IMPORTANT NOTICE. Changes to dispensing of some Behavioral Health Medications for DC Healthcare Alliance members
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1 IMPORTANT NOTICE Changes to dispensing of some Behavioral Health Medications for DC Healthcare Alliance members These changes apply only to members covered under the DC Healthcare Alliance program Alliance members who need to fill the behavioral medications noted on the attached list will be required to fill them at the Core Service Agency (CSA) /Department of Behavioral Health (DBH) Pharmacy located at 35 K Street NE, Washington, DC. The pharmacy is open Monday through Friday from 8:30 am to 5 pm. Prescriptions received before 4:15 pm will be filled the same day. Should assistance be required, call (202) This change applies only to the medications and the dosages and dosage forms indicated on the list. For example, prescriptions for fluoxetine 10 mg and 20 mg capsules should be filled at the CSA/DBH pharmacy, but 40 mg capsules and all tablet doses should be filled at MFC network retail pharmacies. Additional behavioral health medications on the MedStar Family Choice formulary remain available to Alliance members. The standard MFC request procedures for prior authorization, step therapy and non-formulary requests will apply. Emergency 3-Day supplies will be available at MFC network pharmacies for fills when the CSA/DBH pharmacy is closed. Page 1
2 CSA FORMULARY of Medications available through the Department of Behavioral Health Pharmacy at 35 K street NE, Washington, DC Applies to: DC Healthcare Alliance Members Only Generic Name (Brand Name) Forms of Drugs Available Description Alprazolam (Xanax) Tablets 0.25mg, 0.5mg, Anxiety agent 1mg and 2mg Amitripryline (Elavil) Tablets 10mg, 25mg, 50mg, 75mg, and 100mg Antidepressant Amoxapine (Asendin) Tablets 25mg, 50mg, 100mg, Antidepressant/Tranquilizer and 150mg Amphetamine Sulfate/Asparate Tablets 5mg, 10mg, 20mg, 30mg Dextroamphetamine sac/dex Sul Tablets-XR 5mg, 10mg, 20mg, Used to treat narcolepsy and attention deficit hyperactivity (Adderall) and 30mg disorder Ariprazole (Abilify) Tablets 10mg, 15mg, 20mg, Atypical antipsychotic and 30mg Atomoxetine (Strattera) Capsules 10mg, 18mg, 25mg Used to treat Attention- 40mg, 60mg Deficit/Hyperactivity Disorder (ADHD) Bupropion (Wellbutrin) Tablets 75mg, 100mg Antidepressant Tablets-SR (q12h) 100mg, 150mg Tablets-XL (q24h) 150mg, 300mg Buspirone (Buspar) Tablets 5mg, 10mg, and 15mg Antianxiety agent Suspension 100mg.5ml Page 2
3 Chlordiazepoxide (Librium) Capsule 5mg, 10mg, 25mg Used to relieve nervousness, tension, or treat alcohol withdrawal Chlorpromazine (Thorazine) Tablets 25mg, 50mg, 100mg, Antipsychotic and 200mg. Citalopram (Celexa) Tablets 10mg, 20mg and 40mg Antidepressant (SSRI) Clomipramine (Anafranil) Capsules 25mg, 50mg, and Antidepressant 75mg Clozaril (Clozapine) Tablets 25mg and 100mg Atypical antipsychotic Desipramine (Norpramin) Tablets 10mg, 25mg, 50mg, Antidepressant 75mg, and 100mg Dextroamphetamine Sulfate Tablets 5mg Stimulant used to treat (Dexedrine) Spansules 5mg, 10mg & 15mg narcolepsy and attention deficit disorder Diazepam (Valium) Tablets 2mg, 5mg, 10mg Antianxiety agent Depakote-ER Depakote-DR 250mg & 500mg ER 250mg& 500mg Doxepin (Sinequan) Capsules 10mg, 25mg, 50mg, Antidepressant and 75mg Duloxetine HCL (Cymbalta) Capsules 20mg, 30mg & 60mg Antidepressant (SSNRI) Droperidol (Inapsine) Injection 5mg/2ml Used to treat psychosis Page 3
4 Escitalopram Oxalage (Lexapro) Tablets 10mg & 20mg Antidepressant (SSRI) Fluoxetine (Prozac) Capsules 10mg, 20mg Antidepressant Fluphenazine (Prolixin, Permitil) Tablets 1mg, 2.5mg, 5mg, 10mg Typical antipsychotic Injection 2.5mg/ml 10ml vial Deconoate 25mg/ml 5ml vial Concentrate 5mg/ml 120mg Fluvoxamine (Luvox) Tablets 50mg, 100mg Antidepressant 400mg, 600mg, & 800mg treat Bipolar Disorder Haloperidol (Haldol) Tablets 0.5mg, 1mg, 2mg, Typical Antipsychotic 5mg, 10mg & 20mg. Solution 2mg/ml 120ml Injection 5mg/ml Deconoate 50mg/ml 5ml vial 100mg/ml 5ml vial Imipramine (Tofranil) Tablets 10mg, 25mg, 50mg Antidepressant Lithium Carbonate (Eskalith, Tablets 300mg, Used to treat bipolar disorder Lithobid) 450mg (controlled released) Capsules 150mg, 300mg Lithium Citrate Syrup 8meq lithium (as citrate Used to treat bipolar disorder equivalent to 300mg lithium carbonate) 5cc 480ml Lorazepam (Ativan) Tablets 0.5mg, 1mg, 2mg Antianxiety, hypnotic Page 4
5 Injection 2mg/ml Loxapine (Loxitane) Capsules 5mg, 10mg, 25mg, Typical antipsychotic 50mg Methylphenidate (Concerta) Tablets 18mg, 36mg, 54mg Used to treat attention deficit hyperactivity disorder & narcolepsy Methylphenidate (metadate) Tablets ER 10mg Used to treat attention deficit hyperactivity disorder and narcolepsy Methylphenidate (Ritalin Tablets 5mg, 10mg, 20mg Used to treat attention deficit SR 20mg hyperactivity disorder and narcolepsy Mirtazapine (Remeron) Tablets 15mg, 30mg, 45mg Antidepressant Nortriptyline (Pamelor) Capsules 10mg, 25mg, 50mg, Antidepressant 75mg Olanzapine (Zyprexa) Tablets 2.5mg, 5mg, 10mg, Atypical antipsychotic 15mg, 20mg Injection 10mg vials **FOR STABLIZATION ONLY-- NO MORE THAT 5 DAY SUPPLY** Zydis-oral disintegrating tablets 5mg, 10mg, 20mg Paroxetine HCL (Paxil Tablets 10mg, 20mg, 30mg, Antidepressant 40mg Perphenazine (Trilafon) Tablets 2mg, 4mg, 8mg Typical Antipsychotic Page 5
6 Perphenazine/Amitriptyline Tablets 2/10, 2/25, 4/10, 4/25, Used to treat nervous, mental (Triavil, Etrafon) and emotional conditions Phenobarbital Tablets 15mg, 30mg, 60mg Used to relieve anxiety or tension or to help control seizures Quitiapine (Seroquel) Tablets 25mg, 100mg, 200mg Atypical antipsychotic Resperidone (Risperdal) Tablets 0.25mg, 0.5mg, 1mg, Atypical antipsychotic 2mg, 3mg, 4mg, Solution 1mg/ml 30mg **for stabilization only-no more M-Tabs (oral disintegrating) than a 5 day supply** 0.5mg, 1mg, 2mg Sertraline (Zoloft) Tablets 25mg, 50mg, 100mg Antidepressant Thioridazine (Mellaril) Tablets 10mg, 15mg, 25mg, Typical antipsychotic 100mg, 150mg, 200mg Thiothixene (Navane) Capsules 1mg, 2mg, 5mg, Typical antipsychotic 10mg, 20mg Concentrate 5mg/ml 120mg Trazodone (Desyrel) Tablets 50mg, 100mg, 150mg Antidepressant Trifluoperazine (Stelazine) Tablets 1mg, 2mg, 5mg, 10mg Typical antipsychotic Venlafaxine (Effexor) Tablets 25mg, 37.5mg, 50mg Antidepressant Capsules-XR 37.5mg, 75mg, 150mg Ziprasidone (Geodon) Capsules 20mg, 40mg, 60mg, 80mg Atypical antipsychotic Injection 20mg/ml Page 6
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