2021 Formulary Changes – Year to Date
Health Choice Arizona may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, add
prior authorization, quantity limits and/or step therapy restrictions on a drug, and/or move a drug at a higher cost-sharing tier, we
will notify you of the change at least 30 days before the date that the change becomes effective. However, if the Food and Drug
Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will
immediately remove the drug from our formulary.
This table shows drugs that have been removed from the 2021 Health Choice Arizona Formulary.
Name of Drug Description of Change Alternative Drug
Effective Date
ADAPALENE 0.1% GEL Formulary Deletion 01/01/2021
AVAR CLEANSER Formulary Deletion 01/01/2021
AVAR-E GREEN EMOLLIENT CREAM Formulary Deletion 01/01/2021
AVITA 0.025% CREAM Formulary Deletion 01/01/2021
BPO 6% FOAMING CLOTHS Formulary Deletion 01/01/2021
BP 10-1 WASH Formulary Deletion 01/01/2021
CLINDAMYCIN-BENZOYL PEROX 1-5% Formulary Deletion CLIND PH-BENZOYL PEROX 1.2-5% 01/01/2021
CLINDAMYCIN PHOSPHATE 1% FOAM Formulary Deletion 01/01/2021
ERY 2% PADS Formulary Deletion 01/01/2021
SSS 10-5 FOAM Formulary Deletion 01/01/2021
SODIUM SULF-SULFUR CLEANSER Formulary Deletion 01/01/2021
BP CLEANSING WASH
Formulary Deletion 01/01/2021
SODIUM SULFACET-SULFUR WASH
Formulary Deletion 01/01/2021
SOD SULFACET-SULFUR 10-2% CLSR
Formulary Deletion 01/01/2021
SOD SULFACETAMIDE-SULFUR LOTN
Formulary Deletion 01/01/2021
SOD SULFACET-SULFUR 10-4% PAD
Formulary Deletion 01/01/2021
SULFACETAMIDE-SULFUR 8-4% SUSP
Formulary Deletion 01/01/2021
SODIUM SULFACETAMIDE 10% WASH
Formulary Deletion 01/01/2021
SOD SULFACE-SULFUR 9-4.5% WASH
Formulary Deletion 01/01/2021
SULFACETAMIDE-SULFUR 10-2% CRM
Formulary Deletion 01/01/2021
SULFACETAMIDE SOD 10% TOP SUSP
Formulary Deletion 01/01/2021
TRETINOIN CREAM
Formulary Deletion RETIN-A CREAM (BRAND) 01/01/2021
TRETINOIN GEL
Formulary Deletion RETIN-A GEL (BRAND) 01/01/2021
GRISEOFULVIN ULTRA TAB
Formulary Deletion 01/01/2021 ITRACONAZOLE 100 MG CAPSULE Formulary Deletion 01/01/2021 KETOCONAZOLE 200 MG TABLET Formulary Deletion 01/01/2021 NOXAFIL 40 MG/ML SUSPENSION Formulary Deletion 01/01/2021
CICLOPIROX 0.77% TOPICAL SUSP
Formulary Deletion 01/01/2021
ATHLETE'S FOOT 2% POWDER SPRAY
Formulary Deletion OTC ANTIFUNGAL 01/01/2021
ECONAZOLE NITRATE 1% CREAM
Formulary Deletion 01/01/2021
AMANTADINE 100 MG TABLET Formulary Deletion 01/01/2021
CARBIDOPA-LEVODOPA ODT Formulary Deletion 01/01/2021
CARBIDOPA/LEVODOPA/ENTACAPONE TAB Formulary Deletion 01/01/2021
ROPINIROLE HCL ER TABLET Formulary Deletion 01/01/2021
SELEGILINE HCL 5 MG CAPSULE/TABLET Formulary Deletion 01/01/2021
MYRBETRIQ ER TABLET Formulary Deletion DETROL, TOVIAZ, OXYBUTYNIN 01/01/2021
TOLTERODINE TARTRATE TAB Formulary Deletion DETROL, TOVIAZ, OXYBUTYNIN 01/01/2021
TOLTERODINE TART ER CAP Formulary Deletion DETROL, TOVIAZ, OXYBUTYNIN 01/01/2021
TROSPIUM CHLORIDE 20 MG TABLET Formulary Deletion 01/01/2021
VERAPAMIL 360 MG CAP PELLET Formulary Deletion 01/01/2021
VERAPAMIL ER PM CAPSULE Formulary Deletion 01/01/2021
ETONOGESTREL-EE VAGINAL RING Formulary Deletion 01/01/2021
ZAFIRLUKAST 10MG TABLET Formulary Deletion 01/01/2021
COLESTIPOL HCL GRANULES Formulary Deletion 01/01/2021
FENOFIBRIC ACID DR CAP Formulary Deletion 01/01/2021
NIACIN 500 MG TABLET Formulary Deletion 01/01/2021
OMEGA-3 ETHYL ESTERS 1 GM CAP Formulary Deletion 01/01/2021
VASCEPA Formulary Deletion 01/01/2021
AMLODIPINE-ATORVASTATIN TABLET Formulary Deletion AMLODIPINE TABLET + ATORVASTATIN TABLET 01/01/2021
FOSRENOL Formulary Deletion 01/01/2021
LANTHANUM CARB TAB CHEW Formulary Deletion 01/01/2021
OMEPRAZOLE MAG DR 20.6 MG CAP Formulary Deletion 01/01/2021
EDLUAR SL TABLET Formulary Deletion 01/01/2021
ZALEPLON CAPSULE Formulary Deletion 01/01/2021
ZOLPIDEM TART TABLET SL Formulary Deletion 01/01/2021
ZOLPIDEM TART ER TAB Formulary Deletion 01/01/2021
NEXIUM DR 20 MG CAPSULE (BRAND) Formulary Deletion 01/01/2021
CLINDAMYCIN PHOSPHATE 1% GEL Formulary Deletion 01/01/2021
CLOTRIMAZOLE 1% SOLUTION Formulary Deletion OTC ANTIFUNGAL 01/01/2021
ASHLYNA 0.15-0.03-0.01 MG TAB Formulary Deletion CAMRESE 01/01/2021
CAZIANT 28 DAY TABLET Formulary Deletion VELIVET 01/01/2021
CYCLAFEM 1-35-28 TABLET Formulary Deletion ORTHO-NOVUM 1/35; NORTREL 1/35 01/01/2021
CYRED EQ 28 DAY TABLET Formulary Deletion RECLIPSEN 01/01/2021
ECONTRA EZ 1.5 MG TABLET Formulary Deletion PLAN B ONE-STEP 01/01/2021
ECONTRA ONE-STEP 1.5 MG TABLET Formulary Deletion PLAN B ONE-STEP 01/01/2021
EMOQUETTE 28 DAY TABLET Formulary Deletion RECLIPSEN 01/01/2021
GENERESS FE CHEWABLE TABLET Formulary Deletion NORETH/ETHIN CHW FE 01/01/2021
INCASSIA 0.35 MG TABLET Formulary Deletion NORETHINDRON TAB 0.35MG 01/01/2021
JOLESSA 0.15 MG-0.03 MG TABLET Formulary Deletion LEVONOR/ETHI TAB ESTRADIO 01/01/2021
KALLIGA 28 DAY TABLET Formulary Deletion RECLIPSEN 01/01/2021
LAYOLIS FE CHEWABLE TABLET Formulary Deletion NORETH/ETHIN CHW FE 01/01/2021
LEENA 28 TABLET Formulary Deletion ARANELLE TAB 01/01/2021
LEVONO-E ESTRAD 0.15-0.03-0.01 Formulary Deletion CAMRESE TAB 01/01/2021
LEVONOR-E ESTRAD 0.1-0.02-0.01 Formulary Deletion CAMRESE LO TAB 01/01/2021
LO LOESTRIN FE 1-10 TABLET Formulary Deletion 01/01/2021
LOESTRIN 21 1.5-30 TABLET Formulary Deletion JUNEL 1.5/30 TAB 01/01/2021
LOESTRIN 21 1-20 TABLET Formulary Deletion NORETH/ETHIN TAB 1/20 01/01/2021
LOESTRIN FE 1.5-30 TABLET Formulary Deletion JUNEL FE TAB 1.5/30 01/01/2021
LOJAIMIESS 0.1-0.02-0.01 TAB Formulary Deletion CAMRESE LO TAB 01/01/2021
LOSEASONIQUE TABLET Formulary Deletion CAMRESE LO TAB 01/01/2021
LYZA 0.35 MG TABLET Formulary Deletion NORETHINDRON TAB 0.35MG 01/01/2021
MONO-LINYAH 28 TABLET Formulary Deletion SPRINTEC 01/01/2021
NATAZIA 28 TABLET Formulary Deletion 01/01/2021
NORA-BE TABLET Formulary Deletion NORETHINDRON TAB 0.35MG 01/01/2021
OCELLA 3 MG-0.03 MG TABLET Formulary Deletion DROSPIR/ETHI TAB 3-0.03MG 01/01/2021
OGESTREL TABLET Formulary Deletion 01/01/2021
OPCICON ONE-STEP 1.5 MG TABLET Formulary Deletion PLAN B ONE-STEP 01/01/2021
PREVIFEM TABLET Formulary Deletion SPRINTEC 01/01/2021
TILIA FE 28 TABLET Formulary Deletion TRI-LEGEST TAB FE 01/01/2021
TRI-LINYAH TABLET Formulary Deletion TRI-PREVIFEM TAB 01/01/2021
TULANA 0.35 MG TABLET Formulary Deletion NORETHINDRON TAB 0.35MG 01/01/2021
WYMZYA FE CHEWABLE TABLET Formulary Deletion 01/01/2021
This table outlines the positive changes to our formulary that may impact you.
Name of Drug Description of Change Drug Coverage Effective Date
BENZOYL PEROXIDE 2.5% GEL Addition to the Formulary 01/01/2021
ACNE MEDICATION 5% LOTION Addition to the Formulary 01/01/2021
ACNE MEDICATION 10% LOTION Addition to the Formulary 01/01/2021
CLIND PH-BENZOYL PEROX 1.2-5% Addition to the Formulary 01/01/2021
RETIN-A CREAM Addition to the Formulary
PA Required for Age > 26 01/01/2021
RETIN-A GEL Addition to the Formulary
PA Required for Age > 26 01/01/2021
DETROL TABLET Addition to the Formulary
Step Therapy required 01/01/2021 DETROL LA CAPSULE Addition to the Formulary
Step Therapy required 01/01/2021
TOVIAZ ER TABLET Addition to the Formulary
Step Therapy required 01/01/2021
ETHYNODIOL-ETH ESTRA 1MG-50MCG Addition to the Formulary 01/01/2021
KELNOR 1-50 TABLET Addition to the Formulary 01/01/2021
MELODETTA 24 FE CHEWABLE TAB Addition to the Formulary 01/01/2021
NORETH-ESTRAD-FE 1-0.02(24)-75 Addition to the Formulary 01/01/2021
PLAN B ONE-STEP 1.5 MG TABLET Addition to the Formulary 01/01/2021
FISH OIL EC 1,000 MG SOFTGEL Addition to the Formulary 01/01/2021
KRILL OIL 300 MG SOFTGEL Addition to the Formulary 01/01/2021
ESOMEPRAZOLE MAG DR CAP Addition to the Formulary 01/01/2021 ESOMEPRAZOLE DR PACKET
Addition to the Formulary 01/01/2021
LANSOPRAZOLE ODT TABLET
Addition to the Formulary 01/01/2021
PROTONIX 40 MG SUSPENSION
This table outlines the changes to Prior Authorization Criteria that may impact you.
Name of Drug Description of Change Effective Date
