Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 4/01/2018
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1 Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 4/01/2018 Effective April 1, 2014, Mercy Maricopa Integrated Care began operations as the Regional Behavioral Health Authority for Maricopa County. Contract services are funded, in part, under contract with the State of Arizona. Updated 4/01/2018 1
2 About the Behavioral Health Drug List The Mercy Maricopa behavioral health drug list includes all of the behavioral health medications listed on the AHCCCS Behavioral Health Drug List (BHDL). The list specifies which medications require: authorization Quantity limits restriction o If a medication has an age restriction and is being prescribed outside the age limits, the prescribing provider will need to submit a prior authorization to Mercy Maricopa. Any additional information All formulary medications available in generic form are supplied in generic form. Requests for brand name preparations must get prior authorization. For more information about your prescription drug coverage, please refer to your Member Handbook. If you have questions, please call Member Services at or visit Key Drugs listed in Bold/Italic CAPITAL LETTERS indicate the medication is only available as a brand name product (*) Indicates that medication can only be obtained from an Opioid Treatment Program (OTP) provider (X) Indicates that the medication is only available through the (T)RBHA prior authorization process Abbreviations Cap = capsule Chew = chewable Conc = concentrate DR = Delayed Release Elix = Elixir ER = extended release hbr = hydrobromide hcl = hydrochloride IM = intramuscular Inj = injectable IR = Immediate release LA = long acting ODT = orally disintegrating tablet SL = sublingual SOLN = solution SR = sustained release Susp = suspension Syr = Syrup Tab = tablet TD = transdermal XL = extended release The behavioral health drug list begins on page 3. Updated 4/01/2018 2
3 ANTIDEPRESSANTS Alpha-2 Receptor Antagonist Antidepressants Remeron Remeron mirtazapine Tab ODT X SolTab Monoamine Oxidase Inhibitors (MAOIs) EMSAM selegiline TD Patch X isocarboxazid Marplan Tab X phenelzine sulfate Nardil Tab X tranylcypromine Parnate Tab X Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs) bupropion hcl Wellbutrin Wellbutrin SR Wellbutrin XL IR Tab ER Tab ER Tab X IR:75/100mg = #120 SR:100/150/200mg = XL: 150mg/300mg = Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram hbr Various Soln X 600ml citalopram hbr Celexa Tab X 10mg = escitalopram oxalate Lexapro Soln X 600ml escitalopram oxalate Lexapro Tab X 5mg = fluoxetine hcl Prozac Cap X 10mg = 20 mg = #120 40mg = fluoxetine hcl Prozac Soln X 40mg 600ml = # 60 fluoxetine hcl weekly Prozac Weekly DR Cap X 25mg = fluvoxamine maleate Luvox Tab X 50mg = # mg = #90 Updated 4/01/2018 3
4 fluvoxamine maleate Luvox CR ER Cap X 100mg = #90 150mg = PAXIL paroxetine Susp X #900ml paroxetine hcl Paxil Tab X 40mg = #45 paroxetine hcl tab Paxil CR ER Tab X #90 PEXEVA paroxetine mesylate Tab X 10 MG= # MG=#90 30 MG= 40 MG=#45 sertraline hcl Zoloft Conc X 300ml sertraline hcl Zoloft Tab X 25mg = #90 50mg = # mg = VIIBRYD vilazodone hcl Tab X VIIBRYD Starter Pack vilazodone hcl Tab X Serotonin- 2 Antagonist/Reuptake Inhibitors (SARIs) nefazodone Various Tab X 50mg = 100mg = 150mg = # mg = #90 250mg = Updated 4/01/2018 4
5 trazodone hcl Various Tab X 50mg = #90 100mg = # mg = 300mg = Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) desvenlafaxine Pristiq ER Tab X #120 duloxetine 20mg, 30mg and 60mg only Cymbalta Cap X 20mg and 30mg = #120 60mg = SAVELLA Tab X ST 25mg = # mg = #90 venlafaxine hcl Effexor IR Tab X venlafaxine hcl XR Effexor ER Cap X 50mg = #90 75mg = # mg = # mg = #90 75mg = #90 150mg = Tricyclic Antidepressants & Related Non-Selective Reuptake Inhibitors amitriptyline hcl Various Tab X amoxapine tab Various Tab X clomipramine hcl Anafranil Cap X desipramine hcl Norpramin Tab X doxepin hcl Various Cap X #90 doxepin hcl Various Conc X #180ml Updated 4/01/2018 5
6 SILENOR doxepin hcl Tab X imipramine Various Tab X imipramine hcl Tofranil-PM Cap X maprotiline hcl Various Tab X nortriptyline hcl Pamelor Cap X nortriptyline hcl Various Soln X protriptyline hcl Vivactil Tab X trimipramine maleate Surmontil 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 ABILIFY MAINTENA ARISTADA aripiprazole Inj X X ; ; PA for <18 years of age #1/ 28 days ; PA for <18 years of age QLL: #1/ 28 days; 1064mg:#1/56 days Updated 4/01/2018 6
7 clozapine Clozaril Tab X PA for <18 years of age #150 clozapine FazaClo ODT Tab X #150 INVEGA SUSTENNA paliperidone LA Susp X INVEGA TRINZA paliperidone LA Susp X ; PA for <18 years of age #1/ 28 days ; PA for <18 years of age #1/ 84days LATUDA lurasidone hcl Tab X olanzapine Zyprexa, Zydis ODT, Tab X 5MG = 10mg = 15MG = 20mg = quetiapine Seroquel Tab X risperidone Risperdal Tab X RISPERDAL CONSTA risperidone Inj X #2/30days Updated 4/01/2018 7
8 risperidone ODT Risperdal M-TAB ODT X Risperidone soln Risperdal Soln X 240ml SAPHRIS asenapine SL Tab X ziprasidone hcl Geodon Cap X Phenothiazine Antipsychotics chlorpromazine hcl Various Tab X fluphenazine decanoate Various Inj X fluphenazine oral conc Various Oral Conc X fluphenazine hcl elix Various Elix X fluphenazine hcl tab Various Tab X perphenazine Various Tab X thioridazine hcl Various Tab X trifluoperazine hcl Various Tab X ANTICONVULSANTS carbamazepine Tegretol, Epitol Tab Chew carbamazepine Carbatrol, Equetro ER Cap carbamazepine Tegretol XR, ER Tab carbamazepine Tegretol Susp divalproex Depakote DR & ER Tab divalproex Depakote Sprinkles Cap Updated 4/01/2018 8
9 gabapentin Neurontin Cap HORIZANT gabapentin ER Tab X gabapentin Neurontin Soln GRALISE gabapentin Tab X lamotrigine Lamictal Tab Chew ODT LAMICTAL XR lamotrigine ER Tab oxcarbazepine Trileptal Susp oxcarbazepine Trileptal Tab topiramate Topamax Cap/tab valproate sodium soln Various Soln valproate sodium cap/syrup Depakene Cap /Syrup ANTIMANIC AGENTS lithium carbonate cap Various Cap lithium carbonate tab Lithobid ER Tab lithium citrate Various Soln CNS STIMULAT DRUGS QLL=#180 for all strengths except 800mg QLL=#135 ADDERALL (BRAND) X ADDERALL XR (BRAND) SR Cap X APTENSIO XR Methylphenidate XR Cap X Updated 4/01/2018 9
10 amphetaminedextroamphetamine Adderall Tab X DAYTRANA methylphenidate hcl TD Patch X Dextroamphetamine sulfate Dextroamphetamine sulfate Dexedrine ER Cap X Various Tab X FOCALIN (BRAND) Tab X FOCALIN XR (BRAND) ER Cap X clonidine hcl tab Catapres Tab X clonidine patch Catapres TTS TD Patch X #4 guanfacine hcl Tenex Tab X guanfacine hcl ER Intuniv ER Tab X KAPVAY ER (BRAND) Kapvay ER Tab X methylphenidate CD METADATE CD X METHYLIN Chew Tab X METHYLIN Soln X methylphenidate hcl Ritalin Tab X #120 #90 300ml #90 Updated 4/01/
11 methylphenidate hcl Ritalin /CD LA Cap X methylphenidate hcl Concerta ER Tab X QUILLICHEW ER QUILLIVANT XR methylphenidate hcl Susp X RITALIN LA 10MG CAP X STRATTERA atomoxetine Cap X VYVANSE Lisdexamfetamine ER Cap X SUBSTANCE ABUSE Opiate Agonists/Partial Agonists X 150ml SUBOXONE FILM buprenorphine hcl /naloxone Film methadone Opiate Antagonists Dolophine naltrexone Revia Tab NARCAN Naloxone Nasal Spray naloxone Syringe naloxone vial Inj In * medication can only be obtained from an Opioid Treatment Program (OTP) provider Updated 4/01/
12 VIVITROL naltrexone Inj Miscellaneous nts acamprosate Campral DR Tab disulfiram Antabuse Tab ANXIOLYTICS AND HYPNOTICS Benzodiazepines alprazolam Xanax Tab X 0.25/0.5/1mg= #120 2mg = alprazolam intensol Alprazolam Intensol Conc Soln X 120ml alprazolam Xanax XR ER Tab X 0.5/1mg= #120 2/3mg = alprazolam Niravam ODT X 0.25/0.5/1mg= #120 2mg = chlordiazepoxide hcl Librium Cap X clonazepam Klonopin Tab X 0.5/1mg =#120 2mg = clonazepam Various ODT X 0.125/0.25/0.5/1mg=#120 2mg = clorazepate Tranxene-T Tab X diazepam Valium Tab X l#120 diazepam 5mg/ml Conc X 60ml diazepam 1mg/ml Soln X 300ml estazolam Various Tab X flurazepam hcl Dalmane Cap X lorazepam Ativan Tab X 0.5/1 mg =#120 2mg = #90 Updated 4/01/
13 lorazepam Intensol lorazepam Conc Soln X 90ml oxazepam Serax Cap X Temazepam 15mg and 30mg Restoril Cap X Miscellaneous Anxiolytics, Sedatives & Hypnotics buspirone hcl Various Tab X #120 30mg = eszopiclone Lunesta Tab X meprobamate Various Tab X ramelteon Rozerem Tab X triazolam Halcion Tab X zaleplon capsule Sonata Cap X zolpidem Ambien Tab X 5mg = 10mg = Zolpidem ER Ambien CR ER Tab X INTERMEZZO SL, EDULAR zolpidem SL Tab X ZOLPIMIST zolpidem Soln X ANTIHISTAMINES cyproheptadine hcl Various Tab diphenhydramine Various Cap/Tab diphenhydramine hcl Various Elix/Syr hydroxyzine hcl Atarax Tab #240 hydroxyzine Various Syr 300ml hydroxyzine pamoate Vistaril Cap #120 DOPAMINE AGONISTS amantadine hcl Various Cap/Tab AUTONOMIC AGONISTS Updated 4/01/
14 Parasympathomimetic (Cholinergic) nts bethanechol chloride Urecholine Tab Anticholinergic nts benztropine mesylate Cogentin Tab trihexyphenidyl hcl Artane Tab CARDIOVASCULAR DRUG Alpha-1 Adrenergic Blocking nts prazosin hcl Minipres Cap Beta-Adrenergic Blocking nts 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 thiamine hcl Vitamin B1 - Various Tab multiple vitamin Various Tab multiple vitamin / minerals Various Tab Miscellaneous Ear, Nose & Throat Drug Updated 4/01/
15 saliva substitute Salivart Spray Cathartics and Laxative docusate sodium Colace Cap psyllium Metamucil Powder Updated 4/01/
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Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.38 Subject: Hysingla ER Page: 1 of 9 Last Review Date: September 15, 2017 Hysingla ER Description
Briefly state the reason for this evaluation: Patient s Name: Sex: Male/Female (circle one) Date of Birth: Age: Patient s Social Security #
Psychiatric Evaluation Form After Hours Psychiatry, PLLC Aaron Alaniz, M.D. 25722 Kingsland Blvd, Suite 202 Katy, TX 77494 T: 281-978-2515 F: 281-978-2895 Briefly state the reason for this evaluation:
4/2/13 COMMON CLASSES OF MEDICATIONS. Child & Adolescent Behavioral Medicine & Medication Therapies. Behavioral Medicine & Medication Therapies
Child & Adolescent Behavioral Medicine & Medication Therapies Brian J Cowles, PharmD Associate Professor of Pharmacy Practice Albany College of Pharmacy & Health Sciences; Vermont Campus Behavioral Medicine
Belbuca (buprenorphine buccal film) Description. Section: Prescription Drugs Effective Date: October 1, 2016
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Belbuca Page: 1 of 9 Last Review Date: September 15, 2016 Belbuca (buprenorphine buccal film)
Demerol (meperidine oral tablet, oral solution), Meperitab (oral tablet)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Meperidine Page: 1 of 7 Last Review Date: September 15, 2017 Meperidine Description Demerol (meperidine
PHYSICIAN REFERENCE ANTIDEPRESSANT DOSING GUIDELINES
PHYSICIAN REFERENCE ANTIDEPRESSANT DOSING GUIDELINES Table of Contents Print TABLE OF CONTENTS Drug Page Number Anafranil... 2 Asendin... 4 Celexa... 4 Cymbalta... 6 Desyrel... 8 Effexor...10 Elavil...14
Morphine IR Hydromorphone IR Oxymorphone IR. Morphine IR, Dilaudid IR (hydromorphone), Opana IR (oxymorphone),
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.33 Subject: Morphine IR Drug Class Page: 1 of 11 Last Review Date: December 8, 2017 Morphine IR Hydromorphone
Welcome and thank you for choosing University of Florida Physicians!
DEPARTMENT OF PSYCHIATRY Tuesday, Division of March Child and 14, Adolescent 2017 Psychiatry 8491 NW 39 th Ave. Gainesville, FL 32606 Phone: 352-265-4357 Fax: 352-627-4163 Welcome and thank you for choosing
OXYCODONE IR (oxycodone)
RATIONALE FOR INCLUSION IN PA PROGRAM Background Oxycodone hydrochloride, a pure opioid agonist, is used in the treatment of moderate to severe pain (1-2). The precise mechanism of action is unknown; however,
Duragesic patch. Duragesic patch (fentanyl patch) Description
1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.31 Subject: Duragesic patch Page: 1 of 9 Last Review Date: September 15, 2017 Duragesic patch Description Duragesic patch (fentanyl
Steps for Initiating Electroconvulsive Therapy Treatment
Steps for Initiating Electroconvulsive Therapy Treatment PSYCHIATRISTS CAN REFER PATIENTS FOR ECT TREATMENT AT EL CAMINO HOSPITAL BY CALLING THE ECT NURSE COORDINATOR AT 650-962-5795. Once the referral
OBJECTIVES PSYCHOTROPIC MEDICATIONS WHAT IS PSYCHOTROPIC MEDICATION?
PSYCHOTROPIC MEDICATIONS Sally Davies, Ph.D., HSPP Licensed Psychologist OBJECTIVES 1. Identify psychotropic medications and the typical usages 2. Identify effective methods for the practical application
Mental Health Intake Form
Current Symptoms Checklist: (check once for any symptoms present, twice for major symptoms) ( ) ( ) Depressed mood ( ) ( ) Racing thoughts ( ) ( ) Excessive worry ( ) ( ) Unable to enjoy activities ( )
Duragesic patch. Duragesic patch (fentanyl patch) Description
1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.31 Section: Prescription Drugs Effective Date: April1, 2017 Subject: Duragesic patch Page: 1 of 10 Last Review Date: March
Texas Prior Authorization Program Clinical Edit Criteria
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization
Medically Accepted Indications for Pediatric Use of Psychotropic Medications by
Key: White Background: Medically Accepted Indication Yellow Backgroun: Medically Accepted Indication Status Not Ascertained Orange Background: Pediatric Indication cited, but not supported Red Background:
BELBUCA (buprenorphine buccal film)
RATIONALE FOR INCLUSION IN PA PROGRAM Background Belbuca is indicated for the management of chronic pain severe enough to require daily, aroundthe-clock, long-acting opioid treatment for which alternative
POSITIVE YOUTH CONCEPTS Child and Adolescent Therapy 24 Front Street, Suite 302 Exeter, NH
Date: / / NEW CLIENT FORM Client s Name: Address: City State Zip D.O.B.: / / Age: Sex: ================================================================================== Guardian s Name: Custody: Physical
Targiniq ER (oxycodone/naloxone extended-release), Troxyca ER (oxycodone /naltrexone extended-release)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.44 Subject: Oxycodone Naloxone Page: 1 of 9 Last Review Date: December 2, 2016 Oxycodone Naloxone
Duragesic patch. Duragesic patch (fentanyl patch) Description. Section: Prescription Drugs Effective Date: January 1, 2019
1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Duragesic patch Page: 1 of 9 Last Review Date: November 30, 2018 Duragesic patch Description Duragesic patch (fentanyl
Oxycodone. Oxycodone IR, Oxycodone ER, OxyContin, Xtampza ER. Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Oxycodone Page: 1 of 11 Last Review Date: March 17, 2017 Oxycodone Description Oxycodone IR, Oxycodone
Oxycodone. Oxycodone IR, Oxycodone ER, OxyContin, Xtampza ER. Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Oxycodone Page: 1 of 10 Last Review Date: September 15, 2016 Oxycodone Description Oxycodone IR,
CHILD/ADOLESCENT INTAKE FORM
CHILD/ADOLESCENT INTAKE FORM Today's date: 703-437-6311 www.centerforlifestrategies.com Patient Information: Individual Name: Date of Birth: Age: (fi rst) ( la st) Gender M/F Ethnicity (optional): Name
Antidepressant Medication Strategies We ve Come a Long Way or Have We? Who Writes Prescriptions for Psychotropic Medications. Biological Psychiatry
Antidepressant Medication Strategies We ve Come a Long Way or Have We? Joe Wegmann, PD, LCSW The PharmaTherapist Joe@ThePharmaTherapist.com 504.587.9798 www.pharmatherapist.com Are you receiving our free
Professor David Castle. Ms. Nga Tran. St. Vincent s Mental Health Level 2, 46 Nicholson Street, Fitzroy Vic 3065
ARABIIC Professor David Castle Ms. Nga Tran St. Vincent s Mental Health Level 2, 46 Nicholson Street, Fitzroy Vic 3065 (03) 9288 4147 (03) 9288 4751 Psychiatric Medication Information / Arabic 1 Psychiatric
PROBE INITIAL ZERO/ DK: Please include any prescription medicines, even if you took them only once.
04/18/01 PHARMACOEPIDEMIOLOGY (PH) *PH1. The next questions are about your use of medicines. First, how many different kinds of prescription medicine have you taken during the past seven days? (IF NEC:
Methadone. Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.41 Subject: Methadone Page: 1 of 11 Last Review Date: September 15, 2017 Methadone Description Dolophine
Methadone. Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.41 Subject: Methadone Page: 1 of 13 Last Review Date: March 16, 2018 Methadone Description Dolophine
Patients considering TMS Therapy
Charles Hayden MD Patients considering TMS Therapy Thank you for your interest in TMS Therapy. Please take time before you meet with Dr Hayden to carefully fill out this form as completely as possible.