Medication Generic Name Brand Reference Name Formulation(s) Age Limitation Prior Authorization Required Quantity Limit Additional Information ANTIDEPRESSANTS Alpha-2 Receptor Antagonist Antidepressants mirtazapine Remeron Remeron SolTab Tab ODT Monoamine Oxidase Inhibitors (MAOIs) seligilene EMSAM TD Patch X isocarboxazid Marplan Tab phenelzine sulfate Nardil Tab tranylcypromine sulfate Parnate Tab Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs) bupropion hbr APLENZIN ER Tab X bupropion hcl Wellbutrin Wellbutrin SR Wellbutrin XL IR Tab ER Tab ER Tab Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram hbr Various Soln citalopram hbr Celexa Tab escitalopram oxalate Lexapro Soln escitalopram oxalate Lexapro Tab fluoxetine hcl Prozac Cap / Tab fluoxetine hcl Prozac Soln fluoxetine hcl Prozac Weekly DR Cap X fluvoxamine maleate Luvox Tab fluvoxamine maleate Luvox CR ER Cap paroxetine hcl Paxil Susp paroxetine hcl Paxil Tab paroxetine hcl tab Paxil CR ER Tab Paroxetine mesylate PEXEVA Tab X sertraline hcl Zoloft Conc sertraline hcl Zoloft Tab vilazodone hcl VIIBRYD Tab X Sero tonin-2 Antagonist/Reuptake Inhibitors (SARIs) nefazodone Various Tab trazodone hcl Various Tab trazodone hcl OLEPTRO ER Tab X Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) desvenlafaxine PRISTIQ ER Tab X duloxetine hcl CYMBALTA Cap venlafaxine hcl Effexor Tab venlafaxine hcl Effexor ER Cap
Medication Generic Name Brand Reference Name Formulation(s) Age Limitation Prior Authorization Required Quantity Limit Additional Information venlafaxine hcl Various ER Tab Tricyclic Antidepressants & Related Non-Selective Reuptake Inhibitors amitriptyline hcl Various Tab amoxapine tab Various Tab clomipramine hcl Anafranil Cap desipramine hcl Norpramin Tab doxepin hcl Various Cap doxepin hcl Various Conc doxepin hcl SILENOR Tab X imipramine Various Tab imipramine hcl Tofranil-PM Cap maprotiline hcl Various Tab nortriptyline hcl Pamelor Cap nortriptyline hcl Various Soln protriptyline hcl Vivactil Tab trimipramine maleate Surmontil Cap Combination Medications Used for the Treatment of BPAD fluoxetine hcl /olanzapine Symbyax Cap X ANTIPSYCHOTICS 1st Generation Antipsychotics haloperidol Various Tab X haloperidol decanoate Haldol Inj X haloperidol lactate Various Conc X loxapine succinate Loxitane Cap X pimozide ORAP Tab X thiothixene Navane Cap X 2nd Generation Antipsychotics aripiprazole ABILIFY Tab X X aripiprazole ABILIFY DISCMELT ODT Tab X X aripiprazole ABILIFY MAINTENA Inj X X aripiprazole ABILIFY Soln X X clozapine Clozaril Tab X clozapine FazaClo ODT Tab X Iloperidone FANAPT Tab X X paliperiodone INVEGA ER Tab X X paliperidone INVEGA SUSTENNA LA Susp X X lurasidone hcl LATUDA Tab X X
Medication Generic Name Brand Reference Name Formulation(s) Age Limitation Prior Authorization Required Quantity Limit Additional Information oxcarbazepine Trileptal Tab valproate sodium Various Soln valproate sodium Depakene Cap / Syrup ANTIMANIC AGENTS lithium carbonate Various Cap lithium carbonate Lithobid ER Tab lithium citrate Various Soln ADHD DRUGS Amphetamines amphetamine- dextroamphetamine Adderall Tab X amphetamine- dextroamphetamine Adderall XR SR Cap X dextroamphetamine sulfate Dexedrine ER Cap X dextroamphetamine sulfate Various Tab X lisdexamfetamine dimesylate VYVANSE ER Cap X Stimulants dexmethylphenidate hcl Focalin Tab X dexmethylphenidate hcl FOCALIN XR ER Cap X methylphenidate hcl Ritalin Tab X methylphenidate hcl METHYLIN Chew Tab X methylphenidate hcl Ritalin LA / Metadate CD ER Cap X methylphenidate hcl Ritalin SR SR Tab X methylphenidate hcl Concerta ER Tab X methylphenidate hcl DAYTRANA TD Patch methylphenidate hcl METHYLIN Soln X methylphenidate hcl QUILLIVANT XR Susp X X Miscellaneous Agents atomoxetine STRATTERA Cap X Central Alpha-Agonists clonidine hcl Catapres Tab clonidine hcl KAPVAY ER Tab clonidine hcl Catapres TTS TD Patch guanfacine hcl Tenex Tab
Medication Generic Name Brand Reference Name Formulation(s) Age Limitation Prior Authorization Required Quantity Limit Additional Information guanfacine hcl INTUNIV ER Tab X SUBSTANCE ABUSE Opiate Agonists/Partial Agonists buprenorphine hcl Subutex SL Tab buprenorphine hcl / naloxone Suboxone SL Tab buprenorphine hcl / naloxone SUBOXONE FILM Film X methadone Dolophine * Opiate Antagonists naltrexone Revia Tab naltrexone VIVITROL Inj X Miscellaneous Agents acamprosate CAMPRAL DR Tab disulferam Antabuse Tab ANXIOLYTICS AND HYPNOTICS Benzodiazepines alprazolam Xanax Tab alprazolam intensol Alprazolam Intensol Conc Soln alprazolam Xanax XR ER Tab alprazolam Niravam ODT chlordiazepoxide hcl Librium Cap clonazepam Klonopin Tab clonazepam Various ODT clorazepate dipotassium Tranxene-T Tab diazepam Valium Tab diazepam intensol Diazepam Intensol Conc Soln estazolam Various Tab flurazepam hcl Dalmane Cap lorazepam Ativan Tab lorazepam Lorazepam Intensol Conc Soln oxazepam Serax Cap temazepam Restoril Cap Miscellaneous Anxiolytics, Sedatives & Hypnotics buspirone hcl Various Tab
Medication Generic Name Brand Reference Name Formulation(s) Age Limitation Prior Authorization Required Quantity Limit Additional Information eszopiclone LUNESTA Tab X meprobamate Various Tab ramelteon ROZEREM Tab triazolam Halcion Tab zaleplon capsule Sonata Cap zolpidem Ambien Tab zolpidem Ambien CR ER Tab X zolpidem INTERMEZZO SL / EDULAR SL Tab X zolpidem ZOLPIMIST Soln X ANTIHISTAMINES cyproheptadine hcl Various Tab diphenhydramine Various Cap / Tab diphenhydramine hcl Various Elix / Syr hydroxyzine hcl Atarax Tab / Syr hydroxyzine pamoate Vistaril Cap DOPAMINE AGONISTS amantadine hcl Various Cap / Tab AUTONOMIC AGONISTS Parasympathomimetic (Cholinergic) Agents bethanechol chloride Urecholine Tab Anticholinergic Agents benzotropine mesylate Cogentin Tab trihexyphenidyl hcl Artane Tab CARDIOVASCULAR DRUGS Alpha-1 Adrenergic Blocking Agents prazosin hcl Minipres Cap Beta-Adrenergic Blocking Agents nadolol tab Corgard Tab propranolol hcl Inderal Tab THYROID AGENTS levothyroxine sodium Levothroid / Synthroid Tab liothyronine Cytomel Tab VITAMINS AND OTHER MISCELLANEOUS AGENTS alpha-tocopherol Vitamin E – Various Cap cyanocobalamin Vitamin B12 - Various Tab folic acid Various Tab omega 3 fatty acids Various Cap pyridoxine hcl Vitamin B6 - Various Tab
Medication Generic Name Brand Reference Name Formulation(s) Age Limitation Prior Authorization Required Quantity Limit Additional Information thiamine hcl Vitamin B1 - Various Tab multiple vitamin Various Tab multiple vitamin / minerals Various Tab Miscellaneous Ear, Nose & Throat Drug saliva substitute Salivart Spray Cathartics and Laxatives docusate sodium Colace Cap psyllium Metamucil Powder