ACAMPROSATE TABLET DELAYED RELEASE ALPHA-TOCOPHEROL CAPSULES ALPRAZOLAM CONCENTRATE 1 MG/ML ALPRAZOLAM ODT TABLET 0.25MG, 0.5MG, 1MG ALPRAZOLAM ODT TABLET 2MG ALPRAZOLAM SR TABLET 24-HOUR ALPRAZOLAM TABLET 0.25MG, 0.5MG, 1MG ALPRAZOLAM TABLET 2MG AMANTADINE HCL CAPSULES AMANTADINE HCL TABLETS CAMPRAL VITAMIN E - ALPRAZOLAM INTENSOL SYMMETREL SYMMETREL PA Required for > 1 Anxiolytic 60 ML 15 PA Required for > 1 Anxiolytic 30 30 AMITRIPTYLINE HCL TABLETS ELAVIL PA Required for ages < 6 years AMOXAPINE TABLETS ASENDIN PA Required for ages < 6 years AMPHETAMINE-DEXTROAMPHETAMINE CAPSULES 24-HOUR ADDERALL XR Brand PA Required for ages < 6 years 30 30 Brand and Generic PA Required for ages < 6 years 60 30 AMPHETAMINE-DEXTROAMPHETAMINE TABLETS ADDERALL ARIPIPRAZOLE LAUROXIL 442MG, 662MG, 882MG ARISTADA Brand PA Required for ages < 18 years 1 30 ARIPIPRAZOLE LAUROXIL 1064MG ARISTADA Brand PA Required for ages < 18 years 1 60 ARIPIPRAZOLE SUSPENSION ABILIFY MAINTENA Brand PA Required for ages < 18 years 1 30 ARIPIPRAZOLE TABLETS ABILIFY PA Required for ages < 6 years 30 30 ASENAPINE MALEATE TABLETS SUBLINGUAL SAPHRIS Brand PA Required for ages < 6 years 60 30 ATOMOXETINE HCL CAPSULES STRATTERA Brand PA Required for ages < 6 years 30 30 BENZTROPINE MESYLATE TABLETS BETHANECHOL CHLORIDE TABLETS Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand COGENTIN URECHOLINE BUPRENORPHINE HCL / NALOXONE SL FILM SUBOXONE FILM Brand BUPRENORPHINE HCL SL TABLETS SUBUTEX PA Required BUPROPION HCL IR TABLETS WELLBUTRIN PA Required for ages < 6 years 120 30 BUPROPION HCL TABLET 12-HOUR BUDEPRION SR PA Required for ages < 6 years 60 30 BUPROPION HCL TABLET 24-HOUR WELLBUTRIN XL PA Required for ages < 6 years 30 30 BUSPIRONE HCL TABLETS 5 MG, 7.5 MG, 10 MG, 15 MG BUSPIRONE HCL BUSPIRONE HCL TABLETS 30 MG BUSPIRONE HCL CARBAMAZEPINE CHEWABLE TABLETS TEGRETOL CARBAMAZEPINE ER CAPSULES CARBATROL CARBAMAZEPINE ER CAPSULES EQUETRO CARBAMAZEPINE ER TABLETS TEGRETOL XR CARBAMAZEPINE SUSPENSION TEGRETOL CARBAMAZEPINE TABLETS TEGRETOL Page 1 of 7
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand CHLORDIAZEPOXIDE HCL CAPSULES CHLORPROMAZINE HCL TABLETS THORAZINE PA Required for ages < 6 years CITALOPRAM HBR TABLETS 10MG CELEXA 60 30 CITALOPRAM HBR TABLETS 20MG CELEXA 30 30 CITALOPRAM HBR TABLETS 40MG CELEXA 30 30 CITALOPRAM HYDROBROMIDE SOLUTION CELEXA 600 ML 30 CLOMIPRAMINE HCL TABLETS ANAFRANIL PA Required for ages Ages < 6 years CLONAZEPAM ODT TABLET 0.125MG, 0.25MG, 0.5MG, 1MG CLONAZEPAM ODT TABLET 2MG 60 30 CLONAZEPAM TABLETS 0.5MG, 1MG PA Required for > Ages 1 Anxiolytic < 6 years 120 30 CLONAZEPAM TABLETS 2MG CLONIDINE HCL (ADHD) TABLET 12-HOUR KAPVAY Brand PA Required for ages < 6 years 120 30 CLONIDINE HCL TABLETS CATAPRES PA Required for ages < 6 years CLONIDINE HCL TD PATCH CATAPRES PATCH PA Required for ages Ages < 6 years 4 28 CLORAZEPATE DIPOTASSIUM TAB 15 MG CLORAZEPATE DIPOTASSIUM TAB 3.75 MG CLORAZEPATE DIPOTASSIUM TAB 7.5 MG CLOZAPINE ORALLY DISINTEGRATING TABLETS FAZACLO PA Required for ages < 18 years 150 30 CLOZAPINE TABLETS CLOZAPINE PA Required for ages < 18 years 150 30 CYANOCOBALAMIN TABLETS VITAMIN B12 - CYPROHEPTADINE HCL TABLETS DESIPRAMINE HCL TABLETS NORPRAMIN PA Required for ages < 6 years DESVENLAFAXINE ER TABLETS 25MG PRISTIQ 120 30 DESVENLAFAXINE ER TABLETS 50MG PRISTIQ 120 30 DESVENLAFAXINE ER TABLETS 100MG PRISTIQ 120 30 DEXMETHYLPHENIDATE HCL ER CAPSULE 24-HOUR FOCALIN XR Brand PA Required for ages < 6 years 60 30 DEXMETHYLPHENIDATE HCL TABLETS FOCALIN Brand PA Required for ages < 6 years 60 30 DEXTROAMPEHTAMINE SULFATE CAPSULE 24-HOUR PA Required for ages < 6 years 60 30 DEXTROAMPHETAMINE SULFATE TABLETS PA Required for ages < 6 years 60 30 DIAZEPAM CONCENTRATE 5 MG/ML DIAZEPAM INTENSOL PA Required for > 1 Anxiolytic 60ML 30 DIAZEPAM SOLUTION 1 MG/ML 300ML 30 DIAZEPAM TABLETS 120 30 DILSULFIRAM TABLETS ANTABUSE DIPHENHYDRAMINE HCL CAPSULES DIPHENHYDRAMINE HCL CHEWABLE TABLETS DIPHENHYDRAMINE HCL ELIXIR DIPHENHYDRAMINE HCL LIQUID DIPHENHYDRAMINE HCL SYRUP DIPHENHYDRAMINE HCL TABLETS DIVALPROEX CAPSULES SPRINKLE DPAKOTE SPRINKLES Page 2 of 7
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand DIVALPROEX DR TABLETS DEPAKOTE DIVALPROEX ER TABLETS DEPAKOTE DOCUSATE SODIUM CAPSULES COLACE DOXEPIN HCL CAPSULES SINEQUAN PA Required for ages < 6 years 90 30 DOXEPIN HCL CONCENTRATE SINEQUAN PA Required for ages < 6 years 180 ML 30 DOXEPIN HCL TABLETS SILENOR PA Required DULOXETINE CAPSULES 20 MG, 30 MG CYMBALTA 120 30 DULOXETINE CAPSULES 60 MG CYMBALTA 60 30 ESCITALOPRAM OXALATE SOLUTION LEXAPRO 600 ML 30 ESCITALOPRAM OXALATE TABLETS 5MG LEXAPRO 60 30 ESCITALOPRAM OXALATE TABLETS 10MG LEXAPRO 30 30 ESCITALOPRAM OXALATE TABLETS 20MG LEXAPRO 30 30 ESTAZOLAM TABLETS ESZOPICLONE TABLETS LUNESTA FLUOXETINE HCL CAPSULES ONLY 10MG PROZAC 60 30 FLUOXETINE HCL CAPSULES ONLY 220MG PROZAC 120 30 FLUOXETINE HCL CAPSULES ONLY 40MG PROZAC 60 30 FLUOXETINE HCL DR CAPSULES - WEEKLY PROZAC WEEKLY PA Required FLUOXETINE HCL SOLUTION PROZAC 600 ML 30 FLUPHENAZINE DECANOATE SOLUTION FLUPHENAZINE DECANOATE PA Required for ages < 18 years FLUPHENAZINE HCL ELIXIR FLUPHENAZINE PA Required for ages < 6 years FLUPHENAZINE HCL ORAL CONCENTRATE FLUPHENAZINE PA Required for ages < 6 years FLUPHENAZINE HCL TABLETS FLUPHENAZINE PA Required for ages < 6 years FLURAZEPAM HCL CAPSULES DALMANE FLUVOXAMINE MALEATE ER CAPSULES 100MG LUVOX CR 90 30 FLUVOXAMINE MALEATE ER CAPSULES 150MG LUVOX CR 60 30 FLUVOXAMINE MALEATE TABLETS 25MG LUVOX 60 30 FLUVOXAMINE MALEATE TABLETS 50MG LUVOX 180 30 FLUVOXAMINE MALEATE TABLETS 100MG LUVOX 90 30 FOLIC ACID TABLETS GABAPENTIN CAPSULES 100MG, 300MG, 400MG GABAPENTIN ER TABLETS HORIZANT PA Required GABAPENTIN ER TABLETS GRALISE PA Required GABAPENTIN SOLUTION GABAPENTIN TABLETS 600MG, GABAPENTIN TABLETS 800MG GUANFACINE HCL (ADHD)TABLET 24-HOUR GUANFACINE HCL ER PA Required for ages < 6 years 30 30 GUANFACINE HCL TABLETS TENEX PA Required for ages < 6 years HALOPERIDOL DECANOATE SOLUTION HALDOL DECANOATE PA Required for ages < 18years HALOPERIDOL LACTATE CONCENTRATE HALDOL PA Required for ages < 6 years Page 3 of 7
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Drug Class/Drug Name HALOPERIDOL TABLETS HALDOL PA Required for ages < 6 years HYDROXYZINE HCL SYRUP HYDROXYZINE HCL SYRUP 300 ML 30 HYDROXYZINE HCL TABLETS HYDROXYZINE HCL TABLETS 240 30 HYDROXYZINE HCL TABLETS ATARAX HYDROXYZINE PAMOATE CAPSULES VISTARIL 120 30 HYDROXYZINE PAMOATE CAPSULES VISTARIL IMIPRAMINE HCL CAPSULES TOFRANIL PA Required for ages < 6 years IMIPRAMINE HCL TABLETS TOFRANIL PA Required for ages < 6 years ISOCARBOXAZID TABLETS MARPLAN LAMOTRIGINE CHEW TABLETS LAMOTRIGINE ER TABLETS XR LAMOTRIGINE ODT TABLETS 100 MG ODT LAMOTRIGINE ODT TABLETS 200 MG ODT LAMOTRIGINE ODT TABLETS 25 MG, 50MG ODT LAMOTRIGINE TABLETS 100 MG LAMOTRIGINE TABLETS 150 MG, 200 MG LAMOTRIGINE TABLETS 25 MG LEVOTHYROXINE SODIUM TABLETS LEVOTHROID / SYNTHROID LIOTHYRONINE TABLETS CYTOMEL LISDEXAMFETAMINE ER CAPSULES VYVANSE Brand PA Required for ages < 6 years 30 30 LITHIUM CARBONATE CAPSULES LITHIUM LITHIUM CARBONATE ER TABLETS LITHOBID LITHIUM CITRATE SOLUTION LITHIUM LORAZEPAM CONCENTRATE 2 MG/ML LORAZEPAM INTENSOL PA Required for > 1 Anxiolytic 60 ML 30 LORAZEPAM TABLETS 0.5MG, 1MG LORAZEPAM TABLETS 2MG LOXAPINE SUCCINATE CAPSULES LOXITANE PA Required for ages < 6 years LURASIDONE TABLETS LATUDA Brand PA Required for ages < 6 years 30 30 MAPROTILINE HCL TABLETS MAPROTILINE HCL PA Required for ages < 6 years MEPROBAMATE TABLETS METHADONE * DOLOPHINE* METHYLPEHNIDATE HCL CHEWABLET TABLET EXTENDED RELEASE QUILLICHEW ER Brand PA Required for ages < 6 years 30 30 METHYLPHENIDATE HCL CAPSULE 24- HOUR RITALIN LA 10 MG Brand PA Required for ages < 6 years 30 30 METHYLPHENIDATE HCL CAPSULE 24-HOUR APTENSIO XR Brand PA Required for ages < 6 years 30 30 METHYLPHENIDATE HCL CAPSULE CONTROLLED RELEASE METADATE CD PA Required for ages < 6 years 30 30 METHYLPHENIDATE HCL CHEWABLE TABLETS METHYLIN Brand PA Required for ages < 6 years 90 30 METHYLPHENIDATE HCL SOLUTION METHYLIN Brand PA Required for ages < 6 years 300 ML 30 METHYLPHENIDATE HCL SUSPENSION QUILLIVANT XR Brand PA Required for ages < 6 years 150 ML 30 METHYLPHENIDATE HCL TABLET 24-HOUR METHYLPHENIDATE ER PA Required for ages < 6 years 60 30 Page 4 of 7
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand METHYLPHENIDATE HCL TABLET CONTROLLED RELEASE METHYLPEHNIDATE ER PA Required for ages < 6 years 60 30 METHYLPHENIDATE HCL TABLET SUSTAINED RELEASE RITALIN SR PA Required for ages < 6 years 60 30 METHYLPHENIDATE HCL TABLETS RITALIN PA Required for ages < 6 years 90 30 METHYLPHENIDATE HCL TD PATCH DAYTRANA Brand PA Required for ages < 6 years 30 30 MIRTAZAPINE REMERON 30 30 MIRTAZAPINE REMERON SOLTAB 30 30 MULTIPLE VITAMIN TABLETS MULTIPLE VITAMIN W/ MINERAL TABLETS NADOLOL TABLETS CORGARD NALOXONE NASAL NARCAN NASAL NALOXONE SYRINGE NALOXONE NALOXONE VIAL NALOXONE NALTREXONE INJECTION VIVITROL NALTREXONE TABLETS REVIA NEFAZODONE TABLETS 50MG 60 30 NEFAZODONE TABLETS 100MG 60 30 NEFAZODONE TABLETS 150 MG 120 30 NEFAZODONE TABLETS 200MG 90 30 NEFAZODONE TABLETS 250MG 60 30 NORTRIPTYLINE HCL CAPSULES PAMELOR PA Required for ages < 6 years NORTRYIPTYLINE HCL SOLUTION PAMELOR PA Required for ages < 6 years OLANZAPINE ORALLY DISINTEGRATING TABLETS 5MG ZYPREXA ZYDIS PA Required for ages < 6 years 60 30 OLANZAPINE ORALLY DISINTEGRATING TABLETS 10MG ZYPREXA ZYDIS PA Required for ages < 6 years 60 30 OLANZAPINE ORALLY DISINTEGRATING TABLETS 15MG ZYPREXA ZYDIS PA Required for ages < 6 years 30 30 OLANZAPINE ORALLY DISINTEGRATING TABLETS 20MG ZYPREXA ZYDIS PA Required for ages < 6 years 30 30 OLANZAPINE TABLETS 2.5MG OLANZAPINE PA Required for ages < 6 years 30 30 OLANZAPINE TABLETS 5MG OLANZAPINE PA Required for ages < 6 years 60 30 OLANZAPINE TABLETS 10MG OLANZAPINE PA Required for ages < 6 years 60 30 OLANZAPINE TABLETS 15MG OLANZAPINE PA Required for ages < 6 years 30 30 OLANZAPINE TABLETS 20MG OLANZAPINE PA Required for ages < 6 years 30 30 OMEGA 3 FATTY ACID CAPSULES OXAZEPAM CAPSULES OXCABAZEPINE TABLETS TRILEPTAL OXCARBAZEPINE SOLUTON TRILEPTAL PALIPERIDONE PALMITATE SUSPENSION INVEGA SUSTENNA Brand PA Required for ages < 18 years 1 30 PALIPERIDONE PALMITATE SUSPENSION INVEGA TRINZA Brand PA Required for ages < 18 years 1 90 PAROXETINE HCL ER TABLETS 12.5 MG PAXIL CR 90 30 PAROXETINE HCL ER TABLETS 25 MG PAXIL CR 90 30 PAROXETINE HCL ER TABLETS 37.5 MG PAXIL CR 90 30 PAROXETINE HCL SUSPENSION PAXIL Brand 900 ML 30 PAROXETINE HCL TABLETS 10MG PAXIL 30 30 PAROXETINE HCL TABLETS 20MG PAXIL 30 30 PAROXETINE HCL TABLETS 30MG PAXIL 30 30 PAROXETINE HCL TABLETS 40MG PAXIL 45 45 Page 5 of 7
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand PAROXETINE MESYLATE TABLETS PEXEVA PERPHENAZINE TABLETS TRILAFON PA Required for ages < 6 years PHENELZINE SULFATE TABLETS NARDIL PIMOZIDE TABLETS ORAP PA Required for ages < 6 years PRAZOSIN HCL CAPSULES MINIPRESS PROPRANOLOL HCL TABLETS INDERAL PROTRIPTYLINE HCL TABLETS VIVACTIL PA Required for ages < 6 years PSYLLIUM METAMUCIL PYRIDOXINE HCL TABLETS VITAMIN B6 - QUETIAPINE FUMARATE TABLETS SEROQUEL PA Required for ages < 6 years 60 30 RAMELTEON TABLETS ROZEREM PA Required RISPERIDONE MICROSPHERES SUSPENSION RISPERDAL CONSTA Brand PA Required for ages < 18 years 2 30 RISPERIDONE ORALLY DISPERSABLE TABLETS RISPERIDONE ODT PA Required for ages < 6 years 60 30 RISPERIDONE SOLUTION RISPERDAL PA Required for ages < 6 years 240 ML 30 RISPERIDONE TABLETS RISPERIDONE PA Required for ages < 6 years 60 30 SALIVA SUBSTITUTE SPRAY SALIVART SELIGILENE TD PATCH EMSAM PA Required SERTRALINE HCL CONCENTRATE ZOLOFT 300 ML 30 SERTRALINE HCL TABLETS 25MG ZOLOFT 90 30 SERTRALINE HCL TABLETS 50MG ZOLOFT 120 30 SERTRALINE HCL TABLETS 100MG ZOLOFT 60 30 TEMAZEPAM CAPSULES 15MG, 30MG RESTORIL THIAMINE HCL TABLETS VITAMIN B1 - THIORIDAZINE HCL TABLETS MELLARIL PA Required for ages < 6 years THIOTHIXENE CAPSULES NAVANE PA Required for ages < 6 years THRYOID TABLETS ARMOUR THYROID TOPIRAMATE CAPSULES TOPAMAX TOPIRAMATE TABLETS TOPAMAX TRANYLCYPROMINE SULFATE TABLETS PARNATE TRAZODONE TABLETS 50MG 90 30 TRAZODONE TABLETS 100MG 120 30 TRAZODONE TABLETS 150MG 60 30 TRAZODONE TABLETS 300MG 30 30 TRIAZOLAM TABLETS HALCION TRIFLUOPERAZINE HCL TABLETS STELAZINE PA Required for ages < 6 years TRIHEXPHENIDYL HCL TABLETS ARTANE TRIMIPRAMINE MALEATE CAPSULES TRIMIPRAMINE PA Required for ages < 6 years VALPROATE SODIUM CAPSULES DEPAKENE VALPROATE SODIUM SOLUTION DEPAKENE VALPROATE SODIUM SYRUP DEPAKENE VENLAFAXINE HCL CAPSULES CONTROLLED RELEASE 37.5MG EFFEXOR XR 90 30 VENLAFAXINE HCL CAPSULES CONTROLLED RELEASE 75MG EFFEXOR XR 90 30 VENLAFAXINE HCL CAPSULES CONTROLLED RELEASE 150MG EFFEXOR XR 30 30 VENLAFAXINE HCL TABLETS (IMMEDIATE RELEASE ONLY) 25MG VENLAFAXINE 120 30 Page 6 of 7
Generic Drugs Are Preferred Over Brand Name Drugs Unless Specified As Brand Drug Class/Drug Name VENLAFAXINE HCL TABLETS (IMMEDIATE RELEASE ONLY) 37.5MG VENLAFAXINE 90 30 VENLAFAXINE HCL TABLETS (IMMEDIATE RELEASE ONLY) 50MG VENLAFAXINE 90 30 VENLAFAXINE HCL TABLETS (IMMEDIATE RELEASE ONLY) 75MG VENLAFAXINE 150 30 VENLAFAXINE HCL TABLETS (IMMEDIATE RELEASE ONLY) 100MG VENLAFAXINE 90 30 VILAZODONE HCL TABLETS VIIBRYD PA Required ZALEPLON CAPSUELS SONATA ZIPRASIDONE HCL CAPSULES ZIPRASIDONE PA Required for ages < 6 years 60 30 ZOLPIDEM CAPSULES 5MG AMBIEN PA Required for > 1 Hypnotic 60 30 ZOLPIDEM CAPSULES 10MG AMBIEN ZOLPIDEM ER TABLETS AMBIEN CR PA Required ZOLPIDEM SL TABLETS INTERMEZZO SL PA Required ZOLPIDEM SL TABLETS EDULAR PA Required ZOLPIDEM SOLUTION ZOLPIMIST PA Required 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 requires prior authorization. Abbreviations: Cap = capsule HCL = hydrochloride SOLN = solution Chew = chewable IM = intramuscular SR = sustained release Conc = concentrate Inj = injectable Susp = suspension DR = Delayed Release IR = Immediate release Syr = Syrup Elix = Elixir LA = long acting Tab = tablet ER = extended release ODT = orally disintegrating tablet TD = transdermal hbr = hydrobromide SL = sublingual XL = extended release Page 7 of 7