Amitriptyline/Perphenazine Triavil MAJOR TRANQUILIZERS Beneficiaries 10/2, 10/4, 25/2, 25/4, 50/4 Aripiprazole Abilify 2mg, 5mg, 10mg, 15mg, 20mg, 30mg Quantity Limit 31 / mo for Asenapine Saphris 5mg, 10mg On as of 6/1/10 Chlorpromazine Thorazine 25mg, 50mg, 75mg, 100mg, 150mg, 200mg 100mg/ml Conc, 25mg/ml inj Clozapine Clozaril Fluphenazine HCl Prolixin Haloperidol Haldol 25mg, 100mg, 1mg, 2.5mg, 5mg, 10mg, 2.5mg/ml & 5mg/ml Conc, 25mg/ml Amps, Vial Decanoate 0.5mg, 1mg, 2mg, 5mg, 10mg, 20mg, 50mg/ml, 100mg/ml Amp, Vial Decanoate additionally allows 200mg tab and Tar for for 25 12.5, 25, & 100mg orally disintegrating tabs & 100mg tabs iloperidone Fanapt 1mg, 2mg, 4mg, 6mg, 8mg, 10mg, 12mg On as of 5/1/10 Loxapine succinate Loxitane 5mg, 10mg, 25mg, 50mg Caps Mesoridazine Serentil Lurasidone HCl Latuda 10mg, 25mg, 50mg, 100mg 25mg/ml Inj, 25mg/ml Liq 40mg, 80mg On as of 2011 Molindone HCl Moban 5mg, 10mg, 25mg, 50mg, 100mg 20mg/ml Liq Olanzapine Zyprexa 2.5mg, 5mg, 7.5mg,10mg, 15mg, 20mg 5mg, 10mg, 15mg, 20mg Zydis 210mg, 300mg, 405mg IM Relprevv RELPREVV not on BHS Not Available with TAR TAR & registration for Relprevv paliperidone Invega 1.5mg, 3mg, 6mg, 9mg, 117mg, 156mg, 234mg IM Sustenna TAR Perphanzine Trilafon 2mg, 4mg, 8mg, 16mg 16mg/ 5ml Liq, 5mg/ml Inj Pimozide Orap 1mg, 2mg Quetiapine Seroquel 25, 50, 100, 200, 300, 400mg 50, 150, 200, 300, 400mg XR Quanity Limit 31 / mo for 50mg & 150mg XR Risperidone Risperdal.25mg,.5mg, 1mg, 2mg, 3mg, 4mg.5mg, 1mg, 2mg M-, 1mg/ml Liq 12.5mg, 25mg, 37.5mg, 50mg IM Consta Quanity Limit 31 / mo for.25mg,.5mg, 1mg tabs and.5mg, 1mg M- Consta not on BHS Tar for Consta and M- Thioridazine Mellarill 10mg, 15mg, 25mg, 50mg, 100mg, 150mg 200mg 25mg/5ml, 100mg/5ml Liq Thiothixene Navane Trifluoperazine Stelazine Ziprasidone Geodon 1mg, 2mg, 5mg, 10mg, 20mg Caps 5mg/ml Liq 1mg, 2mg, 5mg,10mg 10mg/ml Liq, 2mg/ml Inj 20mg, 40mg, 60mg, 80mg Caps Quantity Limit 62 / mo for 20mg, 40mg, 60mg tabs Blue font indicates changes For BHS Clinics and Contract Clinics Formulary Section - Page 1
Amitriptyline Elavil Amoxapine Asendin Bupropion Wellbutrin Citalopram Celexa Clomipramine Anafranil Desipramine HCL Norpramin Doxepin Sinequan Duloxetine Cymbalta Escitalopram Lexapro Fluoxetine Prozac ANTIDEPRESSANTS 25mg, 50mg, 100mg, 150mg 75mg, 100mg 100mg, 150mg, 200mg SR (budeprion) 300mg XL (budeprion) 10mg, 20mg, 40mg 25mg, 50mg, 75mg Caps Caps, 10mg/ml Liq 150mg XL requires county TAR Quan Limit 31/ mo for 300mg & 62 / mo for 75, 100, 150, 200mg 10mg requires county TAR Quantity Limit 62/ mo for Quantity Limit 124 / mo for Beneficiaries Limit Three per day Limit Two per day SR's XL's Quantity Limit 124 / mo for 20mg, 30mg, 60mg TAR for 20mg 10mg, 20mg 10mg, 20mg Caps (Not ), 20mg/5ml Liq, 90mg Pulvule 40mg Caps requires county TAR Quan Limit 124 / mo for 20mg, 31 /mo for 10 & 10 /mo for 90mg Limit One 10mg per day Max dose 80mg / d Fluvoxamine Luvox Imipramine Tofranil Maprotiline Ludiomil Mirtazapine Remeron 25mg, 50mg, 100mg 10mg, 25mg, 50mg 25mg, 50mg, 75mg 7.5 mg, 15mg, 30mg, 45mg 15mg, 30mg, 45mg Sol- Quan Limit 31 / mo for 25mg, 45 / mo for 50mg, & 93 / mo for 100mg Quan Limit 31 / mo for 15mg tab & all Sol-, 62 / mo for 30 & 45 mg Limit 25mg #31/mo, 50mg #45/mo, 100mg #93/mo Max dose 300mg/d Nefazadone Serzone Nortriptyline HCl Aventyl Paroxetine Paxil Protriptyline Vivactyl Sertraline Zoloft Trazodone Desyrel Trimipramine Surmontil Desvenlafaxine Pristiq 50mg, 100mg, 150mg, 200mg, 250mg 10mg, 25mg, 50mg, 75mg Caps 10mg, 20mg, 30mg, 40mg 12.5mg, 25mg, 37.5mg CR 5mg, 10mg 25mg, 50mg, 100mg 50mg, 100mg, 150mg 25mg, 50mg, 100mg Caps 50mg, 100mg Quan Limit 93 / mo for 200mg, and 62 / mo for all others Quan Limit 62 / mo for 30mg & 40mg, and 31 / mo for all others Quan Limit 31 / mo for 25mg, 15 / mo for 50mg, & 93 / mo for 100mg Limit Two per day Does not cover CR Limit One 50mg per day Limit Two 100mg per day Limit Two per day Venlafaxine (& ER) (generic for Effexor) Vilazodone HCl Viibryd 25mg, 37.5mg, 50mg, 75mg, 100mg 37.5 mg, 75mg, 150mg, 225mg ER 10mg, 20mg, 340mg Quan Limit 93/ mo for, 31 / mo for 37.5 mg, 75mg ER & 62 / mo for 150mg ER Quan Limit 93/ mo for, 31 / mo for 37.5 mg, 75mg XR & 62 / mo for 150mg XR Blue font indicates changes For BHS Clinics and Contract Clinics Formulary Section - Page 2
Phenelzine Nardil Selegiline Emsam Tranylcypromine Parnate Alprazolam Xanax Buspirone Buspar Chloral Hydrate Chlordiazepoxide Librium Clonazepam Klonopin Diazepam Valium Flurazepam Dalmane Lorazepam Ativan Oxazepam Serax Temazepam Restoril Triazolam Halcion Zaleplon Sonata Zolpidem Ambien Carbamazepine Tegretol Divalproex Sodium Depakote Gabapentin Neurontin Lamotrogine Lamictal Lithium Oxcarbazepine Trileptal Topiramate Topamax Valproic Acid Depakene Amantadine Symmetrel 15mg 6mg, 9mg, 12mg patche 10mg.25mg,.5mg, 1mg, 2mg Tab 5mg, 10mg, 15mg Tab 500mg Cap, 500mg Supp, 250mg/5ml, 500mg/ml 5mg, 10mg, 25mg Caps.5mg, 1mg, 2mg 2mg, 5mg, 10mg MAOI ANTIDEPRESSANTS TAR Required ANTI-ANXIETY / HYPNOTICS Beneficiaries Quan Limit 150 / mo for all doses Quan Limit 186 / 2 mo for all doses 15mg, 30mg Caps Insomnia (under age 65) 0.5 mg, 1.0 mg, 2.0mg 2mg/ml, 4mg/ml Inj 10mg, 15mg, 30mg Caps 7.5mg 15mg, 30mg 0.125mg, 0.25mg 5 mg, 10 mg Caps 5 mg, 10 mg 100mg, 200mg, 400mg, 100mg/5ml 125mg IR, 125mg, 250mg, & 500mg EC 250mg, & 500mg ER 100mg, 300mg, 400mg, 600mg, 800mg 25mg, 100mg, 150mg, 200mg 150mg, 300mg, 600mg Caps, 300mg Tab, 300mg CR Tab(Lithobid), 450mg CR Tab (Eskalith) 300mg/5ml 150mg, 300mg, 600mg 300mg/5ml oral suspension 25mg, 50mg,100mg, 200mg 250mg, 250mg/5ml 100mg, 50mg/ml MOOD STABILIZERS Quan Limit 186/ mo for 25mg, 93 / mo for 50mg, & 62 / mo for 100mg & 200mg for Eskalith 450mg MEDICATIONS Primarily Used for SIDE EFFECTS Quan Limit 150 / mo for all doses Insomnia Insomnia (limit #31) Over 55 & Limit #20 per month Over 55 & Limit #31 per month Quan Limit 360 / 2 mo for 100mg, 300mg, 400mg, 600mg & 240 / 2 mo for 800mg Quan Limit 186/ mo for 25mg, 93 / mo for 50mg, & 62 / mo for 100mg & 200mg Blue font indicates changes For BHS Clinics and Contract Clinics Formulary Section - Page 3
Benzotropine Mesylate Cogentin Biperiden Akineton Diphenhydramine Benadryl Hydroxyzine HCl (generic for Vistaril) Triphexyphenidyl Artane Atenolol Tenormin Clondine HCl Catapress Cyanocobalamin Vitamin B-12 Docusate Sodium Colace Disulfiram Antabuse Donepezil Aricept DDAVP Desmopressin Folic Acid 0.5mg, 1mg, 2mg 2mg 12.5mg, 25mg, 50mg, 10mg/ml, 50mg/ml 10mg, 25mg, 50mg, 100mg, 10mg/5ml 2mg, 5mg, 2mg/5ml 25mg, 50 mg, 100mg 0.1mg, 0.2mg, 0.3mg 0.1, 0.2, 0.3 Patches 100mcg/ml, 1000mcg/ml 100mg, 240mg, 250 mg Caps 250mg, 500mg 5mg, 10mg 0.01% Nasal Spray 1mg Tab Non-Specific or Non-Psychoactive MEDICATIONS Not Available GPI 82200010000315 Beneficiaries Quanity Limit #31 / mo and Requires MMSE score of 10-26 and Alzheimer's dx on Rx Guanfacine HCl Tenex Levothyroxine Sodium Synthroid/Levoxyl Liothyronine Cytomel Nicodem Transdermal Patch Nicotine Gum Polacrilex Propanolol Inderal Pyridoxine Vitamin B-6 Thiamine Vitamin B-1 Thyroid Extract Armour Thryoid Vitamin - Multi Multi-vitamins 1mg, 2mg 25mcg, 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg,300mcg 5 mcg, 25mcg, 50mcg 10mcg / ml Inj 7mg, 14mg, 21mg Patches 2mg, 4mg Gum 10mg, 20mg, 40mg, 60mg, 80mg, 90mg, 1mg/ml, 20mg/5ml, 40mg/5ml, 80mg/ml Inj 10mg, 25 mg, 50mg, 100mg, 200mg, 250mg, 500mg 100mg, 200mg, 500mg CR, 100 / l I j 50mg, 100mg, 250mg, 500mg 50mg Cap, 100mg/ml Inj 15mcg, 30mcg, 60mcg, 90mcg, 120mcg, 180mcg, 240mcg, 300mcg Various GPI 77101010102005 GPI 7820-7851 PSYCHOSTIMULANT and ADHD MEDICATIONS Blue font indicates changes For BHS Clinics and Contract Clinics Formulary Section - Page 4
Beneficiaries Amphetamine/ Adderall 5mg, 7.5mg, 10mg, 12.5mg, 15mg, 20mg, 30mg Amphetamine/ XR Adderall XR 5mg, 10mg,15mg, 20mg, 30mg Caps Atomoxetine Strattera 10mg, 18mg, 25mg, 40mg, 60mg, 100mg Caps (for more than one tablet per day) Dexedrine 5mg, 10mg 5mg, 10mg, 15mg Caps Dexedrine Spansules Dexmethylphenidate Focalin Dexmethylphenidate Focalin XR Caps Methylphenidate Methylin Ritalin Methylphenidate ER Metadate ER Methylin ER Ritalin SR Methylphenidate Caps w Long-Acting Pellets Metadate CD Ritalin LA lisdexamfetamine dimesylate Vyvanse Capsules 2.5mg, 5mg, 10mg 5mg, 10mg, 15mg, 20mg, 30mg XR Caps 5mg, 10mg, 20mg (5hr extended-release) 20mg generic ER 10mg, 20mg Metadate ER 20mg Ritalin SR (8hr extended-release) 10, 20, 30, 40, 50, 60 mg Metadate CD 10mg, 20mg, 30mg, 40mg Ritalin LA 20mg, 30mg, 40mg, 50mg, 60mg, 70mg Caps For CYS Only methylphenidate transdermal Daytrana TM Methylphenidate (with trilayer core) Concerta 10mg, 15mg, 20mg, 30mg Transdermal Patches 18mg, 27mg, 36mg, 54mg Caps (14/4), (21/6), (28/8), (42/12) For CYS Only Blue font indicates changes For BHS Clinics and Contract Clinics Formulary Section - Page 5