CurrentArizona Complete HealthPolicy N/A
Acute - Long Term Care Drug List (behavioral health and stimulants)
Customize your policy alerts
Sign up for all Arizona Complete Health policy alerts
Know when Arizona Complete Health releases new policies or updates existing guidance.
Monitor payer policy activity
Receive email alerts as soon as relevant payer policies are published or updated.
Drug coverage preferences, prior authorization requirements, quantity limits, and preferred status for multiple drug classes (including ADHD/stimulants, opioid use disorder treatments, and behavioral health agents) for Arizona Complete Health members; applies to pharmacy benefit and prescribers/pharmacies serving members.
Policy Summary
PayerArizona Complete Health
PolicyAcute - Long Term Care Drug List (behavioral health and stimulants)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateN/A
Next Review DateN/A
Key ActionObtain prior authorization when prescribing listed agents for children under 6 or when specific PA triggers (e.g., >2 short-acting opioids in 30 days) apply.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
PA <6Age-based PA frequent
PreferredNaloxone status
30Common QL Days
30–300Quantity examples
Coverage Criteria (Drug-specific)
Extracted drug-specific coverage criteria (partial section)
Selected coverage rules and limits extracted from the drug list entries in this section
AMPHETAMINE-DEXTROAMPHETAMINE CAPSULE 24-HOUR: Preferred drug; PA REQUIRED for Ages < 6 years of age; Quantity = 30; QL Days = 30.
METHYLPHENIDATE HCL TABLETS: Preferred drug; PA REQUIRED for Ages < 6 years of age; Quantity = 90; QL Days = 30.
LISDEXAMFETAMINE DIMESYLATE CAPSULES: Preferred drug; PA REQUIRED for Ages < 6 years of age; Quantity = 30; QL Days = 30.
BUPRENORPHINE EXTENDED RELEASE INJECTION (SUBLOCADE): Preferred drug; PA REQUIRED; Quantity/QL Days not specified in excerpt.
NALOXONE HCL NASAL SPRAY 8mg (and NALOXONE HCL SOLUTION + SYRINGE): Preferred drug; Quantity = 2; QL Days = 1 (nasal spray shown with entries of 1 and 2).
BUPRENORPHINE (oral formulations): Mixed coverage entries; PA REQUIRED unless the member is pregnant or nursing (prescriber must include specified ICD-10 codes on the prescription); Quantity/QL Days not specified in excerpt.
Coverage criteria by drug entry (excerpt)
Coverage entries show per-drug administrative controls (prior authorization triggers, quantity and days supply limits, and reference brand names).
Alprazolam (various formulations and strengths): PA REQUIRED for Ages < 6 years; PA REQUIRED when >1 anxiolytic medication is prescribed in a 30-day period; Quantity examples 120 or 60 depending on formulation; QL Days = 30.
Clonazepam (tablets, ODT forms): PA REQUIRED for Ages < 6 years; PA REQUIRED when >1 anxiolytic medication is prescribed in a 30-day period; Quantity examples 120 or 60 depending on strength; QL Days = 30.
Clobazam (suspension, tablets): PA REQUIRED (entries for suspension and tablets indicate PA REQUIRED); quantity/QL Days not listed in excerpt.
ANY of the following
- Anticonvulsant rescue/diazepam gels/liquids: examples show Quantity = 2 and QL Days = 30 for rescue products.
- Other anticonvulsants (carbamazepine, gabapentin, lamotrigine, oxcarbazepine): PA varies; some items show no PA in excerpt; quantities vary by product.
Extracted coverage constraints
Selected coverage constraints from the extract:
MIRTAZAPINE TABLETS and ODT: PA REQUIRED for Ages < 6 years of age; Step Therapy = 30; Quantity = 30; QL Days = 30.
ZURANOLONE CAPSULE: PA REQUIRED (quantity/QL Days not specified in excerpt).
ESKETAMINE HYDROCHLORIDE (SPRAVATO): PA REQUIRED (quantity/QL Days not specified in excerpt).
PREGABALIN (selected capsule strengths/solution): Quantity and QL Days specified for various strengths (examples include qty 90/QL 30 and qty 60/QL 30 for higher strengths).
BUPROPION HCL TABLETS: PA REQUIRED for Ages < 6 years of age; step therapy and quantity/QL Days specified by formulation (examples: 120 qty/30 days for some formulations).
CITALOPRAM HYDROBROMIDE (solution/tablets): PA REQUIRED for specified age ranges (solution and tablet age rules differ); step therapy and quantity limits provided (examples: solution qty 600/QL 30; tablets 40mg qty 30; QL Days = 30).
Coverage criteria observed in excerpt
Coverage-related statements and constraints present in this document segment.
PA requirement — Many behavioral health drug entries indicate 'PA REQUIRED for Ages < 6 years of age' (applies to multiple classes and specific agents).
Preferred status — Naloxone formulations are labeled as PREFERRED DRUG in the list; naloxone solution + syringe and nasal spray entries show preferred status.
Quantity limits — NALOXONE HCL SOLUTION + SYRINGE and nasal spray entries include Quantity = 2 and QL Days = 1 (nasal spray entries show quantity values of 1 and 2 in the extract).
PA exception — Lithium products: PA is not required for ages ≥ 6 when prescribed by a psychiatric clinician, developmental pediatrician, or other prescribers approved by MCO Contractors; PA required for ages < 6.
Behavioral Health Drug Coverage Criteria
Coverage stance for behavioral health drugs with age-based PA rules, preferred status and quantity limits.
Age-based PA — Many medications require prior authorization below specified age thresholds (examples in the extract include PA required for Ages <6, <18 for some LAIs/antipsychotics). Exemptions noted when prescribed by an approved psychiatric clinician or developmental pediatrician for older ages.
Preferred drug listings — Several antipsychotics and related agents are listed as PREFERRED DRUG (examples: aripiprazole solution/tablets, clozapine, lurasidone, long-acting injectables).
Quantity and QL Days — Specific quantity and QL Days are provided for many formulations (examples: aripiprazole solution quantity 750 QL Days 30; LAIs and some antipsychotics show QL Days values such as 30, 90, 170, 365 depending on product).
Long-acting injectables — LAI antipsychotics are listed with PA age thresholds and QL Days (examples include aripiprazole lauroxil, paliperidone palmitate, risperidone microspheres).
Coverage criteria — partial drug list
Formulary entries include preferred status, prior authorization requirements (often age-based), quantity limits (QL days), and occasional step therapy notes.
FLUPHENAZINE DECANOATE SOLUTION: PA REQUIRED for Ages < 18 years; PA not required for ages 18+ when prescribed by specified psychiatric clinicians; quantity/QL Days not specified in excerpt.
HALOPERIDOL DECANOATE SOLUTION: PA REQUIRED for Ages < 18 years; PA not required for ages 18+ when prescribed by specified psychiatric clinicians; quantity/QL Days not specified in excerpt.
ESZOPICLONE and other hypnotics: Preferred drug status shown; PA REQUIRED for Ages < 6 years and when >1 hypnotic is prescribed in a 30-day period; Quantity = 30; QL Days = 30.
ZOLPIDEM TARTRATE TABLETS: Preferred drug; PA REQUIRED for Ages <6 years and when >1 hypnotic drug is used; example Quantity = 60 (5 mg) and QL Days = 30.
DEUTETRABENAZINE (AUSTEDO) and VALBENAZINE (INGREZZA) products: PA REQUIRED; quantities and QL Days provided for pack forms (e.g., 1 kit/QL 28; tablets qty 30/QL 30).
AMPHETAMINE-DEXTROAMPHETAMINE CAPSULE 24-HOUR (Adderall XR generic): Preferred drug; PA REQUIRED for Ages < 6 years; Quantity = 30; QL Days = 30.
Formulary criteria
Formulary guidance and utilization management rules for listed ADHD/anti-narcolepsy agents.
Formulary preference: Generic drugs are preferred over brand name drugs unless the drug is specified as 'BRAND ONLY' (stated at section header for ADHD/Anti-narcolepsy).
Age-based PA: Multiple stimulant and nonstimulant products include 'PA REQUIRED for Ages < 6 years of age' (examples repeated across amphetamine, methylphenidate, dexmethylphenidate entries).
Quantity limits: Most listed stimulant products show Quantity and QL Days typically set to 30 days; exceptions in the extract include quantities of 60, 90, or higher (e.g., methylphenidate solution qty up to 300).
ANY of the following
- Brand designations: Some entries are marked BRAND ONLY or show reference brand names (e.g., ADDERALL XR, RITALIN LA) where applicable.
- Step therapy: Certain entries include step therapy fields (values shown where provided).
Per-drug coverage attributes (partial)
Per-drug coverage attributes appearing in the list fragment
ATOMOXETINE HCL CAPSULES: Preferred Drug Status = PREFERRED DRUG; PA REQUIRED for Ages < 6 years of age; Quantity = 30; QL Days = 30.
CLONIDINE HCL TRANSDERMAL PATCH: Reference Brand = CATAPRES PATCHES; PA REQUIRED for Ages < 6 years of age; Quantity = 4; QL Days = 28.
CLONIDINE HCL (ADHD) TABLET 12-HOUR: Reference Brand = CLONIDINE ER; Preferred Drug Status = PREFERRED DRUG; PA REQUIRED for Ages < 6 years of age; Quantity = 120; QL Days = 30.
GUANFACINE HCL (ADHD) TABLET 24-HOUR: Reference Brand = GUANFACINE ER; Preferred Drug Status = PREFERRED DRUG; PA REQUIRED for Ages < 6 years of age; Quantity = 30; QL Days = 30.
PAROMOMYCIN SULFATE CAPSULE / TOBRAMYCIN NEBULIZED: Designated BRAND ONLY with Reference Brand = KITABIS; Preferred Drug Status = PREFERRED DRUG; PA REQUIRED.
Coverage criteria excerpt
Formulary preference and supply limits for listed NSAIDs and analgesics
Formulary preference: Generic drugs are preferred over brand name drugs unless the drug is specified as BRAND ONLY (section header repeated).
Quantity examples: CELECOXIB / DICLOFENAC entries show example Quantity = 60 for at least one listing in the excerpt.
Quantity examples: Some analgesic/NSAID listings show Quantity = 20 for specific items (see indomethacin/suspension example).
QL Days: QL Days = 30 is used for multiple NSAID listings in the extract.
Partial coverage and utilization notes
Coverage stance and utilization controls shown (partial):
Generic preference: The document repeatedly states that generic drugs are preferred over brand name drugs unless designated BRAND ONLY.
Preferred status: Some agents (including certain biologics and small molecules) are marked PREFERRED DRUG in the extract.
Prior authorization: Certain agents (examples include abatacept, leflunomide, adalimumab biosimilars) are listed as PA REQUIRED.
Quantity examples: The extract shows Quantity examples including 20 units for some entries and QL Days commonly set to 30 days.
Adalimumab product coverage attributes
Coverage attributes for specific adalimumab products as shown on the LTC drug list excerpt.
Adalimumab presentations (ADALIMUMAB-ADBM, ADALIMUMAB-BWWD, ADALIMUMAB-RYVK): Preferred Drug Status = PREFERRED DRUG; PA Status = PA REQUIRED; Reference brands shown (e.g., HADLIMA, SIMLANDI); Quantity/QL Days fields present but values not specified in excerpt.
Adalimumab coverage attributes
Formulary stance and access controls for adalimumab products in the acute - long term care drug list.
ADALIMUMAB-RYVK AUTO-INJECTOR KIT and related presentations: Preferred Drug = PREFERRED DRUG; PA REQUIRED is indicated; Reference Brand = SIMLANDI/HADLIMA; QL Days field present but values blank in excerpt.
Partial coverage entries (extract)
Partial formulary listings and attributes present in this section include:
ADALIMUMAB-BWWD (multiple presentations): Preferred Drug Status = PREFERRED DRUG; PA Status = PA REQUIRED; Reference Brand entries include HADLIMA PUSH / HADLIMA; Quantity/QL Days fields present but values not shown in excerpt.
Coverage criteria and examples
Coverage stance and criteria for listed drug categories and specific products in the acute/long-term care formulary excerpt.
ADALIMUMAB-RYVK AUTO-SYRINGE KIT: Reference Brand = SIMLANDI; Preferred Drug Status = PREFERRED DRUG; PA = PA REQUIRED; quantity/QL Days not specified in excerpt.
APREMILAST (OTEZLA) and ETANERCEPT (ENBREL): Marked BRAND ONLY and PREFERRED DRUG where noted; PA = PA REQUIRED for listed presentations.
Short-acting opioid rule: For short-acting opioid formulations, PA is required when > 2 distinct short-acting opioid medications are dispensed in a 30-day period (applies to multiple short-acting opioid products in the extract).
Butalbital combinations example: BUTALBITAL-ACETAMINOPHEN-CAFFEINE TABLETS shown with Quantity = 120 and QL Days = 30 (example of supply limits).
Extracted coverage rules
Selected coverage criteria and utilization controls from the drug list excerpt.
Opioid utilization rule: > 2 distinct short-acting opioid medications dispensed within 30 days triggers prior authorization REQUIRED (applies to hydromorphone, morphine, oxycodone and similar short-acting opioid entries).
NALOXONE HCL SOLUTION + SYRINGE: Preferred drug; Quantity = 2; QL Days = 1.
NALTREXONE SUSPENSION (VIVITROL): PA REQUIRED unless the member is pregnant or nursing; prescriber must note ICD-10 codes O09.91, O09.92, O09.93 on the prescription to qualify for the exception.
BUPRENORPHINE EXTENDED RELEASE INJECTION and BUPRENORPHINE SOLN PREF SYR (BRIXADI/SUBLOCADE): PA REQUIRED; Methadone for OUD is only available through an Opioid Treatment Program (OTP) provider.
ANY of the following
- Anxiolytics (buspirone, alprazolam, hydroxyzine, clonazepam etc.): PA REQUIRED for Ages < 6 years.
- Anxiolytic utilization trigger: PA REQUIRED when >1 anxiolytic medication is prescribed within a 30-day period.
Coding and Required Codes
Coding — Quantity Limits & Triggers (Key Values)
Maximum QL days examples
Most common maximum QL Days30 days (many stimulant and behavioral health agents)
Higher QL Days exampleUp to 300 QL Days for methylphenidate solution (Quantity = 300; QL Days = 30 shown but solution lists larger quantity)
Long-acting injectable QL Days exampleSome LAI antipsychotics show QL Days up to 365
Quantity limits examples
Typical quantity values60 and 120 units commonly observed (e.g., clonazepam, NSAIDs)
Example: MethotrexateQuantity = 60 shown for methotrexate tablets
Example: Indomethacin / KetoprofenQuantity = 20 appears for several NSAID entries
Common QL Days observed
Common QL Days observed30 days (repeated across many product entries)
Pregabalin examplesPregabalin capsule entries show QL Days = 30 for multiple strengths
Some pack/kit exceptionsCertain kits/packs may show different QL Days (e.g., 28 for some packs)
NALOXONE HCL NASAL SPRAY quantity limits
Naloxone HCL nasal spray preferred statusNALOXONE HCL NASAL SPRAY is listed as PREFERRED DRUG
Quantity limits shownEntries show Quantity = 2 and Quantity = 1 for nasal spray formulations
PA status notePA REQUIRED for Ages < 6 years of age (PA status present in nasal spray entry)
Common QL Days
Common QL Days for oral formulations30 days for many oral behavioral health formulations
LAI QL Days exampleSome long‑acting injectables list QL Days = 365 or other multi‑month values
Solution/large quantity exceptionsCertain solutions (e.g., aripiprazole solution) show large numeric Quantity with QL Days = 30
Quantity/QL Days examples
Common Quantity = QL Days pairingMultiple products list Quantity = 30 with QL Days = 30
Bupropion exampleBUPROPION HCL TABLET 24‑HR entries show Quantity = 30 and QL Days = 30
Zolpidem/Eszopiclone examplesHypnotics commonly listed with Quantity = 30 and QL Days = 30
Typical quantity/QL Days
Typical Quantity/QL Days across stimulantsMost stimulant entries show Quantity or QL Days = 30 (some forms list 60 or 300 for solutions)
Adderall XR exampleAMPHETAMINE‑DEXTROAMPHETAMINE CAPSULE 24‑HR shows Quantity = 30; QL Days = 30
Methylphenidate solution exceptionMETHYLPHENIDATE HCL SOLUTION lists Quantity = 300 (with QL Days repeated as 30)
Quantity/QL limits examples
Quantity = 30 with QL Days = 30 examplesATOMOXETINE, GUANFACINE, and other ADHD agents show Quantity = 30; QL Days = 30
Clonidine patch exceptionCLONIDINE HCL TRANSDERMAL PATCH: Quantity = 4; QL Days = 28
Clonidine 12‑hour tablet exampleCLONIDINE HCL (ADHD) TABLET 12‑HR: Quantity = 120; QL Days = 30
Quantity examples
Quantity = 60 exampleMETHOTREXATE SODIUM TABLETS show Quantity = 60
Quantity = 20 exampleSome NSAID entries show Quantity = 20
QL Days = 30 typicalQL Days = 30 used for multiple analgesic/NSAID listings
Quantity limit (example)
Example quantity limitQuantity = 20 observed for several NSAID entries
Associated QL DaysQL Days commonly set to 30 where provided
ContextThese values appear in the analgesic/NSAID section of the drug list (effective April 1, 2025)
Quantity limit days (QL Days)
Example QL Days valueQL Days = 30 is commonly used
Associated quantity exampleQuantity = 20 shown alongside QL Days = 30 for some entries
ApplicabilityUsed across multiple drug classes in this extract (NSAIDs, stimulants, behavioral health)
Quantity/QL Days
Entries with Quantity/QL Days fields blankSome biologic/specialty listings include Quantity and QL Days fields but values are not specified in this excerpt
Adalimumab exampleADALIMUMAB‑BWWD / ADALIMUMAB‑RYVK show QL Days field present but value blank
Formulary contextPreferred status and PA Status appear even when quantity fields are empty
quantity/QL days
Quantity/QL Days fields present but not populatedMultiple entries show the fields for Quantity and QL Days but no numeric values are provided in the extract
HADLIMA / ADALIMUMAB examplesHADLIMA and related ADALIMUMAB entries list Preferred Drug and PA REQUIRED while Quantity/QL Days are blank
Document date contextDrug List Effective Date: April 1, 2025
Quantity/QL Days
Quantity = 30 and QL Days = 30 common pairingSeveral products (e.g., eszopiclone, various stimulants) show Quantity = 30 with QL Days = 30
Higher quantity exceptionsMethylphenidate solution lists Quantity = 300 as an outlier
Hypnotics exampleESZOPICLONE and TEMAZEPAM commonly listed with Quantity = 30 and QL Days = 30
>2 short-acting opioid meds in 30 days
Opioid utilization trigger (short‑acting)>2 distinct short‑acting opioid medications in a 30‑day period triggers PA REQUIRED
Applies to multiple formulationsRule appears across hydromorphone, hydrocodone/acetaminophen, oxycodone combinations and other short‑acting opioids
Provider action implicationPrescriptions meeting this threshold will require prior authorization per the drug list
Short-acting opioid medication threshold
Short‑acting opioid threshold> 2 medications in a 30‑day time period triggers PA REQUIRED
Examples includedHydromorphone, hydrocodone‑acetaminophen, oxycodone combos are flagged under this rule
Repeated statementThe >2 in 30‑day condition is repeated throughout short‑acting opioid entries in the extract
Anxiolytic medication threshold
Anxiolytic PA trigger> 1 anxiolytic medication in a 30‑day time period triggers PA REQUIRED
Age‑based PA also appliesMany anxiolytic entries also include 'PA REQUIRED for Ages < 6 years'
ExamplesAlprazolam, clonazepam, buspirone and other anxiolytics list both the age and multiple‑medication PA conditions
Provider Actions & Authorization Requirements
Prior Authorization
Buprenorphine PA and pregnancy/nursing exception
Buprenorphine (all formulations) requires prior authorization unless the member is pregnant or nursing. When prescribing for pregnant or nursing members, do NOT require PA; the prescriber must include one of the following ICD-10 codes on the prescription: O09.91, O09.92, O09.93, or O09.91 (use the letter 'O' as the first character).
- PA not required when member is pregnant or nursing and correct ICD-10 code is on prescription: O09.91, O09.92, O09.93, or O09.91 (postpartum/nursing).
- PA required for buprenorphine in all other cases.
Prior Authorization
Naloxone dispensing limitation
Naloxone products are covered with dispensing quantity limits. Standard dispensing is limited to a 1–2 unit supply depending on formulation.
- NALOXONE HCL NASAL SPRAY 8mg — Quantity limit: 2 (QL Days = 1).
- NALOXONE HCL SOLUTION + SYRINGE — Quantity limit: 2 (QL Days = 1).
Prior Authorization
Prior authorization requirement for clobazam
Clobazam (ONFI) requires prior authorization for all listed formulations (tablets and suspension).
- CLOBAZAM SUSPENSION — PA REQUIRED.
- CLOBAZAM TABLETS — PA REQUIRED.
Prior Authorization
MirtaZapine PA and quantity
Mirtazapine formulations require prior authorization for pediatric patients under age 6 and have specified quantity/QL limits.
- MIRTAZAPINE TABLETS — PA REQUIRED for Ages < 6 years; Quantity = 30; QL Days = 30.
- MIRTAZAPINE ORALLY DISINTEGRATING TABLETS — PA REQUIRED for Ages < 6 years; Quantity = 30; QL Days = 30.
Prior Authorization
PA exemptions with clinician types
Certain clinician types are exempt from prior authorization requirements for some age-based PA rules. When applicable, prescriptions written by these clinicians do not require PA for older pediatric or adult patients.
- Psychiatric clinicians, developmental pediatricians, or other prescribers approved by the MCO Contractors — may be exempt from PA for agents such as lithium, clozapine, long‑acting injectables, and select antipsychotics when prescribed for patients at or above the specified age threshold.
- Examples: Lithium formulations — PA NOT REQUIRED for ages ≥ 6 when prescribed by an approved psychiatric clinician/developmental pediatrician; Long‑acting antipsychotic injections — PA NOT REQUIRED for ages ≥ 18 when prescribed by psychiatric clinicians or approved prescribers.
Prior Authorization
Prior authorization — hypnotics/sedatives
Hypnotics and sedative agents have age-based PA requirements and limits on concurrent hypnotic use.
- ESZOPICLONE — PA REQUIRED for Ages < 6 years; PA REQUIRED if > 1 Hypnotic Drug in 30 days; Quantity = 30; QL Days = 30.
- TEMAZEPAM — PA REQUIRED for Ages < 6 years; PA REQUIRED if > 1 Hypnotic Drug in 30 days; Quantity = 30; QL Days = 30.
- ZOLPIDEM (5 mg, 10 mg) — PA REQUIRED for Ages < 6 years; PA REQUIRED if > 1 Hypnotic Drug in 30 days; Quantity and QL Days per formulation (example: Zolpidem 5 mg Quantity = 60, QL Days = 30).
Prior Authorization
Prior authorization — movement disorder agents
Movement-disorder agents (e.g., deutetrabenazine, valbenazine) require prior authorization and have quantity/QL settings.
- DEUTETRABENAZINE TABLET ER 24HR — PA REQUIRED; Quantity = 30; QL Days = 30.
- DEUTETRABENAZINE THERAPY PACK — PA REQUIRED; Quantity = 1 kit; QL Days = 28.
- VALBENAZINE TOSYLATE CAPSULE (INGREZZA) — PA REQUIRED; Quantity = 30; QL Days = 30; VALBENAZINE SPRINKLE and therapy packs — PA REQUIRED with corresponding kit/QL settings.
Prior Authorization
Prior authorization for young children (dexmethylphenidate / methylphenidate / atomoxetine)
Prior authorization is required for certain stimulants and related agents when prescribed for very young children (age thresholds vary by agent). Specific daily/quantity limits apply.
- DEXMETHYLPHENIDATE (capsules/tablets) — PA REQUIRED for Ages < 6 years; Quantity = 60; QL Days = 30.
- METHYLPHENIDATE (capsules 24‑hour, controlled‑release formulations) — PA REQUIRED for Ages < 6 years; common Quantity = 30; QL Days = 30.
- ATOMOXETINE CAPSULES — PA REQUIRED for Ages < 6 years; Quantity = 30; QL Days = 30.
- DEXMETHYLPHENIDATE and METHYLPHENIDATE 24‑hour capsule products listed as PREFERRED DRUG but require PA for young children.
Prior Authorization
Prior Authorization requirement (certain brand-only agents)
Some brand‑only or limited‑distribution agents require prior authorization (brand‑only designation noted on the drug list). PA is required when the formulary flags an agent as BRAND ONLY or if the product is specifically listed with PA REQUIRED.
- Examples of brand‑only PA requirements: APREMILAST (BRAND ONLY) — PA REQUIRED.
- OXYCODONE HCL TAB 12HR DETER — labeled BRAND ONLY; PA rules apply per listing.
- When a drug is marked 'BRAND ONLY' on the drug list, verify PA status before dispensing.
Prior Authorization
Opioid utilization prior authorization
Opioid utilization controls include PA for multiple short‑acting opioids within a 30‑day window and quantity limits for naloxone/antidotes.
- PA REQUIRED for > 2 Short Acting Opioid Medications in a 30‑day time period (applies to many short‑acting opioid formulations: hydromorphone, morphine solution, oxycodone solutions, hydrocodone‑acetaminophen, etc.).
- Antidotes/Opioid antagonists (naloxone) — Quantity limits: typically 2 per dispense; QL Days = 1.
- NALTREXONE SUSPENSION (VIVITROL) — PA REQUIRED unless the member is pregnant or nursing; when used in pregnancy/nursing, prescriber must include one of ICD‑10 codes O09.91/O09.92/O09.93 on the prescription.
Prior Authorization
Quantity limits (example)
Quantity limits are applied across many therapeutic classes as examples of operational constraints to prevent overuse or duplicate therapy.
- Stimulants: AMPHETAMINE‑DEXTROAMPHETAMINE CAPSULE 24‑HR — Quantity = 30; QL Days = 30.
- Dexmethylphenidate 24‑HR capsules/tablets — Quantity = 60; QL Days = 30.
- Atomoxetine capsules — Quantity = 30; QL Days = 30.
- Bupropion tablets — Quantity = 120 for some formulations; QL Days = 30 (age‑based PA may also apply).
Definitions & Formulary Notes
Generic Drugs Are Preferred Over Brand Name Drugs Unless The Drug Is Specified As BRAND ONLY
Generic drugs preferred policyGeneric Drugs Are Preferred Over Brand Name Drugs Unless The Drug Is Specified As BRAND ONLY
Brand‑only exceptionsWhere an item is designated 'BRAND ONLY' the brand is used despite generic preference
Section contextPreference statement appears repeatedly in the Acute - Long Term Care drug list (effective April 1, 2025)
Federal reimbursement / prior authorization note
Federal reimbursement noteFederally reimbursable drugs not listed on the AHCCCS Drug List may be available through Prior Authorization
ImplicationPrescribers may request PA for federally reimbursable drugs absent from the listed formulary
Prior Authorization required (document indicates PA REQUIRED conditions such as age <6 or >1 anxiolytic in 30 days)
Examples of conditions requiring PAPA REQUIRED for Ages < 6 years; PA REQUIRED when >1 anxiolytic or >1 hypnotic in a 30‑day period
Hypnotic class exampleESZOPICLONE and ZOLPIDEM entries: PA REQUIRED for Ages <6 and when >1 hypnotic drug prescribed
Anxiolytic class exampleALPRAZOLAM and CLONAZEPAM entries: PA REQUIRED for Ages <6 and for >1 anxiolytic in 30 days
Quantity Limit Days
Quantity Limit Days (QL Days) typical valueQL Days = 30 commonly indicated for dispensing intervals
Occasional shorter QL DaysSome items show QL Days = 28 (e.g., certain patch products)
Where missingFor some specialty biologics QL Days fields are present but not populated in the excerpt
Prior Authorization required for children under 6
PA required for children under 6 (examples)Multiple stimulant and behavioral health agents list 'PA REQUIRED for Ages < 6 years of age'
Lithium exception notePrior Authorization is not required for ages 6+ when prescribed by a psychiatric clinician, developmental pediatrician or other approved prescribers
ScopeThis pediatric PA rule appears across many formulary sections in the extract
Prior Authorization (PA) pediatric rule
Pediatric PA rule summaryPA REQUIRED for Ages < 6 years of age for many agents; some agents require PA <18 years for LAIs and certain antipsychotics
PA exemption for certain prescribersPA not required for older ages when prescribed by psychiatric clinicians, developmental pediatricians, or other approved prescribers
Repeated applicationAge‑based PA thresholds (<6, <12, <18) are applied across multiple drug classes in the list
Quantity Limit Days
Definition: QL DaysQuantity Limit Days (QL Days) indicates the dispensing interval used for quantity controls
Typical numeric valueQL Days = 30 is the most commonly used interval in the extract
Used across classesAppears for stimulants, analgesics, behavioral health agents, and many others
Prior Authorization
Prior Authorization indicated for specialty biologicsPA REQUIRED is shown for adalimumab biosimilars and other specialty agents
Preferred status may still applyMany biologic entries show PREFERRED DRUG alongside PA REQUIRED
Quantity/QL Days often blankQuantity and QL Days fields are sometimes present but not filled for these agents in the excerpt
Generic preference
Generic preference restatedGeneric drugs are preferred over brand name drugs unless specified as 'BRAND ONLY'
Appears across sectionsThis formulary preference statement is repeated throughout the Acute - Long Term Care drug list (effective April 1, 2025)
Generic Drugs Preferred
Generic Drugs Preferred statement'Generic Drugs Are Preferred Over Brand Name Drugs Unless The Drug Is Specified As BRAND ONLY' appears at the top of sections
Provider implicationWhen a generic is available, it should be used unless the product is noted as BRAND ONLY
Preferred Drug Status
Preferred Drug Status exampleSeveral adalimumab biosimilars are listed as PREFERRED DRUG while PA REQUIRED is also indicated
Reference brand mappingReference Brand names (e.g., HADLIMA, SIMLANDI) are shown alongside biosimilar entries
PA REQUIRED (age-based)
Age‑based PA (AMPHETAMINES)AMPHETAMINE‑DEXTROAMPHETAMINE entries: PA REQUIRED for Ages < 6 years of age
Quantity/QL Days shownMany amphetamine entries list Quantity = 30 and QL Days = 30
Generic preference noteGeneric forms are preferred unless 'BRAND ONLY' is specified (Adderall XR referenced)
Generic preference
Generic preference reiterated'Generic Drugs Are Preferred...' phrasing repeated in ADHD/related sections
Implication for prescribersPrescribers should select generics when available unless brand‑only is required
PA REQUIRED (age)
PA required for young childrenATOMOXETINE and other ADHD agents: PA REQUIRED for Ages < 6 years of age
Quantity exampleATOMOXETINE HCL CAPSULES: Quantity = 30; QL Days = 30
Quantity Limit Days (QL Days) indicated for dispensing intervals
QL Days for dispensing intervalsQL Days = 30 used as the standard dispensing interval for many products
Patch exceptionSome transdermal patches show QL Days = 28 (e.g., clonidine patch) where noted
Prior Authorization status field (entries here are blank in this excerpt)
PA status field sometimes blankFor some specialty biologic entries the PA Status and Quantity/QL Days fields appear but are blank in this excerpt
Documentation implicationLook for full formulary record to obtain missing numeric quantity or QL Days values for these listings
Preferred drug / Brand only
Preferred drug / brand only examplesSome entries are designated PREFERRED DRUG while others may be BRAND ONLY; generic preference remains the default
Adalimumab mappingADALIMUMAB entries map to reference brands such as HADLIMA and SIMLANDI
PA REQUIRED
PA REQUIRED example (age-based/pregnancy exception)NALTREXONE SUSPENSION (VIVITROL) = PA REQUIRED unless the member is pregnant or nursing (ICD‑10 codes required for exception)
Naloxone preferred exampleNALOXONE HCL SOLUTION + SYRINGE listed as PREFERRED DRUG with Quantity = 2 and QL Days = 1
OTP access noteMETHADONE for OUD available only at an Opioid Treatment Program (OTP) provider
Formulary attributes
Formulary attributes include reference brandsReference brand names are provided for many entries (e.g., ADDERALL XR, RITALIN LA, CELEXA)
Brand vs generic field presentEach listing shows Brand Only/Generic notes, Preferred Drug Status, PA Status, Quantity and QL Days fields
generic preference
Generic preference repeatedPhrase 'Generic Drugs Are Preferred Over Brand Name Drugs Unless The Drug Is Specified As BRAND ONLY' appears throughout the extract
Applies across classesStatement applies to ADHD, analgesics, behavioral health, biologics and other sections shown
Formulary preference statement
Formulary preference statementGeneric Drugs Are Preferred Over Brand Name Drugs Unless The Drug Is Specified As BRAND ONLY
Provider implicationUse generic products when available unless the drug row indicates BRAND ONLY
Generic Drugs Are Preferred Over Brand Name Drugs Unless The Drug Is Specified As BRAND ONLY
Generic preference summaryGeneric drugs are preferred over brand name drugs unless specified as BRAND ONLY
Repeats across listThis policy note is repeated at the start of multiple sections in the extract (Acute - Long Term Care Drug List)
Preferred Drug Status
Preferred Drug Status example (adalimumab)ADALIMUMAB‑BWWD and ADALIMUMAB‑RYVK listed as PREFERRED DRUG while PA REQUIRED is also indicated
Quantity/QL Days absentQuantity and QL Days fields for these entries are present but values are blank in this excerpt
PA REQUIRED (age-based)
PA REQUIRED (age-based) exampleNALTREXONE SUSPENSION: PA REQUIRED unless pregnant or nursing (ICD‑10 codes required on prescription for exception)
ICD‑10 codes requiredO09.91, O09.92, O09.93 must be documented for pregnancy/nursing exception
Policy Summary
PayerArizona Complete Health
PolicyAcute - Long Term Care Drug List (behavioral health and stimulants)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateN/A
Next Review DateN/A
Key ActionObtain prior authorization when prescribing listed agents for children under 6 or when specific PA triggers (e.g., >2 short-acting opioids in 30 days) apply.
SourceLink
On This Page
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.