Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 10/01/2018
About the Behavioral Health Drug List The Mercy Care 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 Care. 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 1-800-564-5465 or visit www.mercycareaz.org. 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 10/01/2018 2
ANTIDEPRESSANTS Alpha-2 Receptor Antagonist Antidepressants mirtazapine Monoamine Oxidase Inhibitors (MAOIs) Remeron Remeron SolTab Tab ODT X EMSAM selegiline TD Patch X isocarboxazid Marplan Tab X phenelzine sulfate Nardil Tab X tranylcypromine sulfate 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 = #60 XL: 150mg/300mg = Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram hbr Various Soln X 600ml citalopram hbr Celexa Tab X 10mg = #60 escitalopram oxalate Lexapro Soln X 600ml escitalopram oxalate Lexapro Tab X 5mg = #60 fluoxetine hcl Prozac Cap X 10mg = #60 20 mg = #120 40mg = #60 Updated 10/01/2018 3
fluoxetine hcl Prozac Soln X 600ml fluoxetine hcl weekly Prozac Weekly DR Cap X fluvoxamine maleate Luvox Tab X 25mg = #60 50mg = #180 100mg = #90 fluvoxamine maleate Luvox CR ER Cap X 100mg = #90 150mg = #60 XIL 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 sertraline hcl Zoloft Conc X 300ml sertraline hcl Zoloft Tab X 25mg = #90 50mg = #120 100mg =#60 VIIBRYD vilazodone hcl Tab X VIIBRYD Starter Pack vilazodone hcl Tab X Serotonin- 2 Antagonist/Reuptake Inhibitors (SARIs) nefazodone Various Tab X 50mg = #60 100mg = #60 150mg = #120 200mg = #90 Updated 10/01/2018 4
250mg = #60 trazodone hcl Various Tab X Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) 50mg = #90 100mg = #120 150mg = #60 300mg = desvenlafaxine Pristiq ER Tab X #120 duloxetine 20mg, 30mg and 60mg only Cymbalta Cap X 20mg and 30mg = #120 60mg = #60 SAVELLA Tab X ST venlafaxine hcl Effexor IR Tab X 25mg = #120 37.5mg = #90 50mg = #90 75mg = #150 100mg = #90 venlafaxine hcl XR Effexor ER Cap X 37.5mg = #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 Updated 10/01/2018 5
doxepin hcl Various Cap X #90 doxepin hcl Various Conc X #180ml 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 for <18 years of age haloperidol lactate Various Conc X loxapine succinate Loxitane Cap X pimozide Orap Tab X for <12 years of age thiothixene Navane Cap X 2nd Generation Antipsychotics aripiprazole Abilify Tab, ODT X aripiprazole Abilify Solution X ; ; #150 Updated 10/01/2018 6
ABILIFY MAINTENA aripiprazole Inj X ; for <18 years of age #1/ 28 days ARISTADA X ; for <18 years of age QLL: #1/ 28 days; 1064mg:#1/56 days ARISTADA INITIO X clozapine Clozaril Tab X clozapine FazaClo ODT Tab X INVEGA SUSTENNA paliperidone LA Susp X INVEGA TRINZA paliperidone LA Susp X ; for <18 years of age QLL: #2/ 365 days; for <18 years of age #150 #150 ; for <18 years of age #1/ 28 days ; for <18 years of age #1/ 84days Updated 10/01/2018 7
LATUDA lurasidone hcl Tab X olanzapine Zyprexa, Zydis ODT, Tab X 5MG = #60 10mg = #60 15MG = 20mg = quetiapine Seroquel Tab X risperidone Risperdal Tab X RISPERDAL CONSTA risperidone Inj X risperidone ODT Risperdal M-TAB ODT X Risperidone soln Risperdal Soln X SAPHRIS asenapine SL Tab X #60 #60 #2/30days #60 240ml #60 ziprasidone hcl Geodon Cap X #60 Phenothiazine Antipsychotics chlorpromazine hcl Various Tab X Updated 10/01/2018 8
Covered Drug fluphenazine decanoate Various Inj X for <18 years of age 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 gabapentin Neurontin Cap HORIZANT gabapentin ER Tab X gabapentin Neurontin Soln GRALISE gabapentin Tab X Cumulative Daily Dose= 3600mg/day Cumulative Daily Dose= 3600mg/day Cumulative Daily Dose= 3600mg/day Cumulative Daily Dose= 3600mg/day Updated 10/01/2018 9
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 X lithium carbonate tab Lithobid ER Tab X lithium citrate Various Soln X CNS STIMULANT DRUGS ADDERALL (BRAND) X #60 ADDERALL XR (BRAND) SR Cap X APTENSIO XR Methylphenidate XR Cap X amphetaminedextroamphetamine Adderall Tab X Salts (DEXTROAMPatomoxetine STRATTERA Cap X #60 15/20/30mg = #60 Updated 10/01/2018 10
DAYTRANA methylphenidate hcl TD Patch X Dextroamphetamine sulfate Dextroamphetamine sulfate Dexedrine ER Cap X #60 Various Tab X #60 FOCALIN (BRAND) Tab X #60 FOCALIN XR (BRAND) ER Cap X #60 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 #120 methylphenidate CD METADATE CD X METHYLIN Soln X 300ml methylphenidate hcl Ritalin Tab X #90 methylphenidate hcl Ritalin /CD LA Cap X Updated 10/01/2018 11
methylphenidate hcl Concerta ER Tab X #60 QUILLICHEW ER QUILLIVANT XR methylphenidate hcl Susp X RITALIN LA 10MG CAP X X 150ml VYVANSE Lisdexamfetamine ER Cap X VYVANSE Lisdexamfetamine Chew tab X SUBSTANCE ABUSE Opiate Agonists/Partial Agonists SUBOXONE FILM buprenorphine hcl /naloxone Film methadone Dolophine * medication can only be obtained from an Opioid Treatment Program Opiate Antagonists naltrexone Revia Tab Updated 10/01/2018 12
NARCAN Naloxone Nasal Spray naloxone Syringe Inj naloxone vial In 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 = #60 alprazolam intensol Alprazolam Intensol Conc Soln X 120ml alprazolam ER Xanax XR ER Tab X alprazolam Niravam ODT X 0.25/0.5/1mg= #120 2mg = #60 chlordiazepoxide hcl Librium Cap X #60 clonazepam Klonopin Tab X 0.5/1mg =#120 2mg = #60 Updated 10/01/2018 13
clonazepam Various ODT X 0.125/0.25/0.5/1mg=#120 2mg = #60 clorazepate dipotassium Tranxene-T Tab X 3.75mg/7.5mg = #120 15mg= #60 diazepam Valium Tab X #120 diazepam 5mg/ml Conc X 60ml diazepam 1mg/ml Soln X 300ml lorazepam Ativan Tab X 0.5/1 mg =#120 2mg = #60 lorazepam Intensol lorazepam Conc Soln X 60ml oxazepam Serax Cap X #60 Miscellaneous Anxiolytics, Sedatives & Hypnotics buspirone hcl Various Tab X ramelteon Rozerem Tab Temazepam 15mg and 30mg Restoril Cap X zolpidem Ambien Tab X #120 30mg = #60, ST 5mg = #60 10mg = ST through zolpidem and temazepam Updated 10/01/2018 14
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 DOMINE AGONISTS amantadine hcl Various Cap/Tab AUTONOMIC AGONISTS 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 Updated 10/01/2018 15
THYROID AGENTS levothyroxine sodium Levothroid/Synthroid Tab liothyronine Cytomel Tab VITAMINS AND OTHER MISCELLANEOUS AGENTS alpha-tocopherol Vitamin E -Various Cap, chew tab cyanocobalamin Vitamin B12 - Various Tab folic acid Various Tab Niacin Tab, cap, ER 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 saliva substitute Salivart Sol, loz, tab Cathartics and Laxative bisacodyl Enema, supp,tab cascara sagrada cap docusate Colace Cap, tab, liq Fiber Powder, tab, cap Updated 10/01/2018 16
Magnesium citrate soln Magnesium oxide tab Methylcellulose Powder, tab psyllium Metamucil Powder, cap Senna Tab, syr, liq Updated 10/01/2018 17