Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 01/01/2017 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 01/01/2017 1
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 1-800-564-5465 or visit www.mercymaricopa.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 01/01/2017 2
ANTIDEPRESSANTS Alpha-2 Receptor Antagonist Antidepressants mirtazapine Remeron Remeron SolTab Tab ODT Monoamine Oxidase Inhibitors (MAOIs) EMSAM selegiline TD Patch X isocarboxazid Marplan Tab phenelzine sulfate Nardil Tab tranylcypromine Parnate Tab Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs) APLENZIN bupropion hbr ER Tab X bupropion hcl Wellbutrin Wellbutrin SR Wellbutrin XL IR Tab ER Tab ER Tab IR:75/100mg = SR:100/150/200mg = XL: 300mg = XL: 150mg = #90 Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram hbr Various Soln 300ml citalopram hbr Celexa Tab escitalopram oxalate Lexapro Soln 300ml escitalopram oxalate Lexapro Tab 10mg tablets = #45 fluoxetine hcl Prozac Cap/Tab 10mg and 60mg = 10mg tablets = #45 20 mg = #120 40mg = fluoxetine hcl Prozac Soln 600 ml fluoxetine hcl weekly Prozac Weekly DR Cap X #1 pack fluvoxamine maleate Luvox Tab 25mg = 50mg = 100mg = #90 Updated 01/01/2017 3
fluvoxamine maleate Luvox CR ER Cap paroxetine hcl Paxil Susp 900ml paroxetine hcl Paxil Tab 40mg = #45 paroxetine hcl tab Paxil CR ER Tab 12.5mg = 25/ 37.5mg = PEXEVA paroxetine mesylate Tab X 10 MG= #180 20 MG=#90 30 MG= 40 MG=#45 sertraline hcl Zoloft Conc 300ml sertraline hcl Zoloft Tab 25= 50mg, 100mg = VIIBRYD vilazodone hcl Tab X 10mg, 20mg = 40mg = Starter kit = #1 Serotonin- 2 Antagonist/Reuptake Inhibitors (SARIs) nefazodone Various Tab trazodone ER Various Tab trazodone hcl Various Tab 50mg, 100mg, 150mg = #120 300mg= Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) desvenlafaxine Pristiq ER Tab Pristiq ER Tab duloxetine hcl Cymbalta Cap venlafaxine hcl Effexor IR Tab #90 venlafaxine hcl XR Effexor ER Cap venlafaxine hcl ER Various ER Tab Updated 01/01/2017 4
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 SILENOR doxepin hcl 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 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 ABILIFY (BRAND) aripiprazole Tab X ABILIFY MAINTENA aripiprazole Inj X ; ; PA for <18 years of age #1 Updated 01/01/2017 5
ARISTADA clozapine Clozaril Tab X X ; PA for <18 years of age #1 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 ; PA for <18 years of age #1/84days LATUDA lurasidone hcl Tab X olanzapine Zyprexa, Zydis ODT X quetiapine Seroquel Tab X risperidone Risperdal Tab X RISPERDAL CONSTA risperidone Inj X #2/30days Updated 01/01/2017 6
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 01/01/2017 7
gabapentin Neurontin Cap HORIZANT gabapentin ER Tab X gabapentin Neurontin Soln GRALISE gabapentin Tab X QLL=#180 for all strengths except 800mg QLL=#135 lamotrigine Lamictal Tab Chew ODT LAMICTAL XR lamotrigine ER Tab X 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 ADDERALL (BRAND) X ADDERALL XR (BRAND) SR Cap X amphetaminedextroamphetamine Adderall Tab X Updated 01/01/2017 8
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 PA for <6 years of age clonidine patch Catapres TTS TD Patch X PA for <6 years of age #4 guanfacine hcl Tenex Tab X guanfacine hcl ER Intuniv ER Tab KAPVAY ER (BRAND) Kapvay ER Tab X #120 METADATE CD METHYLIN Chew Tab X METHYLIN Soln X methylphenidate hcl Ritalin Tab X methylphenidate hcl Ritalin /CD LA Cap X #90 300ml #90 Updated 01/01/2017 9
methylphenidate hcl Concerta ER Tab X methylphenidate hcl Methylin Soln 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 900ml 150ml SUBOXONE FILM buprenorphine hcl /naloxone Film methadone Dolophine Opiate Antagonists naltrexone Revia Tab NARCAN Naloxone Nasal Spray naloxone Syringe Inj * medication can only be obtained from an Opioid Treatment Program (OTP) provider Updated 01/01/2017 10
naloxone vial In VIVITROL naltrexone Inj Miscellaneous nts acamprosate Campral DR Tab disulfiram Antabuse Tab ANXIOLYTICS AND HYPNOTICS Benzodiazepines alprazolam Xanax Tab 0.25/0.5/1mg= #120 2mg = alprazolam intensol Alprazolam Intensol Conc Soln 120ml alprazolam Xanax XR ER Tab 0.5/1mg= #120 2/3mg = alprazolam Niravam ODT 0.25/0.5/1mg= #120 2mg = chlordiazepoxide hcl Librium Cap clonazepam Klonopin Tab 0.5/1mg =#120 2mg = clonazepam Various ODT 0.125/0.25/0.5/1mg=#120 2mg = clorazepate Tranxene-T Tab diazepam Valium Tab 2/5/10 mg =#120 diazepam intensol Diazepam Intensol Conc Soln 240ml estazolam Various Tab flurazepam hcl Dalmane Cap lorazepam Ativan Tab 0.5/1 mg =#120 2mg = #90 Updated 01/01/2017 11
lorazepam Intensol lorazepam Conc Soln 90ml oxazepam Serax Cap temazepam Restoril Cap Miscellaneous Anxiolytics, Sedatives & Hypnotics buspirone hcl Various Tab eszopiclone Lunesta Tab meprobamate Various Tab ramelteon Rozerem Tab triazolam Halcion Tab zaleplon capsule Sonata Cap zolpidem Ambien Tab 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/Syr hydroxyzine pamoate Vistaril Cap DOPAMINE AGONISTS amantadine hcl Various Cap/Tab AUTONOMIC AGONISTS Parasympathomimetic (Cholinergic) nts bethanechol chloride Urecholine Tab Anticholinergic nts benztropine mesylate Cogentin Tab Updated 01/01/2017 12
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 saliva substitute Salivart Spray Cathartics and Laxative docusate sodium Colace Cap psyllium Metamucil Powder Updated 01/01/2017 13
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