Arizona Complete Health Complete Care Plan Behavioral

Arizona Complete Health Complete Care Plan Behavioral-Free PDF

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Pharmacy Program, Arizona Complete Health Complete Care Plan provides appropriate high quality and. cost effective drug therapy to all Arizona Complete Health Complete Care Plan. members Arizona Complete Health Complete Care Plan covers prescription drugs and. certain over the counter OTC drugs when ordered by a doctor Some drugs require. prior authorization PA or have limits on age dosage and maximum amounts. Generic drugs have the same active ingredient as their brand name equivalents and. should be used as the first line of treatment This is unless a drug specifically notes brand. is preferred If there is no generic available there may be more than one brand name. drug that can be used in your treatment The Arizona Complete Health Complete Care. Plan Behavioral Health PDL is reviewed often by our Arizona Complete Health. Pharmacy and Therapeutics P T Committee This helps promote the appropriate and. cost effective use of medications,Dispensing Limits. You can get up to a maximum thirty 30 day supply for each new prescription or. refill of most medications You can get up to a ninety 90 day supply if. The medication is prescribed for chronic illness, You will be out of the service area for an extended period of time. The prescription is limited to the extended time period. A total of 85 of the 30 day supply must have elapsed before the prescription. can be refilled for most drugs,Prior Authorization and Other Limits. Some drugs listed on the Arizona Complete Health Complete Care Plan Behavioral. Health PDL may require prior authorization PA Your doctor or pharmacist will. request a PA for you The information should be submitted by the practitioner or. pharmacist on the Medication Prior Authorization Form This document is located. on the Arizona Complete Health Complete Care Plan web site at. https www azcompletehealth com providers pharmacy html They may fax the PA. form to 1 855 554 5233 or your provider can send a PA request electronically. to https www covermymeds com epa envolverx, Arizona Complete Health Complete Care Plan will cover the medication if.
1 There is a behavioral health medical reason that requires the specific medication. 2 Depending on the medication other medications on the PDL have not worked. Antipsychotic drugs and lithium on the drug list require a Prior Authorization if they. are not prescribed by a behavioral health or other approved specialist. If the request is approved Arizona Complete Health Complete Care Plan notifies. your prescriber by fax If the clinical information provided does not meet the coverage. criteria for the requested medication Arizona Complete Health Complete Care Plan. will review the request and notify you and your prescriber of our decision We will. also let you know about alternative medications if available and provide information. about what you can do to appeal our decision if you do not agree with it. Abbreviation means How it works, AL Age Limit Some drugs are only covered for certain ages. These drugs are covered by Arizona Complete,F Formulary Health Complete Care Plan. Maintenance These drugs are used to treat long term conditions. MP Product or illnesses, These drugs require authorization to be covered by. NF Non Formulary Arizona Complete Health Complete Care Plan. Your doctor must ask for approval from Arizona, Prior Complete Health Complete Care Plan before some. PA Authorization drugs will be covered, QL Quantity Limit Some drugs are only covered for a certain amount.
These drugs are used to treat complex or rare, Specialty conditions such as hepatitis C or rheumatoid. SP Product arthritis,In some cases you must first try certain drugs. before Arizona Complete Health Complete Care,Plan covers another drug for your medical. For example if Drug A and Drug B both treat your,medical condition Arizona Complete Health. Complete Care Plan may not cover Drug B unless,ST Step Therapy you try Drug A first.
Medical Necessity Requests, If an Arizona Complete Health Complete Care Plan member requires a medication to. treat a behavioral health condition that does not appear on the PDL the member s. doctor can make a medical necessity MN request for the medication. Emergency Supply Policy, State and Federal laws require that a pharmacy dispense up to a 4 day supply of. medication to any member awaiting PA determination The purpose is to avoid. interruption of current therapy or delay in the initiation of therapy Participating. pharmacies are authorized to provide up to a 4 day supply of traditional behavioral. health non specialty medication Have your Pharmacy call the Pharmacy Help. Desk at 1 888 624 1131 for help filling a 4 day emergency supply. Exclusions, The Arizona Complete Health Complete Care Plan Drug List does not include certain. drugs The following types of drugs are excluded from coverage They are also not. available for a 4 day emergency supply, Drugs that are considered experimental or investigational Members who are. enrolled may participate in experimental services however AHCCCS will not. reimburse for the experimental service as per A A C R9 22 203. Drug Efficacy Study and Implementation DESI drugs,Prosthesis appliances and devices.
Medications to treat physical health conditions, Oral vitamins and minerals or OTC drugs with the exception of those listed on the. PDL or if a member has a deficiency of a vitamin not listed on the PDL if it treats a. behavioral health condition,Nutritional supplements. Medical marijuana, Drugs eligible for coverage under Medicare Part D for Medicare eligible. members copayments and cost sharing for behavioral health drugs are covered. for SMI members who are also eligible for Medicare. Newly Approved Products, Arizona Complete Health Complete Care Plan reviews new drugs for safety and. effectiveness before adding them to the PDL During this period access to these. drugs will be considered through the PA review process. Filling a Prescription, You can have prescriptions filled at an Arizona Complete Health Complete Care Plan.
network pharmacy You can locate a pharmacy near you by contacting Arizona. Complete Health Complete Care Plan Member Services When you pick a pharmacy. please bring your Arizona Complete Health Complete Care Plan ID card with you The. pharmacy will need the information located on the card to fill your prescription. For More information about your pharmacy benefits please review your Member Handbook. or call Member Services at 888 788 4408 TTY TDY 711. Drug Requirements Drug Requirements,Drug Name Tier Limits Drug Name Tier Limits. ADHD ANTI NARCOLEPSY ANTI QL 1 ea daily, OBESITY ANOREXIANTS Drugs to Treat VYVANSE CAPS F AL At least 6. ADHD Sleep and Eating Disorders yrs old, Amphetamines Attention Deficit Hyperactivity Disorder ADHD. ADDERALL TABS 1 875 QL 2 ea daily QL 1 ea daily, MG 1 875 MG 1 875 MG AL At least 6 atomoxetine hcl caps F AL At least 6. 1 875 MG 3 125 MG 3 125 yrs old yrs old,MG 3 125 MG 3 125 MG QL 4 ea daily.
1 25 MG 1 25 MG 1 25 clonidine hcl adhd tb12 F AL At least 6. MG 1 25 MG 2 5 MG 2 5 F yrs old,MG 2 5 MG 2 5 MG 5 MG QL 1 ea daily. 5 MG 5 MG 5 MG 7 5 MG guanfacine hcl adhd tb24 F AL At least 6. 7 5 MG 7 5 MG 7 5 MG yrs old,amphetamine, dextroamphetamine INTUNIV TB24 guanfacine NF QL 1 ea daily. AL At least 6,ADDERALL TABS 3 75 QL 2 ea daily hcl adhd yrs old. MG 3 75 MG 3 75 MG 3 75 F,MG amphetamine STRATTERA CAPS QL 1 ea daily. dextroamphetamine NF AL At least 6,atomoxetine hcl.
ADDERALL XR CP24 1 25 QL 1 ea daily, MG 1 25 MG 1 25 MG 1 25 AL At least 6 Stimulants Misc. MG 2 5 MG 2 5 MG 2 5 yrs old QL 1 ea daily, MG 2 5 MG 3 75 MG 3 75 APTENSIO XR CP24 F AL At least 6. MG 3 75 MG 3 75 MG methylphenidate hcl yrs old,6 25 MG 6 25 MG 6 25 QL 2 ea daily. MG 6 25 MG 7 5 MG 7 5 CONCERTA TBCR F AL At least 6. MG 7 5 MG 7 5 MG methylphenidate hcl yrs old,amphetamine. dextroamphetamine QL 1 ea daily,DAYTRANA PTCH F AL At least 6.
ADDERALL XR CP24 5 QL 2 ea daily yrs old,MG 5 MG 5 MG 5 MG F AL At least 6. amphetamine yrs old QL 2 ea daily,dexmethylphenidate hcl F AL At least 6. dextroamphetamine tabs 10 mg 2 5 mg 5 mg yrs old,ADZENYS ER SUER NF. amphetamine FOCALIN TABS QL 2 ea daily,NF AL At least 6. amphetamine QL 2 ea daily dexmethylphenidate hcl,dextroamphetamine tabs AL At least 6.
1 875 mg 1 875 mg 1 875 yrs old QL 2 ea daily,FOCALIN XR CP24 F AL At least 6. mg 1 875 mg 3 125 mg dexmethylphenidate hcl,3 125 mg 3 125 mg 3 125 yrs old. F QL 10 ml,mg 1 25 mg 1 25 mg 1 25 METHYLIN SOLN,mg 1 25 mg 2 5 mg 2 5 F daily AL At. methylphenidate hcl least 6 yrs old,mg 2 5 mg 2 5 mg 5 mg 5. mg 5 mg 5 mg 7 5 mg 7 5 methylphenidate hcl cp24 QL 2 ea daily. mg 7 5 mg 7 5 mg or 10 mg 20 mg 30 mg 40 F AL At least 6. amphetamine QL 2 ea daily mg 60 mg yrs old, dextroamphetamine tabs F methylphenidate hcl cpcr or QL 1 ea daily.
3 75 mg 3 75 mg 3 75 mg 40 mg 10 mg 20 mg 30 F AL At least 6. 3 75 mg mg 50 mg 60 mg yrs old, Arizona Complete Health Complete Care Plan Behavioral Health. Effective November 1 2020,Drug Requirements Drug Requirements. Drug Name Tier Limits Drug Name Tier Limits,methylphenidate hcl tabs or F QL 3 ea daily. AL At least 6,unless member,20 mg 10 mg 5 mg yrs old is pregnant or. QL 2 ea daily nursing, RITALIN LA CP24 10 MG F AL At least 6 Prescriber must.
methylphenidate hcl note ICD 10,diagnosis code, RITALIN LA CP24 20 MG QL 2 ea daily on prescription. 30 MG 40 MG NF AL At least 6 O09 91, methylphenidate hcl yrs old buprenorphine hcl subl sl 2. QL 3 ea daily F O09 92,RITALIN TABS mg O09 93,NF AL At least 6 Supervision of. methylphenidate hcl yrs old high risk, AMINOGLYCOSIDES Drugs to Treat Bacterial pregnancy. Infections postpartum,Aminoglycosides mothers First.
KITABIS PAK NEBU digit Letter 2nd,NF digit zeroQL 12. tobramycin,TOBI NEBU tobramycin NF PA Req d, ANALGESICS NonNarcotic Drugs to Treat unless member. Pain Muscle and Joint Conditions is pregnant or,Analgesic Combinations Prescriber must. BUTALBITAL ACETAMINO note ICD 10,PHEN CAPS butalbital NF diagnosis code. acetaminophen on prescription, ANALGESICS OPIOID Drugs to Treat Pain buprenorphine hcl subl sl 8.
Muscle and Joint Conditions F O09 92,Opioid Agonists Supervision of. CONZIP CP24 tramadol NF pregnancy,hcl postpartum,DILAUDID SOLN IJ 1 nursing. MG ML 2 MG ML NF mothers First,hydromorphone hcl digit Letter 2nd. FENTORA TABS fentanyl digit zeroQL 3,NF ea daily,MORPHINE SULFATE buprenorphine hcl QL 12 ea daily. SOLN IV 10 MG ML NF naloxone hcl dihydrate subl F,morphine sulfate 0 5 mg 2 mg.
Opioid Partial Agonists buprenorphine hcl QL 3 ea daily. naloxone hcl dihydrate subl F,SUBLOCADE SOSY F PA,SUBOXONE FILM 0 5 MG QL 12 ea. 2 MG buprenorphine hcl F daily AL At,naloxone hcl dihydrate least 6 yrs old. Arizona Complete Health Complete Care Plan Behavioral Health. Effective November 1 2020,Drug Requirements Drug Requirements. Drug Name Tier Limits Drug Name Tier Limits, SUBOXONE FILM 1 MG 4 QL 6 ea daily hydroxyzine pamoate caps F QL 4 ea daily. MG buprenorphine hcl F AL At least 6 or 25 mg 50 mg. naloxone hcl dihydrate yrs old VISTARIL CAPS NF QL 4 ea daily. SUBOXONE FILM 12 MG QL 2 ea daily hydroxyzine pamoate. 3 MG buprenorphine hcl F AL At least 6,naloxone hcl dihydrate yrs old Benzodiazepines.
SUBOXONE FILM 2 MG 8 QL 3 ea daily,anxiolytic per,MG buprenorphine hcl F AL At least 6. naloxone hcl dihydrate yrs old ALPRAZOLAM INTENSOL F 30 days QL 60. CONC ml per 15 days,ANDROGENS ANABOLIC Drugs to Regulate retail AL At. Hormones least 6 yrs old,Androgens Limit 1,anxiolytic per. ANDROGEL GEL 25 alprazolam tabs or 0 25 F 30 days QL 4. MG 2 5GM 50 MG 5GM NF mg 0 5 mg 1 mg ea daily AL At. testosterone least 6 yrs old,TESTIM GEL NF Limit 1. testosterone anxiolytic per, VOGELXO GEL NF alprazolam tabs or 2 mg F 30 days QL 2.
testosterone ea daily AL At,VOGELXO PUMP GEL least 6 yrs old. testosterone Limit 1, ANTI INFECTIVE AGENTS MISC Drugs to anxiolytic per. alprazolam tb24 or 0 5 mg F 30 days QL 1, Treat Bacterial Infections 1 mg 2 mg 3 mg ea daily AL At. Cyclic Lipopeptides least 6 yrs old,DAPTOMYCIN SOLR 350 NF Limit 1. MG daptomycin anxiolytic per,alprazolam tbdp or 0 25 F 30 days QL 4.
ANTIANXIETY AGENTS Drugs to Treat Anxiety mg 0 5 mg 1 mg ea daily AL At. Antianxiety Agents Misc least 6 yrs old,QL 4 ea daily Limit 1. buspirone hcl tabs or 10 F AL At least 6 anxiolytic per. mg 5 mg 15 mg 7 5 mg yrs old alprazolam tbdp or 2 mg F 30 days QL 2. ea daily AL At,QL 2 ea daily least 6 yrs old,buspirone hcl tabs or 30 F AL At least 6. mg yrs old ATIVAN SOLN IJ 4 PA,MG ML 2 MG ML NF,hydroxyzine hcl soln im 25 F PA lorazepam. mg ml 50 mg ml,QL 4 ea daily, hydroxyzine hcl syrp or 10 QL 4 ml daily ATIVAN TABS OR 0 5 MG NF AL At least 6. F 1 MG lorazepam,mg 5ml yrs old, hydroxyzine hcl tabs or 10 F QL 8 ea daily Limit 1.
mg 25 mg 50 mg anxiolytic per,QL 4 ea daily ATIVAN TABS OR 2 MG NF 30 days QL 2. hydroxyzine pamoate caps F AL At least 6 lorazepam. or 100 mg ea daily AL At,yrs old least 6 yrs old, Arizona Complete Health Complete Care Plan Behavioral Health. Effective November 1 2020,Drug Requirements Drug Requirements. Arizona Complete Health Complete Care Plan will cover the medication if 1 There is a behavioral health medical reason that requires the specific medication 2 Depending on the medication other medications on the PDL have not worked Antipsychotic drugs and lithium on the drug list require a Prior Authorization if they are not prescribed by a behavioral health or other approved specialist

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