Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 06/01/2016

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1 Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 06/01/2016 Effective April 1, 2014, Mercy Maricopa Integrated Care began operations as the Regional Behavioral Health Authority for Maricopa County. Funds for services are provided through a contract with the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) and the Arizona Health Care Cost Containment System (AHCCCS). Updated 06/01/2016 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 ADHS/DBHS 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 06/01/2016 2

3 ANTIDEPRESSANTS Alpha-2 Receptor Antagonist Antidepressants Remeron Remeron mirtazapine Tab ODT #30 SolTab 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 #30 bupropion hcl Wellbutrin Wellbutrin SR Wellbutrin XL IR Tab ER Tab ER Tab IR:75/100mg = #60 SR:100/150/200mg = #60 XL: 300mg = #30 XL: 150mg = #90 Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram hbr Various Soln 300ml citalopram hbr Celexa Tab #30 escitalopram oxalate Lexapro Soln 300ml escitalopram oxalate Lexapro Tab #30 10mg tablets = #45 fluoxetine hcl Prozac Cap/Tab 10mg and 60mg = #30 10mg tablets = #45 20 mg = #120 fluoxetine hcl Prozac Soln 600 ml fluoxetine hcl weekly Prozac Weekly DR Cap X #1 pack fluvoxamine maleate Luvox Tab 25mg = #30 50mg = #60 100mg = #90 fluvoxamine maleate Luvox CR ER Cap #60 Updated 06/01/2016 3

4 paroxetine hcl Paxil Susp 900ml paroxetine hcl Paxil Tab #60 40mg = #45 paroxetine hcl tab Paxil CR ER Tab 12.5mg = #30 25/ 37.5mg = #60 PEXEVA paroxetine mesylate Tab X 10 MG= # MG=#90 30 MG=#60 40 MG=#45 sertraline hcl Zoloft Conc 300ml sertraline hcl Zoloft Tab 25= #30 50mg, 100mg =#60 VIIBRYD vilazodone hcl Tab X 10mg, 20mg = #60 40mg = #30 Starter kit = #1 Serotonin- 2 Antagonist/Reuptake Inhibitors (SARIs) nefazodone Various Tab trazodone ER Various Tab #30 trazodone hcl Various Tab 50mg, 100mg, 150mg = # mg= #60 Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) desvenlafaxine Pristiq ER Tab #30 Pristiq ER Tab #30 duloxetine hcl Cymbalta Cap #60 venlafaxine hcl Effexor IR Tab #90 venlafaxine hcl XR Effexor ER Cap #60 venlafaxine hcl ER Various ER Tab #60 Tricyclic Antidepressants & Related Non-Selective Reuptake Inhibitors Updated 06/01/2016 4

5 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 Combination Medications Used for the Treatment of BPAD fluoxetine hcl /olanzapine Symbyax Cap X #30 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 aripiprazole Tab X #30 ABILIFY DISCMELT aripiprazole ODT Tab X X #30 Updated 06/01/2016 5

6 ABILIFY MAINTENA aripiprazole Inj X X aripiprazole Abilify Soln X X 480ml clozapine Clozaril Tab X 25mg = #360, 50mg = #90, 100mg = #270, 200mg = #90 clozapine FazaClo ODT Tab X 12.5mg, 25mg = #360, 100mg = #270, 150mg, 200mg = #90 FANAPT Iloperidone Tab X X paliperiodone I Invega ER Tab X 1mg,2mg,4mg #60 6mg,8mg,10mg, 12mg #30 Titration pack = #1 INVEGA SUSTENNA paliperiodone LA Susp X X LATUDA lurasidone hcl Tab X X #60 120mg = #30 olanzapine Zyprexa, Zydis ODT X #30 quetiapine Seroquel Tab X 25/50mg = #30 100/200/300/400mg = #60 SEROQUEL XR quetiapine Tab X X #30 risperidone Risperdal Tab X 0.25/0.5/1/2 mg= #90 3mg, 4mg = #60 RISPERDAL CONSTA risperidone Inj X #2/28days risperidone ODT Risperdal M-TAB ODT X 0.25mg, 0.5mg, 1mg = #90 2mg, 3mg 4mg = #60 Risperidone soln Risperdal Soln X 240ml Updated 06/01/2016 6

7 SAPHRIS asenapine SL Tab X X #60 ziprasidone hcl Geodon Cap X #60 nothiazine 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 gabapentin Neurontin Cap HORIZANT gabapentin ER Tab X gabapentin Neurontin Soln GRALISE gabapentin Tab X lamotrigine Lamictal Tab Chew ODT #60 LAMICTAL XR lamotrigine ER Tab X Updated 06/01/2016 7

8 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 ADHD DRUGS Amphetamines amphetaminedextroamphetamine IR Adderall Tab X amphetaminedextroamphetamine XR Dextroamphetamine sulfate Dextroamphetamine sulfate 5/10/12.5mg= #90 15/20/30mg = #60 Adderall XR SR Cap X #30 Dexedrine ER Cap X #60 Various Tab X #90 VYVANSE Lisdexamfetamine ER Cap X #30 Stimulants dexmethylphenidate hcl dexmethylphenidate hcl ER FOCALIN XR 25mg and 35mg Focalin Tab X #60 FocalinXR ER Cap X #30 dexmethylphenidate hcl ER ER Cap X #30 Updated 06/01/2016 8

9 methylphenidate hcl Ritalin Tab X #90 methylphenidate hcl Methylin Chew Tab X #90 methylphenidate hcl Ritalin LA/Metadate ER Cap X #30 methylphenidate hcl Ritalin SR SR Tab X #30 methylphenidate hcl Concerta ER Tab X 36mg = #90 All other strengths = #30 DAYTRANA methylphenidate hcl TD Patch X methylphenidate hcl Methylin Soln X 900ml QUILLIVANT XR methylphenidate hcl Susp X X 900ml Miscellaneous nts STRATTERA atomoxetine Cap X #30 Central Alpha-Agonists clonidine hcl tab Catapres Tab X clonidine ER Kapvay ER Tab X #120 clonidine patch Catapres TTS TD Patch X #4 guanfacine hcl Tenex Tab X guanfacine hcl ER Intuniv ER Tab X #30 SUBSTANCE ABUSE Opiate Agonists/Partial Agonists buprenorphine hcl Subutex SL Tab #90 buprenorphine hcl /naloxone Suboxone SL Tab #90 SUBOXONE FILM buprenorphine hcl /naloxone Film X #90 methadone Opiate Antagonists Dolophine * medication can only be obtained from an Opioid Treatment Program (OTP) provider Updated 06/01/2016 9

10 naltrexone Revia Tab #30 NARCAN Naloxone Nasal Spray VIVITROL naltrexone Inj X Miscellaneous nts acamprosate Campral DR Tab disulfiram Antabuse Tab ANXIOLYTICS AND HYPNOTICS Benzodiazepines alprazolam Xanax Tab 0.25/0.5/1mg= #120 2mg = #60 alprazolam intensol Alprazolam Intensol Conc Soln 120ml alprazolam Xanax XR ER Tab 0.5/1mg= #120 2/3mg = #60 alprazolam Niravam ODT 0.25/0.5/1mg= #120 2mg = #60 chlordiazepoxide hcl Librium Cap clonazepam Klonopin Tab 0.5/1mg =#120 2mg = #60 clonazepam Various ODT 0.125/0.25/0.5/1mg=#120 2mg = #60 clorazepate Tranxene-T Tab diazepam Valium Tab 2/5/10 mg =#120 diazepam intensol Diazepam Intensol Conc Soln 240ml estazolam Various Tab #30 flurazepam hcl Dalmane Cap #30 Updated 06/01/

11 lorazepam Ativan Tab 0.5/1 mg =#120 2mg = #90 lorazepam Intensol lorazepam Conc Soln 90ml oxazepam Serax Cap temazepam Restoril Cap #30 Miscellaneous Anxiolytics, Sedatives & Hypnotics buspirone hcl Various Tab eszopiclone Lunesta Tab #30 meprobamate Various Tab ramelteon Rozerem Tab #30 triazolam Halcion Tab #30 zaleplon capsule Sonata Cap #30 zolpidem Ambien Tab #30 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 Updated 06/01/

12 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 / Various Tab Miscellaneous Ear, Nose & Throat Drug saliva substitute Salivart Spray Cathartics and Laxative docusate sodium Colace Cap psyllium Metamucil Powder Updated 06/01/

13 Updated 06/01/

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