497 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 16714051401 11407080000320 16714051401 17497 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 27241006203 11407080000320 27241006203 17497 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 43386008803 11407080000320 43386008803 17497 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 43547037703 11407080000320 43547037703 17497 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 51079016403 11407080000320 51079016403 17497 voriconazole VORICONAZOLE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 17

ANTIFUNGALS, ORAL 65862089130 11407080000320 65862089130 17497 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 68382073506 11407080000320 68382073506 17497 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 68462057230 11407080000320 68462057230 17497 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 00049318030 11407080000340 00049318030 17498 voriconazole VFEND NPD NPD Y

ANTIFUNGALS, ORAL 00093529056 11407080000340 00093529056 17498 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 00378164093 11407080000340 00378164093 17498 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 00781566831 11407080000340 00781566831 17498 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 00904647104 11407080000340 00904647104 17498 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 16714051501 11407080000340 16714051501 17498 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 27241006303 11407080000340 27241006303 17498 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 43386008903 11407080000340 43386008903 17498 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 43547037803 11407080000340 43547037803 17498 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 51079016503 11407080000340 51079016503 17498 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 59762093002 11407080000340 59762093002 17498 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 59762093601 11407080000340 59762093601 17498 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 63739070733 11407080000340 63739070733 17498 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 65862089230 11407080000340 65862089230 17498 voriconazole VORICONAZOLE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 18

ANTIFUNGALS, ORAL 68382073606 11407080000340 68382073606 17498 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 68462057330 11407080000340 68462057330 17498 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 00049316044 11407080001920 00049316044 21513 voriconazole VFEND NPD NPD Y

ANTIFUNGALS, ORAL 43386003860 11407080001920 43386003860 21513 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 59762093503 11407080001920 59762093503 21513 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 65162091322 11407080001920 65162091322 21513 voriconazole VORICONAZOLE NPD NPD Y

ANTIFUNGALS, ORAL 00121081002 88100010001805 00121081002 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 00121081016 88100010001805 00121081016 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 00121478505 88100010001805 00121478505 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 00121481005 88100010001805 00121481005 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 00121481040 88100010001805 00121481040 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 00603148149 88100010001805 00603148149 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 00603148158 88100010001805 00603148158 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 50383058716 88100010001805 50383058716 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 50383058766 88100010001805 50383058766 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 51672411704 88100010001805 51672411704 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 51672411709 88100010001805 51672411709 42440 nystatin NYSTATIN PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 19

ANTIFUNGALS, ORAL 60432053716 88100010001805 60432053716 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 60432053760 88100010001805 60432053760 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 66689000802 88100010001805 66689000802 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 66689000816 88100010001805 66689000816 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 66689003701 88100010001805 66689003701 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 66689003750 88100010001805 66689003750 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 66689003799 88100010001805 66689003799 42440 nystatin NYSTATIN PDL PDL Y

ANTIFUNGALS, ORAL 00054414622 88100020004805 00054414622 7590 clotrimazole CLOTRIMAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00054414623 88100020004805 00054414623 7590 clotrimazole CLOTRIMAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00054814622 88100020004805 00054814622 7590 clotrimazole CLOTRIMAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00574010714 88100020004805 00574010714 7590 clotrimazole CLOTRIMAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00574010770 88100020004805 00574010770 7590 clotrimazole CLOTRIMAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 00574010777 88100020004805 00574010777 7590 clotrimazole CLOTRIMAZOLE PDL PDL Y

ANTIFUNGALS, ORAL 89141025014 88100060000310 89141025014 99633 miconazole ORAVIG NPD NPD YANTIFUNGALS, TOPICAL 00067400546 30290 tolnaftate LAMISIL AF PDL PDL YANTIFUNGALS, TOPICAL 00115151048 48470 naftifine HCl NAFTIFINE HCL NPD NPD YANTIFUNGALS, TOPICAL 00115151058 48470 naftifine HCl NAFTIFINE HCL NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 20

ANTIFUNGALS, TOPICAL 00115151063 48470 naftifine HCl NAFTIFINE HCL NPD NPD YANTIFUNGALS, TOPICAL 63868059528 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 00378615146 90150026103720 00378615146 37521 butenafine HCl MENTAX NPD NPD YANTIFUNGALS, TOPICAL 00378615149 90150026103720 00378615149 37521 butenafine HCl MENTAX NPD NPD YANTIFUNGALS, TOPICAL 51672210002 90150026103720 51672210002 37521 butenafine HCl BUTENAFINE HCL PDL PDL YANTIFUNGALS, TOPICAL 51672210008 90150026103720 51672210008 37521 butenafine HCl BUTENAFINE HCL PDL PDL YANTIFUNGALS, TOPICAL 00713031788 90150030002020 00713031788 8040 ciclopirox CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 00781710660 90150030002020 00781710660 8040 ciclopirox CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 43538050006 90150030002020 43538050006 8040 ciclopirox CICLODAN PDL PDL YANTIFUNGALS, TOPICAL 45802014167 90150030002020 45802014167 8040 ciclopirox CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 50383041906 90150030002020 50383041906 8040 ciclopirox CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 51672530200 90150030002020 51672530200 8040 ciclopirox CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 00168040730 90150030004010 00168040730 12618 ciclopirox CICLOPIROX NPD NPD YANTIFUNGALS, TOPICAL 00574206101 90150030004010 00574206101 12618 ciclopirox CICLOPIROX NPD NPD YANTIFUNGALS, TOPICAL 00574206130 90150030004010 00574206130 12618 ciclopirox CICLOPIROX NPD NPD YANTIFUNGALS, TOPICAL 00574206145 90150030004010 00574206145 12618 ciclopirox CICLOPIROX NPD NPD YANTIFUNGALS, TOPICAL 47781053073 90150030004010 47781053073 12618 ciclopirox CICLOPIROX NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 21

ANTIFUNGALS, TOPICAL 47781053085 90150030004010 47781053085 12618 ciclopirox CICLOPIROX NPD NPD YANTIFUNGALS, TOPICAL 68462045535 90150030004010 68462045535 12618 ciclopirox CICLOPIROX NPD NPD YANTIFUNGALS, TOPICAL 68462045547 90150030004010 68462045547 12618 ciclopirox CICLOPIROX NPD NPD YANTIFUNGALS, TOPICAL 68462045594 90150030004010 68462045594 12618 ciclopirox CICLOPIROX NPD NPD YANTIFUNGALS, TOPICAL 00591215990 90150030004510 00591215990 19218 ciclopirox CICLOPIROX NPD NPD YANTIFUNGALS, TOPICAL 45802040109 90150030004510 45802040109 19218 ciclopirox CICLOPIROX NPD NPD YANTIFUNGALS, TOPICAL 51672135108 90150030004510 51672135108 19218 ciclopirox CICLOPIROX NPD NPD YANTIFUNGALS, TOPICAL 52565003212 90150030004510 52565003212 19218 ciclopirox CICLOPIROX NPD NPD YANTIFUNGALS, TOPICAL 99207001010 90150030004510 99207001010 19218 ciclopirox LOPROX NPD NPD YANTIFUNGALS, TOPICAL 42192071401 90150030006420 42192071401 29988

ciclopirox/urea/camph/men/euc CICLOPIROX NPD NPD Y

ANTIFUNGALS, TOPICAL 45802040046 90150030101810 45802040046 95353 ciclopirox olamine CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 45802040049 90150030101810 45802040049 95353 ciclopirox olamine CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 69315030930 90150030101810 69315030930 95353 ciclopirox olamine CICLOPIROX NPD NPD YANTIFUNGALS, TOPICAL 69315030960 90150030101810 69315030960 95353 ciclopirox olamine CICLOPIROX NPD NPD YANTIFUNGALS, TOPICAL 00713063815 90150030103705 00713063815 94677 ciclopirox olamine CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 00713063818 90150030103705 00713063818 94677 ciclopirox olamine CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 00713063831 90150030103705 00713063831 94677 ciclopirox olamine CICLOPIROX PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 22

ANTIFUNGALS, TOPICAL 45802013811 90150030103705 45802013811 94677 ciclopirox olamine CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 45802013818 90150030103705 45802013818 94677 ciclopirox olamine CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 45802013835 90150030103705 45802013835 94677 ciclopirox olamine CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 51672131801 90150030103705 51672131801 94677 ciclopirox olamine CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 51672131802 90150030103705 51672131802 94677 ciclopirox olamine CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 51672131808 90150030103705 51672131808 94677 ciclopirox olamine CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 68462029717 90150030103705 68462029717 94677 ciclopirox olamine CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 68462029735 90150030103705 68462029735 94677 ciclopirox olamine CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 68462029792 90150030103705 68462029792 94677 ciclopirox olamine CICLOPIROX PDL PDL YANTIFUNGALS, TOPICAL 43538054190 90150030406440 43538054190 41674

ciclopirox/skin cleanser no.40 LOPROX NPD NPD Y

ANTIFUNGALS, TOPICAL 40085020160 90150078003710 40085020160 47770 naftifine HCl NAFTIFINE HCL NPD NPD YANTIFUNGALS, TOPICAL 40085020190 90150078003710 40085020190 47770 naftifine HCl NAFTIFINE HCL NPD NPD YANTIFUNGALS, TOPICAL 51672136203 90150078003710 51672136203 47770 naftifine HCl NAFTIFINE HCL NPD NPD YANTIFUNGALS, TOPICAL 00115151246 90150078003720 00115151246 31452 naftifine HCl NAFTIFINE HCL NPD NPD YANTIFUNGALS, TOPICAL 00115151258 90150078003720 00115151258 31452 naftifine HCl NAFTIFINE HCL NPD NPD YANTIFUNGALS, TOPICAL 40085020345 90150078003720 40085020345 31452 naftifine HCl NAFTIFINE HCL NPD NPD YANTIFUNGALS, TOPICAL 40085020360 90150078003720 40085020360 31452 naftifine HCl NAFTIFINE HCL NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 23

ANTIFUNGALS, TOPICAL 51672136803 90150078003720 51672136803 31452 naftifine HCl NAFTIFINE HCL NPD NPD YANTIFUNGALS, TOPICAL 51672136806 90150078003720 51672136806 31452 naftifine HCl NAFTIFINE HCL NPD NPD YANTIFUNGALS, TOPICAL 54766010245 90150078003720 54766010245 31452 naftifine HCl NAFTIN NPD NPD YANTIFUNGALS, TOPICAL 54766010260 90150078003720 54766010260 31452 naftifine HCl NAFTIN NPD NPD YANTIFUNGALS, TOPICAL 54766077040 90150078004010 54766077040 48470 naftifine HCl NAFTIN NPD NPD YANTIFUNGALS, TOPICAL 54766077060 90150078004010 54766077060 48470 naftifine HCl NAFTIN NPD NPD YANTIFUNGALS, TOPICAL 54766077090 90150078004010 54766077090 48470 naftifine HCl NAFTIN NPD NPD YANTIFUNGALS, TOPICAL 54766077245 90150078004030 54766077245 34933 naftifine HCl NAFTIN NPD NPD YANTIFUNGALS, TOPICAL 54766077260 90150078004030 54766077260 34933 naftifine HCl NAFTIN NPD NPD YANTIFUNGALS, TOPICAL 00574200802 90150080002920 00574200802 30160 nystatin NYSTOP PDL PDL YANTIFUNGALS, TOPICAL 00574200815 90150080002920 00574200815 30160 nystatin NYSTOP PDL PDL YANTIFUNGALS, TOPICAL 00574200830 90150080002920 00574200830 30160 nystatin NYSTOP PDL PDL YANTIFUNGALS, TOPICAL 00832046515 90150080002920 00832046515 30160 nystatin NYAMYC PDL PDL YANTIFUNGALS, TOPICAL 00832046530 90150080002920 00832046530 30160 nystatin NYAMYC PDL PDL YANTIFUNGALS, TOPICAL 00832046560 90150080002920 00832046560 30160 nystatin NYAMYC PDL PDL YANTIFUNGALS, TOPICAL 16714076901 90150080002920 16714076901 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 16714076902 90150080002920 16714076902 30160 nystatin NYSTATIN PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 24

ANTIFUNGALS, TOPICAL 16714076903 90150080002920 16714076903 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 39822301501 90150080002920 39822301501 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 39822301503 90150080002920 39822301503 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 39822301506 90150080002920 39822301506 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 42543005261 90150080002920 42543005261 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 42543005262 90150080002920 42543005262 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 42543005263 90150080002920 42543005263 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 42543035215 90150080002920 42543035215 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 42543035230 90150080002920 42543035230 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 42543035260 90150080002920 42543035260 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 42806017815 90150080002920 42806017815 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 42806017830 90150080002920 42806017830 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 42806017860 90150080002920 42806017860 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 43386053001 90150080002920 43386053001 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 43386053002 90150080002920 43386053002 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 43386053006 90150080002920 43386053006 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 68308015215 90150080002920 68308015215 30160 nystatin NYSTATIN PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 25

ANTIFUNGALS, TOPICAL 68308015230 90150080002920 68308015230 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 68308015260 90150080002920 68308015260 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 69315030615 90150080002920 69315030615 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 69315030630 90150080002920 69315030630 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 69315030660 90150080002920 69315030660 30160 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00168005415 90150080003710 00168005415 30140 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00168005430 90150080003710 00168005430 30140 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00316022115 90150080003710 00316022115 30140 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00316022130 90150080003710 00316022130 30140 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00472016315 90150080003710 00472016315 30140 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00472016330 90150080003710 00472016330 30140 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00603781874 90150080003710 00603781874 30140 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00603781878 90150080003710 00603781878 30140 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00713067815 90150080003710 00713067815 30140 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00713067831 90150080003710 00713067831 30140 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 45802005911 90150080003710 45802005911 30140 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 45802005935 90150080003710 45802005935 30140 nystatin NYSTATIN PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 26

ANTIFUNGALS, TOPICAL 51672128901 90150080003710 51672128901 30140 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 51672128902 90150080003710 51672128902 30140 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00168000715 90150080004215 00168000715 30150 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00168000730 90150080004215 00168000730 30150 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00472016615 90150080004215 00472016615 30150 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00472016630 90150080004215 00472016630 30150 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00713068615 90150080004215 00713068615 30150 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00713068631 90150080004215 00713068631 30150 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 13668053401 90150080004215 13668053401 30150 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 45802004811 90150080004215 45802004811 30150 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 45802004835 90150080004215 45802004835 30150 nystatin NYSTATIN PDL PDL YANTIFUNGALS, TOPICAL 00536515026 90150085002905 00536515026 30310 tolnaftate ANTI-FUNGAL PDL PDL YANTIFUNGALS, TOPICAL 00904072645 90150085002905 00904072645 30310 tolnaftate TOLNAFTATE PDL PDL YANTIFUNGALS, TOPICAL 00113015473 90150085003210 00113015473 99729 tolnaftate ATHLETE'S FOOT PDL PDL YANTIFUNGALS, TOPICAL 00067611446 90150085003305 00067611446 30290 tolnaftate LAMISIL AF PDL PDL YANTIFUNGALS, TOPICAL 00113069590 90150085003305 00113069590 30290 tolnaftate JOCK ITCH PDL PDL YANTIFUNGALS, TOPICAL 70000032201 90150085003305 70000032201 30290 tolnaftate ATHLETE'S FOOT PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 27

ANTIFUNGALS, TOPICAL 00904072236 90150085003705 00904072236 30300 tolnaftate ANTIFUNGAL CREAM PDL PDL YANTIFUNGALS, TOPICAL 24385003203 90150085003705 24385003203 30300 tolnaftate TOLNAFTATE PDL PDL YANTIFUNGALS, TOPICAL 37205019710 90150085003705 37205019710 30300 tolnaftate TOLNAFTATE PDL PDL YANTIFUNGALS, TOPICAL 49348015529 90150085003705 49348015529 30300 tolnaftate ANTIFUNGAL CREAM PDL PDL YANTIFUNGALS, TOPICAL 51672202001 90150085003705 51672202001 30300 tolnaftate TOLNAFTATE PDL PDL YANTIFUNGALS, TOPICAL 51672202002 90150085003705 51672202002 30300 tolnaftate TOLNAFTATE PDL PDL YANTIFUNGALS, TOPICAL 63868010446 90150085003705 63868010446 30300 tolnaftate TOLNAFTATE PDL PDL YANTIFUNGALS, TOPICAL 00067629283 90150087102010 00067629283 16258 terbinafine HCl LAMISIL NPD NPD YANTIFUNGALS, TOPICAL 00067629383 90150087102010 00067629383 16258 terbinafine HCl LAMISIL NPD NPD YANTIFUNGALS, TOPICAL 00067810012 90150087103710 00067810012 62498 terbinafine HCl LAMISIL AT NPD NPD YANTIFUNGALS, TOPICAL 00067810030 90150087103710 00067810030 62498 terbinafine HCl LAMISIL AT NPD NPD YANTIFUNGALS, TOPICAL 00536111728 90150087103710 00536111728 62498 terbinafine HCl TERBINAFINE PDL PDL YANTIFUNGALS, TOPICAL 24385052403 90150087103710 24385052403 62498 terbinafine HCl TERBINAFINE PDL PDL YANTIFUNGALS, TOPICAL 24385052405 90150087103710 24385052405 62498 terbinafine HCl TERBINAFINE PDL PDL YANTIFUNGALS, TOPICAL 37205094199 90150087103710 37205094199 62498 terbinafine HCl ATHLETE'S FOOT AF PDL PDL YANTIFUNGALS, TOPICAL 49348079072 90150087103710 49348079072 62498 terbinafine HCl ATHLETE'S FOOT PDL PDL YANTIFUNGALS, TOPICAL 51672208001 90150087103710 51672208001 62498 terbinafine HCl TERBINAFINE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 28

ANTIFUNGALS, TOPICAL 51672208002 90150087103710 51672208002 62498 terbinafine HCl TERBINAFINE PDL PDL YANTIFUNGALS, TOPICAL 00093024831 90154020002005 00093024831 30380 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 00536118170 90154020002005 00536118170 30380 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 51672126003 90154020002005 51672126003 30380 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 51672203701 90154020002005 51672203701 30380 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 70954003620 90154020002005 70954003620 30380 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 00085096315 90154020003705 00085096315 30370 clotrimazole LOTRIMIN AF NPD NPD YANTIFUNGALS, TOPICAL 00085096317 90154020003705 00085096317 30370 clotrimazole LOTRIMIN AF NPD NPD YANTIFUNGALS, TOPICAL 00168013315 90154020003705 00168013315 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 00168013330 90154020003705 00168013330 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 00168013346 90154020003705 00168013346 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 00472035056 90154020003705 00472035056 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 00904782231 90154020003705 00904782231 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 00904782236 90154020003705 00904782236 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 24385020501 90154020003705 24385020501 30370 clotrimazole ANTIFUNGAL PDL PDL YANTIFUNGALS, TOPICAL 24385020503 90154020003705 24385020503 30370 clotrimazole ANTIFUNGAL PDL PDL YANTIFUNGALS, TOPICAL 37205076010 90154020003705 37205076010 30370 clotrimazole CLOTRIMAZOLE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 29

ANTIFUNGALS, TOPICAL 45802043401 90154020003705 45802043401 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 45802043411 90154020003705 45802043411 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 49348027972 90154020003705 49348027972 30370 clotrimazole ANTIFUNGAL PDL PDL YANTIFUNGALS, TOPICAL 51672127501 90154020003705 51672127501 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 51672127502 90154020003705 51672127502 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 51672127506 90154020003705 51672127506 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 51672127507 90154020003705 51672127507 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 51672200201 90154020003705 51672200201 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 51672200202 90154020003705 51672200202 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 68462018117 90154020003705 68462018117 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 68462018135 90154020003705 68462018135 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 68462018147 90154020003705 68462018147 30370 clotrimazole CLOTRIMAZOLE PDL PDL YANTIFUNGALS, TOPICAL 29978091860 90154020004230 29978091860 685 clotrimazole ALEVAZOL NPD NPD YANTIFUNGALS, TOPICAL 00168031215 90154035103705 00168031215 30430 econazole nitrate ECONAZOLE NITRATE NPD NPD YANTIFUNGALS, TOPICAL 00168031230 90154035103705 00168031230 30430 econazole nitrate ECONAZOLE NITRATE NPD NPD YANTIFUNGALS, TOPICAL 00168031285 90154035103705 00168031285 30430 econazole nitrate ECONAZOLE NITRATE NPD NPD YANTIFUNGALS, TOPICAL 45802046611 90154035103705 45802046611 30430 econazole nitrate ECONAZOLE NITRATE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 30

ANTIFUNGALS, TOPICAL 45802046635 90154035103705 45802046635 30430 econazole nitrate ECONAZOLE NITRATE NPD NPD YANTIFUNGALS, TOPICAL 45802046653 90154035103705 45802046653 30430 econazole nitrate ECONAZOLE NITRATE NPD NPD YANTIFUNGALS, TOPICAL 51672130301 90154035103705 51672130301 30430 econazole nitrate ECONAZOLE NITRATE NPD NPD YANTIFUNGALS, TOPICAL 51672130302 90154035103705 51672130302 30430 econazole nitrate ECONAZOLE NITRATE NPD NPD YANTIFUNGALS, TOPICAL 51672130308 90154035103705 51672130308 30430 econazole nitrate ECONAZOLE NITRATE NPD NPD YANTIFUNGALS, TOPICAL 52565002215 90154035103705 52565002215 30430 econazole nitrate ECONAZOLE NITRATE NPD NPD YANTIFUNGALS, TOPICAL 52565002230 90154035103705 52565002230 30430 econazole nitrate ECONAZOLE NITRATE NPD NPD YANTIFUNGALS, TOPICAL 52565002285 90154035103705 52565002285 30430 econazole nitrate ECONAZOLE NITRATE NPD NPD YANTIFUNGALS, TOPICAL 00187540004 90154037002020 00187540004 36653 efinaconazole JUBLIA NPD NPD YANTIFUNGALS, TOPICAL 00187540008 90154037002020 00187540008 36653 efinaconazole JUBLIA NPD NPD YANTIFUNGALS, TOPICAL 00093321915 90154045003710 00093321915 31850 ketoconazole KETOCONAZOLE PDL PDL YANTIFUNGALS, TOPICAL 00093321930 90154045003710 00093321930 31850 ketoconazole KETOCONAZOLE PDL PDL YANTIFUNGALS, TOPICAL 00093321992 90154045003710 00093321992 31850 ketoconazole KETOCONAZOLE PDL PDL YANTIFUNGALS, TOPICAL 00168009915 90154045003710 00168009915 31850 ketoconazole KETOCONAZOLE PDL PDL YANTIFUNGALS, TOPICAL 00168009930 90154045003710 00168009930 31850 ketoconazole KETOCONAZOLE PDL PDL YANTIFUNGALS, TOPICAL 00168009960 90154045003710 00168009960 31850 ketoconazole KETOCONAZOLE PDL PDL YANTIFUNGALS, TOPICAL 00713067115 90154045003710 00713067115 31850 ketoconazole KETOCONAZOLE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 31

ANTIFUNGALS, TOPICAL 00713067131 90154045003710 00713067131 31850 ketoconazole KETOCONAZOLE PDL PDL YANTIFUNGALS, TOPICAL 00713067160 90154045003710 00713067160 31850 ketoconazole KETOCONAZOLE PDL PDL YANTIFUNGALS, TOPICAL 51672129801 90154045003710 51672129801 31850 ketoconazole KETOCONAZOLE PDL PDL YANTIFUNGALS, TOPICAL 51672129802 90154045003710 51672129802 31850 ketoconazole KETOCONAZOLE PDL PDL YANTIFUNGALS, TOPICAL 51672129803 90154045003710 51672129803 31850 ketoconazole KETOCONAZOLE PDL PDL YANTIFUNGALS, TOPICAL 00378700701 90154045003920 00378700701 98848 ketoconazole KETOCONAZOLE NPD NPD YANTIFUNGALS, TOPICAL 00378700750 90154045003920 00378700750 98848 ketoconazole KETOCONAZOLE NPD NPD YANTIFUNGALS, TOPICAL 45802053232 90154045003920 45802053232 98848 ketoconazole KETOCONAZOLE NPD NPD YANTIFUNGALS, TOPICAL 45802053233 90154045003920 45802053233 98848 ketoconazole KETOCONAZOLE NPD NPD YANTIFUNGALS, TOPICAL 00781709004 90154045004510 00781709004 31271 ketoconazole KETOCONAZOLE PDL PDL YANTIFUNGALS, TOPICAL 10147075004 90154045004510 10147075004 31271 ketoconazole KETOCONAZOLE PDL PDL YANTIFUNGALS, TOPICAL 10147075005 90154045004510 10147075005 31271 ketoconazole KETOCONAZOLE PDL PDL YANTIFUNGALS, TOPICAL 45802046564 90154045004510 45802046564 31271 ketoconazole KETOCONAZOLE PDL PDL YANTIFUNGALS, TOPICAL 63646001004 90154045004510 63646001004 31271 ketoconazole KETOCONAZOLE PDL PDL YANTIFUNGALS, TOPICAL 68682085060 90154048003720 68682085060 35638 luliconazole LULICONAZOLE NPD NPD YANTIFUNGALS, TOPICAL 99207085060 90154048003720 99207085060 35638 luliconazole LUZU NPD NPD YANTIFUNGALS, TOPICAL 00884029301 90154050102020 00884029301 30421 miconazole nitrate FUNGOID TINCTURE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 32

ANTIFUNGALS, TOPICAL 00067094915 90154050102910 00067094915 30410 miconazole nitrate DESENEX PDL PDL YANTIFUNGALS, TOPICAL 00067094930 90154050102910 00067094930 30410 miconazole nitrate DESENEX PDL PDL YANTIFUNGALS, TOPICAL 00145150103 90154050102910 00145150103 30410 miconazole nitrate ZEASORB PDL PDL YANTIFUNGALS, TOPICAL 00145150605 90154050102910 00145150605 30410 miconazole nitrate ZEASORB PDL PDL YANTIFUNGALS, TOPICAL 00316023225 90154050102910 00316023225 30410 miconazole nitrate ZEASORB AF PDL PDL YANTIFUNGALS, TOPICAL 37205065318 90154050102910 37205065318 30410 miconazole nitrate MICONAZORB AF PDL PDL YANTIFUNGALS, TOPICAL 46122003927 90154050102910 46122003927 30410 miconazole nitrate MICONAZORB AF PDL PDL Y

ANTIFUNGALS, TOPICAL 53329016979 90154050102910 53329016979 30410 miconazole nitrate

REMEDY PHYTOPLEX ANTIFUNGAL PDL PDL Y

ANTIFUNGALS, TOPICAL 70000032301 90154050102910 70000032301 30410 miconazole nitrate

ANTIFUNGAL POWDER PDL PDL Y

ANTIFUNGALS, TOPICAL 37205099866 90154050103310 37205099866 30390 miconazole nitrate

MICONAZOLE NITRATE PDL PDL Y

ANTIFUNGALS, TOPICAL 70000032101 90154050103310 70000032101 30390 miconazole nitrate

ATHLETE'S FOOT SPRAY NPD NPD Y

ANTIFUNGALS, TOPICAL 00472073514 90154050103705 00472073514 30400 miconazole nitrate ANTIFUNGAL CREAM PDL PDL YANTIFUNGALS, TOPICAL 00472073542 90154050103705 00472073542 30400 miconazole nitrate ANTIFUNGAL CREAM PDL PDL YANTIFUNGALS, TOPICAL 00472073556 90154050103705 00472073556 30400 miconazole nitrate ANTIFUNGAL CREAM PDL PDL YANTIFUNGALS, TOPICAL 00536113428 90154050103705 00536113428 30400 miconazole nitrate

MICONAZOLE NITRATE PDL PDL Y

ANTIFUNGALS, TOPICAL 49348068972 90154050103705 49348068972 30400 miconazole nitrate

MICONAZOLE NITRATE PDL PDL Y

ANTIFUNGALS, TOPICAL 51672200101 90154050103705 51672200101 30400 miconazole nitrate

MICONAZOLE NITRATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 33

ANTIFUNGALS, TOPICAL 51672200102 90154050103705 51672200102 30400 miconazole nitrate

MICONAZOLE NITRATE PDL PDL Y

ANTIFUNGALS, TOPICAL 53329007964 90154050103705 53329007964 30400 miconazole nitrate ANTIFUNGAL CREAM PDL PDL YANTIFUNGALS, TOPICAL 53329016204 90154050103705 53329016204 30654 miconazole nitrate

REMEDY ANTIFUNGAL PDL PDL Y

ANTIFUNGALS, TOPICAL 43553000302 90154050104210 43553000302 13394 miconazole nitrate ALOE VESTA PDL PDL YANTIFUNGALS, TOPICAL 43553000305 90154050104210 43553000305 13394 miconazole nitrate ALOE VESTA PDL PDL Y

ANTIFUNGALS, TOPICAL 53329016710 90154050104210 53329016710 13394 miconazole nitrate

REMEDY PHYTOPLEX ANTIFUNGAL PDL PDL Y

ANTIFUNGALS, TOPICAL 00884549301 90154050106420 00884549301 30422 miconazole nitrate FUNGOID TINCTURE NPD NPD YANTIFUNGALS, TOPICAL 00168035830 90154065003710 00168035830 46920 oxiconazole nitrate

OXICONAZOLE NITRATE NPD NPD Y

ANTIFUNGALS, TOPICAL 00168035860 90154065003710 00168035860 46920 oxiconazole nitrate

OXICONAZOLE NITRATE NPD NPD Y

ANTIFUNGALS, TOPICAL 00168035890 90154065003710 00168035890 46920 oxiconazole nitrate

OXICONAZOLE NITRATE NPD NPD Y

ANTIFUNGALS, TOPICAL 10337035830 90154065003710 10337035830 46920 oxiconazole nitrate OXISTAT NPD NPD YANTIFUNGALS, TOPICAL 10337035860 90154065003710 10337035860 46920 oxiconazole nitrate OXISTAT NPD NPD YANTIFUNGALS, TOPICAL 10337035890 90154065003710 10337035890 46920 oxiconazole nitrate OXISTAT NPD NPD YANTIFUNGALS, TOPICAL 51672135902 90154065003710 51672135902 46920 oxiconazole nitrate

OXICONAZOLE NITRATE NPD NPD Y

ANTIFUNGALS, TOPICAL 51672135903 90154065003710 51672135903 46920 oxiconazole nitrate

OXICONAZOLE NITRATE NPD NPD Y

ANTIFUNGALS, TOPICAL 51672135908 90154065003710 51672135908 46920 oxiconazole nitrate

OXICONAZOLE NITRATE NPD NPD Y

ANTIFUNGALS, TOPICAL 10337035930 90154065004120 10337035930 37561 oxiconazole nitrate OXISTAT NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 34

ANTIFUNGALS, TOPICAL 10337035960 90154065004120 10337035960 37561 oxiconazole nitrate OXISTAT NPD NPD YANTIFUNGALS, TOPICAL 00187511560 90154070103720 00187511560 43590 sertaconazole nitrate ERTACZO NPD NPD YANTIFUNGALS, TOPICAL 10631010030 90154075002010 10631010030 46900 sulconazole nitrate EXELDERM NPD NPD YANTIFUNGALS, TOPICAL 10631010160 90154075003710 10631010160 46910 sulconazole nitrate EXELDERM NPD NPD YANTIFUNGALS, TOPICAL 10337090510 90156080002010 10337090510 36997 tavaborole KERYDIN NPD NPD YANTIFUNGALS, TOPICAL 10337090544 90156080002010 10337090544 36997 tavaborole KERYDIN NPD NPD YANTIFUNGALS, TOPICAL 00085092401 90159902053710 00085092401 6919

clotrimazole/betamethasone dip LOTRISONE NPD NPD Y

ANTIFUNGALS, TOPICAL 00085092402 90159902053710 00085092402 6919

clotrimazole/betamethasone dip LOTRISONE NPD NPD Y

ANTIFUNGALS, TOPICAL 00168025815 90159902053710 00168025815 6919

clotrimazole/betamethasone dip

CLOTRIMAZOLE-BETAMETHASONE PDL PDL Y

ANTIFUNGALS, TOPICAL 00168025846 90159902053710 00168025846 6919

clotrimazole/betamethasone dip

CLOTRIMAZOLE-BETAMETHASONE PDL PDL Y

ANTIFUNGALS, TOPICAL 00472037915 90159902053710 00472037915 6919

clotrimazole/betamethasone dip

CLOTRIMAZOLE-BETAMETHASONE PDL PDL Y

ANTIFUNGALS, TOPICAL 00472037945 90159902053710 00472037945 6919

clotrimazole/betamethasone dip

CLOTRIMAZOLE-BETAMETHASONE PDL PDL Y

ANTIFUNGALS, TOPICAL 16714049601 90159902053710 16714049601 6919

clotrimazole/betamethasone dip

CLOTRIMAZOLE-BETAMETHASONE PDL PDL Y

ANTIFUNGALS, TOPICAL 16714049602 90159902053710 16714049602 6919

clotrimazole/betamethasone dip

CLOTRIMAZOLE-BETAMETHASONE PDL PDL Y

ANTIFUNGALS, TOPICAL 51672404801 90159902053710 51672404801 6919

clotrimazole/betamethasone dip

CLOTRIMAZOLE-BETAMETHASONE PDL PDL Y

ANTIFUNGALS, TOPICAL 51672404806 90159902053710 51672404806 6919

clotrimazole/betamethasone dip

CLOTRIMAZOLE-BETAMETHASONE PDL PDL Y

ANTIFUNGALS, TOPICAL 66993089815 90159902053710 66993089815 6919

clotrimazole/betamethasone dip

CLOTRIMAZOLE-BETAMETHASONE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 35

ANTIFUNGALS, TOPICAL 66993089845 90159902053710 66993089845 6919

clotrimazole/betamethasone dip

CLOTRIMAZOLE-BETAMETHASONE PDL PDL Y

ANTIFUNGALS, TOPICAL 68462029817 90159902053710 68462029817 6919

clotrimazole/betamethasone dip

CLOTRIMAZOLE-BETAMETHASONE PDL PDL Y

ANTIFUNGALS, TOPICAL 68462029855 90159902053710 68462029855 6919

clotrimazole/betamethasone dip

CLOTRIMAZOLE-BETAMETHASONE PDL PDL Y

ANTIFUNGALS, TOPICAL 00168037030 90159902054120 00168037030 14125

clotrimazole/betamethasone dip

CLOTRIMAZOLE-BETAMETHASONE NPD NPD Y

ANTIFUNGALS, TOPICAL 51672130803 90159902054120 51672130803 14125

clotrimazole/betamethasone dip

CLOTRIMAZOLE-BETAMETHASONE NPD NPD Y

ANTIFUNGALS, TOPICAL 00168008115 90159902253700 00168008115 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 00168008130 90159902253700 00168008130 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 00168008160 90159902253700 00168008160 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 00316022315 90159902253700 00316022315 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 00316022330 90159902253700 00316022330 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 00472015015 90159902253700 00472015015 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 00472015030 90159902253700 00472015030 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 00472015060 90159902253700 00472015060 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 43598043130 90159902253700 43598043130 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 43598043160 90159902253700 43598043160 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 45802088014 90159902253700 45802088014 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 45802088094 90159902253700 45802088094 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 36

ANTIFUNGALS, TOPICAL 45802088096 90159902253700 45802088096 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 51672126301 90159902253700 51672126301 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 51672126302 90159902253700 51672126302 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 51672126303 90159902253700 51672126303 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 68180054501 90159902253700 68180054501 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 68180054502 90159902253700 68180054502 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 68180054503 90159902253700 68180054503 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 68462031417 90159902253700 68462031417 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 68462031435 90159902253700 68462031435 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 68462031465 90159902253700 68462031465 14007 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 00168008915 90159902254200 00168008915 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 00168008930 90159902254200 00168008930 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 00168008960 90159902254200 00168008960 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 00472015515 90159902254200 00472015515 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 00472015530 90159902254200 00472015530 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 00472015560 90159902254200 00472015560 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 45802024414 90159902254200 45802024414 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 37

ANTIFUNGALS, TOPICAL 45802024494 90159902254200 45802024494 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 45802024496 90159902254200 45802024496 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 51672127201 90159902254200 51672127201 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 51672127202 90159902254200 51672127202 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 51672127203 90159902254200 51672127203 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 52565004215 90159902254200 52565004215 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 52565004230 90159902254200 52565004230 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 68462079917 90159902254200 68462079917 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 68462079935 90159902254200 68462079935 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 68462079965 90159902254200 68462079965 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 70756081115 90159902254200 70756081115 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 70756081135 90159902254200 70756081135 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 70756081165 90159902254200 70756081165 14008 nystatin/triamcin

NYSTATIN-TRIAMCINOLONE NPD NPD Y

ANTIFUNGALS, TOPICAL 59088089300 9015990322B120 59088089300 42268

clotrimazole/betameth dip/zinc

DERMACINRX THERAZOLE PAK NPD NPD Y

ANTIFUNGALS, TOPICAL 00378822250 90159903404220 00378822250 26571

miconazole nitrate/zinc ox/pet

MICONAZOLE-ZINC OXIDE-PETROLTM NPD NPD Y

ANTIFUNGALS, TOPICAL 40076000250 90159903404220 40076000250 26571

miconazole nitrate/zinc ox/pet VUSION NPD NPD Y

ANTIFUNGALS, TOPICAL 63801010701 90759902104210 63801010701 1344 salicylic acid BENSAL HP NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 38

ANTIMIGRAINE AGENTS, TRIPTANS 00006380001 19593 rizatriptan benzoate MAXALT MLT NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00006380101 19594 rizatriptan benzoate MAXALT MLT NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 68462046746 19593 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 68462046846 19594 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 00378524585 67406010100320 00378524585 13587 almotriptan malate

ALMOTRIPTAN MALATE NPD NPD Y

ANTIMIGRAINE AGENTS, TRIPTANS 27241004111 67406010100320 27241004111 13587 almotriptan malate

ALMOTRIPTAN MALATE NPD NPD Y

ANTIMIGRAINE AGENTS, TRIPTANS 00378524685 67406010100330 00378524685 12472 almotriptan malate

ALMOTRIPTAN MALATE NPD NPD Y

ANTIMIGRAINE AGENTS, TRIPTANS 27241004221 67406010100330 27241004221 12472 almotriptan malate

ALMOTRIPTAN MALATE NPD NPD Y

ANTIMIGRAINE AGENTS, TRIPTANS 00049233045 67406025100320 00049233045 15173 eletriptan hydrobromide RELPAX NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00093831018 67406025100320 00093831018 15173 eletriptan hydrobromide ELETRIPTAN HBR NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00378428785 67406025100320 00378428785 15173 eletriptan hydrobromide ELETRIPTAN HBR NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 27241003911 67406025100320 27241003911 15173 eletriptan hydrobromide ELETRIPTAN HBR NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 59762232101 67406025100320 59762232101 15173 eletriptan hydrobromide ELETRIPTAN HBR NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 65162004280 67406025100320 65162004280 15173 eletriptan hydrobromide ELETRIPTAN HBR NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 68382092286 67406025100320 68382092286 15173 eletriptan hydrobromide ELETRIPTAN HBR NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00049234005 67406025100340 00049234005 15174 eletriptan hydrobromide RELPAX NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00049234045 67406025100340 00049234045 15174 eletriptan hydrobromide RELPAX NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 39

ANTIMIGRAINE AGENTS, TRIPTANS 00093831118 67406025100340 00093831118 15174 eletriptan hydrobromide ELETRIPTAN HBR NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00378428808 67406025100340 00378428808 15174 eletriptan hydrobromide ELETRIPTAN HBR NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00378428885 67406025100340 00378428885 15174 eletriptan hydrobromide ELETRIPTAN HBR NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 27241004011 67406025100340 27241004011 15174 eletriptan hydrobromide ELETRIPTAN HBR NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 27241004021 67406025100340 27241004021 15174 eletriptan hydrobromide ELETRIPTAN HBR NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 59762232201 67406025100340 59762232201 15174 eletriptan hydrobromide ELETRIPTAN HBR NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 65162004380 67406025100340 65162004380 15174 eletriptan hydrobromide ELETRIPTAN HBR NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 68382092386 67406025100340 68382092386 15174 eletriptan hydrobromide ELETRIPTAN HBR NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00378314085 67406030100320 00378314085 14977 frovatriptan succinate

FROVATRIPTAN SUCCINATE NPD NPD Y

ANTIMIGRAINE AGENTS, TRIPTANS 00603371834 67406030100320 00603371834 14977 frovatriptan succinate

FROVATRIPTAN SUCCINATE NPD NPD Y

ANTIMIGRAINE AGENTS, TRIPTANS 63481002509 67406030100320 63481002509 14977 frovatriptan succinate FROVA NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 68462069497 67406030100320 68462069497 14977 frovatriptan succinate

FROVATRIPTAN SUCCINATE NPD NPD Y

ANTIMIGRAINE AGENTS, TRIPTANS 00054027803 67406050100310 00054027803 81112 naratriptan HCl NARATRIPTAN HCL PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 00173056100 67406050100310 00173056100 81112 naratriptan HCl AMERGE NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 23155005419 67406050100310 23155005419 81112 naratriptan HCl NARATRIPTAN HCL PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 00054027903 67406050100320 00054027903 81111 naratriptan HCl NARATRIPTAN HCL PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 00173056200 67406050100320 00173056200 81111 naratriptan HCl AMERGE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 40

ANTIMIGRAINE AGENTS, TRIPTANS 00781552737 67406050100320 00781552737 81111 naratriptan HCl NARATRIPTAN HCL PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 23155005519 67406050100320 23155005519 81111 naratriptan HCl NARATRIPTAN HCL PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 42043013109 67406050100320 42043013109 81111 naratriptan HCl NARATRIPTAN HCL PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 00093747143 67406060100310 00093747143 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 00378140396 67406060100310 00378140396 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 23155024446 67406060100310 23155024446 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 29300031621 67406060100310 29300031621 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 29300031681 67406060100310 29300031681 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 33342008741 67406060100310 33342008741 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 33342008745 67406060100310 33342008745 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 33342008750 67406060100310 33342008750 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 33342008772 67406060100310 33342008772 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 51991035478 67406060100310 51991035478 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 57237008734 67406060100310 57237008734 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 57237008763 67406060100310 57237008763 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 59746041419 67406060100310 59746041419 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 65862059912 67406060100310 65862059912 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 41

ANTIMIGRAINE AGENTS, TRIPTANS 67877026118 67406060100310 67877026118 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 68462046599 67406060100310 68462046599 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 69097086585 67406060100310 69097086585 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 76282046218 67406060100310 76282046218 19591 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 00006026701 67406060100320 00006026701 19592 rizatriptan benzoate MAXALT NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00006026718 67406060100320 00006026718 19592 rizatriptan benzoate MAXALT NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00093747243 67406060100320 00093747243 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 00378140496 67406060100320 00378140496 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 00781548664 67406060100320 00781548664 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 23155024546 67406060100320 23155024546 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 29300031721 67406060100320 29300031721 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 29300031781 67406060100320 29300031781 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 33342008841 67406060100320 33342008841 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 33342008845 67406060100320 33342008845 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 33342008850 67406060100320 33342008850 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 33342008872 67406060100320 33342008872 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 51991035578 67406060100320 51991035578 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 42

ANTIMIGRAINE AGENTS, TRIPTANS 57237008834 67406060100320 57237008834 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 57237008863 67406060100320 57237008863 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 59746041519 67406060100320 59746041519 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 60505369901 67406060100320 60505369901 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 65862060012 67406060100320 65862060012 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 67877026218 67406060100320 67877026218 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 68462046699 67406060100320 68462046699 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 69097086685 67406060100320 69097086685 19592 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 00006380018 67406060107220 00006380018 19593 rizatriptan benzoate MAXALT MLT NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00378370159 67406060107220 00378370159 19593 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 33342009341 67406060107220 33342009341 19593 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 33342009372 67406060107220 33342009372 19593 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 33342009373 67406060107220 33342009373 19593 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 51991036278 67406060107220 51991036278 19593 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 57237008563 67406060107220 57237008563 19593 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 60505372301 67406060107220 60505372301 19593 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 65862062590 67406060107220 65862062590 19593 rizatriptan benzoate RIZATRIPTAN PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 43

ANTIMIGRAINE AGENTS, TRIPTANS 68462046706 67406060107220 68462046706 19593 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 69452015673 67406060107220 69452015673 19593 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 00006380118 67406060107230 00006380118 19594 rizatriptan benzoate MAXALT MLT NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00378370259 67406060107230 00378370259 19594 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 33342009441 67406060107230 33342009441 19594 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 33342009472 67406060107230 33342009472 19594 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 33342009473 67406060107230 33342009473 19594 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 51991036378 67406060107230 51991036378 19594 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 57237008663 67406060107230 57237008663 19594 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 60505372401 67406060107230 60505372401 19594 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 65862062612 67406060107230 65862062612 19594 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 65862062690 67406060107230 65862062690 19594 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 68462046806 67406060107230 68462046806 19594 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 69452015773 67406060107230 69452015773 19594 rizatriptan benzoate RIZATRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 00173052400 67406070002010 00173052400 50740 sumatriptan IMITREX NPD PDL YANTIMIGRAINE AGENTS, TRIPTANS 00527181843 67406070002010 00527181843 50740 sumatriptan SUMATRIPTAN PDL NPD YANTIMIGRAINE AGENTS, TRIPTANS 00781652486 67406070002010 00781652486 50740 sumatriptan SUMATRIPTAN PDL NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 44

ANTIMIGRAINE AGENTS, TRIPTANS 00173052300 67406070002040 00173052300 50744 sumatriptan IMITREX NPD PDL YANTIMIGRAINE AGENTS, TRIPTANS 00527185943 67406070002040 00527185943 50744 sumatriptan SUMATRIPTAN PDL NPD YANTIMIGRAINE AGENTS, TRIPTANS 00781652386 67406070002040 00781652386 50744 sumatriptan SUMATRIPTAN PDL NPD YANTIMIGRAINE AGENTS, TRIPTANS 00173073500 67406070100305 00173073500 5702 sumatriptan succinate IMITREX NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00378563059 67406070100305 00378563059 5702 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 16714053111 67406070100305 16714053111 5702 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 16714079601 67406070100305 16714079601 5702 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 55111029109 67406070100305 55111029109 5702 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 55111029136 67406070100305 55111029136 5702 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 55111029190 67406070100305 55111029190 5702 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 62756052069 67406070100305 62756052069 5702 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 62756052088 67406070100305 62756052088 5702 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 63304009719 67406070100305 63304009719 5702 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 65862014636 67406070100305 65862014636 5702 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 00173073601 67406070100310 00173073601 5700 sumatriptan succinate IMITREX NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00378563159 67406070100310 00378563159 5700 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 16714053211 67406070100310 16714053211 5700 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 45

ANTIMIGRAINE AGENTS, TRIPTANS 16714079701 67406070100310 16714079701 5700 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 55111029209 67406070100310 55111029209 5700 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 55111029236 67406070100310 55111029236 5700 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 55111029290 67406070100310 55111029290 5700 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 62756052169 67406070100310 62756052169 5700 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 62756052188 67406070100310 62756052188 5700 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 63304009819 67406070100310 63304009819 5700 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 65862014736 67406070100310 65862014736 5700 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 00173073701 67406070100320 00173073701 5701 sumatriptan succinate IMITREX NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00378563259 67406070100320 00378563259 5701 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 16714053311 67406070100320 16714053311 5701 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 16714079801 67406070100320 16714079801 5701 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 55111029309 67406070100320 55111029309 5701 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 55111029336 67406070100320 55111029336 5701 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 55111029390 67406070100320 55111029390 5701 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 62756052269 67406070100320 62756052269 5701 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 62756052288 67406070100320 62756052288 5701 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 46

ANTIMIGRAINE AGENTS, TRIPTANS 63304009919 67406070100320 63304009919 5701 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 65862014836 67406070100320 65862014836 5701 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 00143963805 67406070102010 00143963805 50742 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 00173044902 67406070102010 00173044902 50742 sumatriptan succinate IMITREX NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00781317414 67406070102010 00781317414 50742 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 55150017301 67406070102010 55150017301 50742 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 55150017305 67406070102010 55150017305 50742 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 63323027301 67406070102010 63323027301 50742 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 64679072801 67406070102010 64679072801 50742 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 67857080938 6740607010D505 67857080938 40811 sumatriptan succinate

ZEMBRACE SYMTOUCH NPD NPD Y

ANTIMIGRAINE AGENTS, TRIPTANS 00093201312 6740607010D510 00093201312 26666 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 00173073900 6740607010D510 00173073900 26666 sumatriptan succinate IMITREX NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00781316907 6740607010D510 00781316907 26666 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 00093201412 6740607010D520 00093201412 50741 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 00173047900 6740607010D520 00173047900 50741 sumatriptan succinate IMITREX NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00781317207 6740607010D520 00781317207 50741 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 47335027641 6740607010D520 47335027641 50741 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 47

ANTIMIGRAINE AGENTS, TRIPTANS 55111069312 6740607010D520 55111069312 50741 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 00173073902 ############## 00173073902 26667 sumatriptan succinate IMITREX NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00781317007 ############## 00781317007 26667 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 00173047800 ############## 00173047800 24708 sumatriptan succinate IMITREX NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00781317307 ############## 00781317307 24708 sumatriptan succinate

SUMATRIPTAN SUCCINATE PDL PDL Y

ANTIMIGRAINE AGENTS, TRIPTANS 67457087900 6740607010E520 67457087900 4428 sumatriptan succinate

SUMATRIPTAN SUCCINATE NPD NPD Y

ANTIMIGRAINE AGENTS, TRIPTANS 67457087905 6740607010E520 67457087905 4428 sumatriptan succinate

SUMATRIPTAN SUCCINATE NPD NPD Y

ANTIMIGRAINE AGENTS, TRIPTANS 64597031108 6740607010G420 64597031108 40608 sumatriptan succinate ONZETRA XSAIL NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 00115067151 67406080000320 00115067151 46131 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 27241002168 67406080000320 27241002168 46131 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 59746043216 67406080000320 59746043216 46131 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 64896067151 67406080000320 64896067151 46131 zolmitriptan ZOMIG NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 64980020316 67406080000320 64980020316 46131 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 65862091469 67406080000320 65862091469 46131 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 68001024901 67406080000320 68001024901 46131 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 68462049776 67406080000320 68462049776 46131 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 00115067250 67406080000330 00115067250 46132 zolmitriptan ZOLMITRIPTAN PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 48

ANTIMIGRAINE AGENTS, TRIPTANS 27241002238 67406080000330 27241002238 46132 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 33342011352 67406080000330 33342011352 46132 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 50742062603 67406080000330 50742062603 46132 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 59746043313 67406080000330 59746043313 46132 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 60505369400 67406080000330 60505369400 46132 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 64896067250 67406080000330 64896067250 46132 zolmitriptan ZOMIG NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 64980020413 67406080000330 64980020413 46132 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 65862091564 67406080000330 65862091564 46132 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 68001025001 67406080000330 68001025001 46132 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 68462049833 67406080000330 68462049833 46132 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 69097086484 67406080000330 69097086484 46132 zolmitriptan ZOLMITRIPTAN PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 64896068251 67406080002010 64896068251 24217 zolmitriptan ZOMIG NPD PDL YANTIMIGRAINE AGENTS, TRIPTANS 64896068151 67406080002020 64896068151 18972 zolmitriptan ZOMIG NPD PDL YANTIMIGRAINE AGENTS, TRIPTANS 00115069151 67406080007220 00115069151 42098 zolmitriptan ZOLMITRIPTAN ODT PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 64896069151 67406080007220 64896069151 42098 zolmitriptan ZOMIG ZMT NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 64980025616 67406080007220 64980025616 42098 zolmitriptan ZOLMITRIPTAN ODT PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 68382071586 67406080007220 68382071586 42098 zolmitriptan ZOLMITRIPTAN ODT PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 49

ANTIMIGRAINE AGENTS, TRIPTANS 68462049976 67406080007220 68462049976 42098 zolmitriptan ZOLMITRIPTAN ODT PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 00115069250 67406080007230 00115069250 14324 zolmitriptan ZOLMITRIPTAN ODT PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 59746046213 67406080007230 59746046213 14324 zolmitriptan ZOLMITRIPTAN ODT PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 64896069250 67406080007230 64896069250 14324 zolmitriptan ZOMIG ZMT NPD NPD YANTIMIGRAINE AGENTS, TRIPTANS 64980025713 67406080007230 64980025713 14324 zolmitriptan ZOLMITRIPTAN ODT PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 68382071782 67406080007230 68382071782 14324 zolmitriptan ZOLMITRIPTAN ODT PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 68462050033 67406080007230 68462050033 14324 zolmitriptan ZOLMITRIPTAN ODT PDL PDL YANTIMIGRAINE AGENTS, TRIPTANS 59088008300 6799000360B120 59088008300 41338

sumatriptan su/menthol/camphor MIGRANOW NPD NPD Y

ANTIMIGRAINE AGENTS, TRIPTANS 00378875559 67992002600320 00378875559 99597

sumatriptan succ/naproxen sod

SUMATRIPTAN SUCC-NAPROXEN SOD NPD NPD Y

ANTIMIGRAINE AGENTS, TRIPTANS 44183085009 67992002600320 44183085009 99597

sumatriptan succ/naproxen sod

SUMATRIPTAN SUCC-NAPROXEN SOD NPD NPD Y

ANTIMIGRAINE AGENTS, TRIPTANS 47335041022 67992002600320 47335041022 99597

sumatriptan succ/naproxen sod

SUMATRIPTAN SUCC-NAPROXEN SOD NPD NPD Y

ANTIMIGRAINE AGENTS, TRIPTANS 65224085009 67992002600320 65224085009 99597

sumatriptan succ/naproxen sod TREXIMET NPD NPD Y

ANTIMIGRAINE AGENTS, TRIPTANS 65862092836 67992002600320 65862092836 99597

sumatriptan succ/naproxen sod

SUMATRIPTAN SUCC-NAPROXEN SOD NPD NPD Y

BETA-BLOCKERS 00093527156 63820 bisoprolol fumarateBISOPROLOL FUMARATE PDL PDL Y

BETA-BLOCKERS 16714002304 20632 propranolol HCl PROPRANOLOL HCL PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 50

BETA-BLOCKERS 57664050608 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL YBETA-BLOCKERS 00093423501 33100010000303 00093423501 20654 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 00378002801 33100010000303 00378002801 20654 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 00781800401 33100010000303 00781800401 20654 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 27505010001 33100010000303 27505010001 20654 nadolol CORGARD NPD NPD YBETA-BLOCKERS 50742017801 33100010000303 50742017801 20654 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 51079081220 33100010000303 51079081220 20654 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 59762081001 33100010000303 59762081001 20654 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 68001031700 33100010000303 68001031700 20654 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 68382073201 33100010000303 68382073201 20654 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 69097086707 33100010000303 69097086707 20654 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 69238112309 33100010000303 69238112309 20654 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 00093423601 33100010000305 00093423601 20652 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 00378117101 33100010000305 00378117101 20652 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 00781118201 33100010000305 00781118201 20652 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 00781800501 33100010000305 00781800501 20652 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 27505010101 33100010000305 27505010101 20652 nadolol CORGARD NPD NPD YBETA-BLOCKERS 31722034801 33100010000305 31722034801 20652 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 50742017901 33100010000305 50742017901 20652 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 51079081320 33100010000305 51079081320 20652 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 59762081101 33100010000305 59762081101 20652 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 68001031800 33100010000305 68001031800 20652 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 68382073301 33100010000305 68382073301 20652 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 69097086807 33100010000305 69097086807 20652 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 69238112409 33100010000305 69238112409 20652 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 00093423701 33100010000310 00093423701 20653 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 00378113201 33100010000310 00378113201 20653 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 00781800692 33100010000310 00781800692 20653 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 27505010201 33100010000310 27505010201 20653 nadolol CORGARD NPD NPD YBETA-BLOCKERS 50742018001 33100010000310 50742018001 20653 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 59762081201 33100010000310 59762081201 20653 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 68001031900 33100010000310 68001031900 20653 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 68382073401 33100010000310 68382073401 20653 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 69097086907 33100010000310 69097086907 20653 nadolol NADOLOL PDL NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 51

BETA-BLOCKERS 69238112509 33100010000310 69238112509 20653 nadolol NADOLOL PDL NPD YBETA-BLOCKERS 00378005201 33100030000305 00378005201 20681 pindolol PINDOLOL NPD NPD YBETA-BLOCKERS 29033002801 33100030000305 29033002801 20681 pindolol PINDOLOL NPD NPD YBETA-BLOCKERS 57664065588 33100030000305 57664065588 20681 pindolol PINDOLOL NPD NPD YBETA-BLOCKERS 62559056001 33100030000305 62559056001 20681 pindolol PINDOLOL NPD NPD YBETA-BLOCKERS 00378012701 33100030000310 00378012701 20680 pindolol PINDOLOL NPD NPD YBETA-BLOCKERS 29033002901 33100030000310 29033002901 20680 pindolol PINDOLOL NPD NPD YBETA-BLOCKERS 57664065688 33100030000310 57664065688 20680 pindolol PINDOLOL NPD NPD YBETA-BLOCKERS 62559056101 33100030000310 62559056101 20680 pindolol PINDOLOL NPD NPD Y

BETA-BLOCKERS 00115165901 33100040100305 00115165901 20630 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00115165903 33100040100305 00115165903 20630 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00378018201 33100040100305 00378018201 20630 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00378018210 33100040100305 00378018210 20630 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00591555401 33100040100305 00591555401 20630 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00591555410 33100040100305 00591555410 20630 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00603548221 33100040100305 00603548221 20630 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00603548232 33100040100305 00603548232 20630 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00904655061 33100040100305 00904655061 20630 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 23155011001 33100040100305 23155011001 20630 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 23155011010 33100040100305 23155011010 20630 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 50111046701 33100040100305 50111046701 20630 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 50111046703 33100040100305 50111046703 20630 propranolol HCl PROPRANOLOL HCL PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 52

BETA-BLOCKERS 00115166001 33100040100310 00115166001 20631 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00115166003 33100040100310 00115166003 20631 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00378018301 33100040100310 00378018301 20631 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00378018310 33100040100310 00378018310 20631 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00591555501 33100040100310 00591555501 20631 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00591555510 33100040100310 00591555510 20631 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00603548321 33100040100310 00603548321 20631 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00603548332 33100040100310 00603548332 20631 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00904670561 33100040100310 00904670561 20631 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 23155011101 33100040100310 23155011101 20631 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 23155011110 33100040100310 23155011110 20631 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 50111046801 33100040100310 50111046801 20631 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 50111046803 33100040100310 50111046803 20631 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00115166101 33100040100315 00115166101 20632 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00115166103 33100040100315 00115166103 20632 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00378018401 33100040100315 00378018401 20632 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00378018410 33100040100315 00378018410 20632 propranolol HCl PROPRANOLOL HCL PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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BETA-BLOCKERS 00591555601 33100040100315 00591555601 20632 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00591555610 33100040100315 00591555610 20632 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00603548421 33100040100315 00603548421 20632 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00603548432 33100040100315 00603548432 20632 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 23155011201 33100040100315 23155011201 20632 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 23155011210 33100040100315 23155011210 20632 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 50111046901 33100040100315 50111046901 20632 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 50111046903 33100040100315 50111046903 20632 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00115169301 33100040100320 00115169301 20633 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00378018701 33100040100320 00378018701 20633 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00603548521 33100040100320 00603548521 20633 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 23155011301 33100040100320 23155011301 20633 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 50111047001 33100040100320 50111047001 20633 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00115166201 33100040100325 00115166201 20634 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00115166202 33100040100325 00115166202 20634 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00378018501 33100040100325 00378018501 20634 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00378018505 33100040100325 00378018505 20634 propranolol HCl PROPRANOLOL HCL PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 54

BETA-BLOCKERS 00591555701 33100040100325 00591555701 20634 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00591555705 33100040100325 00591555705 20634 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00603548621 33100040100325 00603548621 20634 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00603548628 33100040100325 00603548628 20634 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 23155011401 33100040100325 23155011401 20634 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 23155011405 33100040100325 23155011405 20634 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 50111047102 33100040100325 50111047102 20634 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00054372763 33100040102050 00054372763 45260 propranolol HCl PROPRANOLOL HCL PDL PDL Y

BETA-BLOCKERS 00054373063 33100040102060 00054373063 45261 propranolol HCl PROPRANOLOL HCL PDL PDL YBETA-BLOCKERS 64370037501 33100040102080 64370037501 36526 propranolol HCl HEMANGEOL NPD NPD Y

BETA-BLOCKERS 00228277811 33100040107025 00228277811 3233 propranolol HClPROPRANOLOL HCL

ER PDL PDL YBETA-BLOCKERS 24090047088 33100040107025 24090047088 3233 propranolol HCl INDERAL LA NPD NPD Y

BETA-BLOCKERS 43478090088 33100040107025 43478090088 3233 propranolol HClPROPRANOLOL HCL

ER PDL PDL Y

BETA-BLOCKERS 51991081701 33100040107025 51991081701 3233 propranolol HClPROPRANOLOL HCL

ER PDL PDL Y

BETA-BLOCKERS 51991081705 33100040107025 51991081705 3233 propranolol HClPROPRANOLOL HCL

ER PDL PDL YBETA-BLOCKERS 62559052001 33100040107025 62559052001 3233 propranolol HCl INDERAL LA NPD NPD Y

BETA-BLOCKERS 62559053001 33100040107025 62559053001 3233 propranolol HClPROPRANOLOL HCL

ER PDL PDL Y

BETA-BLOCKERS 00228277911 33100040107030 00228277911 3230 propranolol HClPROPRANOLOL HCL

ER PDL PDL YBETA-BLOCKERS 24090047188 33100040107030 24090047188 3230 propranolol HCl INDERAL LA NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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BETA-BLOCKERS 43478090188 33100040107030 43478090188 3230 propranolol HClPROPRANOLOL HCL

ER PDL PDL Y

BETA-BLOCKERS 51991081801 33100040107030 51991081801 3230 propranolol HClPROPRANOLOL HCL

ER PDL PDL Y

BETA-BLOCKERS 51991081805 33100040107030 51991081805 3230 propranolol HClPROPRANOLOL HCL

ER PDL PDL YBETA-BLOCKERS 62559052101 33100040107030 62559052101 3230 propranolol HCl INDERAL LA NPD NPD Y

BETA-BLOCKERS 62559053101 33100040107030 62559053101 3230 propranolol HClPROPRANOLOL HCL

ER PDL PDL Y

BETA-BLOCKERS 00228278011 33100040107035 00228278011 3231 propranolol HClPROPRANOLOL HCL

ER PDL PDL YBETA-BLOCKERS 24090047388 33100040107035 24090047388 3231 propranolol HCl INDERAL LA NPD NPD Y

BETA-BLOCKERS 43478090288 33100040107035 43478090288 3231 propranolol HClPROPRANOLOL HCL

ER PDL PDL Y

BETA-BLOCKERS 51991081901 33100040107035 51991081901 3231 propranolol HClPROPRANOLOL HCL

ER PDL PDL Y

BETA-BLOCKERS 51991081905 33100040107035 51991081905 3231 propranolol HClPROPRANOLOL HCL

ER PDL PDL YBETA-BLOCKERS 62559052201 33100040107035 62559052201 3231 propranolol HCl INDERAL LA NPD NPD Y

BETA-BLOCKERS 62559053201 33100040107035 62559053201 3231 propranolol HClPROPRANOLOL HCL

ER NPD NPD Y

BETA-BLOCKERS 00228278111 33100040107040 00228278111 3232 propranolol HClPROPRANOLOL HCL

ER PDL PDL YBETA-BLOCKERS 24090047988 33100040107040 24090047988 3232 propranolol HCl INDERAL LA NPD NPD Y

BETA-BLOCKERS 43478090388 33100040107040 43478090388 3232 propranolol HClPROPRANOLOL HCL

ER PDL PDL Y

BETA-BLOCKERS 51991082001 33100040107040 51991082001 3232 propranolol HClPROPRANOLOL HCL

ER PDL PDL Y

BETA-BLOCKERS 51991082005 33100040107040 51991082005 3232 propranolol HClPROPRANOLOL HCL

ER PDL PDL YBETA-BLOCKERS 62559052301 33100040107040 62559052301 3232 propranolol HCl INDERAL LA NPD NPD Y

BETA-BLOCKERS 62559053301 33100040107040 62559053301 3232 propranolol HClPROPRANOLOL HCL

ER NPD NPD YBETA-BLOCKERS 24090045085 33100040127020 24090045085 20621 propranolol HCl INNOPRAN XL NPD NPD YBETA-BLOCKERS 62559059030 33100040127020 62559059030 20621 propranolol HCl INNOPRAN XL NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 56

BETA-BLOCKERS 62559060030 33100040127020 62559060030 20621 propranolol HCl INDERAL XL NPD NPD YBETA-BLOCKERS 76299042085 33100040127020 76299042085 20621 propranolol HCl INDERAL XL NPD NPD YBETA-BLOCKERS 24090045185 33100040127030 24090045185 19359 propranolol HCl INNOPRAN XL NPD NPD YBETA-BLOCKERS 62559059130 33100040127030 62559059130 19359 propranolol HCl INNOPRAN XL NPD NPD YBETA-BLOCKERS 62559060130 33100040127030 62559060130 19359 propranolol HCl INDERAL XL NPD NPD YBETA-BLOCKERS 76299042285 33100040127030 76299042285 19359 propranolol HCl INDERAL XL NPD NPD YBETA-BLOCKERS 00093106101 33100045100310 00093106101 39512 sotalol HCl SOTALOL PDL PDL YBETA-BLOCKERS 00603576928 33100045100310 00603576928 39512 sotalol HCl SOTALOL PDL PDL YBETA-BLOCKERS 60505008000 33100045100310 60505008000 39512 sotalol HCl SOTALOL PDL PDL YBETA-BLOCKERS 68084065401 33100045100310 68084065401 39512 sotalol HCl SOTALOL PDL PDL YBETA-BLOCKERS 70515010510 33100045100310 70515010510 39512 sotalol HCl BETAPACE NPD NPD YBETA-BLOCKERS 76385011401 33100045100310 76385011401 39512 sotalol HCl SOTALOL PDL PDL YBETA-BLOCKERS 00093106001 33100045100315 00093106001 39516 sotalol HCl SOTALOL PDL PDL YBETA-BLOCKERS 00185017001 33100045100315 00185017001 39516 sotalol HCl SOTALOL PDL PDL YBETA-BLOCKERS 60505015900 33100045100315 60505015900 39516 sotalol HCl SOTALOL PDL PDL YBETA-BLOCKERS 70515010910 33100045100315 70515010910 39516 sotalol HCl BETAPACE NPD NPD YBETA-BLOCKERS 76385011501 33100045100315 76385011501 39516 sotalol HCl SOTALOL PDL PDL YBETA-BLOCKERS 00093106201 33100045100320 00093106201 39511 sotalol HCl SOTALOL PDL PDL YBETA-BLOCKERS 00603577121 33100045100320 00603577121 39511 sotalol HCl SOTALOL PDL PDL YBETA-BLOCKERS 60505008100 33100045100320 60505008100 39511 sotalol HCl SOTALOL PDL PDL YBETA-BLOCKERS 70515010610 33100045100320 70515010610 39511 sotalol HCl BETAPACE NPD NPD YBETA-BLOCKERS 76385011601 33100045100320 76385011601 39511 sotalol HCl SOTALOL PDL PDL YBETA-BLOCKERS 00093106301 33100045100330 00093106301 39513 sotalol HCl SOTALOL PDL PDL YBETA-BLOCKERS 60505008200 33100045100330 60505008200 39513 sotalol HCl SOTALOL PDL PDL YBETA-BLOCKERS 24338053025 33100045102070 24338053025 37877 sotalol HCl SOTYLIZE NPD NPD YBETA-BLOCKERS 24338053048 33100045102070 24338053048 37877 sotalol HCl SOTYLIZE NPD NPD YBETA-BLOCKERS 00378512301 33100045120310 00378512301 39512 sotalol HCl SOTALOL AF PDL PDL YBETA-BLOCKERS 42806012101 33100045120310 42806012101 39512 sotalol HCl SOTALOL AF PDL PDL YBETA-BLOCKERS 60505022201 33100045120310 60505022201 39512 sotalol HCl SOTALOL AF PDL PDL YBETA-BLOCKERS 70515011506 33100045120310 70515011506 39512 sotalol HCl BETAPACE AF NPD NPD YBETA-BLOCKERS 00378512401 33100045120315 00378512401 39516 sotalol HCl SOTALOL AF PDL PDL YBETA-BLOCKERS 42806012201 33100045120315 42806012201 39516 sotalol HCl SOTALOL AF PDL PDL YBETA-BLOCKERS 60505022301 33100045120315 60505022301 39516 sotalol HCl SOTALOL AF PDL PDL YBETA-BLOCKERS 70515011906 33100045120315 70515011906 39516 sotalol HCl BETAPACE AF NPD NPD YBETA-BLOCKERS 00378512501 33100045120320 00378512501 39511 sotalol HCl SOTALOL AF PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 57

BETA-BLOCKERS 42806012301 33100045120320 42806012301 39511 sotalol HCl SOTALOL AF PDL PDL YBETA-BLOCKERS 60505022401 33100045120320 60505022401 39511 sotalol HCl SOTALOL AF PDL PDL YBETA-BLOCKERS 70515011606 33100045120320 70515011606 39511 sotalol HCl BETAPACE AF NPD NPD YBETA-BLOCKERS 00378022101 33100050100310 00378022101 20670 timolol maleate TIMOLOL MALEATE NPD NPD YBETA-BLOCKERS 00378071501 33100050100315 00378071501 20671 timolol maleate TIMOLOL MALEATE NPD NPD YBETA-BLOCKERS 00378120001 33200010100105 00378120001 26460 acebutolol HCl ACEBUTOLOL HCL NPD NPD YBETA-BLOCKERS 53746066901 33200010100105 53746066901 26460 acebutolol HCl ACEBUTOLOL HCL NPD NPD YBETA-BLOCKERS 65162066910 33200010100105 65162066910 26460 acebutolol HCl ACEBUTOLOL HCL NPD NPD YBETA-BLOCKERS 00378140001 33200010100110 00378140001 26461 acebutolol HCl ACEBUTOLOL HCL NPD NPD YBETA-BLOCKERS 53746067001 33200010100110 53746067001 26461 acebutolol HCl ACEBUTOLOL HCL NPD NPD YBETA-BLOCKERS 65162067010 33200010100110 65162067010 26461 acebutolol HCl ACEBUTOLOL HCL NPD NPD YBETA-BLOCKERS 00093078701 33200020000303 00093078701 20662 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00093078710 33200020000303 00093078710 20662 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00378021801 33200020000303 00378021801 20662 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00378021810 33200020000303 00378021810 20662 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00781107801 33200020000303 00781107801 20662 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00781107810 33200020000303 00781107810 20662 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 51079075920 33200020000303 51079075920 20662 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 52427042990 33200020000303 52427042990 20662 atenolol TENORMIN NPD NPD YBETA-BLOCKERS 63304062101 33200020000303 63304062101 20662 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 63304062110 33200020000303 63304062110 20662 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 64980043701 33200020000303 64980043701 20662 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 64980043710 33200020000303 64980043710 20662 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 68382002201 33200020000303 68382002201 20662 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 68382002210 33200020000303 68382002210 20662 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00093075201 33200020000305 00093075201 20661 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00093075210 33200020000305 00093075210 20661 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00378023101 33200020000305 00378023101 20661 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00378023110 33200020000305 00378023110 20661 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00781150601 33200020000305 00781150601 20661 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00781150610 33200020000305 00781150610 20661 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00781522510 33200020000305 00781522510 20661 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 51079068420 33200020000305 51079068420 20661 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 52427043090 33200020000305 52427043090 20661 atenolol TENORMIN NPD NPD YBETA-BLOCKERS 63304062201 33200020000305 63304062201 20661 atenolol ATENOLOL PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 58

BETA-BLOCKERS 63304062210 33200020000305 63304062210 20661 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 64980043801 33200020000305 64980043801 20661 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 64980043810 33200020000305 64980043810 20661 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 68382002301 33200020000305 68382002301 20661 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 68382002310 33200020000305 68382002310 20661 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 68645049354 33200020000305 68645049354 20661 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00093075301 33200020000310 00093075301 20660 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00093075305 33200020000310 00093075305 20660 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00378075701 33200020000310 00378075701 20660 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00378075710 33200020000310 00378075710 20660 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00781150701 33200020000310 00781150701 20660 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 00781150710 33200020000310 00781150710 20660 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 51079068520 33200020000310 51079068520 20660 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 52427043190 33200020000310 52427043190 20660 atenolol TENORMIN NPD NPD YBETA-BLOCKERS 63304062301 33200020000310 63304062301 20660 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 63304062310 33200020000310 63304062310 20660 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 64980043901 33200020000310 64980043901 20660 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 64980043910 33200020000310 64980043910 20660 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 68382002401 33200020000310 68382002401 20660 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 68382002410 33200020000310 68382002410 20660 atenolol ATENOLOL PDL PDL YBETA-BLOCKERS 10702001301 33200021100310 10702001301 12791 betaxolol HCl BETAXOLOL HCL NPD NPD YBETA-BLOCKERS 42806003801 33200021100310 42806003801 12791 betaxolol HCl BETAXOLOL HCL NPD NPD Y

BETA-BLOCKERS 00185077101 33200022100310 00185077101 63821 bisoprolol fumarateBISOPROLOL FUMARATE PDL PDL Y

BETA-BLOCKERS 00185077130 33200022100310 00185077130 63821 bisoprolol fumarateBISOPROLOL FUMARATE PDL PDL Y

BETA-BLOCKERS 00378052301 33200022100310 00378052301 63821 bisoprolol fumarateBISOPROLOL FUMARATE PDL PDL Y

BETA-BLOCKERS 00378052393 33200022100310 00378052393 63821 bisoprolol fumarateBISOPROLOL FUMARATE PDL PDL Y

BETA-BLOCKERS 29300012601 33200022100310 29300012601 63821 bisoprolol fumarateBISOPROLOL FUMARATE PDL PDL Y

BETA-BLOCKERS 29300012613 33200022100310 29300012613 63821 bisoprolol fumarateBISOPROLOL FUMARATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 59

BETA-BLOCKERS 00185077401 33200022100320 00185077401 63820 bisoprolol fumarateBISOPROLOL FUMARATE PDL PDL Y

BETA-BLOCKERS 00185077430 33200022100320 00185077430 63820 bisoprolol fumarateBISOPROLOL FUMARATE PDL PDL Y

BETA-BLOCKERS 00378052401 33200022100320 00378052401 63820 bisoprolol fumarateBISOPROLOL FUMARATE PDL PDL Y

BETA-BLOCKERS 00378052493 33200022100320 00378052493 63820 bisoprolol fumarateBISOPROLOL FUMARATE PDL PDL Y

BETA-BLOCKERS 29300012701 33200022100320 29300012701 63820 bisoprolol fumarateBISOPROLOL FUMARATE PDL PDL Y

BETA-BLOCKERS 29300012713 33200022100320 29300012713 63820 bisoprolol fumarateBISOPROLOL FUMARATE PDL PDL Y

BETA-BLOCKERS 00186108805 33200030057510 00186108805 12947 metoprolol succinate TOPROL XL NPD NPD YBETA-BLOCKERS 00186108835 33200030057510 00186108835 12947 metoprolol succinate TOPROL XL NPD NPD Y

BETA-BLOCKERS 00378459510 33200030057510 00378459510 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 00378459577 33200030057510 00378459577 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 00527260037 33200030057510 00527260037 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 00527260043 33200030057510 00527260043 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 00904632261 33200030057510 00904632261 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 16714085201 33200030057510 16714085201 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 16714085202 33200030057510 16714085202 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 16714085203 33200030057510 16714085203 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 49884082501 33200030057510 49884082501 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 49884082510 33200030057510 49884082510 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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BETA-BLOCKERS 50742061501 33200030057510 50742061501 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 50742061505 33200030057510 50742061505 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 50742061510 33200030057510 50742061510 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 55111046601 33200030057510 55111046601 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 55111046605 33200030057510 55111046605 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 62037083001 33200030057510 62037083001 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 62037083010 33200030057510 62037083010 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68001012100 33200030057510 68001012100 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68001012103 33200030057510 68001012103 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68001035600 33200030057510 68001035600 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68001035603 33200030057510 68001035603 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68084065901 33200030057510 68084065901 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68382056401 33200030057510 68382056401 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68645047754 33200030057510 68645047754 12947 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL YBETA-BLOCKERS 70347002502 33200030057510 70347002502 12947 metoprolol succinate TOPROL XL NPD NPD YBETA-BLOCKERS 70347002503 33200030057510 70347002503 12947 metoprolol succinate TOPROL XL NPD NPD YBETA-BLOCKERS 00186109005 33200030057520 00186109005 20741 metoprolol succinate TOPROL XL NPD NPD Y

BETA-BLOCKERS 00378459610 33200030057520 00378459610 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 00378459677 33200030057520 00378459677 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 61

BETA-BLOCKERS 00527260137 33200030057520 00527260137 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 00527260143 33200030057520 00527260143 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 00904632361 33200030057520 00904632361 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 16714085301 33200030057520 16714085301 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 16714085302 33200030057520 16714085302 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 16714085303 33200030057520 16714085303 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 49884082601 33200030057520 49884082601 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 49884082610 33200030057520 49884082610 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 50742061601 33200030057520 50742061601 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 50742061605 33200030057520 50742061605 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 50742061610 33200030057520 50742061610 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 51079017020 33200030057520 51079017020 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 55111046701 33200030057520 55111046701 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 55111046705 33200030057520 55111046705 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 62037083101 33200030057520 62037083101 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 62037083110 33200030057520 62037083110 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68001012200 33200030057520 68001012200 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 62

BETA-BLOCKERS 68001012203 33200030057520 68001012203 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68001035700 33200030057520 68001035700 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68001035703 33200030057520 68001035703 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68382056501 33200030057520 68382056501 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68645047854 33200030057520 68645047854 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 69097040707 33200030057520 69097040707 20741 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL YBETA-BLOCKERS 70347005002 33200030057520 70347005002 20741 metoprolol succinate TOPROL XL NPD NPD YBETA-BLOCKERS 70347005003 33200030057520 70347005003 20741 metoprolol succinate TOPROL XL NPD NPD YBETA-BLOCKERS 00186109205 33200030057530 00186109205 20742 metoprolol succinate TOPROL XL NPD NPD Y

BETA-BLOCKERS 00378459710 33200030057530 00378459710 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 00378459777 33200030057530 00378459777 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 00527260237 33200030057530 00527260237 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 00527260243 33200030057530 00527260243 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 00904632461 33200030057530 00904632461 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 16714085401 33200030057530 16714085401 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 16714085402 33200030057530 16714085402 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 16714085403 33200030057530 16714085403 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 49884082701 33200030057530 49884082701 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 49884082710 33200030057530 49884082710 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 63

BETA-BLOCKERS 50742061701 33200030057530 50742061701 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 50742061705 33200030057530 50742061705 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 50742061710 33200030057530 50742061710 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 55111046801 33200030057530 55111046801 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 55111046805 33200030057530 55111046805 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 62037083201 33200030057530 62037083201 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 62037083210 33200030057530 62037083210 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 63739045410 33200030057530 63739045410 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68001011900 33200030057530 68001011900 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68001011903 33200030057530 68001011903 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68001035800 33200030057530 68001035800 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68001035803 33200030057530 68001035803 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68382056601 33200030057530 68382056601 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68382056610 33200030057530 68382056610 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68645047954 33200030057530 68645047954 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 69097040807 33200030057530 69097040807 20742 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL YBETA-BLOCKERS 70347010002 33200030057530 70347010002 20742 metoprolol succinate TOPROL XL NPD NPD YBETA-BLOCKERS 70347010003 33200030057530 70347010003 20742 metoprolol succinate TOPROL XL NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 64

BETA-BLOCKERS 00378459805 33200030057540 00378459805 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 00378459877 33200030057540 00378459877 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 00527260337 33200030057540 00527260337 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 00527260343 33200030057540 00527260343 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 16714085501 33200030057540 16714085501 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 16714085502 33200030057540 16714085502 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 49884082801 33200030057540 49884082801 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 49884082810 33200030057540 49884082810 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 50742061801 33200030057540 50742061801 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 55111046901 33200030057540 55111046901 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 55111046905 33200030057540 55111046905 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 62037083301 33200030057540 62037083301 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68001012000 33200030057540 68001012000 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68001012003 33200030057540 68001012003 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68001036000 33200030057540 68001036000 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68001036003 33200030057540 68001036003 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

BETA-BLOCKERS 68382056701 33200030057540 68382056701 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 65

BETA-BLOCKERS 68382056705 33200030057540 68382056705 20743 metoprolol succinateMETOPROLOL

SUCCINATE PDL PDL YBETA-BLOCKERS 70347020002 33200030057540 70347020002 20743 metoprolol succinate TOPROL XL NPD NPD Y

BETA-BLOCKERS 10631000830 3320003005F310 10631000830 44398 metoprolol succinateKAPSPARGO

SPRINKLE NPD NPD Y

BETA-BLOCKERS 10631000930 3320003005F320 10631000930 44399 metoprolol succinateKAPSPARGO

SPRINKLE NPD NPD Y

BETA-BLOCKERS 10631001030 3320003005F330 10631001030 44403 metoprolol succinateKAPSPARGO

SPRINKLE NPD NPD Y

BETA-BLOCKERS 10631001130 3320003005F340 10631001130 44404 metoprolol succinateKAPSPARGO

SPRINKLE NPD NPD Y

BETA-BLOCKERS 00378001801 33200030100305 00378001801 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00378001805 33200030100305 00378001805 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00904634060 33200030100305 00904634060 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00904634061 33200030100305 00904634061 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00904634080 33200030100305 00904634080 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 42543000101 33200030100305 42543000101 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 42543000110 33200030100305 42543000110 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 51079025501 33200030100305 51079025501 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 51079025520 33200030100305 51079025520 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 52817036000 33200030100305 52817036000 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 52817036010 33200030100305 52817036010 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 57237010001 33200030100305 57237010001 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 66

BETA-BLOCKERS 57237010099 33200030100305 57237010099 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 57664050652 33200030100305 57664050652 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 57664050658 33200030100305 57664050658 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 62332011231 33200030100305 62332011231 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 62332011291 33200030100305 62332011291 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 62584026501 33200030100305 62584026501 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 63304057901 33200030100305 63304057901 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 63304057910 33200030100305 63304057910 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 65862006201 33200030100305 65862006201 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 65862006299 33200030100305 65862006299 17734 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00378459301 33200030100307 00378459301 37653 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00378003201 33200030100310 00378003201 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00378003210 33200030100310 00378003210 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00591046201 33200030100310 00591046201 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00591046210 33200030100310 00591046210 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00904634160 33200030100310 00904634160 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00904634161 33200030100310 00904634161 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 67

BETA-BLOCKERS 00904634180 33200030100310 00904634180 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL YBETA-BLOCKERS 30698045801 33200030100310 30698045801 20642 metoprolol tartrate LOPRESSOR NPD NPD Y

BETA-BLOCKERS 42543000201 33200030100310 42543000201 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 42543000210 33200030100310 42543000210 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 51079080101 33200030100310 51079080101 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 51079080120 33200030100310 51079080120 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 52817036100 33200030100310 52817036100 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 52817036110 33200030100310 52817036110 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 57237010101 33200030100310 57237010101 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 57237010199 33200030100310 57237010199 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 57664016652 33200030100310 57664016652 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 57664016658 33200030100310 57664016658 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 57664047752 33200030100310 57664047752 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 57664047758 33200030100310 57664047758 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 62332011331 33200030100310 62332011331 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 62332011391 33200030100310 62332011391 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 63304058001 33200030100310 63304058001 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 63304058010 33200030100310 63304058010 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 68

BETA-BLOCKERS 65862006301 33200030100310 65862006301 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 65862006399 33200030100310 65862006399 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 68645019059 33200030100310 68645019059 20642 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00378459401 33200030100312 00378459401 37656 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00378004701 33200030100315 00378004701 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00378004710 33200030100315 00378004710 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00591046301 33200030100315 00591046301 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00591046310 33200030100315 00591046310 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00904634260 33200030100315 00904634260 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00904634261 33200030100315 00904634261 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 00904634280 33200030100315 00904634280 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL YBETA-BLOCKERS 30698045901 33200030100315 30698045901 20641 metoprolol tartrate LOPRESSOR NPD NPD Y

BETA-BLOCKERS 42543000301 33200030100315 42543000301 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 42543000310 33200030100315 42543000310 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 51079080220 33200030100315 51079080220 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 52817036200 33200030100315 52817036200 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 52817036210 33200030100315 52817036210 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 57237010201 33200030100315 57237010201 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 69

BETA-BLOCKERS 57237010299 33200030100315 57237010299 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 57664016752 33200030100315 57664016752 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 57664016758 33200030100315 57664016758 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 62332011431 33200030100315 62332011431 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 62584026701 33200030100315 62584026701 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 63304058101 33200030100315 63304058101 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 63304058110 33200030100315 63304058110 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 65862006401 33200030100315 65862006401 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 65862006499 33200030100315 65862006499 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL Y

BETA-BLOCKERS 68645019159 33200030100315 68645019159 20641 metoprolol tartrateMETOPROLOL

TARTRATE PDL PDL YBETA-BLOCKERS 00456140230 33200040100310 00456140230 99235 nebivolol HCl BYSTOLIC NPD NPD YBETA-BLOCKERS 00456140530 33200040100320 00456140530 7055 nebivolol HCl BYSTOLIC NPD NPD YBETA-BLOCKERS 00456140563 33200040100320 00456140563 7055 nebivolol HCl BYSTOLIC NPD NPD YBETA-BLOCKERS 00456140590 33200040100320 00456140590 7055 nebivolol HCl BYSTOLIC NPD NPD YBETA-BLOCKERS 00456141030 33200040100330 00456141030 99236 nebivolol HCl BYSTOLIC NPD NPD YBETA-BLOCKERS 00456141090 33200040100330 00456141090 99236 nebivolol HCl BYSTOLIC NPD NPD YBETA-BLOCKERS 00456142030 33200040100340 00456142030 18703 nebivolol HCl BYSTOLIC NPD NPD YBETA-BLOCKERS 00456142090 33200040100340 00456142090 18703 nebivolol HCl BYSTOLIC NPD NPD YBETA-BLOCKERS 00007413920 33300007000305 00007413920 1553 carvedilol COREG NPD NPD YBETA-BLOCKERS 00093005101 33300007000305 00093005101 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00093005105 33300007000305 00093005105 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00378363101 33300007000305 00378363101 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00378363105 33300007000305 00378363105 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00781522101 33300007000305 00781522101 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00904630061 33300007000305 00904630061 1553 carvedilol CARVEDILOL PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 70

BETA-BLOCKERS 13107014201 33300007000305 13107014201 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 13107014205 33300007000305 13107014205 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 43547025410 33300007000305 43547025410 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 43547025450 33300007000305 43547025450 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 51079077120 33300007000305 51079077120 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 57664024218 33300007000305 57664024218 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 57664024288 33300007000305 57664024288 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 65862014201 33300007000305 65862014201 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 65862014205 33300007000305 65862014205 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68001015300 33300007000305 68001015300 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68001015303 33300007000305 68001015303 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68382009201 33300007000305 68382009201 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68382009205 33300007000305 68382009205 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68462016201 33300007000305 68462016201 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68462016205 33300007000305 68462016205 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 76385011001 33300007000305 76385011001 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 76385011050 33300007000305 76385011050 1553 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00007414020 33300007000310 00007414020 1554 carvedilol COREG NPD NPD YBETA-BLOCKERS 00093013501 33300007000310 00093013501 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00093013505 33300007000310 00093013505 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00378363201 33300007000310 00378363201 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00378363205 33300007000310 00378363205 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00781522201 33300007000310 00781522201 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00904630161 33300007000310 00904630161 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 13107014301 33300007000310 13107014301 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 13107014305 33300007000310 13107014305 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 43547025510 33300007000310 43547025510 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 43547025550 33300007000310 43547025550 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 51079093020 33300007000310 51079093020 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 57664024413 33300007000310 57664024413 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 57664024488 33300007000310 57664024488 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 65862014301 33300007000310 65862014301 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 65862014305 33300007000310 65862014305 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68001015400 33300007000310 68001015400 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68001015403 33300007000310 68001015403 1554 carvedilol CARVEDILOL PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 71

BETA-BLOCKERS 68382009301 33300007000310 68382009301 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68382009305 33300007000310 68382009305 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68462016301 33300007000310 68462016301 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68462016305 33300007000310 68462016305 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68645035059 33300007000310 68645035059 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 76385011150 33300007000310 76385011150 1554 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00007414120 33300007000320 00007414120 1552 carvedilol COREG NPD NPD YBETA-BLOCKERS 00093729501 33300007000320 00093729501 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00093729505 33300007000320 00093729505 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00378363301 33300007000320 00378363301 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00378363305 33300007000320 00378363305 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00781522301 33300007000320 00781522301 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00904630261 33300007000320 00904630261 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 13107014401 33300007000320 13107014401 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 13107014405 33300007000320 13107014405 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 43547025610 33300007000320 43547025610 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 43547025650 33300007000320 43547025650 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 51079093120 33300007000320 51079093120 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 57664024513 33300007000320 57664024513 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 57664024518 33300007000320 57664024518 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 57664024588 33300007000320 57664024588 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 65862014401 33300007000320 65862014401 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 65862014405 33300007000320 65862014405 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68001015100 33300007000320 68001015100 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68001015103 33300007000320 68001015103 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68084086501 33300007000320 68084086501 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68382009401 33300007000320 68382009401 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68382009405 33300007000320 68382009405 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68462016401 33300007000320 68462016401 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68462016405 33300007000320 68462016405 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68645035159 33300007000320 68645035159 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 76385011201 33300007000320 76385011201 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 76385011250 33300007000320 76385011250 1552 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00007414220 33300007000330 00007414220 1551 carvedilol COREG NPD NPD YBETA-BLOCKERS 00093729601 33300007000330 00093729601 1551 carvedilol CARVEDILOL PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 72

BETA-BLOCKERS 00093729605 33300007000330 00093729605 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00378363401 33300007000330 00378363401 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00378363405 33300007000330 00378363405 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00781522401 33300007000330 00781522401 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00904630361 33300007000330 00904630361 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 13107014501 33300007000330 13107014501 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 13107014505 33300007000330 13107014505 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 43547025710 33300007000330 43547025710 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 43547025750 33300007000330 43547025750 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 51079093220 33300007000330 51079093220 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 57664024718 33300007000330 57664024718 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 57664024788 33300007000330 57664024788 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 65862014501 33300007000330 65862014501 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 65862014505 33300007000330 65862014505 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68001015200 33300007000330 68001015200 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68001015203 33300007000330 68001015203 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68084087601 33300007000330 68084087601 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68382009501 33300007000330 68382009501 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68382009505 33300007000330 68382009505 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68462016501 33300007000330 68462016501 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68462016505 33300007000330 68462016505 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 68645049659 33300007000330 68645049659 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 76385011301 33300007000330 76385011301 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 76385011350 33300007000330 76385011350 1551 carvedilol CARVEDILOL PDL PDL YBETA-BLOCKERS 00007337013 33300007207010 00007337013 97596 carvedilol phosphate COREG CR NPD NPD YBETA-BLOCKERS 57664066383 33300007207010 57664066383 97596 carvedilol phosphate CARVEDILOL ER NPD NPD YBETA-BLOCKERS 60505367803 33300007207010 60505367803 97596 carvedilol phosphate CARVEDILOL ER NPD NPD YBETA-BLOCKERS 00007337113 33300007207020 00007337113 97597 carvedilol phosphate COREG CR NPD NPD YBETA-BLOCKERS 57664066483 33300007207020 57664066483 97597 carvedilol phosphate CARVEDILOL ER NPD NPD YBETA-BLOCKERS 60505367903 33300007207020 60505367903 97597 carvedilol phosphate CARVEDILOL ER NPD NPD YBETA-BLOCKERS 00007337213 33300007207030 00007337213 97598 carvedilol phosphate COREG CR NPD NPD YBETA-BLOCKERS 57664066583 33300007207030 57664066583 97598 carvedilol phosphate CARVEDILOL ER NPD NPD YBETA-BLOCKERS 60505368003 33300007207030 60505368003 97598 carvedilol phosphate CARVEDILOL ER NPD NPD YBETA-BLOCKERS 00007337313 33300007207050 00007337313 97599 carvedilol phosphate COREG CR NPD NPD YBETA-BLOCKERS 57664066683 33300007207050 57664066683 97599 carvedilol phosphate CARVEDILOL ER NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 73

BETA-BLOCKERS 60505368103 33300007207050 60505368103 97599 carvedilol phosphate CARVEDILOL ER NPD NPD YBETA-BLOCKERS 00172436460 33300010100305 00172436460 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00172436470 33300010100305 00172436470 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00185001001 33300010100305 00185001001 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00185001005 33300010100305 00185001005 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00591060501 33300010100305 00591060501 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00591060505 33300010100305 00591060505 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00904592861 33300010100305 00904592861 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 24979016801 33300010100305 24979016801 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 24979016802 33300010100305 24979016802 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 43199003701 33300010100305 43199003701 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 43199003705 33300010100305 43199003705 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 47781055201 33300010100305 47781055201 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 49884012201 33300010100305 49884012201 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 49884012205 33300010100305 49884012205 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 58657060501 33300010100305 58657060501 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 68001020500 33300010100305 68001020500 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 68001020503 33300010100305 68001020503 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 68001038100 33300010100305 68001038100 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 68382079801 33300010100305 68382079801 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 68382079805 33300010100305 68382079805 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 69292050110 33300010100305 69292050110 10342 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00172436560 33300010100310 00172436560 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00172436570 33300010100310 00172436570 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00185011701 33300010100310 00185011701 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00185011705 33300010100310 00185011705 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00591060601 33300010100310 00591060601 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00591060605 33300010100310 00591060605 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00904592961 33300010100310 00904592961 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 24979016901 33300010100310 24979016901 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 24979016902 33300010100310 24979016902 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 43199003801 33300010100310 43199003801 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 43199003805 33300010100310 43199003805 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 47781055301 33300010100310 47781055301 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 47781055305 33300010100310 47781055305 10341 labetalol HCl LABETALOL HCL PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 74

BETA-BLOCKERS 49884012301 33300010100310 49884012301 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 49884012305 33300010100310 49884012305 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 51079092920 33300010100310 51079092920 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 58657060601 33300010100310 58657060601 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 63739036610 33300010100310 63739036610 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 68001020400 33300010100310 68001020400 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 68001020403 33300010100310 68001020403 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 68001038200 33300010100310 68001038200 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 68001038203 33300010100310 68001038203 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 68382079901 33300010100310 68382079901 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 68382079905 33300010100310 68382079905 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 69292050210 33300010100310 69292050210 10341 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00172436660 33300010100315 00172436660 10340 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00185011801 33300010100315 00185011801 10340 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00185011805 33300010100315 00185011805 10340 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00591060701 33300010100315 00591060701 10340 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 00904593061 33300010100315 00904593061 10340 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 24979017001 33300010100315 24979017001 10340 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 24979017002 33300010100315 24979017002 10340 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 43199003901 33300010100315 43199003901 10340 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 47781055401 33300010100315 47781055401 10340 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 49884012401 33300010100315 49884012401 10340 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 49884012405 33300010100315 49884012405 10340 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 58657060701 33300010100315 58657060701 10340 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 68001020600 33300010100315 68001020600 10340 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 68001020603 33300010100315 68001020603 10340 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 68382080001 33300010100315 68382080001 10340 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 68382080005 33300010100315 68382080005 10340 labetalol HCl LABETALOL HCL PDL PDL YBETA-BLOCKERS 69292050310 33300010100315 69292050310 10340 labetalol HCl LABETALOL HCL PDL PDL Y

BETA-BLOCKERS 00378206301 36992002100310 00378206301 66990 atenolol/chlorthalidoneATENOLOL-

CHLORTHALIDONE PDL PDL Y

BETA-BLOCKERS 00591578201 36992002100310 00591578201 66990 atenolol/chlorthalidoneATENOLOL-

CHLORTHALIDONE PDL PDL Y

BETA-BLOCKERS 70710116701 36992002100310 70710116701 66990 atenolol/chlorthalidoneATENOLOL-

CHLORTHALIDONE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 75

BETA-BLOCKERS 00378206401 36992002100320 00378206401 66991 atenolol/chlorthalidoneATENOLOL-

CHLORTHALIDONE PDL PDL Y

BETA-BLOCKERS 00591578301 36992002100320 00591578301 66991 atenolol/chlorthalidoneATENOLOL-

CHLORTHALIDONE PDL PDL Y

BETA-BLOCKERS 70710116801 36992002100320 70710116801 66991 atenolol/chlorthalidoneATENOLOL-

CHLORTHALIDONE PDL PDL Y

BETA-BLOCKERS 00378050101 36992002130310 00378050101 45061bisoprolol/hydrochlorothi

azide

BISOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 29300018701 36992002130310 29300018701 45061bisoprolol/hydrochlorothi

azide

BISOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 29300018705 36992002130310 29300018705 45061bisoprolol/hydrochlorothi

azide

BISOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 29300018713 36992002130310 29300018713 45061bisoprolol/hydrochlorothi

azide

BISOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 51285004702 36992002130310 51285004702 45061bisoprolol/hydrochlorothi

azide ZIAC NPD NPD Y

BETA-BLOCKERS 00378050301 36992002130320 00378050301 45062bisoprolol/hydrochlorothi

azide

BISOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 29300018801 36992002130320 29300018801 45062bisoprolol/hydrochlorothi

azide

BISOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 29300018805 36992002130320 29300018805 45062bisoprolol/hydrochlorothi

azide

BISOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 29300018813 36992002130320 29300018813 45062bisoprolol/hydrochlorothi

azide

BISOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 51285005002 36992002130320 51285005002 45062bisoprolol/hydrochlorothi

azide ZIAC NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 76

BETA-BLOCKERS 00185070701 36992002130330 00185070701 45063bisoprolol/hydrochlorothi

azide

BISOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 00185070730 36992002130330 00185070730 45063bisoprolol/hydrochlorothi

azide

BISOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 00378050501 36992002130330 00378050501 45063bisoprolol/hydrochlorothi

azide

BISOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 29300018901 36992002130330 29300018901 45063bisoprolol/hydrochlorothi

azide

BISOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 29300018905 36992002130330 29300018905 45063bisoprolol/hydrochlorothi

azide

BISOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 29300018913 36992002130330 29300018913 45063bisoprolol/hydrochlorothi

azide

BISOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 51285004001 36992002130330 51285004001 45063bisoprolol/hydrochlorothi

azide ZIAC NPD NPD Y

BETA-BLOCKERS 00378042401 36992002200310 00378042401 51550metoprolol/hydrochloroth

iazide

METOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 62332011531 36992002200310 62332011531 51550metoprolol/hydrochloroth

iazide

METOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 00378043401 36992002200320 00378043401 51551metoprolol/hydrochloroth

iazide

METOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 62332011631 36992002200320 62332011631 51551metoprolol/hydrochloroth

iazide

METOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

BETA-BLOCKERS 00378044501 36992002200325 00378044501 51552metoprolol/hydrochloroth

iazide

METOPROLOL-HYDROCHLOROTHIA

ZIDE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 77

BETA-BLOCKERS 00115532201 36992002300320 00115532201 52061nadolol/bendroflumethiaz

ide

NADOLOL-BENDROFLUMETHIA

ZIDE PDL NPD Y

BETA-BLOCKERS 00378073101 36992002400310 00378073101 52030propranolol/hydrochlorot

hiazid

PROPRANOLOL-HYDROCHLOROTHIA

ZID PDL PDL Y

BETA-BLOCKERS 00378034701 36992002400320 00378034701 52031propranolol/hydrochlorot

hiazid

PROPRANOLOL-HYDROCHLOROTHIA

ZID PDL PDL YBPH TREATMENTS 00049275066 36202005100310 00049275066 33431 doxazosin mesylate CARDURA NPD NPD Y

BPH TREATMENTS 00093207001 36202005100310 00093207001 33431 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 00378402101 36202005100310 00378402101 33431 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 00832035611 36202005100310 00832035611 33431 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 00904552261 36202005100310 00904552261 33431 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 16729021101 36202005100310 16729021101 33431 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 16729021117 36202005100310 16729021117 33431 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 51079095701 36202005100310 51079095701 33431 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 59762231006 36202005100310 59762231006 33431 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 60505009300 36202005100310 60505009300 33431 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 60505009301 36202005100310 60505009301 33431 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 68382078301 36202005100310 68382078301 33431 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 68382078310 36202005100310 68382078310 33431 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 00049276066 36202005100320 00049276066 33432 doxazosin mesylate CARDURA NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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BPH TREATMENTS 00093206901 36202005100320 00093206901 33432 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 00378402201 36202005100320 00378402201 33432 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 00832035711 36202005100320 00832035711 33432 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 16729021201 36202005100320 16729021201 33432 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 16729041401 36202005100320 16729041401 33432 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 16729041417 36202005100320 16729041417 33432 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 51079095820 36202005100320 51079095820 33432 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 59762232006 36202005100320 59762232006 33432 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 60505009400 36202005100320 60505009400 33432 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 60505009401 36202005100320 60505009401 33432 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 67253038110 36202005100320 67253038110 33432 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 68382078401 36202005100320 68382078401 33432 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 68382078410 36202005100320 68382078410 33432 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 68645046354 36202005100320 68645046354 33432 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 00049277066 36202005100330 00049277066 33433 doxazosin mesylate CARDURA NPD NPD Y

BPH TREATMENTS 00093206801 36202005100330 00093206801 33433 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 00378402401 36202005100330 00378402401 33433 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 00832135811 36202005100330 00832135811 33433 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 79

BPH TREATMENTS 16729021301 36202005100330 16729021301 33433 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 16729021317 36202005100330 16729021317 33433 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 51079095901 36202005100330 51079095901 33433 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 51079095920 36202005100330 51079095920 33433 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 59762234006 36202005100330 59762234006 33433 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 60505009500 36202005100330 60505009500 33433 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 60505009501 36202005100330 60505009501 33433 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 60505009505 36202005100330 60505009505 33433 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 67253038210 36202005100330 67253038210 33433 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 68382078501 36202005100330 68382078501 33433 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 68382078510 36202005100330 68382078510 33433 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 68645046454 36202005100330 68645046454 33433 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 00049278066 36202005100340 00049278066 33434 doxazosin mesylate CARDURA NPD NPD Y

BPH TREATMENTS 00093206701 36202005100340 00093206701 33434 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 00378402801 36202005100340 00378402801 33434 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 00832135911 36202005100340 00832135911 33434 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 16729041501 36202005100340 16729041501 33434 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 16729041517 36202005100340 16729041517 33434 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 80

BPH TREATMENTS 59762238006 36202005100340 59762238006 33434 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 60505009600 36202005100340 60505009600 33434 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 60505009601 36202005100340 60505009601 33434 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 68382078601 36202005100340 68382078601 33434 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 68645046554 36202005100340 68645046554 33434 doxazosin mesylateDOXAZOSIN MESYLATE PDL PDL Y

BPH TREATMENTS 00378226001 36202040100105 00378226001 47124 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 00781205101 36202040100105 00781205101 47124 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 00781205105 36202040100105 00781205105 47124 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 00904612661 36202040100105 00904612661 47124 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 51079093620 36202040100105 51079093620 47124 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 59746038306 36202040100105 59746038306 47124 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 59746038310 36202040100105 59746038310 47124 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 00378226401 36202040100110 00378226401 47125 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 00781205201 36202040100110 00781205201 47125 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 00781205205 36202040100110 00781205205 47125 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 00904612761 36202040100110 00904612761 47125 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 51079093720 36202040100110 51079093720 47125 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 59746038406 36202040100110 59746038406 47125 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 59746038410 36202040100110 59746038410 47125 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 60505011600 36202040100110 60505011600 47125 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 00378226801 36202040100115 00378226801 47126 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 00781205301 36202040100115 00781205301 47126 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 00781205305 36202040100115 00781205305 47126 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 51079093820 36202040100115 51079093820 47126 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 59746038506 36202040100115 59746038506 47126 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 59746038510 36202040100115 59746038510 47126 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 00378157001 36202040100120 00378157001 47127 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 00781205401 36202040100120 00781205401 47127 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 00781205405 36202040100120 00781205405 47127 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 59746038606 36202040100120 59746038606 47127 terazosin HCl TERAZOSIN HCL PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 81

BPH TREATMENTS 59746038610 36202040100120 59746038610 47127 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 60505011800 36202040100120 60505011800 47127 terazosin HCl TERAZOSIN HCL PDL PDL YBPH TREATMENTS 00093301665 40304080000302 00093301665 99409 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 66993070030 40304080000302 66993070030 99409 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 69097037302 40304080000302 69097037302 99409 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 00002446230 40304080000305 00002446230 20736 tadalafil CIALIS NPD NPD YBPH TREATMENTS 00093301756 40304080000305 00093301756 20736 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 00093301765 40304080000305 00093301765 20736 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 16729037010 40304080000305 16729037010 20736 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 27241011203 40304080000305 27241011203 20736 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 29300028713 40304080000305 29300028713 20736 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 31722064430 40304080000305 31722064430 20736 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 35573041030 40304080000305 35573041030 20736 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 43598057530 40304080000305 43598057530 20736 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 66993070130 40304080000305 66993070130 20736 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 66993070138 40304080000305 66993070138 20736 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 68382089706 40304080000305 68382089706 20736 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 69097037402 40304080000305 69097037402 20736 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 00002446330 40304080000310 00002446330 18995 tadalafil CIALIS NPD NPD YBPH TREATMENTS 00093301856 40304080000310 00093301856 18995 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 35573041130 40304080000310 35573041130 18995 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 43598057430 40304080000310 43598057430 18995 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 60505468503 40304080000310 60505468503 18995 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 66993070230 40304080000310 66993070230 18995 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 68382089806 40304080000310 68382089806 18995 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 69097037502 40304080000310 69097037502 18995 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 00002446430 40304080000320 00002446430 18996 tadalafil CIALIS NPD NPD YBPH TREATMENTS 00093301956 40304080000320 00093301956 18996 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 27241011403 40304080000320 27241011403 18996 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 31722064630 40304080000320 31722064630 18996 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 60505468603 40304080000320 60505468603 18996 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 66993070330 40304080000320 66993070330 18996 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 68382089906 40304080000320 68382089906 18996 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 69097037602 40304080000320 69097037602 18996 tadalafil TADALAFIL NPD NPD YBPH TREATMENTS 00115143808 56851020000120 00115143808 18428 dutasteride DUTASTERIDE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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BPH TREATMENTS 00115143810 56851020000120 00115143810 18428 dutasteride DUTASTERIDE PDL PDL YBPH TREATMENTS 00173071204 56851020000120 00173071204 18428 dutasteride AVODART NPD NPD YBPH TREATMENTS 00173071215 56851020000120 00173071215 18428 dutasteride AVODART NPD NPD YBPH TREATMENTS 31722013130 56851020000120 31722013130 18428 dutasteride DUTASTERIDE PDL PDL YBPH TREATMENTS 31722013190 56851020000120 31722013190 18428 dutasteride DUTASTERIDE PDL PDL YBPH TREATMENTS 42806054909 56851020000120 42806054909 18428 dutasteride DUTASTERIDE PDL PDL YBPH TREATMENTS 42806054930 56851020000120 42806054930 18428 dutasteride DUTASTERIDE PDL PDL YBPH TREATMENTS 60505387703 56851020000120 60505387703 18428 dutasteride DUTASTERIDE PDL PDL YBPH TREATMENTS 60505387709 56851020000120 60505387709 18428 dutasteride DUTASTERIDE PDL PDL YBPH TREATMENTS 64380076304 56851020000120 64380076304 18428 dutasteride DUTASTERIDE PDL PDL YBPH TREATMENTS 64380076305 56851020000120 64380076305 18428 dutasteride DUTASTERIDE PDL PDL YBPH TREATMENTS 64980022409 56851020000120 64980022409 18428 dutasteride DUTASTERIDE PDL PDL YBPH TREATMENTS 65162075003 56851020000120 65162075003 18428 dutasteride DUTASTERIDE PDL PDL YBPH TREATMENTS 65162075009 56851020000120 65162075009 18428 dutasteride DUTASTERIDE PDL PDL YBPH TREATMENTS 00006007231 56851030000320 00006007231 30521 finasteride PROSCAR NPD NPD YBPH TREATMENTS 00006007258 56851030000320 00006007258 30521 finasteride PROSCAR NPD NPD YBPH TREATMENTS 00093735505 56851030000320 00093735505 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 00093735556 56851030000320 00093735556 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 00093735598 56851030000320 00093735598 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 00378503677 56851030000320 00378503677 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 00378503693 56851030000320 00378503693 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 16729009001 56851030000320 16729009001 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 16729009010 56851030000320 16729009010 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 16729009015 56851030000320 16729009015 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 16729009016 56851030000320 16729009016 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 31722052510 56851030000320 31722052510 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 31722052530 56851030000320 31722052530 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 31722052590 56851030000320 31722052590 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 43598030330 56851030000320 43598030330 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 43598030390 56851030000320 43598030390 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 45963050002 56851030000320 45963050002 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 45963050008 56851030000320 45963050008 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 45963050030 56851030000320 45963050030 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 55111017290 56851030000320 55111017290 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 57237006205 56851030000320 57237006205 30521 finasteride FINASTERIDE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 83

BPH TREATMENTS 57237006230 56851030000320 57237006230 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 57237006290 56851030000320 57237006290 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 65862014901 56851030000320 65862014901 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 65862014905 56851030000320 65862014905 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 65862014930 56851030000320 65862014930 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 65862014990 56851030000320 65862014990 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 67877028805 56851030000320 67877028805 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 67877028810 56851030000320 67877028810 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 67877028830 56851030000320 67877028830 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 67877028890 56851030000320 67877028890 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 68084039901 56851030000320 68084039901 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 68645054154 56851030000320 68645054154 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 76282041205 56851030000320 76282041205 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 76282041230 56851030000320 76282041230 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 76282041290 56851030000320 76282041290 30521 finasteride FINASTERIDE PDL PDL YBPH TREATMENTS 00378500577 56852010107530 00378500577 92024 alfuzosin HCl ALFUZOSIN HCL ER PDL PDL YBPH TREATMENTS 13668002101 56852010107530 13668002101 92024 alfuzosin HCl ALFUZOSIN HCL ER PDL PDL YBPH TREATMENTS 29300015501 56852010107530 29300015501 92024 alfuzosin HCl ALFUZOSIN HCL ER PDL PDL YBPH TREATMENTS 29300015519 56852010107530 29300015519 92024 alfuzosin HCl ALFUZOSIN HCL ER PDL PDL YBPH TREATMENTS 47335095618 56852010107530 47335095618 92024 alfuzosin HCl ALFUZOSIN HCL ER PDL PDL YBPH TREATMENTS 47335095688 56852010107530 47335095688 92024 alfuzosin HCl ALFUZOSIN HCL ER PDL PDL YBPH TREATMENTS 57237011490 56852010107530 57237011490 92024 alfuzosin HCl ALFUZOSIN HCL ER PDL PDL YBPH TREATMENTS 60505285001 56852010107530 60505285001 92024 alfuzosin HCl ALFUZOSIN HCL ER PDL PDL YBPH TREATMENTS 69097084407 56852010107530 69097084407 92024 alfuzosin HCl ALFUZOSIN HCL ER PDL PDL YBPH TREATMENTS 76282030205 56852010107530 76282030205 92024 alfuzosin HCl ALFUZOSIN HCL ER PDL PDL YBPH TREATMENTS 76282030290 56852010107530 76282030290 92024 alfuzosin HCl ALFUZOSIN HCL ER PDL PDL YBPH TREATMENTS 00049271030 56852025207520 00049271030 91985 doxazosin mesylate CARDURA XL NPD NPD YBPH TREATMENTS 00049272030 56852025207530 00049272030 84848 doxazosin mesylate CARDURA XL NPD NPD YBPH TREATMENTS 00023614730 56852060000120 00023614730 16857 silodosin RAPAFLO NPD NPD YBPH TREATMENTS 00781262331 56852060000120 00781262331 16857 silodosin SILODOSIN NPD NPD YBPH TREATMENTS 27241014401 56852060000120 27241014401 16857 silodosin SILODOSIN NPD NPD YBPH TREATMENTS 59651009530 56852060000120 59651009530 16857 silodosin SILODOSIN NPD NPD YBPH TREATMENTS 68180074006 56852060000120 68180074006 16857 silodosin SILODOSIN NPD NPD YBPH TREATMENTS 69238142103 56852060000120 69238142103 16857 silodosin SILODOSIN NPD NPD YBPH TREATMENTS 72205000930 56852060000120 72205000930 16857 silodosin SILODOSIN NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 84

BPH TREATMENTS 00023614230 56852060000140 00023614230 16858 silodosin RAPAFLO NPD NPD YBPH TREATMENTS 00023614290 56852060000140 00023614290 16858 silodosin RAPAFLO NPD NPD YBPH TREATMENTS 00781262431 56852060000140 00781262431 16858 silodosin SILODOSIN NPD NPD YBPH TREATMENTS 00781262492 56852060000140 00781262492 16858 silodosin SILODOSIN NPD NPD YBPH TREATMENTS 27241014501 56852060000140 27241014501 16858 silodosin SILODOSIN NPD NPD YBPH TREATMENTS 33342038507 56852060000140 33342038507 16858 silodosin SILODOSIN NPD NPD YBPH TREATMENTS 59651009630 56852060000140 59651009630 16858 silodosin SILODOSIN NPD NPD YBPH TREATMENTS 59651009690 56852060000140 59651009690 16858 silodosin SILODOSIN NPD NPD YBPH TREATMENTS 68180074106 56852060000140 68180074106 16858 silodosin SILODOSIN NPD NPD YBPH TREATMENTS 68180074109 56852060000140 68180074109 16858 silodosin SILODOSIN NPD NPD YBPH TREATMENTS 69238142003 56852060000140 69238142003 16858 silodosin SILODOSIN NPD NPD YBPH TREATMENTS 72205001030 56852060000140 72205001030 16858 silodosin SILODOSIN NPD NPD YBPH TREATMENTS 72205001090 56852060000140 72205001090 16858 silodosin SILODOSIN NPD NPD YBPH TREATMENTS 00024583701 56852070100110 00024583701 48191 tamsulosin HCl FLOMAX NPD NPD YBPH TREATMENTS 00228299611 56852070100110 00228299611 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 00228299650 56852070100110 00228299650 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 00378250010 56852070100110 00378250010 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 00378250077 56852070100110 00378250077 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 00597005801 56852070100110 00597005801 48191 tamsulosin HCl FLOMAX NPD NPD YBPH TREATMENTS 00781207601 56852070100110 00781207601 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 00904640161 56852070100110 00904640161 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 00904640180 56852070100110 00904640180 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 00904640189 56852070100110 00904640189 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 16714071301 56852070100110 16714071301 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 16714071302 56852070100110 16714071302 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 33342015911 56852070100110 33342015911 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 33342015915 56852070100110 33342015915 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 33342015944 56852070100110 33342015944 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 51079029420 56852070100110 51079029420 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 57237001401 56852070100110 57237001401 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 57237001405 56852070100110 57237001405 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 62756016013 56852070100110 62756016013 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 62756016081 56852070100110 62756016081 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 62756016088 56852070100110 62756016088 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 63739056710 56852070100110 63739056710 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 85

BPH TREATMENTS 65862059801 56852070100110 65862059801 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 65862059805 56852070100110 65862059805 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 67877045001 56852070100110 67877045001 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 67877045005 56852070100110 67877045005 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 67877045010 56852070100110 67877045010 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 68084029901 56852070100110 68084029901 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 68382013201 56852070100110 68382013201 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL YBPH TREATMENTS 68382013210 56852070100110 68382013210 48191 tamsulosin HCl TAMSULOSIN HCL PDL PDL Y

BPH TREATMENTS 00173080913 56859902250120 00173080913 28596dutasteride/tamsulosin

HCl JALYN NPD NPD Y

BPH TREATMENTS 00173080959 56859902250120 00173080959 28596dutasteride/tamsulosin

HCl JALYN NPD NPD Y

BPH TREATMENTS 10370028009 56859902250120 10370028009 28596dutasteride/tamsulosin

HClDUTASTERIDE-TAMSULOSIN NPD NPD Y

BPH TREATMENTS 10370028011 56859902250120 10370028011 28596dutasteride/tamsulosin

HClDUTASTERIDE-TAMSULOSIN NPD NPD Y

BPH TREATMENTS 66993058030 56859902250120 66993058030 28596dutasteride/tamsulosin

HClDUTASTERIDE-TAMSULOSIN NPD NPD Y

BPH TREATMENTS 68382064006 56859902250120 68382064006 28596dutasteride/tamsulosin

HClDUTASTERIDE-TAMSULOSIN NPD NPD Y

BPH TREATMENTS 68382064016 56859902250120 68382064016 28596dutasteride/tamsulosin

HClDUTASTERIDE-TAMSULOSIN NPD NPD Y

CALCIUM CHANNEL BLOCKERS 00228111603 2328 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 52652500101 34000003081820 52652500101 46652 amlodipine benzoate KATERZIA NR NPD YCALCIUM CHANNEL BLOCKERS 00054010022 34000003100320 00054010022 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00069152068 34000003100320 00069152068 2681 amlodipine besylate NORVASC NPD NPD YCALCIUM CHANNEL BLOCKERS 00093008398 34000003100320 00093008398 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00378520805 34000003100320 00378520805 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 86

CALCIUM CHANNEL BLOCKERS 00378520877 34000003100320 00378520877 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00603210828 34000003100320 00603210828 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00904636961 34000003100320 00904636961 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 29300024105 34000003100320 29300024105 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 29300024110 34000003100320 29300024110 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 29300024119 34000003100320 29300024119 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 42806005505 34000003100320 42806005505 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 42806005509 34000003100320 42806005509 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 42806005510 34000003100320 42806005510 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 51079045020 34000003100320 51079045020 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 57664005518 34000003100320 57664005518 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 57664005599 34000003100320 57664005599 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 59762152001 34000003100320 59762152001 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 59762152002 34000003100320 59762152002 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 65862010105 34000003100320 65862010105 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 67877019705 34000003100320 67877019705 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 67877019710 34000003100320 67877019710 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 87

CALCIUM CHANNEL BLOCKERS 67877019790 34000003100320 67877019790 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68180071909 34000003100320 68180071909 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68180075009 34000003100320 68180075009 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68382012105 34000003100320 68382012105 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68382012116 34000003100320 68382012116 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 69097012605 34000003100320 69097012605 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 69097012615 34000003100320 69097012615 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 69097083605 34000003100320 69097083605 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 69097083615 34000003100320 69097083615 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 71093014605 34000003100320 71093014605 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 76282023710 34000003100320 76282023710 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 76282023790 34000003100320 76282023790 2681 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00054010122 34000003100330 00054010122 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00054010131 34000003100330 00054010131 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00069153041 34000003100330 00069153041 2683 amlodipine besylate NORVASC NPD NPD YCALCIUM CHANNEL BLOCKERS 00069153068 34000003100330 00069153068 2683 amlodipine besylate NORVASC NPD NPD YCALCIUM CHANNEL BLOCKERS 00069153072 34000003100330 00069153072 2683 amlodipine besylate NORVASC NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 88

CALCIUM CHANNEL BLOCKERS 00093716755 34000003100330 00093716755 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00093716798 34000003100330 00093716798 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00378520905 34000003100330 00378520905 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00378520977 34000003100330 00378520977 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00603210925 34000003100330 00603210925 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00603210928 34000003100330 00603210928 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00603210932 34000003100330 00603210932 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00904637061 34000003100330 00904637061 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 29300024205 34000003100330 29300024205 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 29300024210 34000003100330 29300024210 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 29300024219 34000003100330 29300024219 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 31722023810 34000003100330 31722023810 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 31722023890 34000003100330 31722023890 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 42806005605 34000003100330 42806005605 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 42806005609 34000003100330 42806005609 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 42806005610 34000003100330 42806005610 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 51079045101 34000003100330 51079045101 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 89

CALCIUM CHANNEL BLOCKERS 51079045120 34000003100330 51079045120 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 57664005613 34000003100330 57664005613 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 57664005618 34000003100330 57664005618 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 57664005699 34000003100330 57664005699 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 59762153001 34000003100330 59762153001 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 59762153002 34000003100330 59762153002 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 59762153003 34000003100330 59762153003 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 59762153004 34000003100330 59762153004 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 59762153005 34000003100330 59762153005 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 65862010290 34000003100330 65862010290 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 65862010299 34000003100330 65862010299 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 67877019805 34000003100330 67877019805 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 67877019810 34000003100330 67877019810 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 67877019890 34000003100330 67877019890 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68180072003 34000003100330 68180072003 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68180072009 34000003100330 68180072009 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68180075103 34000003100330 68180075103 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 90

CALCIUM CHANNEL BLOCKERS 68180075109 34000003100330 68180075109 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68382012205 34000003100330 68382012205 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68382012216 34000003100330 68382012216 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68645051554 34000003100330 68645051554 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 69097012705 34000003100330 69097012705 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 69097012715 34000003100330 69097012715 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 69097083705 34000003100330 69097083705 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 69097083715 34000003100330 69097083715 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 71093014706 34000003100330 71093014706 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 76282023810 34000003100330 76282023810 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 76282023890 34000003100330 76282023890 2683 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00054010222 34000003100340 00054010222 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00054010231 34000003100340 00054010231 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00069154041 34000003100340 00069154041 2682 amlodipine besylate NORVASC NPD NPD YCALCIUM CHANNEL BLOCKERS 00069154068 34000003100340 00069154068 2682 amlodipine besylate NORVASC NPD NPD YCALCIUM CHANNEL BLOCKERS 00093716898 34000003100340 00093716898 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00378521005 34000003100340 00378521005 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 91

CALCIUM CHANNEL BLOCKERS 00378521077 34000003100340 00378521077 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00603211002 34000003100340 00603211002 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00603211028 34000003100340 00603211028 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00603211032 34000003100340 00603211032 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00603211033 34000003100340 00603211033 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00904637161 34000003100340 00904637161 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 29300024305 34000003100340 29300024305 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 29300024310 34000003100340 29300024310 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 29300024319 34000003100340 29300024319 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 31722023910 34000003100340 31722023910 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 31722023990 34000003100340 31722023990 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 33342001610 34000003100340 33342001610 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 42806005705 34000003100340 42806005705 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 42806005709 34000003100340 42806005709 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 42806005710 34000003100340 42806005710 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 51079045201 34000003100340 51079045201 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 51079045220 34000003100340 51079045220 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 92

CALCIUM CHANNEL BLOCKERS 57664005713 34000003100340 57664005713 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 57664005718 34000003100340 57664005718 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 57664005799 34000003100340 57664005799 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 59762154001 34000003100340 59762154001 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 59762154002 34000003100340 59762154002 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 59762154003 34000003100340 59762154003 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 59762154004 34000003100340 59762154004 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 63739063110 34000003100340 63739063110 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 65862010305 34000003100340 65862010305 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 65862010399 34000003100340 65862010399 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 67877019905 34000003100340 67877019905 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 67877019910 34000003100340 67877019910 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 67877019990 34000003100340 67877019990 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68180072103 34000003100340 68180072103 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68180072109 34000003100340 68180072109 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68180075203 34000003100340 68180075203 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68180075209 34000003100340 68180075209 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 93

CALCIUM CHANNEL BLOCKERS 68382012305 34000003100340 68382012305 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68382012316 34000003100340 68382012316 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68645044570 34000003100340 68645044570 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68645051654 34000003100340 68645051654 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68645058054 34000003100340 68645058054 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 69097012805 34000003100340 69097012805 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 69097012815 34000003100340 69097012815 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 69097083805 34000003100340 69097083805 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 69097083815 34000003100340 69097083815 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 71093014803 34000003100340 71093014803 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 71093014806 34000003100340 71093014806 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 76282023910 34000003100340 76282023910 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 76282023990 34000003100340 76282023990 2682 amlodipine besylate

AMLODIPINE BESYLATE PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00093031801 34000010100305 00093031801 2360 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00093031805 34000010100305 00093031805 2360 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00378002301 34000010100305 00378002301 2360 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00378002305 34000010100305 00378002305 2360 diltiazem HCl DILTIAZEM HCL PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 94

CALCIUM CHANNEL BLOCKERS 51079074520 34000010100305 51079074520 2360 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 63739007910 34000010100305 63739007910 2360 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 68682000610 34000010100305 68682000610 2360 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 68682000650 34000010100305 68682000650 2360 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00093031901 34000010100310 00093031901 2361 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00093031905 34000010100310 00093031905 2361 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00378004501 34000010100310 00378004501 2361 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00378004505 34000010100310 00378004505 2361 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 63739008010 34000010100310 63739008010 2361 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 68682000710 34000010100310 68682000710 2361 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 68682000750 34000010100310 68682000750 2361 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00093032001 34000010100315 00093032001 2362 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00378013501 34000010100315 00378013501 2362 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00378013505 34000010100315 00378013505 2362 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 68682000810 34000010100315 68682000810 2362 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00093032101 34000010100320 00093032101 2363 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00378052501 34000010100320 00378052501 2363 diltiazem HCl DILTIAZEM HCL PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 95

CALCIUM CHANNEL BLOCKERS 68682000910 34000010100320 68682000910 2363 diltiazem HCl DILTIAZEM HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00378606001 34000010106910 00378606001 2322 diltiazem HCl DILTIAZEM 12HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00378609001 34000010106915 00378609001 2320 diltiazem HCl DILTIAZEM 12HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 51079092520 34000010106915 51079092520 2320 diltiazem HCl DILTIAZEM 12HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00378612001 34000010106920 00378612001 2321 diltiazem HCl DILTIAZEM 12HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 51079092620 34000010106920 51079092620 2321 diltiazem HCl DILTIAZEM 12HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00378522001 34000010107020 00378522001 7463 diltiazem HCl

DILTIAZEM 24HR ER (XR) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00378522005 34000010107020 00378522005 7463 diltiazem HCl

DILTIAZEM 24HR ER (XR) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 60505001406 34000010107020 60505001406 7463 diltiazem HCl DILT-XR PDL PDL YCALCIUM CHANNEL BLOCKERS 60505001408 34000010107020 60505001408 7463 diltiazem HCl DILT-XR PDL PDL YCALCIUM CHANNEL BLOCKERS 00378528001 34000010107030 00378528001 7461 diltiazem HCl

DILTIAZEM 24HR ER (XR) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00378528005 34000010107030 00378528005 7461 diltiazem HCl

DILTIAZEM 24HR ER (XR) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 60505001506 34000010107030 60505001506 7461 diltiazem HCl DILT-XR PDL PDL YCALCIUM CHANNEL BLOCKERS 60505001508 34000010107030 60505001508 7461 diltiazem HCl DILT-XR PDL PDL YCALCIUM CHANNEL BLOCKERS 00378534001 34000010107040 00378534001 7462 diltiazem HCl

DILTIAZEM 24HR ER (XR) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00378534005 34000010107040 00378534005 7462 diltiazem HCl

DILTIAZEM 24HR ER (XR) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 60505001606 34000010107040 60505001606 7462 diltiazem HCl DILT-XR PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 96

CALCIUM CHANNEL BLOCKERS 60505001608 34000010107040 60505001608 7462 diltiazem HCl DILT-XR PDL PDL YCALCIUM CHANNEL BLOCKERS 00781245231 34000010117020 00781245231 2330 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 24658034190 34000010117020 24658034190 2330 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 47335066913 34000010117020 47335066913 2330 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 47335066981 34000010117020 47335066981 2330 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68682036790 34000010117020 68682036790 2330 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 24658034230 34000010117030 24658034230 2329 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 47335067081 34000010117030 47335067081 2329 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 62037069730 34000010117030 62037069730 2329 diltiazem HCl TAZTIA XT PDL PDL YCALCIUM CHANNEL BLOCKERS 62037069790 34000010117030 62037069790 2329 diltiazem HCl TAZTIA XT PDL PDL YCALCIUM CHANNEL BLOCKERS 68682036890 34000010117030 68682036890 2329 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00781245431 34000010117040 00781245431 2332 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 24658034390 34000010117040 24658034390 2332 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 47335067181 34000010117040 47335067181 2332 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 62037069890 34000010117040 62037069890 2332 diltiazem HCl TAZTIA XT PDL PDL YCALCIUM CHANNEL BLOCKERS 68682036990 34000010117040 68682036990 2332 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 47335067281 34000010117050 47335067281 2333 diltiazem HCl DILTIAZEM 24HR ER PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 97

CALCIUM CHANNEL BLOCKERS 62037069930 34000010117050 62037069930 2333 diltiazem HCl TAZTIA XT PDL PDL YCALCIUM CHANNEL BLOCKERS 68682037090 34000010117050 68682037090 2333 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 47335067313 34000010117060 47335067313 2328 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 47335067381 34000010117060 47335067381 2328 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 62037070030 34000010117060 62037070030 2328 diltiazem HCl TAZTIA XT PDL PDL YCALCIUM CHANNEL BLOCKERS 62037070090 34000010117060 62037070090 2328 diltiazem HCl TAZTIA XT PDL PDL YCALCIUM CHANNEL BLOCKERS 68682037190 34000010117060 68682037190 2328 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00187261730 34000010117070 00187261730 94691 diltiazem HCl TIAZAC NPD NPD YCALCIUM CHANNEL BLOCKERS 00187261790 34000010117070 00187261790 94691 diltiazem HCl TIAZAC NPD NPD YCALCIUM CHANNEL BLOCKERS 68682037290 34000010117070 68682037290 94691 diltiazem HCl DILTIAZEM 24HR ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00187079530 34000010127020 00187079530 2326 diltiazem HCl CARDIZEM CD NPD NPD YCALCIUM CHANNEL BLOCKERS 00187079542 34000010127020 00187079542 2326 diltiazem HCl CARDIZEM CD NPD NPD YCALCIUM CHANNEL BLOCKERS 10370082905 34000010127020 10370082905 2326 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 10370082909 34000010127020 10370082909 2326 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 10370082911 34000010127020 10370082911 2326 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 24979002602 34000010127020 24979002602 2326 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 24979002606 34000010127020 24979002606 2326 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 98

CALCIUM CHANNEL BLOCKERS 24979002607 34000010127020 24979002607 2326 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 47335067513 34000010127020 47335067513 2326 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 47335067581 34000010127020 47335067581 2326 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 62037059705 34000010127020 62037059705 2326 diltiazem HCl CARTIA XT PDL PDL YCALCIUM CHANNEL BLOCKERS 62037059790 34000010127020 62037059790 2326 diltiazem HCl CARTIA XT PDL PDL YCALCIUM CHANNEL BLOCKERS 68382059505 34000010127020 68382059505 2326 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68382059516 34000010127020 68382059516 2326 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68682099398 34000010127020 68682099398 2326 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00187079630 34000010127030 00187079630 2323 diltiazem HCl CARDIZEM CD NPD NPD YCALCIUM CHANNEL BLOCKERS 00187079642 34000010127030 00187079642 2323 diltiazem HCl CARDIZEM CD NPD NPD YCALCIUM CHANNEL BLOCKERS 10370083005 34000010127030 10370083005 2323 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 10370083009 34000010127030 10370083009 2323 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 10370083011 34000010127030 10370083011 2323 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 24979002702 34000010127030 24979002702 2323 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 24979002706 34000010127030 24979002706 2323 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 24979002707 34000010127030 24979002707 2323 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 47335067613 34000010127030 47335067613 2323 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 99

CALCIUM CHANNEL BLOCKERS 47335067681 34000010127030 47335067681 2323 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 62037059805 34000010127030 62037059805 2323 diltiazem HCl CARTIA XT PDL PDL YCALCIUM CHANNEL BLOCKERS 62037059890 34000010127030 62037059890 2323 diltiazem HCl CARTIA XT PDL PDL YCALCIUM CHANNEL BLOCKERS 63739001510 34000010127030 63739001510 2323 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68382059605 34000010127030 68382059605 2323 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68382059616 34000010127030 68382059616 2323 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68682099498 34000010127030 68682099498 2323 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00093511898 34000010127040 00093511898 2324 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00187079730 34000010127040 00187079730 2324 diltiazem HCl CARDIZEM CD NPD NPD YCALCIUM CHANNEL BLOCKERS 00187079742 34000010127040 00187079742 2324 diltiazem HCl CARDIZEM CD NPD NPD YCALCIUM CHANNEL BLOCKERS 10370083105 34000010127040 10370083105 2324 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 10370083109 34000010127040 10370083109 2324 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 10370083111 34000010127040 10370083111 2324 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 24979002802 34000010127040 24979002802 2324 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 24979002806 34000010127040 24979002806 2324 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 24979002807 34000010127040 24979002807 2324 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 47335067781 34000010127040 47335067781 2324 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 100

CALCIUM CHANNEL BLOCKERS 62037059905 34000010127040 62037059905 2324 diltiazem HCl CARTIA XT PDL PDL YCALCIUM CHANNEL BLOCKERS 62037059990 34000010127040 62037059990 2324 diltiazem HCl CARTIA XT PDL PDL YCALCIUM CHANNEL BLOCKERS 63739001610 34000010127040 63739001610 2324 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68382059705 34000010127040 68382059705 2324 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68382059716 34000010127040 68382059716 2324 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68682099798 34000010127040 68682099798 2324 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00187079830 34000010127050 00187079830 2325 diltiazem HCl CARDIZEM CD NPD NPD YCALCIUM CHANNEL BLOCKERS 00187079842 34000010127050 00187079842 2325 diltiazem HCl CARDIZEM CD NPD NPD YCALCIUM CHANNEL BLOCKERS 10370083205 34000010127050 10370083205 2325 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 10370083209 34000010127050 10370083209 2325 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 10370083211 34000010127050 10370083211 2325 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 24979002906 34000010127050 24979002906 2325 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 47335067813 34000010127050 47335067813 2325 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 47335067881 34000010127050 47335067881 2325 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 62037060005 34000010127050 62037060005 2325 diltiazem HCl CARTIA XT PDL PDL YCALCIUM CHANNEL BLOCKERS 62037060090 34000010127050 62037060090 2325 diltiazem HCl CARTIA XT PDL PDL YCALCIUM CHANNEL BLOCKERS 68382059805 34000010127050 68382059805 2325 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 101

CALCIUM CHANNEL BLOCKERS 68382059816 34000010127050 68382059816 2325 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68682099898 34000010127050 68682099898 2325 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00187079942 34000010127060 00187079942 7460 diltiazem HCl CARDIZEM CD NPD NPD YCALCIUM CHANNEL BLOCKERS 00228291809 34000010127060 00228291809 7460 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 24979003007 34000010127060 24979003007 7460 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 47335067981 34000010127060 47335067981 7460 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 63304072290 34000010127060 63304072290 7460 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68382059916 34000010127060 68382059916 7460 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 68682052101 34000010127060 68682052101 7460 diltiazem HCl

DILTIAZEM 24HR ER (CD) PDL PDL Y

CALCIUM CHANNEL BLOCKERS 00187204530 34000010127520 00187204530 19180 diltiazem HCl CARDIZEM LA NPD NPD YCALCIUM CHANNEL BLOCKERS 00187204590 34000010127520 00187204590 19180 diltiazem HCl CARDIZEM LA NPD NPD YCALCIUM CHANNEL BLOCKERS 00187204630 34000010127530 00187204630 19183 diltiazem HCl CARDIZEM LA NPD NPD YCALCIUM CHANNEL BLOCKERS 52544069119 34000010127530 52544069119 19183 diltiazem HCl MATZIM LA NPD NPD YCALCIUM CHANNEL BLOCKERS 52544069130 34000010127530 52544069130 19183 diltiazem HCl MATZIM LA NPD NPD YCALCIUM CHANNEL BLOCKERS 68682070530 34000010127530 68682070530 19183 diltiazem HCl

DILTIAZEM 24HR ER (LA) NPD NPD Y

CALCIUM CHANNEL BLOCKERS 68682070590 34000010127530 68682070590 19183 diltiazem HCl

DILTIAZEM 24HR ER (LA) NPD NPD Y

CALCIUM CHANNEL BLOCKERS 00187204730 34000010127540 00187204730 19184 diltiazem HCl CARDIZEM LA NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 102

CALCIUM CHANNEL BLOCKERS 00187204790 34000010127540 00187204790 19184 diltiazem HCl CARDIZEM LA NPD NPD YCALCIUM CHANNEL BLOCKERS 52544069230 34000010127540 52544069230 19184 diltiazem HCl MATZIM LA NPD NPD YCALCIUM CHANNEL BLOCKERS 68682070630 34000010127540 68682070630 19184 diltiazem HCl

DILTIAZEM 24HR ER (LA) NPD NPD Y

CALCIUM CHANNEL BLOCKERS 68682070690 34000010127540 68682070690 19184 diltiazem HCl

DILTIAZEM 24HR ER (LA) NPD NPD Y

CALCIUM CHANNEL BLOCKERS 00187204830 34000010127550 00187204830 19185 diltiazem HCl CARDIZEM LA NPD NPD YCALCIUM CHANNEL BLOCKERS 52544069319 34000010127550 52544069319 19185 diltiazem HCl MATZIM LA NPD NPD YCALCIUM CHANNEL BLOCKERS 52544069330 34000010127550 52544069330 19185 diltiazem HCl MATZIM LA NPD NPD YCALCIUM CHANNEL BLOCKERS 68682070730 34000010127550 68682070730 19185 diltiazem HCl

DILTIAZEM 24HR ER (LA) NPD NPD Y

CALCIUM CHANNEL BLOCKERS 52544069419 34000010127560 52544069419 19186 diltiazem HCl MATZIM LA NPD NPD YCALCIUM CHANNEL BLOCKERS 52544069430 34000010127560 52544069430 19186 diltiazem HCl MATZIM LA NPD NPD YCALCIUM CHANNEL BLOCKERS 68682070830 34000010127560 68682070830 19186 diltiazem HCl

DILTIAZEM 24HR ER (LA) NPD NPD Y

CALCIUM CHANNEL BLOCKERS 68682070890 34000010127560 68682070890 19186 diltiazem HCl

DILTIAZEM 24HR ER (LA) NPD NPD Y

CALCIUM CHANNEL BLOCKERS 52544069530 34000010127570 52544069530 19187 diltiazem HCl MATZIM LA NPD NPD YCALCIUM CHANNEL BLOCKERS 68682070930 34000010127570 68682070930 19187 diltiazem HCl

DILTIAZEM 24HR ER (LA) NPD NPD Y

CALCIUM CHANNEL BLOCKERS 68682070990 34000010127570 68682070990 19187 diltiazem HCl

DILTIAZEM 24HR ER (LA) NPD NPD Y

CALCIUM CHANNEL BLOCKERS 00378501101 34000013007505 00378501101 2620 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00603358121 34000013007505 00603358121 2620 felodipine FELODIPINE ER PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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CALCIUM CHANNEL BLOCKERS 13668013201 34000013007505 13668013201 2620 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 23155004801 34000013007505 23155004801 2620 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 53489036801 34000013007505 53489036801 2620 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 57237010801 34000013007505 57237010801 2620 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68462023301 34000013007505 68462023301 2620 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00378501201 34000013007510 00378501201 2621 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00603358221 34000013007510 00603358221 2621 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 13668013301 34000013007510 13668013301 2621 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 23155004901 34000013007510 23155004901 2621 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 53489036901 34000013007510 53489036901 2621 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 57237010901 34000013007510 57237010901 2621 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 59746037001 34000013007510 59746037001 2621 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68462023401 34000013007510 68462023401 2621 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00378501301 34000013007520 00378501301 2622 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00603358321 34000013007520 00603358321 2622 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00603358328 34000013007520 00603358328 2622 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 13668013401 34000013007520 13668013401 2622 felodipine FELODIPINE ER PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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CALCIUM CHANNEL BLOCKERS 23155005001 34000013007520 23155005001 2622 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 53489037001 34000013007520 53489037001 2622 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 57237011001 34000013007520 57237011001 2622 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68462023501 34000013007520 68462023501 2622 felodipine FELODIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 16252053901 34000015000110 16252053901 2611 isradipine ISRADIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 42806026301 34000015000110 42806026301 2611 isradipine ISRADIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 68462080701 34000015000110 68462080701 2611 isradipine ISRADIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 16252054001 34000015000120 16252054001 2612 isradipine ISRADIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 42806026401 34000015000120 42806026401 2612 isradipine ISRADIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 00378102077 34000018100120 00378102077 2390 nicardipine HCl NICARDIPINE HCL NPD NPD YCALCIUM CHANNEL BLOCKERS 42806050109 34000018100120 42806050109 2390 nicardipine HCl NICARDIPINE HCL NPD NPD YCALCIUM CHANNEL BLOCKERS 00378143077 34000018100125 00378143077 2391 nicardipine HCl NICARDIPINE HCL NPD NPD YCALCIUM CHANNEL BLOCKERS 24658075190 34000018100125 24658075190 2391 nicardipine HCl NICARDIPINE HCL NPD NPD YCALCIUM CHANNEL BLOCKERS 42806050209 34000018100125 42806050209 2391 nicardipine HCl NICARDIPINE HCL NPD NPD YCALCIUM CHANNEL BLOCKERS 00069260066 34000020000105 00069260066 2350 nifedipine PROCARDIA NPD NPD YCALCIUM CHANNEL BLOCKERS 00228249710 34000020000105 00228249710 2350 nifedipine NIFEDIPINE PDL PDL YCALCIUM CHANNEL BLOCKERS 43386044024 34000020000105 43386044024 2350 nifedipine NIFEDIPINE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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CALCIUM CHANNEL BLOCKERS 59762100401 34000020000105 59762100401 2350 nifedipine NIFEDIPINE PDL PDL YCALCIUM CHANNEL BLOCKERS 68084002201 34000020000105 68084002201 2350 nifedipine NIFEDIPINE PDL PDL YCALCIUM CHANNEL BLOCKERS 69315021101 34000020000105 69315021101 2350 nifedipine NIFEDIPINE PDL PDL YCALCIUM CHANNEL BLOCKERS 00228253010 34000020000110 00228253010 2351 nifedipine NIFEDIPINE PDL PDL YCALCIUM CHANNEL BLOCKERS 69315021201 34000020000110 69315021201 2351 nifedipine NIFEDIPINE PDL PDL YCALCIUM CHANNEL BLOCKERS 00378035301 34000020007530 00378035301 2226 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00591319301 34000020007530 00591319301 2226 nifedipine AFEDITAB CR PDL PDL YCALCIUM CHANNEL BLOCKERS 10370067701 34000020007530 10370067701 2226 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 10370067705 34000020007530 10370067705 2226 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 47781036801 34000020007530 47781036801 2226 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 50742062001 34000020007530 50742062001 2226 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 52427049401 34000020007530 52427049401 2226 nifedipine ADALAT CC NPD NPD YCALCIUM CHANNEL BLOCKERS 68682010510 34000020007530 68682010510 2226 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68682010530 34000020007530 68682010530 2226 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00378036001 34000020007540 00378036001 2227 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 10370067801 34000020007540 10370067801 2227 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 10370067805 34000020007540 10370067805 2227 nifedipine NIFEDIPINE ER PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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CALCIUM CHANNEL BLOCKERS 47781036901 34000020007540 47781036901 2227 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 50742062101 34000020007540 50742062101 2227 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 52427049501 34000020007540 52427049501 2227 nifedipine ADALAT CC NPD NPD YCALCIUM CHANNEL BLOCKERS 68682010610 34000020007540 68682010610 2227 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68682010630 34000020007540 68682010630 2227 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00378039001 34000020007550 00378039001 2228 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 10370067901 34000020007550 10370067901 2228 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 45963015202 34000020007550 45963015202 2228 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 47781037001 34000020007550 47781037001 2228 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 50742062201 34000020007550 50742062201 2228 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 52427049601 34000020007550 52427049601 2228 nifedipine ADALAT CC NPD NPD YCALCIUM CHANNEL BLOCKERS 68682010710 34000020007550 68682010710 2228 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00069265066 34000020007570 00069265066 2221 nifedipine PROCARDIA XL NPD NPD YCALCIUM CHANNEL BLOCKERS 00069265072 34000020007570 00069265072 2221 nifedipine PROCARDIA XL NPD NPD YCALCIUM CHANNEL BLOCKERS 00378048001 34000020007570 00378048001 2221 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00378048030 34000020007570 00378048030 2221 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 24979001101 34000020007570 24979001101 2221 nifedipine NIFEDIPINE ER PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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CALCIUM CHANNEL BLOCKERS 24979001112 34000020007570 24979001112 2221 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 50742026001 34000020007570 50742026001 2221 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 51079040020 34000020007570 51079040020 2221 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 59762669003 34000020007570 59762669003 2221 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 59762669005 34000020007570 59762669005 2221 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 62175026037 34000020007570 62175026037 2221 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 62175026043 34000020007570 62175026043 2221 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 62175026046 34000020007570 62175026046 2221 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 62175026055 34000020007570 62175026055 2221 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68645051254 34000020007570 68645051254 2221 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68682010810 34000020007570 68682010810 2221 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68682010830 34000020007570 68682010830 2221 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00069266066 34000020007575 00069266066 2222 nifedipine PROCARDIA XL NPD NPD YCALCIUM CHANNEL BLOCKERS 00069266072 34000020007575 00069266072 2222 nifedipine PROCARDIA XL NPD NPD YCALCIUM CHANNEL BLOCKERS 00378048101 34000020007575 00378048101 2222 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00378048130 34000020007575 00378048130 2222 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 24979001001 34000020007575 24979001001 2222 nifedipine NIFEDIPINE ER PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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CALCIUM CHANNEL BLOCKERS 24979001012 34000020007575 24979001012 2222 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 50742026101 34000020007575 50742026101 2222 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 59762669103 34000020007575 59762669103 2222 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 59762669105 34000020007575 59762669105 2222 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 62175026137 34000020007575 62175026137 2222 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 62175026146 34000020007575 62175026146 2222 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 62175026155 34000020007575 62175026155 2222 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68645051354 34000020007575 68645051354 2222 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68682010910 34000020007575 68682010910 2222 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68682010930 34000020007575 68682010930 2222 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00069267066 34000020007580 00069267066 2223 nifedipine PROCARDIA XL NPD NPD YCALCIUM CHANNEL BLOCKERS 00378049401 34000020007580 00378049401 2223 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 24979000901 34000020007580 24979000901 2223 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 24979000912 34000020007580 24979000912 2223 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 50742026201 34000020007580 50742026201 2223 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 59762669203 34000020007580 59762669203 2223 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 62175026232 34000020007580 62175026232 2223 nifedipine NIFEDIPINE ER PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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CALCIUM CHANNEL BLOCKERS 62175026237 34000020007580 62175026237 2223 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 62175026246 34000020007580 62175026246 2223 nifedipine NIFEDIPINE ER PDL PDL YCALCIUM CHANNEL BLOCKERS 23155051200 34000022000120 23155051200 2440 nimodipine NIMODIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 23155051230 34000022000120 23155051230 2440 nimodipine NIMODIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 62559021031 34000022000120 62559021031 2440 nimodipine NIMODIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 62559021081 34000022000120 62559021081 2440 nimodipine NIMODIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 63739079733 34000022000120 63739079733 2440 nimodipine NIMODIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 68084091231 34000022000120 68084091231 2440 nimodipine NIMODIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 68084091232 34000022000120 68084091232 2440 nimodipine NIMODIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 69452020913 34000022000120 69452020913 2440 nimodipine NIMODIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 69452020920 34000022000120 69452020920 2440 nimodipine NIMODIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 24338020012 34000022002050 24338020012 35194 nimodipine NYMALIZE NPD NPD YCALCIUM CHANNEL BLOCKERS 24338020016 34000022002050 24338020016 34794 nimodipine NYMALIZE NPD NPD YCALCIUM CHANNEL BLOCKERS 24338020020 34000022002050 24338020020 35194 nimodipine NYMALIZE NPD NPD YCALCIUM CHANNEL BLOCKERS 24338020510 34000022002050 24338020510 43848 nimodipine NYMALIZE NPD NPD YCALCIUM CHANNEL BLOCKERS 24338020512 34000022002050 24338020512 43848 nimodipine NYMALIZE NPD NPD YCALCIUM CHANNEL BLOCKERS 66993047202 34000024007508 66993047202 99445 nisoldipine NISOLDIPINE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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CALCIUM CHANNEL BLOCKERS 00378209701 34000024007517 00378209701 99446 nisoldipine NISOLDIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 66993047302 34000024007517 66993047302 99446 nisoldipine NISOLDIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 00378222201 34000024007520 00378222201 14702 nisoldipine NISOLDIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 66993047502 34000024007535 66993047502 99448 nisoldipine NISOLDIPINE NPD NPD YCALCIUM CHANNEL BLOCKERS 00591040401 34000030100303 00591040401 47110 verapamil HCl VERAPAMIL HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 23155005901 34000030100303 23155005901 47110 verapamil HCl VERAPAMIL HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00378051201 34000030100305 00378051201 2342 verapamil HCl VERAPAMIL HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00591034301 34000030100305 00591034301 2342 verapamil HCl VERAPAMIL HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00591034305 34000030100305 00591034305 2342 verapamil HCl VERAPAMIL HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00591034310 34000030100305 00591034310 2342 verapamil HCl VERAPAMIL HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00904292061 34000030100305 00904292061 2342 verapamil HCl VERAPAMIL HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 23155002601 34000030100305 23155002601 2342 verapamil HCl VERAPAMIL HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00378077201 34000030100310 00378077201 2341 verapamil HCl VERAPAMIL HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00378077205 34000030100310 00378077205 2341 verapamil HCl VERAPAMIL HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00591034501 34000030100310 00591034501 2341 verapamil HCl VERAPAMIL HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00591034505 34000030100310 00591034505 2341 verapamil HCl VERAPAMIL HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00591034510 34000030100310 00591034510 2341 verapamil HCl VERAPAMIL HCL PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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CALCIUM CHANNEL BLOCKERS 00904292461 34000030100310 00904292461 2341 verapamil HCl VERAPAMIL HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 23155002701 34000030100310 23155002701 2341 verapamil HCl VERAPAMIL HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 23155048601 34000030100310 23155048601 2341 verapamil HCl VERAPAMIL HCL PDL PDL YCALCIUM CHANNEL BLOCKERS 00025190131 34000030100410 00025190131 32472 verapamil HCl CALAN SR NPD NPD YCALCIUM CHANNEL BLOCKERS 00093304301 34000030100410 00093304301 32472 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00378212001 34000030100410 00378212001 32472 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 51079089420 34000030100410 51079089420 32472 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 57664011688 34000030100410 57664011688 32472 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 60505274001 34000030100410 60505274001 32472 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68462029201 34000030100410 68462029201 32472 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00025191131 34000030100415 00025191131 32471 verapamil HCl CALAN SR NPD NPD YCALCIUM CHANNEL BLOCKERS 00093304401 34000030100415 00093304401 32471 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00093304405 34000030100415 00093304405 32471 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00378218001 34000030100415 00378218001 32471 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00378218005 34000030100415 00378218005 32471 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 51079089920 34000030100415 51079089920 32471 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 57664011713 34000030100415 57664011713 32471 verapamil HCl VERAPAMIL ER PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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CALCIUM CHANNEL BLOCKERS 57664011788 34000030100415 57664011788 32471 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68462029301 34000030100415 68462029301 32471 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68462029305 34000030100415 68462029305 32471 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 75834015801 34000030100415 75834015801 32471 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00025189131 34000030100420 00025189131 32470 verapamil HCl CALAN SR NPD NPD YCALCIUM CHANNEL BLOCKERS 00093304501 34000030100420 00093304501 32470 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00093304505 34000030100420 00093304505 32470 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00378141101 34000030100420 00378141101 32470 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00378141105 34000030100420 00378141105 32470 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 51079086920 34000030100420 51079086920 32470 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 57664011813 34000030100420 57664011813 32470 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 57664011888 34000030100420 57664011888 32470 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68462026001 34000030100420 68462026001 32470 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 68462026005 34000030100420 68462026005 32470 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 75834015901 34000030100420 75834015901 32470 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00378620101 34000030107015 00378620101 94122 verapamil HCl VERAPAMIL ER PM PDL PDL YCALCIUM CHANNEL BLOCKERS 62175048537 34000030107015 62175048537 94122 verapamil HCl VERAPAMIL ER PM PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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CALCIUM CHANNEL BLOCKERS 62175057037 34000030107015 62175057037 94122 verapamil HCl VERELAN PM NPD NPD YCALCIUM CHANNEL BLOCKERS 00378632001 34000030107020 00378632001 3003 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00591288001 34000030107020 00591288001 3003 verapamil HCl VERAPAMIL SR PDL PDL YCALCIUM CHANNEL BLOCKERS 62175058037 34000030107020 62175058037 3003 verapamil HCl VERELAN NPD NPD YCALCIUM CHANNEL BLOCKERS 00378638001 34000030107025 00378638001 3001 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00591288201 34000030107025 00591288201 3001 verapamil HCl VERAPAMIL SR PDL PDL YCALCIUM CHANNEL BLOCKERS 62175058137 34000030107025 62175058137 3001 verapamil HCl VERELAN NPD NPD YCALCIUM CHANNEL BLOCKERS 00378620201 34000030107030 00378620201 94123 verapamil HCl VERAPAMIL ER PM PDL PDL YCALCIUM CHANNEL BLOCKERS 62175048637 34000030107030 62175048637 94123 verapamil HCl VERAPAMIL ER PM PDL PDL YCALCIUM CHANNEL BLOCKERS 62175057137 34000030107030 62175057137 94123 verapamil HCl VERELAN PM NPD NPD YCALCIUM CHANNEL BLOCKERS 00378644001 34000030107035 00378644001 3002 verapamil HCl VERAPAMIL ER PDL PDL YCALCIUM CHANNEL BLOCKERS 00591288401 34000030107035 00591288401 3002 verapamil HCl VERAPAMIL SR PDL PDL YCALCIUM CHANNEL BLOCKERS 62175058237 34000030107035 62175058237 3002 verapamil HCl VERELAN NPD NPD YCALCIUM CHANNEL BLOCKERS 62175048737 34000030107040 62175048737 94124 verapamil HCl VERAPAMIL ER PM PDL PDL YCALCIUM CHANNEL BLOCKERS 62175057237 34000030107040 62175057237 94124 verapamil HCl VERELAN PM NPD NPD YCALCIUM CHANNEL BLOCKERS 00591288601 34000030107045 00591288601 3004 verapamil HCl VERAPAMIL HCL NPD NPD YCALCIUM CHANNEL BLOCKERS 62175058337 34000030107045 62175058337 3004 verapamil HCl VERELAN NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

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LEUKOTRIENE MODIFIERS 10122090112 44504085000330 10122090112 40321 zileuton ZYFLO NPD NPD YLEUKOTRIENE MODIFIERS 64980020612 44504085007420 64980020612 98822 zileuton ZILEUTON ER NPD NPD YLEUKOTRIENE MODIFIERS 66993048532 44504085007420 66993048532 98822 zileuton ZILEUTON ER NPD NPD YLEUKOTRIENE MODIFIERS 00006911731 44505050100330 00006911731 94444 montelukast sodium SINGULAIR NPD NPD YLEUKOTRIENE MODIFIERS 00006911754 44505050100330 00006911754 94444 montelukast sodium SINGULAIR NPD NPD YLEUKOTRIENE MODIFIERS 00054025913 44505050100330 00054025913 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00054025922 44505050100330 00054025922 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00093742610 44505050100330 00093742610 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00093742656 44505050100330 00093742656 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00093742698 44505050100330 00093742698 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00143964909 44505050100330 00143964909 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00143964910 44505050100330 00143964910 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00143964930 44505050100330 00143964930 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00378520193 44505050100330 00378520193 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00603465502 44505050100330 00603465502 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00603465516 44505050100330 00603465516 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00603465528 44505050100330 00603465528 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 115

LEUKOTRIENE MODIFIERS 00603465532 44505050100330 00603465532 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00603465534 44505050100330 00603465534 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00781556031 44505050100330 00781556031 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00781556092 44505050100330 00781556092 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00904652961 44505050100330 00904652961 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00904680861 44505050100330 00904680861 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 13668008105 44505050100330 13668008105 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 13668008130 44505050100330 13668008130 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 13668008190 44505050100330 13668008190 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 16729011910 44505050100330 16729011910 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 16729011915 44505050100330 16729011915 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 16729011917 44505050100330 16729011917 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 27241001803 44505050100330 27241001803 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 27241001809 44505050100330 27241001809 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 27241001890 44505050100330 27241001890 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 29300022010 44505050100330 29300022010 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 29300022013 44505050100330 29300022013 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 116

LEUKOTRIENE MODIFIERS 29300022019 44505050100330 29300022019 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 31722072610 44505050100330 31722072610 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 31722072630 44505050100330 31722072630 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 31722072690 44505050100330 31722072690 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 33342010207 44505050100330 33342010207 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 33342010210 44505050100330 33342010210 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 33342010215 44505050100330 33342010215 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 51079022320 44505050100330 51079022320 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 55111072510 44505050100330 55111072510 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 55111072530 44505050100330 55111072530 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 55111072590 44505050100330 55111072590 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 57237025530 44505050100330 57237025530 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 57237025590 44505050100330 57237025590 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 60505356203 44505050100330 60505356203 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 60505356208 44505050100330 60505356208 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 60505356209 44505050100330 60505356209 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 62175021032 44505050100330 62175021032 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 117

LEUKOTRIENE MODIFIERS 62175021043 44505050100330 62175021043 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 62175021046 44505050100330 62175021046 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 65862057490 44505050100330 65862057490 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 68001024803 44505050100330 68001024803 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 68001024804 44505050100330 68001024804 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 68001024805 44505050100330 68001024805 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 68001036103 44505050100330 68001036103 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 68001036104 44505050100330 68001036104 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 68001036105 44505050100330 68001036105 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 68084087501 44505050100330 68084087501 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 68645046654 44505050100330 68645046654 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 68645056054 44505050100330 68645056054 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 69452010513 44505050100330 69452010513 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 69452010519 44505050100330 69452010519 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 69452010532 44505050100330 69452010532 94444 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00006171131 44505050100516 00006171131 42373 montelukast sodium SINGULAIR NPD NPD YLEUKOTRIENE MODIFIERS 00054028813 44505050100516 00054028813 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 118

LEUKOTRIENE MODIFIERS 00054028822 44505050100516 00054028822 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00093742456 44505050100516 00093742456 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00093742498 44505050100516 00093742498 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00143965109 44505050100516 00143965109 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00143965130 44505050100516 00143965130 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00603465302 44505050100516 00603465302 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00603465316 44505050100516 00603465316 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00603465328 44505050100516 00603465328 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00603465332 44505050100516 00603465332 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00781555431 44505050100516 00781555431 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00781555492 44505050100516 00781555492 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 13668007905 44505050100516 13668007905 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 13668007930 44505050100516 13668007930 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 13668007990 44505050100516 13668007990 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 27241001603 44505050100516 27241001603 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 27241001609 44505050100516 27241001609 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 29300022119 44505050100516 29300022119 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 119

LEUKOTRIENE MODIFIERS 31722072730 44505050100516 31722072730 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 31722072790 44505050100516 31722072790 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 33342011007 44505050100516 33342011007 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 33342011010 44505050100516 33342011010 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 57237021230 44505050100516 57237021230 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 57237021290 44505050100516 57237021290 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 59746035890 44505050100516 59746035890 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 60505357309 44505050100516 60505357309 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 62175020432 44505050100516 62175020432 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 62175020443 44505050100516 62175020443 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 62175020446 44505050100516 62175020446 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 65862056790 44505050100516 65862056790 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 69452010613 44505050100516 69452010613 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 69452010619 44505050100516 69452010619 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 70436009006 44505050100516 70436009006 42373 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00006927531 44505050100520 00006927531 94440 montelukast sodium SINGULAIR NPD NPD YLEUKOTRIENE MODIFIERS 00054028913 44505050100520 00054028913 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 120

LEUKOTRIENE MODIFIERS 00054028922 44505050100520 00054028922 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00093742556 44505050100520 00093742556 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00093742598 44505050100520 00093742598 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00143965009 44505050100520 00143965009 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00603465402 44505050100520 00603465402 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00603465416 44505050100520 00603465416 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00603465428 44505050100520 00603465428 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00603465432 44505050100520 00603465432 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00781555531 44505050100520 00781555531 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00781555592 44505050100520 00781555592 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 13668008005 44505050100520 13668008005 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 13668008030 44505050100520 13668008030 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 13668008090 44505050100520 13668008090 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 27241001703 44505050100520 27241001703 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 27241001709 44505050100520 27241001709 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 29300022210 44505050100520 29300022210 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 29300022219 44505050100520 29300022219 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 121

LEUKOTRIENE MODIFIERS 31722072830 44505050100520 31722072830 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 31722072890 44505050100520 31722072890 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 33342011107 44505050100520 33342011107 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 33342011110 44505050100520 33342011110 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 57237021330 44505050100520 57237021330 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 57237021390 44505050100520 57237021390 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 59746035990 44505050100520 59746035990 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 60505357403 44505050100520 60505357403 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 60505357409 44505050100520 60505357409 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 62175020532 44505050100520 62175020532 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 62175020543 44505050100520 62175020543 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 62175020546 44505050100520 62175020546 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 65862056890 44505050100520 65862056890 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 69452010713 44505050100520 69452010713 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 69452010719 44505050100520 69452010719 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 70436009106 44505050100520 70436009106 94440 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 00006384130 44505050103020 00006384130 18803 montelukast sodium SINGULAIR NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 122

LEUKOTRIENE MODIFIERS 00093748756 44505050103020 00093748756 18803 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 13668053194 44505050103020 13668053194 18803 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 27241001531 44505050103020 27241001531 18803 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 55111076303 44505050103020 55111076303 18803 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 66993041630 44505050103020 66993041630 18803 montelukast sodium

MONTELUKAST SODIUM PDL PDL Y

LEUKOTRIENE MODIFIERS 49884054902 44505080000310 49884054902 52271 zafirlukast ZAFIRLUKAST NPD NPD YLEUKOTRIENE MODIFIERS 55111062560 44505080000310 55111062560 52271 zafirlukast ZAFIRLUKAST NPD NPD YLEUKOTRIENE MODIFIERS 00904664604 44505080000320 00904664604 18690 zafirlukast ZAFIRLUKAST NPD NPD YLEUKOTRIENE MODIFIERS 49884055402 44505080000320 49884055402 18690 zafirlukast ZAFIRLUKAST NPD NPD YLEUKOTRIENE MODIFIERS 49884059002 44505080000320 49884059002 18690 zafirlukast ACCOLATE NPD NPD YLEUKOTRIENE MODIFIERS 55111062660 44505080000320 55111062660 18690 zafirlukast ZAFIRLUKAST NPD NPD YLEUKOTRIENE MODIFIERS 68084005921 44505080000320 68084005921 18690 zafirlukast ZAFIRLUKAST NPD NPD Y

PHOSPHATE BINDERS 00054008813 52800020100120 00054008813 13675 calcium acetate CALCIUM ACETATE PDL PDL Y

PHOSPHATE BINDERS 00054008826 52800020100120 00054008826 13675 calcium acetate CALCIUM ACETATE PDL PDL Y

PHOSPHATE BINDERS 00781208102 52800020100120 00781208102 13675 calcium acetate CALCIUM ACETATE PDL PDL Y

PHOSPHATE BINDERS 00904654606 52800020100120 00904654606 13675 calcium acetate CALCIUM ACETATE PDL PDL Y

PHOSPHATE BINDERS 00904654661 52800020100120 00904654661 13675 calcium acetate CALCIUM ACETATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 123

PHOSPHATE BINDERS 00904666825 52800020100120 00904666825 13675 calcium acetate CALCIUM ACETATE PDL PDL Y

PHOSPHATE BINDERS 23155053102 52800020100120 23155053102 13675 calcium acetate CALCIUM ACETATE PDL PDL Y

PHOSPHATE BINDERS 29033002602 52800020100120 29033002602 13675 calcium acetate CALCIUM ACETATE PDL PDL Y

PHOSPHATE BINDERS 65162059020 52800020100120 65162059020 13675 calcium acetate CALCIUM ACETATE PDL PDL Y

PHOSPHATE BINDERS 68084047901 52800020100120 68084047901 13675 calcium acetate CALCIUM ACETATE PDL PDL Y

PHOSPHATE BINDERS 68180013415 52800020100120 68180013415 13675 calcium acetate CALCIUM ACETATE PDL PDL Y

PHOSPHATE BINDERS 69097086283 52800020100120 69097086283 13675 calcium acetate CALCIUM ACETATE PDL PDL Y

PHOSPHATE BINDERS 76282037702 52800020100120 76282037702 13675 calcium acetate CALCIUM ACETATE PDL PDL Y

PHOSPHATE BINDERS 00574011302 52800020100320 00574011302 75051 calcium acetate CALCIUM ACETATE PDL PDL Y

PHOSPHATE BINDERS 23155062102 52800020100320 23155062102 75051 calcium acetate CALCIUM ACETATE PDL PDL Y

PHOSPHATE BINDERS 59528033102 52800020100320 59528033102 75051 calcium acetate CALPHRON NPD NPD Y

PHOSPHATE BINDERS 49230064331 52800020102020 49230064331 29943 calcium acetate PHOSLYRA NPD NPD Y

PHOSPHATE BINDERS 59922063101 52800030100320 59922063101 37075 ferric citrate AURYXIA NPD NPD Y

PHOSPHATE BINDERS 54092025290 52800045200540 54092025290 23813 lanthanum carbonate FOSRENOL NPD NPD Y

PHOSPHATE BINDERS 66993042285 52800045200540 66993042285 23813 lanthanum carbonateLANTHANUM CARBONATE NPD NPD Y

PHOSPHATE BINDERS 68180081942 52800045200540 68180081942 23813 lanthanum carbonateLANTHANUM CARBONATE NPD NPD Y

PHOSPHATE BINDERS 68180081952 52800045200540 68180081952 23813 lanthanum carbonateLANTHANUM CARBONATE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 124

PHOSPHATE BINDERS 54092025390 52800045200550 54092025390 26116 lanthanum carbonate FOSRENOL NPD NPD Y

PHOSPHATE BINDERS 66993042385 52800045200550 66993042385 26116 lanthanum carbonateLANTHANUM CARBONATE NPD NPD Y

PHOSPHATE BINDERS 68180082046 52800045200550 68180082046 26116 lanthanum carbonateLANTHANUM CARBONATE NPD NPD Y

PHOSPHATE BINDERS 54092025490 52800045200560 54092025490 26115 lanthanum carbonate FOSRENOL NPD NPD Y

PHOSPHATE BINDERS 66993042485 52800045200560 66993042485 26115 lanthanum carbonateLANTHANUM CARBONATE NPD NPD Y

PHOSPHATE BINDERS 68180082147 52800045200560 68180082147 26115 lanthanum carbonateLANTHANUM CARBONATE NPD NPD Y

PHOSPHATE BINDERS 54092025601 52800045203030 54092025601 32453 lanthanum carbonate FOSRENOL NPD NPD Y

PHOSPHATE BINDERS 54092025602 52800045203030 54092025602 32453 lanthanum carbonate FOSRENOL NPD NPD Y

PHOSPHATE BINDERS 54092025701 52800045203040 54092025701 32454 lanthanum carbonate FOSRENOL NPD NPD Y

PHOSPHATE BINDERS 54092025702 52800045203040 54092025702 32454 lanthanum carbonate FOSRENOL NPD NPD Y

PHOSPHATE BINDERS 00115130927 52800070050340 00115130927 99200 sevelamer carbonateSEVELAMER CARBONATE NPD PDL Y

PHOSPHATE BINDERS 00955105027 52800070050340 00955105027 99200 sevelamer carbonateSEVELAMER CARBONATE NPD PDL Y

PHOSPHATE BINDERS 16714081401 52800070050340 16714081401 99200 sevelamer carbonateSEVELAMER CARBONATE NPD PDL Y

PHOSPHATE BINDERS 55111078927 52800070050340 55111078927 99200 sevelamer carbonateSEVELAMER CARBONATE NPD PDL Y

PHOSPHATE BINDERS 58468013001 52800070050340 58468013001 99200 sevelamer carbonate RENVELA PDL NPD Y

PHOSPHATE BINDERS 65162005827 52800070050340 65162005827 99200 sevelamer carbonateSEVELAMER CARBONATE NPD PDL Y

PHOSPHATE BINDERS 65862092127 52800070050340 65862092127 99200 sevelamer carbonateSEVELAMER CARBONATE NPD PDL Y

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PHOSPHATE BINDERS 69097089393 52800070050340 69097089393 99200 sevelamer carbonateSEVELAMER CARBONATE NPD PDL Y

PHOSPHATE BINDERS 00955105290 52800070053020 00955105290 27483 sevelamer carbonateSEVELAMER CARBONATE NPD NPD Y

PHOSPHATE BINDERS 43598047890 52800070053020 43598047890 27483 sevelamer carbonateSEVELAMER CARBONATE NPD NPD Y

PHOSPHATE BINDERS 58468013202 52800070053020 58468013202 27483 sevelamer carbonate RENVELA NPD NPD Y

PHOSPHATE BINDERS 65862093008 52800070053020 65862093008 27483 sevelamer carbonateSEVELAMER CARBONATE NPD NPD Y

PHOSPHATE BINDERS 65862093090 52800070053020 65862093090 27483 sevelamer carbonateSEVELAMER CARBONATE NPD NPD Y

PHOSPHATE BINDERS 00955105401 52800070053040 00955105401 27484 sevelamer carbonateSEVELAMER CARBONATE NPD NPD Y

PHOSPHATE BINDERS 00955105490 52800070053040 00955105490 27484 sevelamer carbonateSEVELAMER CARBONATE NPD NPD Y

PHOSPHATE BINDERS 43598047990 52800070053040 43598047990 27484 sevelamer carbonateSEVELAMER CARBONATE NPD NPD Y

PHOSPHATE BINDERS 58468013102 52800070053040 58468013102 27484 sevelamer carbonate RENVELA NPD NPD Y

PHOSPHATE BINDERS 65862093190 52800070053040 65862093190 27484 sevelamer carbonateSEVELAMER CARBONATE NPD NPD Y

PHOSPHATE BINDERS 58468002001 52800070100320 58468002001 16852 sevelamer HCl RENAGEL PDL NPD Y

PHOSPHATE BINDERS 68462044626 52800070100320 68462044626 16852 sevelamer HCl SEVELAMER HCL NPD NPD Y

PHOSPHATE BINDERS 00955104818 52800070100340 00955104818 16853 sevelamer HCl SEVELAMER HCL NPD NPD Y

PHOSPHATE BINDERS 58468002101 52800070100340 58468002101 16853 sevelamer HCl RENAGEL PDL NPD Y

PHOSPHATE BINDERS 68462044718 52800070100340 68462044718 16853 sevelamer HCl SEVELAMER HCL NPD NPD Y

PHOSPHATE BINDERS 49230064551 52800080100520 49230064551 36003 sucroferric oxyhydroxide VELPHORO NPD NPD Y

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PHOSPHATE BINDERS 10542004550 79100006000309 10542004550 3692 calcium acetate CALCIUM ACETATE NPD NPD Y

PHOSPHATE BINDERS 59528041605 79409903200320 59528041605 92574calcium carb/mag

carb/folic ac MAGNEBIND 400 RX NPD NPD Y

SEDATIVE HYPNOTICS 00591074401 60201005000310 00591074401 19181 estazolam ESTAZOLAM NPD NPD Y

SEDATIVE HYPNOTICS 51862006901 60201005000310 51862006901 19181 estazolam ESTAZOLAM NPD NPD Y

SEDATIVE HYPNOTICS 00591074501 60201005000320 00591074501 19182 estazolam ESTAZOLAM NPD NPD Y

SEDATIVE HYPNOTICS 51862007001 60201005000320 51862007001 19182 estazolam ESTAZOLAM NPD NPD Y

SEDATIVE HYPNOTICS 00378441501 60201010100105 00378441501 14250 flurazepam HCl FLURAZEPAM HCL NPD NPD Y

SEDATIVE HYPNOTICS 00378443001 60201010100110 00378443001 14251 flurazepam HCl FLURAZEPAM HCL NPD NPD Y

SEDATIVE HYPNOTICS 00378311001 60201030000103 00378311001 13845 temazepam TEMAZEPAM NPD NPD Y

SEDATIVE HYPNOTICS 00406996001 60201030000103 00406996001 13845 temazepam TEMAZEPAM NPD NPD Y

SEDATIVE HYPNOTICS 00904643604 60201030000103 00904643604 13845 temazepam TEMAZEPAM NPD NPD Y

SEDATIVE HYPNOTICS 00904643660 60201030000103 00904643660 13845 temazepam TEMAZEPAM NPD NPD Y

SEDATIVE HYPNOTICS 53489064801 60201030000103 53489064801 13845 temazepam TEMAZEPAM NPD NPD Y

SEDATIVE HYPNOTICS 63739000333 60201030000103 63739000333 13845 temazepam TEMAZEPAM NPD NPD Y

SEDATIVE HYPNOTICS 67877014801 60201030000103 67877014801 13845 temazepam TEMAZEPAM NPD NPD Y

SEDATIVE HYPNOTICS 68084054921 60201030000103 68084054921 13845 temazepam TEMAZEPAM NPD NPD Y

SEDATIVE HYPNOTICS 00228207610 60201030000105 00228207610 13840 temazepam TEMAZEPAM PDL PDL Y

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SEDATIVE HYPNOTICS 00228207650 60201030000105 00228207650 13840 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 00378401001 60201030000105 00378401001 13840 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 00378401005 60201030000105 00378401005 13840 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 00406991601 60201030000105 00406991601 13840 temazepam RESTORIL NPD NPD Y

SEDATIVE HYPNOTICS 51079041820 60201030000105 51079041820 13840 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 63739087710 60201030000105 63739087710 13840 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 67877014601 60201030000105 67877014601 13840 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 67877014605 60201030000105 67877014605 13840 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 00378312093 60201030000108 00378312093 24036 temazepam TEMAZEPAM NPD NPD Y

SEDATIVE HYPNOTICS 00406995903 60201030000108 00406995903 24036 temazepam TEMAZEPAM NPD NPD Y

SEDATIVE HYPNOTICS 53489065007 60201030000108 53489065007 24036 temazepam TEMAZEPAM NPD NPD Y

SEDATIVE HYPNOTICS 67877014930 60201030000108 67877014930 24036 temazepam TEMAZEPAM NPD NPD Y

SEDATIVE HYPNOTICS 00228207710 60201030000110 00228207710 13841 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 00228207750 60201030000110 00228207750 13841 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 00378505001 60201030000110 00378505001 13841 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 00378505005 60201030000110 00378505005 13841 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 00378505077 60201030000110 00378505077 13841 temazepam TEMAZEPAM PDL PDL Y

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SEDATIVE HYPNOTICS 00406991701 60201030000110 00406991701 13841 temazepam RESTORIL NPD NPD Y

SEDATIVE HYPNOTICS 00781220205 60201030000110 00781220205 13841 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 51079041920 60201030000110 51079041920 13841 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 63739012510 60201030000110 63739012510 13841 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 65162055710 60201030000110 65162055710 13841 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 67877014701 60201030000110 67877014701 13841 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 67877014705 60201030000110 67877014705 13841 temazepam TEMAZEPAM PDL PDL Y

SEDATIVE HYPNOTICS 00054485825 60201040000305 00054485825 14282 triazolam TRIAZOLAM NPD NPD Y

SEDATIVE HYPNOTICS 59762371704 60201040000305 59762371704 14282 triazolam TRIAZOLAM NPD NPD Y

SEDATIVE HYPNOTICS 59762371709 60201040000305 59762371709 14282 triazolam TRIAZOLAM NPD NPD Y

SEDATIVE HYPNOTICS 00009001755 60201040000310 00009001755 14280 triazolam HALCION NPD NPD Y

SEDATIVE HYPNOTICS 00009001758 60201040000310 00009001758 14280 triazolam HALCION NPD NPD Y

SEDATIVE HYPNOTICS 00054485925 60201040000310 00054485925 14280 triazolam TRIAZOLAM NPD NPD Y

SEDATIVE HYPNOTICS 00054485929 60201040000310 00054485929 14280 triazolam TRIAZOLAM NPD NPD Y

SEDATIVE HYPNOTICS 59762371803 60201040000310 59762371803 14280 triazolam TRIAZOLAM NPD NPD Y

SEDATIVE HYPNOTICS 59762371804 60201040000310 59762371804 14280 triazolam TRIAZOLAM NPD NPD Y

SEDATIVE HYPNOTICS 59762371809 60201040000310 59762371809 14280 triazolam TRIAZOLAM NPD NPD Y

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SEDATIVE HYPNOTICS 00054029013 60204035000320 00054029013 23927 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 00093553756 60204035000320 00093553756 23927 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 00378527001 60204035000320 00378527001 23927 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 33342029907 60204035000320 33342029907 23927 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 42043032003 60204035000320 42043032003 23927 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 47335058683 60204035000320 47335058683 23927 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 55111062930 60204035000320 55111062930 23927 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 63402019030 60204035000320 63402019030 23927 eszopiclone LUNESTA NPD NPD Y

SEDATIVE HYPNOTICS 65862096701 60204035000320 65862096701 23927 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 65862096730 60204035000320 65862096730 23927 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 68180032201 60204035000320 68180032201 23927 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 68462038201 60204035000320 68462038201 23927 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 00054029125 60204035000330 00054029125 23926 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 00093553801 60204035000330 00093553801 23926 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 00378527101 60204035000330 00378527101 23926 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 33342030011 60204035000330 33342030011 23926 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 42043032101 60204035000330 42043032101 23926 eszopiclone ESZOPICLONE NPD PDL Y

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SEDATIVE HYPNOTICS 47335058788 60204035000330 47335058788 23926 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 55111061901 60204035000330 55111061901 23926 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 63402019103 60204035000330 63402019103 23926 eszopiclone LUNESTA NPD NPD Y

SEDATIVE HYPNOTICS 63402019110 60204035000330 63402019110 23926 eszopiclone LUNESTA NPD NPD Y

SEDATIVE HYPNOTICS 65862096801 60204035000330 65862096801 23926 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 68180032301 60204035000330 68180032301 23926 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 68462038301 60204035000330 68462038301 23926 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 00093553901 60204035000340 00093553901 23925 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 00378527201 60204035000340 00378527201 23925 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 33342030111 60204035000340 33342030111 23925 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 42043032201 60204035000340 42043032201 23925 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 47335058888 60204035000340 47335058888 23925 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 51079041403 60204035000340 51079041403 23925 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 55111061701 60204035000340 55111061701 23925 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 63402019310 60204035000340 63402019310 23925 eszopiclone LUNESTA NPD NPD Y

SEDATIVE HYPNOTICS 65862096901 60204035000340 65862096901 23925 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 68180032401 60204035000340 68180032401 23925 eszopiclone ESZOPICLONE NPD PDL Y

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SEDATIVE HYPNOTICS 68462038401 60204035000340 68462038401 23925 eszopiclone ESZOPICLONE NPD PDL Y

SEDATIVE HYPNOTICS 00054008425 60204070000120 00054008425 92713 zaleplon ZALEPLON NPD NPD Y

SEDATIVE HYPNOTICS 00093526801 60204070000120 00093526801 92713 zaleplon ZALEPLON NPD NPD Y

SEDATIVE HYPNOTICS 29300013101 60204070000120 29300013101 92713 zaleplon ZALEPLON NPD NPD Y

SEDATIVE HYPNOTICS 42043021001 60204070000120 42043021001 92713 zaleplon ZALEPLON NPD NPD Y

SEDATIVE HYPNOTICS 57237023901 60204070000120 57237023901 92713 zaleplon ZALEPLON NPD NPD Y

SEDATIVE HYPNOTICS 00054008525 60204070000130 00054008525 92723 zaleplon ZALEPLON NPD NPD Y

SEDATIVE HYPNOTICS 00093526901 60204070000130 00093526901 92723 zaleplon ZALEPLON NPD NPD Y

SEDATIVE HYPNOTICS 29300013201 60204070000130 29300013201 92723 zaleplon ZALEPLON NPD NPD Y

SEDATIVE HYPNOTICS 42043021101 60204070000130 42043021101 92723 zaleplon ZALEPLON NPD NPD Y

SEDATIVE HYPNOTICS 57237024001 60204070000130 57237024001 92723 zaleplon ZALEPLON NPD NPD Y

SEDATIVE HYPNOTICS 00024540131 60204080100310 00024540131 870 zolpidem tartrate AMBIEN NPD NPD Y

SEDATIVE HYPNOTICS 00093007301 60204080100310 00093007301 870 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 00378530501 60204080100310 00378530501 870 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 00378530505 60204080100310 00378530505 870 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 00781531701 60204080100310 00781531701 870 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 00781531710 60204080100310 00781531710 870 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

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SEDATIVE HYPNOTICS 00904608261 60204080100310 00904608261 870 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 13668000701 60204080100310 13668000701 870 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 13668000705 60204080100310 13668000705 870 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 13668000710 60204080100310 13668000710 870 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 13668000715 60204080100310 13668000715 870 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 16714062101 60204080100310 16714062101 870 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 16714062102 60204080100310 16714062102 870 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 51079072401 60204080100310 51079072401 870 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 51079072420 60204080100310 51079072420 870 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 55111047801 60204080100310 55111047801 870 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 65862015901 60204080100310 65862015901 870 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 00024542131 60204080100315 00024542131 871 zolpidem tartrate AMBIEN NPD NPD Y

SEDATIVE HYPNOTICS 00093007401 60204080100315 00093007401 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 00378531001 60204080100315 00378531001 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 00378531005 60204080100315 00378531005 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 00603646932 60204080100315 00603646932 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 00781531801 60204080100315 00781531801 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

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SEDATIVE HYPNOTICS 00781531810 60204080100315 00781531810 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 00904608361 60204080100315 00904608361 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 13668000801 60204080100315 13668000801 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 13668000805 60204080100315 13668000805 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 13668000810 60204080100315 13668000810 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 13668000815 60204080100315 13668000815 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 16714062201 60204080100315 16714062201 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 16714062202 60204080100315 16714062202 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 51079072501 60204080100315 51079072501 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 51079072520 60204080100315 51079072520 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 55111047901 60204080100315 55111047901 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 55111047905 60204080100315 55111047905 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 65862016001 60204080100315 65862016001 871 zolpidem tartrate ZOLPIDEM TARTRATE PDL PDL Y

SEDATIVE HYPNOTICS 00024550131 60204080100410 00024550131 25456 zolpidem tartrate AMBIEN CR NPD NPD Y

SEDATIVE HYPNOTICS 00228348111 60204080100410 00228348111 25456 zolpidem tartrateZOLPIDEM TARTRATE

ER NPD NPD Y

SEDATIVE HYPNOTICS 00781531501 60204080100410 00781531501 25456 zolpidem tartrateZOLPIDEM TARTRATE

ER NPD NPD Y

SEDATIVE HYPNOTICS 00955170210 60204080100410 00955170210 25456 zolpidem tartrateZOLPIDEM TARTRATE

ER NPD NPD Y

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SEDATIVE HYPNOTICS 10370011710 60204080100410 10370011710 25456 zolpidem tartrateZOLPIDEM TARTRATE

ER NPD NPD Y

SEDATIVE HYPNOTICS 47335030788 60204080100410 47335030788 25456 zolpidem tartrateZOLPIDEM TARTRATE

ER NPD NPD Y

SEDATIVE HYPNOTICS 68180077901 60204080100410 68180077901 25456 zolpidem tartrateZOLPIDEM TARTRATE

ER NPD NPD Y

SEDATIVE HYPNOTICS 00024552131 60204080100420 00024552131 25457 zolpidem tartrate AMBIEN CR NPD NPD Y

SEDATIVE HYPNOTICS 00228348211 60204080100420 00228348211 25457 zolpidem tartrateZOLPIDEM TARTRATE

ER NPD NPD Y

SEDATIVE HYPNOTICS 00781531601 60204080100420 00781531601 25457 zolpidem tartrateZOLPIDEM TARTRATE

ER NPD NPD Y

SEDATIVE HYPNOTICS 00955170310 60204080100420 00955170310 25457 zolpidem tartrateZOLPIDEM TARTRATE

ER NPD NPD Y

SEDATIVE HYPNOTICS 10370011610 60204080100420 10370011610 25457 zolpidem tartrateZOLPIDEM TARTRATE

ER NPD NPD Y

SEDATIVE HYPNOTICS 47335030888 60204080100420 47335030888 25457 zolpidem tartrateZOLPIDEM TARTRATE

ER NPD NPD Y

SEDATIVE HYPNOTICS 68180078001 60204080100420 68180078001 25457 zolpidem tartrateZOLPIDEM TARTRATE

ER NPD NPD Y

SEDATIVE HYPNOTICS 43386076230 60204080100708 43386076230 31562 zolpidem tartrate ZOLPIDEM TARTRATE NPD NPD Y

SEDATIVE HYPNOTICS 49884089811 60204080100708 49884089811 31562 zolpidem tartrate ZOLPIDEM TARTRATE NPD NPD Y

SEDATIVE HYPNOTICS 59011025630 60204080100708 59011025630 31562 zolpidem tartrate INTERMEZZO NPD NPD Y

SEDATIVE HYPNOTICS 43386076130 60204080100715 43386076130 31563 zolpidem tartrate ZOLPIDEM TARTRATE NPD NPD Y

SEDATIVE HYPNOTICS 49884089911 60204080100715 49884089911 31563 zolpidem tartrate ZOLPIDEM TARTRATE NPD NPD Y

SEDATIVE HYPNOTICS 59011025530 60204080100715 59011025530 31563 zolpidem tartrate INTERMEZZO NPD NPD Y

SEDATIVE HYPNOTICS 00037605030 60204080100720 00037605030 26183 zolpidem tartrate EDLUAR NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 135

SEDATIVE HYPNOTICS 00037601030 60204080100730 00037601030 26182 zolpidem tartrate EDLUAR NPD NPD Y

SEDATIVE HYPNOTICS 00591219101 60250060000320 00591219101 25202 ramelteon RAMELTEON NR NPD Y

SEDATIVE HYPNOTICS 00591219130 60250060000320 00591219130 25202 ramelteon RAMELTEON NR NPD Y

SEDATIVE HYPNOTICS 43598074101 60250060000320 43598074101 25202 ramelteon RAMELTEON NR NPD Y

SEDATIVE HYPNOTICS 43598074130 60250060000320 43598074130 25202 ramelteon RAMELTEON NR NPD Y

SEDATIVE HYPNOTICS 64764080510 60250060000320 64764080510 25202 ramelteon ROZEREM PDL PDL Y

SEDATIVE HYPNOTICS 64764080530 60250060000320 64764080530 25202 ramelteon ROZEREM PDL PDL Y

SEDATIVE HYPNOTICS 70710134401 60250060000320 70710134401 25202 ramelteon RAMELTEON NR NPD Y

SEDATIVE HYPNOTICS 70710134403 60250060000320 70710134403 25202 ramelteon RAMELTEON NR NPD Y

SEDATIVE HYPNOTICS 43068022001 60250070000130 43068022001 36068 tasimelteon HETLIOZ NPD NPD Y

SEDATIVE HYPNOTICS 42847010330 60400030100320 42847010330 28914 doxepin HCl SILENOR NPD NPD Y

SEDATIVE HYPNOTICS 42847010630 60400030100330 42847010630 28915 doxepin HCl SILENOR NPD NPD Y

SEDATIVE HYPNOTICS 00006000530 60500070000305 00006000530 36967 suvorexant BELSOMRA NPD NPD Y

SEDATIVE HYPNOTICS 00006003330 60500070000310 00006003330 36968 suvorexant BELSOMRA NPD NPD Y

SEDATIVE HYPNOTICS 00006032510 60500070000315 00006032510 36969 suvorexant BELSOMRA NPD NPD Y

SEDATIVE HYPNOTICS 00006032530 60500070000315 00006032530 36969 suvorexant BELSOMRA NPD NPD Y

SEDATIVE HYPNOTICS 00006033530 60500070000320 00006033530 36971 suvorexant BELSOMRA NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 136

STEROIDS, TOPICAL HIGH 00168027815 90550010003705 00168027815 31490 amcinonide AMCINONIDE NPD NPD YSTEROIDS, TOPICAL HIGH 00168027830 90550010003705 00168027830 31490 amcinonide AMCINONIDE NPD NPD YSTEROIDS, TOPICAL HIGH 00168027860 90550010003705 00168027860 31490 amcinonide AMCINONIDE NPD NPD YSTEROIDS, TOPICAL HIGH 00168028060 90550010004105 00168028060 31560 amcinonide AMCINONIDE NPD NPD YSTEROIDS, TOPICAL HIGH 67857080804 90550020001620 67857080804 40655

betamethasone dipropionate SERNIVO NPD NPD Y

STEROIDS, TOPICAL HIGH 00168005515 90550020003705 00168005515 31060

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL HIGH 00168005546 90550020003705 00168005546 31060

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL HIGH 00472038015 90550020003705 00472038015 31060

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL HIGH 00472038045 90550020003705 00472038045 31060

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL HIGH 00713065915 90550020003705 00713065915 31060

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL HIGH 00713065937 90550020003705 00713065937 31060

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL HIGH 00713075937 90550020003705 00713075937 31060

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL HIGH 51672127401 90550020003705 51672127401 31060

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL HIGH 51672127406 90550020003705 51672127406 31060

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL HIGH 70710123304 90550020003705 70710123304 31060

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL HIGH 00168005760 90550020004105 00168005760 31080

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE PDL PDL Y

STEROIDS, TOPICAL HIGH 00713072853 90550020004105 00713072853 31080

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 137

STEROIDS, TOPICAL HIGH 00713080753 90550020004105 00713080753 31080

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE PDL PDL Y

STEROIDS, TOPICAL HIGH 45802002146 90550020004105 45802002146 31080

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE PDL PDL Y

STEROIDS, TOPICAL HIGH 61748047560 90550020004105 61748047560 31080

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE PDL PDL Y

STEROIDS, TOPICAL HIGH 00472038115 90550020004205 00472038115 31070

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL HIGH 00472038145 90550020004205 00472038145 31070

betamethasone dipropionate

BETAMETHASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL HIGH 00168026515 90550020053705 00168026515 31890

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED PDL PDL Y

STEROIDS, TOPICAL HIGH 00168026550 90550020053705 00168026550 31890

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED PDL PDL Y

STEROIDS, TOPICAL HIGH 45802037632 90550020053705 45802037632 31890

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED PDL PDL Y

STEROIDS, TOPICAL HIGH 45802037635 90550020053705 45802037635 31890

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED PDL PDL Y

STEROIDS, TOPICAL HIGH 51672131001 90550020053705 51672131001 31890

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED PDL PDL Y

STEROIDS, TOPICAL HIGH 51672131003 90550020053705 51672131003 31890

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED PDL PDL Y

STEROIDS, TOPICAL HIGH 68462029017 90550020053705 68462029017 31890

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED PDL PDL Y

STEROIDS, TOPICAL HIGH 68462029052 90550020053705 68462029052 31890

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 138

STEROIDS, TOPICAL HIGH 51672130901 90550020054005 51672130901 32091

betamethasone dipropionate

BETAMETHASONE DIPROP

AUGMENTED NPD NPD Y

STEROIDS, TOPICAL HIGH 51672130903 90550020054005 51672130903 32091

betamethasone dipropionate

BETAMETHASONE DIPROP

AUGMENTED NPD NPD Y

STEROIDS, TOPICAL HIGH 00168026730 90550020054105 00168026730 30980

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED NPD NPD Y

STEROIDS, TOPICAL HIGH 00168026760 90550020054105 00168026760 30980

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED NPD NPD Y

STEROIDS, TOPICAL HIGH 51672134003 90550020054105 51672134003 30980

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED NPD NPD Y

STEROIDS, TOPICAL HIGH 51672134004 90550020054105 51672134004 30980

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED NPD NPD Y

STEROIDS, TOPICAL HIGH 52565002329 90550020054105 52565002329 30980

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED NPD NPD Y

STEROIDS, TOPICAL HIGH 52565002359 90550020054105 52565002359 30980

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED NPD NPD YSTEROIDS, TOPICAL HIGH 00085057502 90550020054205 00085057502 31910

betamethasone/propylene glyc DIPROLENE NPD NPD Y

STEROIDS, TOPICAL HIGH 00085057505 90550020054205 00085057505 31910

betamethasone/propylene glyc DIPROLENE NPD NPD Y

STEROIDS, TOPICAL HIGH 00168026815 90550020054205 00168026815 31910

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED NPD NPD Y

STEROIDS, TOPICAL HIGH 00168026850 90550020054205 00168026850 31910

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 139

STEROIDS, TOPICAL HIGH 00472038215 90550020054205 00472038215 31910

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED NPD NPD Y

STEROIDS, TOPICAL HIGH 00472038245 90550020054205 00472038245 31910

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED NPD NPD Y

STEROIDS, TOPICAL HIGH 52565001915 90550020054205 52565001915 31910

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED NPD NPD Y

STEROIDS, TOPICAL HIGH 52565001951 90550020054205 52565001951 31910

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED NPD NPD Y

STEROIDS, TOPICAL HIGH 66993089715 90550020054205 66993089715 31910

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED NPD NPD Y

STEROIDS, TOPICAL HIGH 66993089749 90550020054205 66993089749 31910

betamethasone/propylene glyc

BETAMETHASONE DIPROP

AUGMENTED NPD NPD YSTEROIDS, TOPICAL HIGH 00168004015 90550020103710 00168004015 31101 betamethasone valerate

BETAMETHASONE VALERATE PDL PDL Y

STEROIDS, TOPICAL HIGH 00168004046 90550020103710 00168004046 31101 betamethasone valerate

BETAMETHASONE VALERATE PDL PDL Y

STEROIDS, TOPICAL HIGH 00472037015 90550020103710 00472037015 31101 betamethasone valerate

BETAMETHASONE VALERATE PDL PDL Y

STEROIDS, TOPICAL HIGH 00472037045 90550020103710 00472037045 31101 betamethasone valerate

BETAMETHASONE VALERATE PDL PDL Y

STEROIDS, TOPICAL HIGH 00713032615 90550020103710 00713032615 31101 betamethasone valerate

BETAMETHASONE VALERATE PDL PDL Y

STEROIDS, TOPICAL HIGH 00713032637 90550020103710 00713032637 31101 betamethasone valerate

BETAMETHASONE VALERATE PDL PDL Y

STEROIDS, TOPICAL HIGH 51672126901 90550020103710 51672126901 31101 betamethasone valerate

BETAMETHASONE VALERATE PDL PDL Y

STEROIDS, TOPICAL HIGH 51672126906 90550020103710 51672126906 31101 betamethasone valerate

BETAMETHASONE VALERATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 140

STEROIDS, TOPICAL HIGH 00168004160 90550020104105 00168004160 31120 betamethasone valerate

BETAMETHASONE VALERATE PDL PDL Y

STEROIDS, TOPICAL HIGH 54879000460 90550020104105 54879000460 31120 betamethasone valerate

BETAMETHASONE VALERATE PDL PDL Y

STEROIDS, TOPICAL HIGH 00168003315 90550020104205 00168003315 31110 betamethasone valerate

BETAMETHASONE VALERATE PDL PDL Y

STEROIDS, TOPICAL HIGH 00168003346 90550020104205 00168003346 31110 betamethasone valerate

BETAMETHASONE VALERATE PDL PDL Y

STEROIDS, TOPICAL HIGH 00472037115 90550020104205 00472037115 31110 betamethasone valerate

BETAMETHASONE VALERATE PDL PDL Y

STEROIDS, TOPICAL HIGH 00472037145 90550020104205 00472037145 31110 betamethasone valerate

BETAMETHASONE VALERATE PDL PDL Y

STEROIDS, TOPICAL HIGH 00713032715 90550020104205 00713032715 31110 betamethasone valerate

BETAMETHASONE VALERATE PDL PDL Y

STEROIDS, TOPICAL HIGH 00713032737 90550020104205 00713032737 31110 betamethasone valerate

BETAMETHASONE VALERATE PDL PDL Y

STEROIDS, TOPICAL HIGH 45802080798 90550040000910 45802080798 34545 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 51672139607 90550040000910 51672139607 34545 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 51672528107 90550040000910 51672528107 34545 desoximetasone TOPICORT NPD NPD YSTEROIDS, TOPICAL HIGH 68180094433 90550040000910 68180094433 34545 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 51672127101 90550040003705 51672127101 31180 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 51672127103 90550040003705 51672127103 31180 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 68180094902 90550040003705 68180094902 31180 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 68180094904 90550040003705 68180094904 31180 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 00472047815 90550040003710 00472047815 31181 desoximetasone DESOXIMETASONE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 141

STEROIDS, TOPICAL HIGH 00472047860 90550040003710 00472047860 31181 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 45802049535 90550040003710 45802049535 31181 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 45802049537 90550040003710 45802049537 31181 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 51672127001 90550040003710 51672127001 31181 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 51672127003 90550040003710 51672127003 31181 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 68180095001 90550040003710 68180095001 31181 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 68180095002 90550040003710 68180095002 31181 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 68180095004 90550040003710 68180095004 31181 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 51672126101 90550040004005 51672126101 6120 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 51672126103 90550040004005 51672126103 6120 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 51672135203 90550040004203 51672135203 11403 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 51672135207 90550040004203 51672135207 11403 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 51672526303 90550040004203 51672526303 11403 desoximetasone TOPICORT NPD NPD YSTEROIDS, TOPICAL HIGH 52565004560 90550040004203 52565004560 11403 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 68180094804 90550040004203 68180094804 11403 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 00168015115 90550040004205 00168015115 30800 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 00168015160 90550040004205 00168015160 30800 desoximetasone DESOXIMETASONE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 142

STEROIDS, TOPICAL HIGH 00472047915 90550040004205 00472047915 30800 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 00472047960 90550040004205 00472047960 30800 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 45802049614 90550040004205 45802049614 30800 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 45802049696 90550040004205 45802049696 30800 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 51672126201 90550040004205 51672126201 30800 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 51672126203 90550040004205 51672126203 30800 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 51672126207 90550040004205 51672126207 30800 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 51672520303 90550040004205 51672520303 30800 desoximetasone TOPICORT NPD NPD YSTEROIDS, TOPICAL HIGH 52565003015 90550040004205 52565003015 30800 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 52565003060 90550040004205 52565003060 30800 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 52565003099 90550040004205 52565003099 30800 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 68180094601 90550040004205 68180094601 30800 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 68180094604 90550040004205 68180094604 30800 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 68462053117 90550040004205 68462053117 30800 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 68462053165 90550040004205 68462053165 30800 desoximetasone DESOXIMETASONE NPD NPD YSTEROIDS, TOPICAL HIGH 51672129601 90550050103705 51672129601 31470 diflorasone diacetate

DIFLORASONE DIACETATE NPD NPD Y

STEROIDS, TOPICAL HIGH 51672129602 90550050103705 51672129602 31470 diflorasone diacetate

DIFLORASONE DIACETATE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 143

STEROIDS, TOPICAL HIGH 51672129603 90550050103705 51672129603 31470 diflorasone diacetate

DIFLORASONE DIACETATE NPD NPD Y

STEROIDS, TOPICAL HIGH 51672529203 90550050103705 51672529203 31470 diflorasone diacetate PSORCON NPD NPD YSTEROIDS, TOPICAL HIGH 51672129501 90550050104205 51672129501 31480 diflorasone diacetate

DIFLORASONE DIACETATE NPD NPD Y

STEROIDS, TOPICAL HIGH 51672129502 90550050104205 51672129502 31480 diflorasone diacetate

DIFLORASONE DIACETATE NPD NPD Y

STEROIDS, TOPICAL HIGH 51672129503 90550050104205 51672129503 31480 diflorasone diacetate

DIFLORASONE DIACETATE NPD NPD Y

STEROIDS, TOPICAL HIGH 52565006315 90550050104205 52565006315 31480 diflorasone diacetate

DIFLORASONE DIACETATE NPD NPD Y

STEROIDS, TOPICAL HIGH 52565006330 90550050104205 52565006330 31480 diflorasone diacetate

DIFLORASONE DIACETATE NPD NPD Y

STEROIDS, TOPICAL HIGH 52565006360 90550050104205 52565006360 31480 diflorasone diacetate

DIFLORASONE DIACETATE NPD NPD Y

STEROIDS, TOPICAL HIGH 00168013460 90550060002005 00168013460 31401 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 00472082902 90550060002005 00472082902 31401 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 43199003160 90550060002005 43199003160 31401 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 43386002602 90550060002005 43386002602 31401 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 43386002606 90550060002005 43386002606 31401 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 47781060249 90550060002005 47781060249 31401 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51672127302 90550060002005 51672127302 31401 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51672127304 90550060002005 51672127304 31401 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 52565002559 90550060002005 52565002559 31401 fluocinonide FLUOCINONIDE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 144

STEROIDS, TOPICAL HIGH 71428000160 90550060002005 71428000160 31401 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 00093026215 90550060003705 00093026215 31390 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 00093026230 90550060003705 00093026230 31390 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 00093026292 90550060003705 00093026292 31390 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 00168013960 90550060003705 00168013960 31390 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51672125302 90550060003705 51672125302 31390 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51672125303 90550060003705 51672125303 31390 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51672138601 90550060003705 51672138601 31390 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51672138602 90550060003705 51672138602 31390 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51672138603 90550060003705 51672138603 31390 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51672138604 90550060003705 51672138604 31390 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51862049415 90550060003705 51862049415 31390 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51862049430 90550060003705 51862049430 31390 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51862049460 90550060003705 51862049460 31390 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 00168045704 90550060003710 00168045704 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 00168045730 90550060003710 00168045730 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 00168045760 90550060003710 00168045760 24306 fluocinonide FLUOCINONIDE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 145

STEROIDS, TOPICAL HIGH 45802015153 90550060003710 45802015153 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 45802015194 90550060003710 45802015194 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 45802015196 90550060003710 45802015196 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51672135302 90550060003710 51672135302 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51672135303 90550060003710 51672135303 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51672135304 90550060003710 51672135304 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 68462050535 90550060003710 68462050535 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 68462050565 90550060003710 68462050565 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 68462050566 90550060003710 68462050566 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 68682099210 90550060003710 68682099210 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 68682099230 90550060003710 68682099230 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 68682099260 90550060003710 68682099260 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 69238127102 90550060003710 69238127102 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 69238127103 90550060003710 69238127103 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 69238127106 90550060003710 69238127106 24306 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 99207052510 90550060003710 99207052510 24306 fluocinonide VANOS NPD NPD YSTEROIDS, TOPICAL HIGH 99207052530 90550060003710 99207052530 24306 fluocinonide VANOS NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 146

STEROIDS, TOPICAL HIGH 99207052560 90550060003710 99207052560 24306 fluocinonide VANOS NPD NPD YSTEROIDS, TOPICAL HIGH 00713080360 90550060004005 00713080360 31380 fluocinonide FLUOCINONIDE NPD NPD YSTEROIDS, TOPICAL HIGH 47781053326 90550060004005 47781053326 31380 fluocinonide FLUOCINONIDE NPD NPD YSTEROIDS, TOPICAL HIGH 47781053372 90550060004005 47781053372 31380 fluocinonide FLUOCINONIDE NPD NPD YSTEROIDS, TOPICAL HIGH 47781053373 90550060004005 47781053373 31380 fluocinonide FLUOCINONIDE NPD NPD YSTEROIDS, TOPICAL HIGH 51672127901 90550060004005 51672127901 31380 fluocinonide FLUOCINONIDE NPD NPD YSTEROIDS, TOPICAL HIGH 51672127902 90550060004005 51672127902 31380 fluocinonide FLUOCINONIDE NPD NPD YSTEROIDS, TOPICAL HIGH 51672127903 90550060004005 51672127903 31380 fluocinonide FLUOCINONIDE NPD NPD YSTEROIDS, TOPICAL HIGH 52565005415 90550060004005 52565005415 31380 fluocinonide FLUOCINONIDE NPD NPD YSTEROIDS, TOPICAL HIGH 52565005460 90550060004005 52565005460 31380 fluocinonide FLUOCINONIDE NPD NPD YSTEROIDS, TOPICAL HIGH 00093026415 90550060004205 00093026415 31400 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 00093026430 90550060004205 00093026430 31400 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 00093026492 90550060004205 00093026492 31400 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 16714050201 90550060004205 16714050201 31400 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 16714050202 90550060004205 16714050202 31400 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 16714050203 90550060004205 16714050203 31400 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 43199002930 90550060004205 43199002930 31400 fluocinonide FLUOCINONIDE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 147

STEROIDS, TOPICAL HIGH 43199002960 90550060004205 43199002960 31400 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 47781056926 90550060004205 47781056926 31400 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 47781056972 90550060004205 47781056972 31400 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 47781056973 90550060004205 47781056973 31400 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51672126401 90550060004205 51672126401 31400 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51672126402 90550060004205 51672126402 31400 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 51672126403 90550060004205 51672126403 31400 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 52565004030 90550060004205 52565004030 31400 fluocinonide FLUOCINONIDE PDL PDL YSTEROIDS, TOPICAL HIGH 00093026315 90550060103705 00093026315 54650

fluocinonide/emollient base FLUOCINONIDE-E NPD NPD Y

STEROIDS, TOPICAL HIGH 00093026330 90550060103705 00093026330 54650

fluocinonide/emollient base FLUOCINONIDE-E NPD NPD Y

STEROIDS, TOPICAL HIGH 00093026392 90550060103705 00093026392 54650

fluocinonide/emollient base FLUOCINONIDE-E NPD NPD Y

STEROIDS, TOPICAL HIGH 00115170758 90550060103705 00115170758 54650

fluocinonide/emollient base FLUOCINONIDE-E NPD NPD Y

STEROIDS, TOPICAL HIGH 00713066415 90550060103705 00713066415 54650

fluocinonide/emollient base FLUOCINONIDE-E NPD NPD Y

STEROIDS, TOPICAL HIGH 00713066431 90550060103705 00713066431 54650

fluocinonide/emollient base FLUOCINONIDE-E NPD NPD Y

STEROIDS, TOPICAL HIGH 00713066460 90550060103705 00713066460 54650

fluocinonide/emollient base FLUOCINONIDE-E NPD NPD Y

STEROIDS, TOPICAL HIGH 51672125401 90550060103705 51672125401 54650

fluocinonide/emollient base FLUOCINONIDE-E NPD NPD Y

STEROIDS, TOPICAL HIGH 51672125402 90550060103705 51672125402 54650

fluocinonide/emollient base FLUOCINONIDE-E NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 148

STEROIDS, TOPICAL HIGH 51672125403 90550060103705 51672125403 54650

fluocinonide/emollient base FLUOCINONIDE-E NPD NPD Y

STEROIDS, TOPICAL HIGH 00378805649 90550070003710 00378805649 31441 halcinonide HALCINONIDE NPD NPD YSTEROIDS, TOPICAL HIGH 00378805660 90550070003710 00378805660 31441 halcinonide HALCINONIDE NPD NPD YSTEROIDS, TOPICAL HIGH 10631009420 90550070003710 10631009420 31441 halcinonide HALOG NPD NPD YSTEROIDS, TOPICAL HIGH 10631009430 90550070003710 10631009430 31441 halcinonide HALOG NPD NPD YSTEROIDS, TOPICAL HIGH 10631009471 90550070003710 10631009471 31441 halcinonide HALOG NPD NPD YSTEROIDS, TOPICAL HIGH 10631009476 90550070003710 10631009476 31441 halcinonide HALOG NPD NPD YSTEROIDS, TOPICAL HIGH 10631009620 90550070004205 10631009620 31451 halcinonide HALOG NPD NPD YSTEROIDS, TOPICAL HIGH 10631009630 90550070004205 10631009630 31451 halcinonide HALOG NPD NPD YSTEROIDS, TOPICAL HIGH 10631009671 90550070004205 10631009671 31451 halcinonide HALOG NPD NPD YSTEROIDS, TOPICAL HIGH 10631009307 90550085103400 10631009307 98339 triamcinolone acetonide KENALOG NPD NPD YSTEROIDS, TOPICAL HIGH 10631009362 90550085103400 10631009362 98339 triamcinolone acetonide KENALOG NPD NPD YSTEROIDS, TOPICAL HIGH 45802004501 90550085103400 45802004501 98339 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL HIGH 45802004502 90550085103400 45802004502 98339 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL HIGH 64980042901 90550085103400 64980042901 98339 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL HIGH 64980042963 90550085103400 64980042963 98339 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL HIGH 00168000315 90550085103705 00168000315 31231 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 149

STEROIDS, TOPICAL HIGH 00168000380 90550085103705 00168000380 31231 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00603786174 90550085103705 00603786174 31231 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00603786190 90550085103705 00603786190 31231 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00713022615 90550085103705 00713022615 31231 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00713022680 90550085103705 00713022680 31231 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 33342032715 90550085103705 33342032715 31231 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 33342032780 90550085103705 33342032780 31231 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 45802006305 90550085103705 45802006305 31231 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 45802006335 90550085103705 45802006335 31231 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 45802006336 90550085103705 45802006336 31231 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 67877031715 90550085103705 67877031715 31231 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 67877031745 90550085103705 67877031745 31231 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 67877031780 90550085103705 67877031780 31231 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00168000415 90550085103710 00168000415 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00168000416 90550085103710 00168000416 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00168000480 90550085103710 00168000480 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00316017001 90550085103710 00316017001 31232 triamcinolone acetonide TRIDERM PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 150

STEROIDS, TOPICAL HIGH 00603786274 90550085103710 00603786274 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00603786278 90550085103710 00603786278 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00603786290 90550085103710 00603786290 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00713022515 90550085103710 00713022515 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00713022531 90550085103710 00713022531 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00713022580 90550085103710 00713022580 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 33342032915 90550085103710 33342032915 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 33342032954 90550085103710 33342032954 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 33342032980 90550085103710 33342032980 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 45802006405 90550085103710 45802006405 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 45802006435 90550085103710 45802006435 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 45802006436 90550085103710 45802006436 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 51672128201 90550085103710 51672128201 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 51672128202 90550085103710 51672128202 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 51672128208 90550085103710 51672128208 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 52565005615 90550085103710 52565005615 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 52565005626 90550085103710 52565005626 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 151

STEROIDS, TOPICAL HIGH 52565005630 90550085103710 52565005630 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 52565005680 90550085103710 52565005680 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 67877025115 90550085103710 67877025115 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 67877025130 90550085103710 67877025130 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 67877025145 90550085103710 67877025145 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 67877025180 90550085103710 67877025180 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 68462013117 90550085103710 68462013117 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 68462013135 90550085103710 68462013135 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 68462013149 90550085103710 68462013149 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 68462013159 90550085103710 68462013159 31232 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00168000215 90550085103720 00168000215 31233 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 33342032815 90550085103720 33342032815 31233 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 45802006535 90550085103720 45802006535 31233 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 67877031815 90550085103720 67877031815 31233 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 52565001059 90550085104105 52565001059 31260 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 60432056060 90550085104105 60432056060 31260 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 60432056061 90550085104105 60432056061 31260 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 152

STEROIDS, TOPICAL HIGH 00603786449 90550085104110 00603786449 31261 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00713067653 90550085104110 00713067653 31261 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 52565001159 90550085104110 52565001159 31261 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 60432056160 90550085104110 60432056160 31261 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 60432056161 90550085104110 60432056161 31261 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 61748022060 90550085104110 61748022060 31261 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00168000580 90550085104205 00168000580 31241 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00713022915 90550085104205 00713022915 31241 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00713022980 90550085104205 00713022980 31241 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 33342033154 90550085104205 33342033154 31241 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 45802005405 90550085104205 45802005405 31241 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 45802005435 90550085104205 45802005435 31241 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 45802005436 90550085104205 45802005436 31241 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 67857080619 90550085104207 67857080619 31243 triamcinolone acetonide TRIANEX NPD NPD YSTEROIDS, TOPICAL HIGH 00168000615 90550085104210 00168000615 31242 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00168000616 90550085104210 00168000616 31242 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00168000680 90550085104210 00168000680 31242 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 153

STEROIDS, TOPICAL HIGH 00713022815 90550085104210 00713022815 31242 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00713022880 90550085104210 00713022880 31242 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 33342033380 90550085104210 33342033380 31242 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 45802005505 90550085104210 45802005505 31242 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 45802005535 90550085104210 45802005535 31242 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 45802005536 90550085104210 45802005536 31242 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 51672128401 90550085104210 51672128401 31242 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 51672128402 90550085104210 51672128402 31242 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 51672128408 90550085104210 51672128408 31242 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 52565001415 90550085104210 52565001415 31242 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 52565001426 90550085104210 52565001426 31242 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 52565001480 90550085104210 52565001480 31242 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00713067915 90550085104215 00713067915 31244 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 45802004935 90550085104215 45802004935 31244 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 52565004815 90550085104215 52565004815 31244 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 68462079817 90550085104215 68462079817 31244 triamcinolone acetonide

TRIAMCINOLONE ACETONIDE PDL PDL Y

STEROIDS, TOPICAL HIGH 00316101501 90550085206420 00316101501 35653

triamcinolone/emollient comb86 DERMASORB TA NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 154

STEROIDS, TOPICAL HIGH 59088084600 9055990265B120 59088084600 43088

triamcinolone acet/dimethicone ELLZIA PAK NPD NPD Y

STEROIDS, TOPICAL HIGH 75840009301 90559903906420 75840009301 38908

triamcinolone/dimeth/silicone SANADERMRX NPD NPD Y

STEROIDS, TOPICAL LOW 00259180201 31631

hydrocortisone/skin cleanser25 AQUA GLYCOLIC HC NPD NPD Y

STEROIDS, TOPICAL LOW 63868059628 30942 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 65649050130 89100010003705 65649050130 30942 hydrocortisone PROCTOCORT PDL PDL YSTEROIDS, TOPICAL LOW 10631040701 89100010003720 10631040701 28850 hydrocortisone PROCTOSOL-HC PDL PDL YSTEROIDS, TOPICAL LOW 62559043130 89100010003720 62559043130 28850 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 64980030130 89100010003720 64980030130 28850 hydrocortisone PROCTOZONE-HC PDL PDL YSTEROIDS, TOPICAL LOW 64980032430 89100010003720 64980032430 28850 hydrocortisone PROCTOZONE-HC PDL PDL YSTEROIDS, TOPICAL LOW 65649040130 89100010003720 65649040130 28850 hydrocortisone ANUSOL-HC PDL PDL YSTEROIDS, TOPICAL LOW 69315030230 89100010003720 69315030230 28850 hydrocortisone PROCTO-MED HC PDL PDL YSTEROIDS, TOPICAL LOW 00168026315 90550005103710 00168026315 33710

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 00168026345 90550005103710 00168026345 33710

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 00168026360 90550005103710 00168026360 33710

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 51672130601 90550005103710 51672130601 33710

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 51672130603 90550005103710 51672130603 33710

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 51672130606 90550005103710 51672130606 33710

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 155

STEROIDS, TOPICAL LOW 68462030017 90550005103710 68462030017 33710

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 68462030047 90550005103710 68462030047 33710

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 68462030065 90550005103710 68462030065 33710

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 00168026415 90550005104210 00168026415 33730

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 00168026445 90550005104210 00168026445 33730

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 00168026460 90550005104210 00168026460 33730

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 51672131601 90550005104210 51672131601 33730

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 51672131603 90550005104210 51672131603 33730

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 51672131606 90550005104210 51672131606 33730

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 68462029917 90550005104210 68462029917 33730

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 68462029947 90550005104210 68462029947 33730

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 68462029965 90550005104210 68462029965 33730

alclometasone dipropionate

ALCLOMETASONE DIPROPIONATE NPD NPD Y

STEROIDS, TOPICAL LOW 00472080415 90550035003705 00472080415 31425 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 00472080460 90550035003705 00472080460 31425 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 00713066115 90550035003705 00713066115 31425 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 00713066160 90550035003705 00713066160 31425 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 16714072901 90550035003705 16714072901 31425 desonide DESONIDE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 156

STEROIDS, TOPICAL LOW 16714072902 90550035003705 16714072902 31425 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 45802042235 90550035003705 45802042235 31425 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 45802042237 90550035003705 45802042237 31425 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 51672128001 90550035003705 51672128001 31425 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 51672128003 90550035003705 51672128003 31425 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 68462025217 90550035003705 68462025217 31425 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 68462025265 90550035003705 68462025265 31425 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 50419082806 90550035004020 50419082806 97930 desonide DESONATE NPD NPD YSTEROIDS, TOPICAL LOW 00115151764 90550035004105 00115151764 48971 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 00115151765 90550035004105 00115151765 48971 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 00168031002 90550035004105 00168031002 48971 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 00168031004 90550035004105 00168031004 48971 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 00472080302 90550035004105 00472080302 48971 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 00472080304 90550035004105 00472080304 48971 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 51672407904 90550035004105 51672407904 48971 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 51672407908 90550035004105 51672407908 48971 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 68462051339 90550035004105 68462051339 48971 desonide DESONIDE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 157

STEROIDS, TOPICAL LOW 68462051389 90550035004105 68462051389 48971 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 00168030915 90550035004205 00168030915 31430 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 00168030960 90550035004205 00168030960 31430 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 16714082801 90550035004205 16714082801 31430 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 16714082802 90550035004205 16714082802 31430 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 45802042335 90550035004205 45802042335 31430 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 45802042337 90550035004205 45802042337 31430 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 51672128101 90550035004205 51672128101 31430 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 51672128103 90550035004205 51672128103 31430 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 61748047015 90550035004205 61748047015 31430 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 61748047060 90550035004205 61748047060 31430 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 68462052817 90550035004205 68462052817 31430 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 68462052865 90550035004205 68462052865 31430 desonide DESONIDE NPD NPD YSTEROIDS, TOPICAL LOW 45802088726 90550055101712 45802088726 85080 fluocinolone acetonide

FLUOCINOLONE ACETONIDE PDL NPD Y

STEROIDS, TOPICAL LOW 51672135608 90550055101712 51672135608 85080 fluocinolone acetonide

FLUOCINOLONE ACETONIDE PDL NPD Y

STEROIDS, TOPICAL LOW 64980033104 90550055101712 64980033104 85080 fluocinolone acetonide

FLUOCINOLONE ACETONIDE PDL NPD Y

STEROIDS, TOPICAL LOW 65162070486 90550055101712 65162070486 85080 fluocinolone acetonide

FLUOCINOLONE ACETONIDE PDL NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 158

STEROIDS, TOPICAL LOW 68462059189 90550055101712 68462059189 85080 fluocinolone acetonide

FLUOCINOLONE ACETONIDE PDL NPD Y

STEROIDS, TOPICAL LOW 68791010104 90550055101712 68791010104 85080 fluocinolone acetonide

DERMA-SMOOTHE-FS NPD PDL Y

STEROIDS, TOPICAL LOW 45802048526 90550055101714 45802048526 24484 fluocinolone/shower cap

FLUOCINOLONE ACETONIDE PDL NPD Y

STEROIDS, TOPICAL LOW 51672135708 90550055101714 51672135708 24484 fluocinolone/shower cap

FLUOCINOLONE ACETONIDE PDL NPD Y

STEROIDS, TOPICAL LOW 64980033004 90550055101714 64980033004 24484 fluocinolone/shower cap

FLUOCINOLONE ACETONIDE PDL NPD Y

STEROIDS, TOPICAL LOW 65162070386 90550055101714 65162070386 24484 fluocinolone/shower cap

FLUOCINOLONE ACETONIDE PDL NPD Y

STEROIDS, TOPICAL LOW 68462059089 90550055101714 68462059089 24484 fluocinolone/shower cap

FLUOCINOLONE ACETONIDE PDL NPD Y

STEROIDS, TOPICAL LOW 68791010204 90550055101714 68791010204 24484 fluocinolone/shower cap

DERMA-SMOOTHE-FS NPD PDL Y

STEROIDS, TOPICAL LOW 00299550004 90550055104501 00299550004 86641 fluocinolone acetonide CAPEX SHAMPOO NPD NPD YSTEROIDS, TOPICAL LOW 63824085015 90550075002005 63824085015 9180 hydrocortisone SCALPICIN NPD NPD YSTEROIDS, TOPICAL LOW 00178045501 90550075002020 00178045501 9181 hydrocortisone TEXACORT NPD NPD YSTEROIDS, TOPICAL LOW 00168001431 90550075003715 00168001431 30941 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 24385019003 90550075003715 24385019003 30842 hydrocortisone acetate

HYDROCORTISONE ACETATE PDL PDL Y

STEROIDS, TOPICAL LOW 00113054164 90550075003720 00113054164 30942 hydrocortisone ANTI-ITCH PDL PDL YSTEROIDS, TOPICAL LOW 00113097364 90550075003720 00113097364 30942 hydrocortisone ANTI-ITCH PDL PDL YSTEROIDS, TOPICAL LOW 00168001516 90550075003720 00168001516 30942 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00168001531 90550075003720 00168001531 30942 hydrocortisone HYDROCORTISONE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 159

STEROIDS, TOPICAL LOW 00168015431 90550075003720 00168015431 30942 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00316018601 90550075003720 00316018601 30942 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00316018616 90550075003720 00316018616 30942 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00472032126 90550075003720 00472032126 30942 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00472034356 90550075003720 00472034356 30942 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00904762331 90550075003720 00904762331 92421 hydrocortisone/aloe vera

HYDROCORTISONE-ALOE PDL PDL Y

STEROIDS, TOPICAL LOW 24385002103 90550075003720 24385002103 30942 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 37205016210 90550075003720 37205016210 30942 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 45802043803 90550075003720 45802043803 30942 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 45802043805 90550075003720 45802043805 30942 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 49348052172 90550075003720 49348052172 92421 hydrocortisone/aloe vera

HYDROCORTISONE-ALOE PDL PDL Y

STEROIDS, TOPICAL LOW 51672201301 90550075003720 51672201301 30942 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 51672201302 90550075003720 51672201302 92421 hydrocortisone/aloe vera

HYDROCORTISONE-ALOE PDL PDL Y

STEROIDS, TOPICAL LOW 51672206302 90550075003720 51672206302 30942 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 51672206902 90550075003720 51672206902 30942 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 53329009101 90550075003720 53329009101 30942 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00168008016 90550075003725 00168008016 30943 hydrocortisone HYDROCORTISONE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 160

STEROIDS, TOPICAL LOW 00168008031 90550075003725 00168008031 30943 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00316019316 90550075003725 00316019316 30943 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00316019320 90550075003725 00316019320 30943 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00316019330 90550075003725 00316019330 30943 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00472033720 90550075003725 00472033720 30943 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00472033730 90550075003725 00472033730 30943 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 45802000402 90550075003725 45802000402 30943 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 45802000403 90550075003725 45802000403 30943 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 51672300302 90550075003725 51672300302 30943 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00536107997 90550075004115 00536107997 30974 hydrocortisone HYDRO SKIN PDL PDL YSTEROIDS, TOPICAL LOW 00316014001 90550075004118 00316014001 26603 hydrocortisone ALA-SCALP NPD NPD YSTEROIDS, TOPICAL LOW 45802093716 90550075004120 45802093716 30975 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 45802093726 90550075004120 45802093726 30975 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00168001631 90550075004205 00168001631 30950 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00168002016 90550075004210 00168002016 30951 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00168002031 90550075004210 00168002031 30951 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00168018131 90550075004210 00168018131 30951 hydrocortisone HYDROCORTISONE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 161

STEROIDS, TOPICAL LOW 00472034556 90550075004210 00472034556 30951 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00472132626 90550075004210 00472132626 30951 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 24385027603 90550075004210 24385027603 30951 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 45802027603 90550075004210 45802027603 30951 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 49348052272 90550075004210 49348052272 30951 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 51672201802 90550075004210 51672201802 30951 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00168014616 90550075004215 00168014616 30952 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00168014630 90550075004215 00168014630 30952 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 45802001402 90550075004215 45802001402 30952 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 45802001405 90550075004215 45802001405 30952 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00316100501 90550075656420 00316100501 35656

hydrocortisone/skin cleanser35 DERMASORB HC NPD NPD Y

STEROIDS, TOPICAL LOW 51672201002 90559902503710 51672201002 30941 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL LOW 00472033956 90559902503720 00472033956 92421 hydrocortisone/aloe vera

HYDROCORTISONE-ALOE PDL PDL Y

STEROIDS, TOPICAL LOW 24385027403 90559902503720 24385027403 30841 hydrocortisone acetate

HYDROCORTISONE ACETATE PDL PDL Y

STEROIDS, TOPICAL LOW 37205027210 90559902503720 37205027210 92421 hydrocortisone/aloe vera

HYDROCORTISONE-ALOE PDL PDL Y

STEROIDS, TOPICAL LOW 49348044172 90559902503720 49348044172 92421 hydrocortisone/aloe vera

HYDROCORTISONE PLUS PDL PDL Y

STEROIDS, TOPICAL LOW 62011009501 90559902503720 62011009501 30942 hydrocortisone HYDROCORTISONE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 162

STEROIDS, TOPICAL LOW 62011009601 90559902503720 62011009601 30942 hydrocortisone HYDROCORTISONE PDL PDL YSTEROIDS, TOPICAL MEDIUM 00378818050 90550020103920 00378818050 32052 betamethasone valerate

BETAMETHASONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00378818099 90550020103920 00378818099 32052 betamethasone valerate

BETAMETHASONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 45802005301 90550020103920 45802005301 32052 betamethasone valerate

BETAMETHASONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 45802005302 90550020103920 45802005302 32052 betamethasone valerate

BETAMETHASONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 50742031501 90550020103920 50742031501 32052 betamethasone valerate

BETAMETHASONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 50742031550 90550020103920 50742031550 32052 betamethasone valerate

BETAMETHASONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 51672418803 90550020103920 51672418803 32052 betamethasone valerate

BETAMETHASONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 51672418807 90550020103920 51672418807 32052 betamethasone valerate

BETAMETHASONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 43598034145 90550030103705 43598034145 31190 clocortolone pivalate

CLOCORTOLONE PIVALATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 43598034175 90550030103705 43598034175 31190 clocortolone pivalate

CLOCORTOLONE PIVALATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 43598034190 90550030103705 43598034190 31190 clocortolone pivalate

CLOCORTOLONE PIVALATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 66993094748 90550030103705 66993094748 31190 clocortolone pivalate

CLOCORTOLONE PIVALATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 67857080430 90550030103705 67857080430 31190 clocortolone pivalate CLODERM NPD NPD YSTEROIDS, TOPICAL MEDIUM 67857080445 90550030103705 67857080445 31190 clocortolone pivalate CLODERM NPD NPD YSTEROIDS, TOPICAL MEDIUM 67857080451 90550030103705 67857080451 31190 clocortolone pivalate CLODERM NPD NPD YSTEROIDS, TOPICAL MEDIUM 67857080490 90550030103705 67857080490 31190 clocortolone pivalate CLODERM NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 163

STEROIDS, TOPICAL MEDIUM 71403080445 90550030103705 71403080445 31190 clocortolone pivalate CLODERM NPD NPD YSTEROIDS, TOPICAL MEDIUM 00168005960 90550055102005 00168005960 31360 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00591299060 90550055102005 00591299060 31360 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 43386006960 90550055102005 43386006960 31360 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 43538092060 90550055102005 43538092060 31360 fluocinolone acetonide SYNALAR NPD NPD YSTEROIDS, TOPICAL MEDIUM 43538092090 90550055102005 43538092090 31360 fluocinolone acetonide SYNALAR NPD NPD YSTEROIDS, TOPICAL MEDIUM 51672136504 90550055102005 51672136504 31360 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 52565001259 90550055102005 52565001259 31360 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 71428000260 90550055102005 71428000260 31360 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00713022315 90550055103705 00713022315 31342 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00713022360 90550055103705 00713022360 31342 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 52565003115 90550055103705 52565003115 31342 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 52565003160 90550055103705 52565003160 31342 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00713032415 90550055103710 00713032415 31344 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00713032460 90550055103710 00713032460 31344 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00713070915 90550055103710 00713070915 31344 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00713070960 90550055103710 00713070960 31344 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 164

STEROIDS, TOPICAL MEDIUM 52565002015 90550055103710 52565002015 31344 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 52565002060 90550055103710 52565002060 31344 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00168006415 90550055104205 00168006415 31351 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00168006460 90550055104205 00168006460 31351 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00713022415 90550055104205 00713022415 31351 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00713022460 90550055104205 00713022460 31351 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 43538091012 90550055104205 43538091012 31351 fluocinolone acetonide SYNALAR NPD NPD YSTEROIDS, TOPICAL MEDIUM 52565001315 90550055104205 52565001315 31351 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 52565001360 90550055104205 52565001360 31351 fluocinolone acetonide

FLUOCINOLONE ACETONIDE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 51672530104 90550065003710 51672530104 28711 flurandrenolide FLURANDRENOLIDE NPD NPD YSTEROIDS, TOPICAL MEDIUM 45802092803 90550065004105 45802092803 31310 flurandrenolide FLURANDRENOLIDE NPD NPD YSTEROIDS, TOPICAL MEDIUM 51672529808 90550065004105 51672529808 31310 flurandrenolide FLURANDRENOLIDE NPD NPD YSTEROIDS, TOPICAL MEDIUM 52565001760 90550065004210 52565001760 28721 flurandrenolide FLURANDRENOLIDE NPD NPD YSTEROIDS, TOPICAL MEDIUM 00023587080 90550065004605 00023587080 31300 flurandrenolide CORDRAN NPD NPD YSTEROIDS, TOPICAL MEDIUM 00115147358 90550068103710 00115147358 43951 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00168033215 90550068103710 00168033215 43951 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00168033230 90550068103710 00168033230 43951 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 165

STEROIDS, TOPICAL MEDIUM 00168033260 90550068103710 00168033260 43951 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713063115 90550068103710 00713063115 43951 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713063131 90550068103710 00713063131 43951 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713063160 90550068103710 00713063160 43951 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713072915 90550068103710 00713072915 43951 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713072931 90550068103710 00713072931 43951 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713072960 90550068103710 00713072960 43951 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 45802022211 90550068103710 45802022211 43951 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 45802022235 90550068103710 45802022235 43951 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 45802022237 90550068103710 45802022237 43951 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00168043404 90550068104120 00168043404 24717 fluticasone propionate

FLUTICASONE PROPIONATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00168043460 90550068104120 00168043460 24717 fluticasone propionate

FLUTICASONE PROPIONATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 43538097060 90550068104120 43538097060 24717 fluticasone propionate BESER NPD NPD YSTEROIDS, TOPICAL MEDIUM 45802044102 90550068104120 45802044102 24717 fluticasone propionate

FLUTICASONE PROPIONATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 68462042702 90550068104120 68462042702 24717 fluticasone propionate

FLUTICASONE PROPIONATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00713063215 90550068104210 00713063215 48641 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713063231 90550068104210 00713063231 48641 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 166

STEROIDS, TOPICAL MEDIUM 00713063260 90550068104210 00713063260 48641 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 45802022111 90550068104210 45802022111 48641 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 45802022135 90550068104210 45802022135 48641 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 45802022137 90550068104210 45802022137 48641 fluticasone propionate

FLUTICASONE PROPIONATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713066815 90550075203705 00713066815 30890 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00713066837 90550075203705 00713066837 30890 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00713066860 90550075203705 00713066860 30890 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 45802045535 90550075203705 45802045535 30890 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 45802045537 90550075203705 45802045537 30890 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 45802045542 90550075203705 45802045542 30890 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 51672129001 90550075203705 51672129001 30890 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 51672129003 90550075203705 51672129003 30890 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 51672129006 90550075203705 51672129006 30890 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 68462057517 90550075203705 68462057517 30890 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 68462057547 90550075203705 68462057547 30890 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 68462057565 90550075203705 68462057565 30890 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00713066915 90550075204205 00713066915 6040 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 167

STEROIDS, TOPICAL MEDIUM 00713066937 90550075204205 00713066937 6040 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00713066960 90550075204205 00713066960 6040 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 51672129201 90550075204205 51672129201 6040 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 51672129203 90550075204205 51672129203 6040 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 51672129206 90550075204205 51672129206 6040 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 68462021017 90550075204205 68462021017 6040 hydrocortisone valerate

HYDROCORTISONE VALERATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 10337015380 90550075273720 10337015380 50550 hydrocortisone probutate PANDEL NPD NPD YSTEROIDS, TOPICAL MEDIUM 51672406102 90550075302020 51672406102 48811 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 51672406104 90550075302020 51672406104 48811 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 68682027361 90550075302020 68682027361 48811 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 51672407401 90550075303705 51672407401 30880 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 51672407406 90550075303705 51672407406 30880 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 68682027015 90550075303705 68682027015 30880 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 68682027045 90550075303705 68682027045 30880 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 52565008702 90550075304120 52565008702 62480 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 52565008704 90550075304120 52565008704 62480 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 68180095101 90550075304120 68180095101 62480 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 168

STEROIDS, TOPICAL MEDIUM 68180095102 90550075304120 68180095102 62480 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 68682039202 90550075304120 68682039202 62480 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 51672408301 90550075304205 51672408301 30885 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 51672408306 90550075304205 51672408306 30885 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 68682027115 90550075304205 68682027115 30885 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 68682027145 90550075304205 68682027145 30885 hydrocortisone butyrate

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 68462046447 90550075323705 68462046447 20706

hydrocortisone butyrate/emoll

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 68462046465 90550075323705 68462046465 20706

hydrocortisone butyrate/emoll

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 68682038445 90550075323705 68682038445 20706

hydrocortisone butyrate/emoll

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 68682038460 90550075323705 68682038460 20706

hydrocortisone butyrate/emoll

HYDROCORTISONE BUTYRATE NPD NPD Y

STEROIDS, TOPICAL MEDIUM 00115147154 90550082102010 00115147154 6034 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00115147155 90550082102010 00115147155 6034 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713070153 90550082102010 00713070153 6034 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713070185 90550082102010 00713070185 6034 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 45802011846 90550082102010 45802011846 6034 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 45802011859 90550082102010 45802011859 6034 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 51672130503 90550082102010 51672130503 6034 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 169

STEROIDS, TOPICAL MEDIUM 51672130504 90550082102010 51672130504 6034 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00085314901 90550082103710 00085314901 45850 mometasone furoate ELOCON NPD NPD YSTEROIDS, TOPICAL MEDIUM 00085314903 90550082103710 00085314903 45850 mometasone furoate ELOCON NPD NPD YSTEROIDS, TOPICAL MEDIUM 00115147046 90550082103710 00115147046 45850 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00115147052 90550082103710 00115147052 45850 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713063415 90550082103710 00713063415 45850 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713063437 90550082103710 00713063437 45850 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713072615 90550082103710 00713072615 45850 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713072637 90550082103710 00713072637 45850 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 45802025735 90550082103710 45802025735 45850 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 45802025742 90550082103710 45802025742 45850 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 68462019217 90550082103710 68462019217 45850 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 68462019255 90550082103710 68462019255 45850 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00115146952 90550082104210 00115146952 45930 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00168027115 90550082104210 00168027115 45930 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00168027146 90550082104210 00168027146 45930 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713063515 90550082104210 00713063515 45930 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 170

STEROIDS, TOPICAL MEDIUM 00713063537 90550082104210 00713063537 45930 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713072715 90550082104210 00713072715 45930 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 00713072737 90550082104210 00713072737 45930 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 45802011937 90550082104210 45802011937 45930 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 45802011942 90550082104210 45802011942 45930 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 67405030015 90550082104210 67405030015 45930 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 68462022517 90550082104210 68462022517 45930 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 68462022555 90550082104210 68462022555 45930 mometasone furoate

MOMETASONE FUROATE PDL PDL Y

STEROIDS, TOPICAL MEDIUM 68682088060 90550083003710 68682088060 37181 prednicarbate PREDNICARBATE NPD NPD YSTEROIDS, TOPICAL MEDIUM 00168041015 90550083004210 00168041015 37182 prednicarbate PREDNICARBATE NPD NPD YSTEROIDS, TOPICAL MEDIUM 00168041060 90550083004210 00168041060 37182 prednicarbate PREDNICARBATE NPD NPD YSTEROIDS, TOPICAL MEDIUM 43538092160 90559902396420 43538092160 33227 fluocinolone/skin clnsr28 SYNALAR TS NPD NPD YSTEROIDS, TOPICAL MEDIUM 43538092190 90559902396420 43538092190 33227 fluocinolone/skin clnsr28 SYNALAR TS NPD NPD YSTEROIDS, TOPICAL MEDIUM 43538090112 90559902406430 43538090112 33828

fluocinolone/emol comb no.65 SYNALAR NPD NPD Y

STEROIDS, TOPICAL MEDIUM 43538091112 90559902406435 43538091112 33829

fluocinolone/emol comb no.65 SYNALAR NPD NPD Y

STEROIDS, TOPICAL MEDIUM 43538097160 90559902456420 43538097160 46291

fluticasone/emollient no.65 BESER KIT NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 00574206302 90550025100910 00574206302 25909 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 171

STEROIDS, TOPICAL VERY HIGH 00574206304 90550025100910 00574206304 25909 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 00591403946 90550025100910 00591403946 25909 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 00591403974 90550025100910 00591403974 25909 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 51672137104 90550025100910 51672137104 25909 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 51672137108 90550025100910 51672137108 25909 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 68180055111 90550025100910 68180055111 25909 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 68180055122 90550025100910 68180055122 25909 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 68382099801 90550025100910 68382099801 25909 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 68382099802 90550025100910 68382099802 25909 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 68462048039 90550025100910 68462048039 25909 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 68462048056 90550025100910 68462048056 25909 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 00168026950 90550025102005 00168026950 15891 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00472040225 90550025102005 00472040225 15891 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00472040250 90550025102005 00472040250 15891 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 33342032186 90550025102005 33342032186 15891 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 43386002860 90550025102005 43386002860 15891 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 50383026625 90550025102005 50383026625 15891 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 172

STEROIDS, TOPICAL VERY HIGH 50383026650 90550025102005 50383026650 15891 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51672129302 90550025102005 51672129302 15891 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51672129303 90550025102005 51672129303 15891 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 60432013325 90550025102005 60432013325 15891 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 60432013350 90550025102005 60432013350 15891 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 63646050025 90550025102005 63646050025 15891 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 63646050050 90550025102005 63646050050 15891 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 68462053228 90550025102005 68462053228 15891 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 68462053253 90550025102005 68462053253 15891 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00168016315 90550025103705 00168016315 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00168016330 90550025103705 00168016330 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00168016346 90550025103705 00168016346 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00168016360 90550025103705 00168016360 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00472040015 90550025103705 00472040015 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00472040030 90550025103705 00472040030 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00472040045 90550025103705 00472040045 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00472040060 90550025103705 00472040060 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 173

STEROIDS, TOPICAL VERY HIGH 10337016330 90550025103705 10337016330 32140 clobetasol propionate TEMOVATE NPD NPD YSTEROIDS, TOPICAL VERY HIGH 10337016360 90550025103705 10337016360 32140 clobetasol propionate TEMOVATE NPD NPD YSTEROIDS, TOPICAL VERY HIGH 16714073001 90550025103705 16714073001 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 16714073002 90550025103705 16714073002 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 16714073003 90550025103705 16714073003 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 16714073004 90550025103705 16714073004 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 50383026715 90550025103705 50383026715 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 50383026730 90550025103705 50383026730 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 50383026745 90550025103705 50383026745 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 50383026760 90550025103705 50383026760 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51672125801 90550025103705 51672125801 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51672125802 90550025103705 51672125802 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51672125803 90550025103705 51672125803 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51672125806 90550025103705 51672125806 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 52565005115 90550025103705 52565005115 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 52565005130 90550025103705 52565005130 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 52565005145 90550025103705 52565005145 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 174

STEROIDS, TOPICAL VERY HIGH 52565005160 90550025103705 52565005160 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 64980044103 90550025103705 64980044103 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 64980044115 90550025103705 64980044115 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 64980044145 90550025103705 64980044145 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 64980044160 90550025103705 64980044160 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 68180095601 90550025103705 68180095601 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 68180095602 90550025103705 68180095602 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 68180095603 90550025103705 68180095603 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 68180095604 90550025103705 68180095604 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 68462052917 90550025103705 68462052917 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 68462052935 90550025103705 68462052935 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 68462052947 90550025103705 68462052947 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 68462052965 90550025103705 68462052965 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 70700010915 90550025103705 70700010915 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 70700010916 90550025103705 70700010916 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 70700010917 90550025103705 70700010917 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 70700010918 90550025103705 70700010918 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 175

STEROIDS, TOPICAL VERY HIGH 70710145601 90550025103705 70710145601 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 70710145602 90550025103705 70710145602 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 70710145603 90550025103705 70710145603 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 70710145604 90550025103705 70710145604 32140 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00378816701 90550025103920 00378816701 89743 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 00378816750 90550025103920 00378816750 89743 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 40085088800 90550025103920 40085088800 89743 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 40085088850 90550025103920 40085088850 89743 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 45802043732 90550025103920 45802043732 89743 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 45802043733 90550025103920 45802043733 89743 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 50742030401 90550025103920 50742030401 89743 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 50742030450 90550025103920 50742030450 89743 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 51672419303 90550025103920 51672419303 89743 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 51672419307 90550025103920 51672419307 89743 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 68462060827 90550025103920 68462060827 89743 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 68462060894 90550025103920 68462060894 89743 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 00168029315 90550025104010 00168029315 15892 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 176

STEROIDS, TOPICAL VERY HIGH 00168029330 90550025104010 00168029330 15892 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00168029360 90550025104010 00168029360 15892 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 45802092514 90550025104010 45802092514 15892 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 45802092594 90550025104010 45802092594 15892 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 45802092596 90550025104010 45802092596 15892 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 50383026960 90550025104010 50383026960 15892 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51672129401 90550025104010 51672129401 15892 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51672129402 90550025104010 51672129402 15892 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51672129403 90550025104010 51672129403 15892 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 52565008215 90550025104010 52565008215 15892 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 52565008230 90550025104010 52565008230 15892 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 52565008260 90550025104010 52565008260 15892 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00299384802 90550025104110 00299384802 34040 clobetasol propionate CLOBEX NPD NPD YSTEROIDS, TOPICAL VERY HIGH 00299384804 90550025104110 00299384804 34040 clobetasol propionate CLOBEX NPD NPD YSTEROIDS, TOPICAL VERY HIGH 00472040492 90550025104110 00472040492 34040 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 00472040494 90550025104110 00472040494 34040 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 00574210302 90550025104110 00574210302 34040 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 177

STEROIDS, TOPICAL VERY HIGH 00574210304 90550025104110 00574210304 34040 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 51672135004 90550025104110 51672135004 34040 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 51672135008 90550025104110 51672135008 34040 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 52565005502 90550025104110 52565005502 34040 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 52565005504 90550025104110 52565005504 34040 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 68180053601 90550025104110 68180053601 34040 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 68180053602 90550025104110 68180053602 34040 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 00168016215 90550025104205 00168016215 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00168016230 90550025104205 00168016230 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00168016246 90550025104205 00168016246 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00168016260 90550025104205 00168016260 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00378819015 90550025104205 00378819015 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00378819030 90550025104205 00378819030 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00378819045 90550025104205 00378819045 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00378819060 90550025104205 00378819060 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00713065615 90550025104205 00713065615 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00713065631 90550025104205 00713065631 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 178

STEROIDS, TOPICAL VERY HIGH 00713065637 90550025104205 00713065637 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00713065660 90550025104205 00713065660 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 10337016215 90550025104205 10337016215 32130 clobetasol propionate TEMOVATE NPD NPD YSTEROIDS, TOPICAL VERY HIGH 10337016230 90550025104205 10337016230 32130 clobetasol propionate TEMOVATE NPD NPD YSTEROIDS, TOPICAL VERY HIGH 16714078201 90550025104205 16714078201 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 16714078202 90550025104205 16714078202 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 16714078203 90550025104205 16714078203 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 16714078204 90550025104205 16714078204 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 43386009660 90550025104205 43386009660 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 43386009661 90550025104205 43386009661 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 43386009662 90550025104205 43386009662 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 43386009663 90550025104205 43386009663 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 50383026815 90550025104205 50383026815 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 50383026830 90550025104205 50383026830 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 50383026845 90550025104205 50383026845 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 50383026860 90550025104205 50383026860 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51672125901 90550025104205 51672125901 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 179

STEROIDS, TOPICAL VERY HIGH 51672125902 90550025104205 51672125902 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51672125903 90550025104205 51672125903 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51672125906 90550025104205 51672125906 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 52565003915 90550025104205 52565003915 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 52565003930 90550025104205 52565003930 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 52565003960 90550025104205 52565003960 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 68462053017 90550025104205 68462053017 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 68462053035 90550025104205 68462053035 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 68462053047 90550025104205 68462053047 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 68462053065 90550025104205 68462053065 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 70700010617 90550025104205 70700010617 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 70710140101 90550025104205 70710140101 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 70710140102 90550025104205 70710140102 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 70710140103 90550025104205 70710140103 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 70710140104 90550025104205 70710140104 32130 clobetasol propionate

CLOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00299384704 90550025104520 00299384704 21475 clobetasol propionate CLOBEX NPD NPD YSTEROIDS, TOPICAL VERY HIGH 00472040394 90550025104520 00472040394 21475 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 180

STEROIDS, TOPICAL VERY HIGH 00781713704 90550025104520 00781713704 21475 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 43538095004 90550025104520 43538095004 21475 clobetasol propionate CLODAN NPD NPD YSTEROIDS, TOPICAL VERY HIGH 45802096126 90550025104520 45802096126 21475 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 50383097904 90550025104520 50383097904 21475 clobetasol propionate

CLOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 00168030115 90550025153705 00168030115 34141

clobetasol propionate/emoll

CLOBETASOL EMOLLIENT PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00168030130 90550025153705 00168030130 34141

clobetasol propionate/emoll

CLOBETASOL EMOLLIENT PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00168030160 90550025153705 00168030160 34141

clobetasol propionate/emoll

CLOBETASOL EMOLLIENT PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 50383027015 90550025153705 50383027015 34141

clobetasol propionate/emoll

CLOBETASOL EMOLLIENT PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 50383027030 90550025153705 50383027030 34141

clobetasol propionate/emoll

CLOBETASOL EMOLLIENT PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 50383027060 90550025153705 50383027060 34141

clobetasol propionate/emoll

CLOBETASOL EMOLLIENT PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51672129701 90550025153705 51672129701 34141

clobetasol propionate/emoll

CLOBETASOL EMOLLIENT PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51672129702 90550025153705 51672129702 34141

clobetasol propionate/emoll

CLOBETASOL EMOLLIENT PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51672129703 90550025153705 51672129703 34141

clobetasol propionate/emoll

CLOBETASOL EMOLLIENT PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 52565009415 90550025153705 52565009415 34141

clobetasol propionate/emoll

CLOBETASOL EMOLLIENT PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 52565009430 90550025153705 52565009430 34141

clobetasol propionate/emoll

CLOBETASOL EMOLLIENT PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 52565009445 90550025153705 52565009445 34141

clobetasol propionate/emoll

CLOBETASOL EMOLLIENT PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 52565009460 90550025153705 52565009460 34141

clobetasol propionate/emoll

CLOBETASOL EMOLLIENT PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 181

STEROIDS, TOPICAL VERY HIGH 00378805501 90550025203920 00378805501 97649

clobetasol propionate/emoll

CLOBETASOL EMULSION NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 00378814701 90550025203920 00378814701 97649

clobetasol propionate/emoll OLUX-E NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 00378814750 90550025203920 00378814750 97649

clobetasol propionate/emoll OLUX-E NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 40076010150 90550025203920 40076010150 97649

clobetasol propionate/emoll OLUX-E NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 40085089300 90550025203920 40085089300 97649

clobetasol propionate/emoll

CLOBETASOL EMULSION NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 40085089350 90550025203920 40085089350 97649

clobetasol propionate/emoll

CLOBETASOL EMULSION NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 45802063732 90550025203920 45802063732 97649

clobetasol propionate/emoll

CLOBETASOL EMOLLIENT NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 45802063733 90550025203920 45802063733 97649

clobetasol propionate/emoll

CLOBETASOL EMOLLIENT NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 10337039530 90550050153705 10337039530 67730

diflorasone diacetate/emoll APEXICON E NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 10337039560 90550050153705 10337039560 67730

diflorasone diacetate/emoll APEXICON E NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 00168035515 90550073103710 00168035515 31251 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00168035550 90550073103710 00168035550 31251 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00713064015 90550073103710 00713064015 31251 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00713064086 90550073103710 00713064086 31251 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 45802012932 90550073103710 45802012932 31251 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 45802012935 90550073103710 45802012935 31251 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51862060402 90550073103920 51862060402 45667 halobetasol propionate LEXETTE NPD NPD Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 182

STEROIDS, TOPICAL VERY HIGH 51862060450 90550073103920 51862060450 45667 halobetasol propionate LEXETTE NPD NPD YSTEROIDS, TOPICAL VERY HIGH 51862060602 90550073103920 51862060602 45667 halobetasol propionate

HALOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 51862060650 90550073103920 51862060650 45667 halobetasol propionate

HALOBETASOL PROPIONATE NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 00187000201 90550073104105 00187000201 45728 halobetasol propionate BRYHALI NPD NPD YSTEROIDS, TOPICAL VERY HIGH 00187000260 90550073104105 00187000260 45728 halobetasol propionate BRYHALI NPD NPD YSTEROIDS, TOPICAL VERY HIGH 10631012204 90550073104110 10631012204 40975 halobetasol propionate ULTRAVATE NPD NPD YSTEROIDS, TOPICAL VERY HIGH 10631012251 90550073104110 10631012251 40975 halobetasol propionate ULTRAVATE NPD NPD YSTEROIDS, TOPICAL VERY HIGH 00713033915 90550073104210 00713033915 31211 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00713033986 90550073104210 00713033986 31211 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00713063915 90550073104210 00713063915 31211 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00713063986 90550073104210 00713063986 31211 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00713075815 90550073104210 00713075815 31211 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 00713075886 90550073104210 00713075886 31211 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 45802013132 90550073104210 45802013132 31211 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 45802013135 90550073104210 45802013135 31211 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 51672132203 90550073104210 51672132203 31211 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 52565007315 90550073104210 52565007315 31211 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

AHCCCS PREFERRED DRUG LIST CHANGES EFFECTIVE JANUARY 1, 2020

11/7/2019 183

STEROIDS, TOPICAL VERY HIGH 52565007351 90550073104210 52565007351 31211 halobetasol propionate

HALOBETASOL PROPIONATE PDL PDL Y

STEROIDS, TOPICAL VERY HIGH 43538095104 90559902346420 43538095104 36752

clobetasol/skin cleanser no.28 CLODAN NPD NPD Y

STEROIDS, TOPICAL VERY HIGH 10631012101 90559902496420 10631012101 32631 halobetasol/lactic acid ULTRAVATE X NPD NPD YSTEROIDS, TOPICAL VERY HIGH 10631011901 90559902496440 10631011901 32630 halobetasol/lactic acid ULTRAVATE X NPD NPD Y