Spreadsheet: 057880b8-fbe8-4610-8b0b-d63f2a2e8fc9
Sheet: Sheet1

Generic Name | STRENGTH & PREPARATIONS | If no other Rx Benefit | Medi-Cal Beneficiaries | Unnamed: 4
Representative Brand Name |  | MedImpact (BHS)  Default use is generics | Medi-Cal 6 Rx per mo | CalOptima 6 Rx per mo
BLUE ITALICIZED=Non Formulary; item listed for reference only.
MAJOR TRANQUILIZERS
Amitriptyline/Perphenazine Triavil | 10/2, 25/2, 25/4, 50/4 Tabs |  |  | PAB Required
Aripiprazole Abilify | 2mg, 5mg, 10mg, 15mg, 20mg, 30mg Tabs | Quantity Limit 31 / mo for  all tabs
Asenapine  Saphris | 5mg, 10mg | Pt Assistance Program Required | On Medi-Cal as of 6/1/10
Chlorpromazine Thorazine | 25mg, 50mg, 100mg, 200mg Tab, 25mg/ml inj
Clozapine Clozaril | 25mg, 100mg, Tabs |  | Medi-Cal Tar for for 25 & 100mg tabs | Medi-Cal additionally allows 200mg tab and 12.5, 25, & 100mg orally disintegrating tabs
Fluphenazine HCl Prolixin | 1mg, 2.5mg, 5mg, 10mg Tabs,   5ml Vial Decanoate
[NAME] Haldol | 0.5mg, 1mg, 2mg, 5mg, 10mg, 20mg Tabs   50mg/ml, 100mg/ml   [NAME], [NAME]
iloperidone Fanapt | 1mg, 2mg, 4mg, 6mg, 8mg, 10mg, 12mg | Pt Assistance Program Required | On Medi-Cal as of 5/1/10
Loxapine succinate [NAME] | 5mg, 10mg, 25mg, 50mg Caps |  | MEDI-CAL TAR REQUIRED
Lurasidone HCl [NAME] | 40mg, 80mg Tabs | Pt Assistance Program Required | On Medi-Cal as of 2011
Molindone HCl Moban | 5mg, 10mg, 25mg, 50mg
Olanzapine Zyprexa | 2.5mg, 5mg, 7.5mg,10mg, 15mg, 20mg Tabs 5mg, 10mg, 15mg, 20mg [NAME], 300mg, 405mg    IM Relprevv | [NAME] not on BHS     Not Available with TAR | Medi-Cal TAR & registration for [NAME]
paliperidone Invega | 1.5mg, 3mg, 6mg, 9mg Tabs,   117mg, 156mg, 234mg  IM Sustenna | Pt Assistance Program Required | Medi-Cal TAR
Perphenazine Trilafon | 2mg, 4mg, 8mg, 16mg Tabs
Pimozide Orap | 1mg, 2mg Tabs
Quetiapine Seroquel | 25, 50, 100, 200, 300, 400mg  Tabs 50, 150, 200, 300, 400mg SR (XR) | Quanity Limit 31 / mo for  50mg & 150mg XR  (XR generic is SR)
Risperidone Risperdal | 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg Tabs 0.5mg, 1mg, 2mg M-Tabs,   1mg/ml Liq  12.5mg, 25mg, 37.5mg, 50mg IM Consta | Qty Limit 31 / mo for M-Tabs For [NAME]; Non Formulary item, requires Pt Assistance Program | Medi-Cal Tar     for Consta and M-Tabs
Thioridazine Mellarill | 10mg, 25mg, 50mg, 100mg, Tabs
[NAME] | 1mg, 2mg, 5mg, 10mg, 20mg Caps
Trifluoperazine Stelazine | 1mg, 2mg, 5mg,10mg Tabs
Ziprasidone Geodon | 20mg, 40mg, 60mg, 80mg Caps | No quantity limits for [NAME]. For [NAME]: Quantity Limit 62 / mo for  20mg, 40mg, 60mg tabs
ANTIDEPRESSANTS
Amitriptyline Elavil | 10mg, 25mg, 50mg, 75mg, 100mg, 150mg Tabs
[NAME] | 25mg, 50mg, 100mg, 150mg Tabs
Bupropion  Wellbutrin | 75mg, 100mg Tabs 100mg, 150mg, 200mg SR-12H Tabs (Budeprion) 300mg SR-24H (XL) Tabs (Budeprion)
Citalopram Celexa | 10mg, 20mg, 40mg Tabs |  |  | For Brand; Limit One per day
[NAME] | 25mg, 50mg, 75mg Caps
Desipramine HCL Norpramin | 10mg, 25mg, 50mg, 75mg, 100mg, 150mg Tabs
[NAME] | 10mg, 25mg, 50mg, 75mg, 100mg,  150mg Caps
Duloxetine Cymbalta | 30mg, 60mg | 20mg requires county TAR Quantity Limit 62 / mo for all tabs |  | PAB Required
Escitalopram Lexapro | 10mg, 20mg Tabs |  |  | Will be added 04/13
[NAME] | 10mg, 20mg Caps (Not Tabs),         [NAME],    90mg Pulvule |  |  | Limit One 10mg per day [NAME] dose 80mg / d
Fluvoxamine Luvox | 25mg, 50mg, 100mg Tabs |  |  | Limit 25mg #31/mo, 50mg #45/mo, 100mg #93/mo   [NAME] dose 300mg/d
Imipramine Tofranil | 10mg, 25mg, 50mg Tabs
Maprotiline Ludiomil | 25mg, 50mg, 75mg Tabs |  |  | PAB Required
Mirtazapine [NAME] | 7.5 mg, 15mg, 30mg, 45mg Tabs 15mg, 30mg, 45mg [NAME]
Nefazadone Serzone | 50mg, 100mg, 150mg, 200mg, 250mg Tabs | Quantity Limit 62 / mo for  all tabs [NAME] dose 600mg/d |  | Quantity Limit 62 / mo
[NAME] HCl Aventyl or Pamelor | 10mg, 25mg, 50mg, 75mg  Caps
Paroxetine Paxil | 10mg, 20mg, 30mg, 40mg  Tabs                      12.5mg, 25mg, 37.5mg CR Tabs |  |  | Limit One per day Does not cover CR Tabs
Protriptyline Vivactyl | 5mg, 10mg Tabs
[NAME] | 25mg, 50mg, 100mg Tabs |  |  | Limit per day 25 & 50 mg Limit Two per day 100mg
[NAME] | 50mg, 100mg, 150mg Tabs |  |  | Quantity Limit 62 / mo
Trimipramine Surmontil | 25mg, 50mg, 100mg Caps
Desvenlafaxine Pristiq | 50mg, 100mg Tabs | Pt Assistance Program Required |  | PAB Required
Venlafaxine (& ER) [NAME] | 25mg, 37.5mg, 50mg, 75mg, 100mg Tabs    37.5 mg, 75mg, 150mg, Caps |  |  | Quan Limit 93/ mo for Tabs,   31 / mo for 37.5 mg, 75mg XR & 62 / mo for 150mg XR
Vilazodone HCl Viibryd | 10mg, 20mg, 40mg Tabs | Pt Assistance Program Required |  | PAB Required
MAOI ANTIDEPRESSANTS
Phenelzine Nardil | 15mg |  | MEDI-CAL TAR REQUIRED
[NAME] 24H | 6mg, 9mg, 12mg patch | TAR Required | MEDI-CAL TAR REQUIRED
[NAME] | 5mg [NAME] | TAR Required | MEDI-CAL TAR REQUIRED
Tranylcypromine Parnate | 10mg |  | MEDI-CAL TAR REQUIRED
ANTI-ANXIETY / HYPNOTICS
[NAME] | 0.25mg, 0.5mg, 1mg, 2mg Tab |  |  | Quan Limit 150 / mo for all doses
Buspirone Buspar | 5mg, 10mg, 15mg  [NAME]
Chloral Hydrate | 500mg/ml Liq
Chlordiazepoxide Librium | 5mg, 10mg, 25mg Caps
Clonazepam Klonopin | 0.5mg, 1mg, 2mg Tabs |  |  | Quan Limit 186 / 2 mo for all doses
Diazepam Valium | 2mg, 5mg, 10mg  Tabs
Flurazepam Dalmane | 15mg, 30mg Caps |  |  | Insomnia  (under age 65)
Lorazepam Ativan | 0.5 mg, 1.0 mg, 2.0mg Tabs |  |  | Quan Limit 150 / mo for all doses
Oxazepam Serax | 10mg, 15mg, 30mg Caps
Temazepam Restoril | 7.5mg 15mg, 30mg Caps |  |  | Insomnia
[NAME] | 0.125mg, 0.25mg Tabs | Quantity Limit 20 / mo for  all tabs |  | Insomnia  (limit #31)
Zaleplon Sonata | 5 mg, 10 mg Caps | Quantity Limit 20 / mo for  all tabs |  | Over 55 & Limit #20 per month
[NAME] | 5 mg, 10 mg Tabs | Quantity Limit 20 / mo for  all tabs |  | Over 55 & Limit #31 per month
MOOD STABILIZERS
[NAME] | 100mg, 200mg, 400mg
Divalproex Sodium Depakote | 125mg IR, 125mg, 250mg, & 500mg EC 250mg, & 500mg ER
Gabapentin Neurontin | 100mg, 300mg, 400mg, 600mg, 800mg |  |  | Quan Limit 360 / 2 mo for 100mg, 300mg, 400mg, 600mg & 240 / 2 mo for 800mg
Lamotrogine Lamictal | 25mg, 100mg, 150mg, 200mg
Lithium | 150mg, 300mg, 600mg Caps, 300mg Tab, 300mg CR Tab(Lithobid), 450mg [NAME] ([NAME]) |  | MEDI-CAL TAR for [NAME] 450mg
Oxcarbazepine  Trileptal | 150mg, 300mg, 600mg
Topiramate Topamax | 25mg, 50mg,100mg, 200mg Tabs | Quan Limit 186 / mo for 25mg,   93 / mo for 50mg, & 62 / mo for 100mg & 200mg |  | Quan Limit 186/ mo for 25mg,   93 / mo for 50mg, & 62 / mo for 100mg & 200mg
Valproic Acid Depakene | 250mg, 250mg/5ml
MEDICATIONS Primarily Used for SIDE EFFECTS
[NAME] | 100mg, 50mg/ml
Benztropine Mesylate Cogentin | 0.5mg, 1mg, 2mg Tabs
Diphenhydramine Benadryl | 12.5mg Chew; 25mg, 50mg Caps & Tabs
Hydroxyzine HCl (Generic For Vistaril) | 10mg, 25mg, 50mg, 25mg, 50mg pamoate Caps
Triphexyphenidyl Artane | 2mg, 5mg
Non-Specific or Non-Psychoactive MEDICATIONS
[NAME] | 25mg, 50 mg, 100mg Tabs
Clondine HCl Catapress | 0.1mg, 0.2mg, 0.3mg Tabs   0.1, 0.2, 0.3  once per day patches
Cyanocobalamin Vitamin B-12 | 1000mcg/ml
Docusate Sodium Colace | 100mg, 250 mg Caps
Disulfiram Antabuse | 250mg, 500mg Tabs
Donepezil Aricept | 5mg, 10mg Tabs |  |  | Quanity Limit #31 / mo and Requires MMSE score of 10-26 and Alzheimer's dx on Rx
Desmopressin DDAVP | 0.1mg,0.2mg Tabs; 0.01% Nasal Spray
Folic Acid | 1mg Tab | GPI 82200010000315
Guanfacine HCl [NAME] | 1mg, 2mg
Levothyroxine Sodium Synthroid/Levoxyl | 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg,300mcg Tabs
Liothyronine Cytomel | 5 mcg, 25mcg, 50mcg Tabs
Nicodem Transdermal Patch | 7mg, 14mg, 21mg Patches
Nicotine Gum  Polacrilex | 2mg, 4mg Gum
Propranolol Inderal | 10mg, 20mg, 40mg, 60mg, 80mgTabs
Pyridoxine Vitamin B-6 | 25 mg, 50mg, 100mg, 250mg, 500mg Tabs
Thiamine [NAME] | 50mg, 100mg, 250mg, 500mg Tabs | GPI  77101010102005
Thyroid Extract [NAME] | 15mg, 30mg, 60mg, 90mg, 120mg, 180mg, 240mg, 300mg Tabs
Vitamin - Multi Multi-vitamins | Various Tabs and Caps | GPI   7820 - 7851
PSYCHOSTIMULANT and ADHD MEDICATIONS
Amphetamine/ Dextroamphetamine  Adderall | 5mg, 7.5mg, 10mg, 12.5mg, 15mg, 20mg, 30mg Tabs
Amphetamine/ Dextroamphetamine XR Adderall XR | 5mg, 10mg,15mg, 20mg, 25mg, 30mg Caps
Atomoxetine Strattera | 10mg, 18mg, 25mg, 40mg, 60mg,              100mg Caps |  |  | PAB Required (for more than one tablet      per day)
Dextroamphetamine  Dexedrine | 5mg, 10mg  Tabs
[NAME] Dexedrine Spansules | 5mg, 10mg, 15mg Caps
Dexmethylphenidate Focalin Tabs | 2.5mg, 5mg, 10mg Tabs
Dexmethylphenidate Focalin XR Caps | 5mg, 10mg, 15mg, 20mg, 30mg XR Caps
Methylphenidate Tabs Methylin Ritalin | 5mg, 10mg, 20mg Tabs
Methylphenidate ER Metadate ER [NAME] Ritalin SR | (5hr extended-release)        20mg generic ER Tabs      10mg, 20mg Metadate ER Tabs        20mg Ritalin SR Tabs
Methylphenidate Caps w Long-Acting Pellets Metadate CD Ritalin LA | (8hr extended-release)        10, 20, 30, 40, 50, 60 mg Metadate CD 10mg, 20mg, 30mg, 40mg Ritalin LA
Lisdexamfetamine dimesylate                         Vyvanse Capsules | 20mg, 30mg, 40mg, 50mg, 60mg, 70mg Caps | For CYS Only
Methylphenidate transdermal                          Daytrana TM | 10mg, 15mg, 20mg, 30mg                               Transdermal Patches | For CYS Only
Methylphenidate  (with trilayer core) Concerta | 18mg, 27mg, 36mg, 54mg (14/4), (21/6), (28/8), (42/12)
BLUE ITALICIZED=Non Formulary; item listed for reference only.