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1 I N D I A N A H E A L T H C O V E R A G E P R O G R A M S U T I L I Z A T I O N E D I T S A P R I L 1 9, s for s Refer to Provider Bulletin BT for additional information regarding the Mental Health Quality Advisory Committee s utilization edits for mental health medications. The following is a list of mental health medications that will be subjected to the utilization edits. The utilization edit is listed as a quantity per day unless otherwise indicated. Quantities exceeding those specified in the chart require prior authorization. Contact Information For prior authorization requests and questions, please contact: Phone: (866) Fax: (866) Table 1 s and s ABILIFY 1MG/ML SOLUTION ABILIFY 2MG TABLET ABILIFY 5MG TABLET ABILIFY 10MG TABLET ABILIFY 15MG TABLET ABILIFY 20MG TABLET ABILIFY 30MG TABLET ABILIFY DISCMELT 10MG TABL ABILIFY DISCMELT 15MG TABL ADDERALL XR 5MG CAPSULE SA ADDERALL XR 10MG CAPSULES ADDERALL XR 15MG CAPSULES ADDERALL XR 20MG CAPSULES ADDERALL XR 25MG CAPSULES ADDERALL XR 30MG CAPSULES ALPRAZOLAM 0.25MG TABLET ALPRAZOLAM 0.5MG TABLET ALPRAZOLAM 1MG TABLET ALPRAZOLAM 2MG TABLET ALPRAZOLAM 0.25MG ODT 30ml/day 1.5/day HP Enterprise Services Page 1 of 13
2 s for s ALPRAZOLAM 0.5MG ODT ALPRAZOLAM 1MG ODT ALPRAZOLAM 2MG ODT ALPRAZOLAM 1MG/ML ORALCON ALPRAZOLAM XR 0.5MG TABLET ALPRAZOLAM XR 1MG TABLET ALPRAZOLAM XR 2MG TABLET ALPRAZOLAM XR 3MG TABLET AMBIEN 5MG TABLET AMBIEN 10MG TABLET AMBIEN CR 6.25MG TABLET AMBIEN CR 12.5MG TABLET AMITRIPTYLINE HCL 10MG TAB AMITRIPTYLINE HCL 25MG TAB AMITRIPTYLINE HCL 50MG TAB AMITRIPTYLINE HCL 75MG TAB AMITRIPTYLINE HCL 100MG TA AMITRIPTYLINE HCL 150MG TA AMPHETAMINE SALTS 5MG TAB AMPHETAMINE SALTS 7.5MG TA AMPHETAMINE SALTS 10MG TAB AMPHETAMINE SALTS 12.5MG T AMPHETAMINE SALTS 15MG TAB AMPHETAMINE SALTS 20MG TAB AMPHETAMINE SALTS 30MG TAB ARICEPT 5MG TABLET ARICEPT 10MG TABLET ARICEPT 23MG TABLET ARICEPT ODT 5MG TABLET ARICEPT ODT 10MG TABLET BUPROPION HBR 348MG TAB SR 24H ORAL BUPROPION HBR 522MG TAB SR 24H ORAL BUPROPION HCL 75MG TABLET BUPROPION HCL 100MG TABLET BUPROPION SR 100MG TABLET BUPROPION SR 150MG TABLET BUPROPION HCL SR 200MG TAB BUSPIRONE HCL 5MG TABLET BUSPIRONE HCL 7.5MG TABLET BUSPIRONE HCL 10MG TABLET 4ml/day HP Enterprise Services Page 2 of 13
3 s for s BUSPIRONE HCL 15MG TABLET BUSPIRONE HCL 30MG TABLET BUTISOL SODIUM 30MG/5 ML ELIXIR BUTISOL SODIUM 30MG TABLET BUTISOL SODIUM 50MG TABLET CHLORAL HYDRATE 250MG/5ML CHLORAL HYDRATE 500MG/5 ML CHLORAL HYDRATE 500MGCAPS CHLORAL HYDRATE 500MGSUPP CHLORDIAZEPOXIDE 5MG CAP CHLORDIAZEPOXIDE 10MG CAP CHLORDIAZEPOXIDE 25MG CAP CHLORPROMAZINE 10MG TABLET CHLORPROMAZINE 25MG TABLET CHLORPROMAZINE 50MG TABLET CHLORPROMAZINE100MGTABLET CHLORPROMAZINE200MGTABLET CITALOPRAM 10MG/5 ML SOLUT CITALOPRAM HBR 10MG TABLET CITALOPRAM HBR 20MG TABLET CITALOPRAM HBR 40MG TABLET CLOMIPRAMINE 25MG CAPSULE CLOMIPRAMINE 50MG CAPSULE CLOMIPRAMINE 75MG CAPSULE CLONAZEPAM.125MG DIS TAB CLONAZEPAM.25MG DIS TAB CLONAZEPAM 0.5MG DIS TAB CLONAZEPAM 1MG DIS TABLET CLONAZEPAM 2MG DIS TAB CLONAZEPAM 0.5 MG TABLET CLONAZEPAM 1MG TABLET CLONAZEPAM 2MG TABLET CLONIDINE HCL 0.1MG TABLET CLONIDINE HCL 0.2MG TABLET CLONIDINE HCL 0.3MG TABLET CLORAZEPATE 3.75MG TABLET CLORAZEPATE 7.5MG TABLET CLORAZEPATE 15MG TABLET CLOZAPINE 12.5MG TABLET CLOZAPINE 25MG TABLET 15 ML/day 20ml/day 10ml/day 20ml/day 5/day 10/day 10/day 8/day HP Enterprise Services Page 3 of 13
4 s for s CLOZAPINE 50MG TABLET CLOZAPINE 100MG TABLET CLOZAPINE 200MG TABLET COGNEX 10MG CAPSULE COGNEX 20MG CAPSULE COGNEX 30MG CAPSULE COGNEX 40MG CAPSULE CONCERTA 18MG TABLET SA CONCERTA 27MG TABLET SA CONCERTA 36MG TABLET SA CONCERTA 54MG TABLET SA CYMBALTA 20MG CAPSULE CYMBALTA 30MG CAPSULE CYMBALTA 60MG CAPSULE D-AMPHETAMINE 5MG CAP SA D-AMPHETAMINE 15MG CAP SA D-AMPHETAMINE SULFATE, 5MG/5ML SOLUTION DAYTRANA 10MG/9 HR PATCH DAYTRANA 15MG/9 HR PATCH DAYTRANA 20MG/9 HOUR PATCH DAYTRANA 30MG/9 HOUR PATCH DESIPRAMINE 10MG TABLET DESIPRAMINE 25MG TABLET DESIPRAMINE 50MG TABLET DESIPRAMINE 75MG TABLET DESIPRAMINE 100MG TABLET DESIPRAMINE 150MG TABLET DEXEDRINE SPANSULES, 5MG CAPSULE DEXEDRINE SPANSULES, 15MG CAPSULE DEXTROAMPHETAMINE 5MG TAB DEXTROAMPHETAMINE 10MG TAB DEXTROAMPHET 10MG SR CAPSULE DIAZEPAM 2MG TABLET DIAZEPAM 5MG TABLET DIAZEPAM 10MG TABLET DIAZEPAM 5MG/ML ORAL CONC DORAL 7.5MG TABLET DORAL 15MG TABLET DOXEPIN 10MG/ML ORAL CONC DOXEPIN 10MG CAPSULE 6/day 40ml/day 8ml/day 30ml/day HP Enterprise Services Page 4 of 13
5 s for s DOXEPIN 25MG CAPSULE DOXEPIN 50MG CAPSULE DOXEPIN 75MG CAPSULE DOXEPIN 100MG CAPSULE DOXEPIN 150MG CAPSULE EDLUAR 5MG SL TABLET EDLUAR 10MG SL TABLET EFFEXOR XR 37.5MG CAPSULE EFFEXOR XR 75MG CAPSULE EFFEXOR XR 150MG CAPSULE EMSAM 6MG/24 HOURS PATCH EMSAM 9MG/24 HOURS PATCH EMSAM 12MG/24 HOURS PATCH ERGOLOID MESYL 0.5MG TAB SL ERGOLOID MESYL 1MG TAB SL ERGOLOID MESYLATES 1MG TAB ESTAZOLAM 1MG TABLET ESTAZOLAM 2MG TABLET EXELON 2MG/ML ORAL SOLUTIO EXELON 1.5MG CAPSULE EXELON 3MG CAPSULE EXELON 4.5MG CAPSULE EXELON 6MG CAPSULE EXELON 4.6MG/24 HOUR PATCH EXELON 9.5MG/24 HOUR PATCH FANAPT 1MG FANAPT 2MG FANAPT 4MG FANAPT 6MG FANAPT 8MG FANAPT 10MG FANAPT 12MG FANAPT MG DOSEPAK FAZACLO 12.5MG TABLET FAZACLO 25MG TABLET FAZACLO 100MG TABLET FAZACLO 150MG TABLET FAZACLO 200MG TABLET FLUOXETINE 20MG/5 ML SOLUT FLUOXETINE HCL 10MG CAPSUL 6ml/day 6/day 20ml/day HP Enterprise Services Page 5 of 13
6 s for s FLUOXETINE HCL 10MG TABLET FLUOXETINE HCL 20MG CAPSUL FLUOXETINE HCL 20MG TABLET FLUOXETINE HCL 40MG CAPSUL FLUOXETINE HCL 60MG TABLET FLUPHENAZINE 1MG TABLET FLUPHENAZINE 2.5MG TABLET FLUPHENAZINE 5MG TABLET FLUPHENAZINE 10MG TABLET FLURAZEPAM 15MG CAPSULE FLURAZEPAM 30MG CAPSULE FLUVOXAMINE MALEATE 25MG T FLUVOXAMINE MALEATE 50MG T FLUVOXAMINE MAL 100MG TAB FOCALIN 2.5MG TABLET FOCALIN 5MG TABLET FOCALIN 10MG TABLET FOCALIN XR 5MG CAPSULE FOCALIN XR 10MG CAPSULE FOCALIN XR 15MG CAPSULE FOCALIN XR 20MG CAPSULE FOCALIN XR 25MG CAPSULE FOCALIN XR 30MG CAPSULE FOCALIN XR 35MG CAPSULE FOCALIN XR 40MG CAPSULE GEODON 20MG CAPSULE GEODON 40MG CAPSULE GEODON 60MG CAPSULE GEODON 80MG CAPSULE HALOPERIDOL 0.5MG TABLET HALOPERIDOL 1MG TABLET HALOPERIDOL 2MG TABLET HALOPERIDOL 5MG TABLET HALOPERIDOL 10MG TABLET HALOPERIDOL 20MG TABLET HYDERGINE LC 1MG CAPSULE HYDROXYZINE 10MG/5 ML SYRU HYDROXYZINE HCL 10MG TABLE HYDROXYZINE HCL 25MG TABLE HYDROXYZINE HCL 50MG TABLE 1.5/day 100ml/day 8/day HP Enterprise Services Page 6 of 13
7 s for s HYDROXYZINE PAM 25MG CAP HYDROXYZINE PAM 50MG CAP HYDROXYZINE PAM 100MG CAP IMIPRAMINE HCL 10MG TABLET IMIPRAMINE HCL 25MG TABLET IMIPRAMINE HCL 50MG TABLET IMIPRAMINE PAMOATE 75MG CA IMIPRAMINE PAMOATE 100MG C IMIPRAMINE PAMOATE 125MG C IMIPRAMINE PAMOATE 150MG C INTUNIV ER 1MG INTUNIV ER 2MG INTUNIV ER 3MG INTUNIV ER 4MG INVEGA 3MG TABLET INVEGA 6MG TABLET INVEGA 9MG TABLET INVEGA ER 1.5MG TABLET INVEGA SUSTENNA 39MG PREFILLED SYRINGE INVEGA SUSTENNA 78MG PREFILLED SYRINGE INVEGA SUSTENNA 117MG PREFILLED SYRINGE INVEGA SUSTENNA 156MG PREFILLED SYRINGE INVEGA SUSTENNA 234MG PREFILLED SYRINGE KAPVAY ER 0.1MG LATUDA 20MG LATUDA 40MG LATUDA 80MG LEXAPRO 5MG TABLET LEXAPRO 10MG TABLET LEXAPRO 20MG TABLET LEXAPRO 5MG/5 ML SOLUTION LIBRITABS 25MG TABLET 6/day 1/28 days 1/28 days 1/28 days 1/28 days 1/28 days 20ml/day LORAZEPAM 0.5MG TABLET ;max quantity 120 LORAZEPAM 1MG TABLET ;max quantity 120 LORAZEPAM 2MG TABLET ;max quantity 120 LOXAPINE SUCCINATE 5MG CA LOXAPINE SUCCINATE 10MG CA LOXAPINE SUCCINATE 25MG CAP LOXAPINE SUCCINATE 50MG CA LUNESTA 1MG TABLET HP Enterprise Services Page 7 of 13
8 s for s LUNESTA 2MG TABLET LUNESTA 3MG TABLET LUVOX CR 100MG CAPSULES LUVOX CR 150MG CAPSULES MARPLAN 10MG TABLET MAPROTILINE 25MG TABLET MAPROTILINE 50MG TABLET MAPROTILINE 75MG TABLET MEPROBAMATE 200MG TABLET MEPROBAMATE 400MG TABLET METADATE CD 10MG CAPSULE METADATE CD 20MG CAPSULE METADATE CD 30MG CAPSULE METADATE CD 40MG CAPSULE METADATE CD 50MG CAPSULE METADATE CD 60MG CAPSULE METADATE ER 10MG TABLET METADATE ER 20MG TABLET METHAMPHETAMINE HCL 5MG TA METHYLIN 2.5MG CHEWABLE TAB METHYLIN 5MG CHEWABLE TAB METHYLIN 10MG CHEWABLE TABL METHYLIN 5MG/5 ML SOLUTION METHYLIN 10MG/5 ML SOLUTIO METHYLIN ER 10MG TABLET SA METHYLIN ER 20MG TABLET SA METHYLPHENIDATE 5MG TABLE METHYLPHENIDATE 10MG TABLE METHYLPHENIDATE 20MG TABLET METHYLPHENIDATE ER 20MG TA MIRTAZAPINE 7.5MG TABLET MIRTAZAPINE 15MG RPD DISLV MIRTAZAPINE 15MG TABLET MIRTAZAPINE 30MG RPD DISLV MIRTAZAPINE 30MG TABLET MIRTAZAPINE 45MG RPD DISLV MIRTAZAPINE 45MG TABLET MOBAN 5MG TABLET MOBAN 10MG TABLET MOBAN 25MG TABLET PA 60ml/day 30ml/day HP Enterprise Services Page 8 of 13
9 s for s MOBAN 50MG TABLET MOBAN 100MG TABLET NAMENDA 10MG/5 ML SOLUTION NAMENDA 5MG TABLET NAMENDA 10MG TABLET NAMENDA 5-10MG TITRATION P NARDIL 15MG TABLET NEFAZODONE HCL 50MG TABLET NEFAZODONE HCL 100MG TABLE NEFAZODONE HCL 150MG TABLE NEFAZODONE HCL 200MG TABLE NEFAZODONE HCL 250MG TABLE NIRAVAM 0.25MG TABLET NIRAVAM 0.5MG TABLET NIRAVAM 1MG TABLET NIRAVAM 2MG TABLET NORPRAMIN 25MG TABLET NORPRAMIN 50MG TABLET NORTRIPTYLINE 10MG/5 ML SO NORTRIPTYLINE HCL 10MG CAP NORTRIPTYLINE HCL 25MG CAP NORTRIPTYLINE HCL 50MG CAP NORTRIPTYLINE HCL 75MG CAP NUVIGIL 50MG NUVIGIL 150MG NUVIGIL 250MG OLEPTRO ER 150MG TABLET OLEPTRO ER 300MG TABLET ORAP 1MG TABLET ORAP 2MG TABLET 10ml/day 6/day 20ml/day 1.5/day 10/day 5/day OXAZEPAM 10MG CAPSULE ;max quantity 120 OXAZEPAM 15MG CAPSULE ;max quantity 120 OXAZEPAM 30MG CAPSULE ;max quantity 120 OXAZEPAM 15MG TABLET ;max quantity 120 PAMELOR 10MG CAPSULE PAROXETINE HCL 10MG TABLET PAROXETINE HCL 20MG TABLET PAROXETINE HCL 30MG TABLET PAROXETINE HCL 40MG TABLET PAXIL 10MG/5 ML SUSPENSION 40ml/day HP Enterprise Services Page 9 of 13
10 s for s PAXIL CR 12.5MG TABLET PAXIL CR 25MG TABLET PAXIL CR 37.5MG TABLET PERPHENAZINE 2MG TABLET PERPHENAZINE 4MG TABLET PERPHENAZINE 8MG TABLET PERPHENAZINE 16MG TABLET PEXEVA 10MG TABLET PEXEVA 20MG TABLET PEXEVA 30MG TABLET PEXEVA 40MG TABLET PLACIDYL 500MG CAPSULE PLACIDYL 750MG CAPSULE PRISTIQ 50MG TABLET PRISTIQ 100MG TABLET PROCENTRA 5MG/5ML SOLUTION PROTRIPTYLINE 5MG TABLET PROTRIPTYLINE 10MG TABLET PROVIGIL 100MG TABLET PROVIGIL 200MG TABLET PROZAC WEEKLY 90MG CAPSULE RAZADYNE 4MG/ML ORAL SOLUT RAZADYNE 4MG TABLET RAZADYNE 8MG TABLET RAZADYNE 12MG TABLET RAZADYNE ER 8MG CAPSULE RAZADYNE ER 16MG CAPSULE RAZADYNE ER 24MG CAPSULE RESTORIL 22.5MG CAPSULE RISPERDAL 0.25MG TABLET RISPERDAL 0.5MG TABLET RISPERDAL 0.5 M-TAB RISPERDAL 1MG M-TAB RISPERDAL 1MG TABLET RISPERDAL 2MG M-TAB RISPERDAL 2MG TABLET RISPERDAL 3MG M-TAB RISPERDAL 3MG TABLET RISPERDAL 4MG M-TAB RISPERDAL 4MG TABLET 40ml/day 4/28 days 6ml/day HP Enterprise Services Page 10 of 13
11 s for s RISPERDAL CONSTA 12.5MG SYR RISPERDAL CONSTA 25MG SYR RISPERDAL CONSTA 37.5MG SY RISPERDAL CONSTA 50MG SYR RISPERIDONE 0.25MG ODT RISPERIDONE 1MG/1ML SOLUTION RITALIN LA 10MG CAPSULE RITALIN LA 20MG CAPSULE RITALIN LA 30MG CAPSULE RITALIN LA 40MG CAPSULE ROZEREM 8MG TABLET SAPHRIS 5MG SUBLINGUAL TABLET SAPHRIS 10MG SUBLINGUAL TABLET SARAFEM 10MG TABLET SARAFEM 20MG TABLET 2/28 days 2/28 days 2/28 days 2/28 days 8ml/day 1.5/day SERAX 15MG TABLET ;max quantity 120 SEROQUEL 25MG TABLET SEROQUEL 50MG TABLET SEROQUEL 100MG TABLET SEROQUEL 200MG TABLET SEROQUEL 300MG TABLET SEROQUEL 400MG TABLET SEROQUEL XR 150MG TABLET SEROQUEL XR 200MG TABLET SEROQUEL XR 300MG TABLET SEROQUEL XR 400MG TABLET SERTRALINE 20MG/ML ORAL CO SERTRALINE HCL 25MG TABLET SERTRALINE HCL 50MG TABLET SERTRALINE HCL 100MG TABLET SILENOR 3MG TABLET SILENOR 6MG TABLET SONATA 5MG CAPSULE SONATA 10MG CAPSULE STRATTERA 10MG CAPSULE STRATTERA 18MG CAPSULE STRATTERA 25MG CAPSULE STRATTERA 40MG CAPSULE STRATTERA 60MG CAPSULE STRATTERA 80MG CAPSULE 10ml/day HP Enterprise Services Page 11 of 13
12 s for s STRATTERA 100MG CAPSULE SURMONTIL 25MG CAPSULE SURMONTIL 50MG CAPSULE SURMONTIL 100MG CAPSULE SYMBYAX 3-25MG CAPSULE SYMBYAX 6-25MG CAPSULE SYMBYAX 6-50MG CAPSULE SYMBYAX 12-25MG CAPSULE SYMBYAX 12-50MG CAPSULE TEMAZEPAM 7.5MG CAPSULE TEMAZEPAM 15MG CAPSULE TEMAZEPAM 30MG CAPSULE THIOTHIXENE 20MG CAPSULE THIORIDAZINE 10MG TABLET THIORIDAZINE 15MG TABLET THIORIDAZINE 25MG TABLET THIORIDAZINE 50MG TABLET THIORIDAZINE 100MG TABLET THIORIDAZINE 150MG TABLET THIORIDAZINE 200MG TABLET THIOTHIXENE 1MG CAPSULE THIOTHIXENE 2MG CAPSULE THIOTHIXENE 5MG CAPSULE THIOTHIXENE 10MG CAPSULE TRANYLCYPROMINE SULF 10MG TRANXENE SD 11.25MG TABLET TRANXENE SD 22.5MG TAB TRAZODONE 50MG TABLET TRAZODONE 100MG TABLET TRAZODONE 150MG TABLET TRAZODONE 300MG TABLET TRIAZOLAM 0.125MG TABLET TRIAZOLAM 0.25MG TABLET TRIFLUOPERAZINE 1MG TABLET TRIFLUOPERAZINE 2MG TABLET TRIFLUOPERAZINE 5MG TABLET TRIFLUOPERAZINE 10MG TABLET VENLAFAXINE HCL 25MG TABLE VENLAFAXINE HCL 37.5MG TAB VENLAFAXINE HCL 50MG TABLE 6/day HP Enterprise Services Page 12 of 13
13 s for s VENLAFAXINE HCL 75MG TABLE VENLAFAXINE HCL 100MG TABL VENLAFAXINE HCL 37.5MG TAB OSM 24 ORAL VENLAFAXINE HCL 75MG TAB OSM 24 ORAL VENLAFAXINE HCL 150MG TAB OSM 24 ORAL VENLAFAXINE HCL 225 MG TAB OSM 24 ORAL VENLAFAXINE XR 150MG CAPSULE VIIBRYD 10MG VIIBRYD 20MG VIIBRYD 40MG VYVANSE 20MG CAPSULE VYVANSE 30MG CAPSULE VYVANSE 40MG CAPSULE VYVANSE 50MG CAPSULE VYVANSE 60MG CAPSULE VYVANSE 70MG CAPSULE WELLBUTRIN XL 150MG TABLET WELLBUTRIN XL 300MG TABLET ZOLPIMIST 5MG ORAL SPRAY ZYPREXA 2.5MG TABLET ZYPREXA 5MG TABLET ZYPREXA 7.5MG TABLET ZYPREXA 10MG TABLET ZYPREXA 15MG TABLET ZYPREXA 20MG TABLET ZYPREXA ZYDIS 5MG TABLET ZYPREXA ZYDIS 10MG TABLET ZYPREXA ZYDIS 15MG TAB ZYPREXA ZYDIS 20MG TABLET 2 sprays(0.25ml)/day HP Enterprise Services Page 13 of 13
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MORPHINE IR DRUG CLASS Morphine IR, Dilaudid IR (hydromorphone), Opana IR (oxymorphone)
Pre - PA Allowance Tablets & Suppositories Morphine sulfate tablets Morphine sulfate suppositories Oxymorphone tablets Hydromorphone tablets Hydromorphone suppositories 360 tablets per 90 days OR 360 suppositories
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HYSINGLA ER (hydrocodone bitartrate) Prior authorization is not required if prescribed by an oncologist.
Pre - PA Allowance None Prior authorization is not required if prescribed by an oncologist. Prior-Approval Requirements Age 18 years of age or older Diagnosis Patient must have the following: 1. Pain,
Pre - PA Allowance. Prior-Approval Requirements LEVORPHANOL TARTRATE. None
Pre - PA Allowance None Prior-Approval Requirements Prior authorization is not required if prescribed by an oncologist and/or the member has paid pharmacy claims for an oncology medication(s) in the past
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Scanned Ages 12-17 Dear Parent: To help your clinician understand and help your child, please answer the questions on this form and bring it with you to your child s first appointment. Please print using
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