Drug Class/Drug Name	
Reference Brand Name	
Use Brand Only	Preferred Drug
Status	
Prior Authorization Required	
Quantity Limits	
Days Supply	
ANTIDEPRESSANTS	
ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS	
MIRTAZAPINE	REMERON			PA Required for Ages < 6 years	30	30	
MIRTAZAPINE	REMERON SOLTAB			PA Required for Ages < 6 years	30	30	
MONOAMINE OXIDASE INHIBITORS (MAOIs)	
SELIGILENE	EMSAM			PA Required			
ISOCARBOXAZID	MARPLAN			PA Required for Ages < 6 years			
PHENELZINE SULFATE	NARDIL			PA Required for Ages < 6 years			
TRANYLCYPROMINE SULFATE	PARNATE			PA Required for Ages < 6 years			
NOREPINEPHRINE & DOPAMINE REUPTAKE INHIITORS (NDRIs)	
BUPROPION HCL 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	
MAPROTILINE HCL TABLETS	MAPROTILINE HCL			PA Required for Ages < 6 years			
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)	
CITALOPRAM HYDROBROMIDE SOLUTION	CELEXA			PA Required for Ages < 6 years	600	30	

CITALOPRAM HYDROBROMIDE TABLETS	

CELEXA			

PA Required for Ages < 6 years	10mg : 60
20mg: 30
40mg: 30	
30	
ESCITALOPRAM OXALATE SOLUTION	LEXAPRO			PA Required for Ages < 6 years	600ml	30	

ESCITALOPRAM OXALATE TABLETS	

LEXAPRO			

PA Required for Ages < 6 years	5mg : 60
10mg: 30
20mg: 30	30
30
30	

FLUOXETINE HCL CAPSULES ONLY	

PROZAC			

PA Required for Ages < 6 years	
10mg: 60
20MG: 120
40mg:60	
30
30
30	
FLUOXETINE HCL SOLUTION	PROZAC			PA Required for Ages < 6 years	600	30	
FLUOXETINE HCL TABLETS - WEEKLY	PROZAC WEEKLY			PA Required			

Drug Class/Drug Name	
Reference Brand Name	
Use Brand Only	Preferred Drug
Status	
Prior Authorization Required	
Quantity Limits	
Days Supply	

FLUVOXAMINE MALEATE TABLETS	

LUVOX			

PA Required for Ages < 6 years	25mg:  60
50mg:180
100mg: 90	30
30
30	
FLUVOXAMINE MALEATE TABLETS EXTENDED
RELEASE	
LUVOX CR			
PA Required for Ages < 6 years	100mg: 90
150mg: 60	30
30	
PAROXETINE HCL SUSPENSION	PAXIL			PA Required for Ages < 6 years	900	30	

PAROXETINE HCL TABLETS	

PAXIL			

PA Required for Ages < 6 years	10mg: 30
20mg: 30
30mg: 30
40mg: 45	30
30
30
30	
PAROXETINE HCL TABLETS	PAXIL CR			PA Required for Ages < 6 years	90	30	
PAROXETINE MESYLATE	PEXEVA			PA Required			
SERTRALINE HCL Concentrate	ZOLOFT			PA Required for Ages < 6 years	300	30	

SERTRALINE HCL	

ZOLOFT			

PA Required for Ages < 6 years	
25mg: 90
50mg : 120
100mg: 60	
30
30
30	
VILAZODONE HCL	VIIBRYD			PA Required			
SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIs)	

NEFAZODONE	

VARIOUS			

PA Required for Ages < 6 years	50mg: 60
100mg: 60
150mg: 120
200mg: 90
250mg: 60	30
30
30
30
30	

TRAZODONE HCL	
VARIOUS			

PA Required for Ages < 6 years	50mg:90
100mg:120
150mg: 60
300mg 30	30
30
30
30	
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs}	

Drug Class/Drug Name	
Reference Brand Name	
Use Brand Only	Preferred Drug
Status	
Prior Authorization Required	
Quantity Limits	
Days Supply	

DESVENLAFAXINE	
PRISTIQ			

PA Required for Ages < 6 years	25mg:120
50mg: 120
100mg: 120	30
30
30	

DULOXETINE HCL 20MG, 30MG & 60MG ONLY	
CYMBALTA			

PA Required for Ages < 6 years	20mg: 120
30mg: 120
60mg: 60	30
30
30	

VENLAFAXINE HCL CAPSULE CONTROLLED RELEASE	

EFFEXOR XR			

PA Required for Ages < 6 years	37.5mg: 90
75mg: 90
150mg: 30	30
30
30	

VENLAFAXINE HCL TABLETS IMMEDIATE RELEASE ONLY	

VENLAFAXINE HCL			

PA Required for Ages < 6 years	25mg: 120
37.5mg: 90
50mg:  90
75mg: 150
100mg: 90	30
30
30
30
30	
TRICYCLIC ANTIDEPRASSANTS &RELATED NON-SELECTIVE REUPTAKE INHIBITORS	
AMITRIPTYLINE HCL TABLETS	AMITRIPTYLINE HCL			PA Required for ages < 6 years			
AMOXAPINE TABLETS	VARIOUS			PA Required for ages < 6 years			
CLOMIPRAMINE HCL CAPSULES	ANAFRANIL			PA Required for ages < 6 years			
DESIPRAMINE HCL TABLETS	NORPRAMIN			PA Required for ages < 6 years			
DOXEPIN HCL CAPSULES	DOXEPIN HCL			PA Required for ages < 6 years			
DOXEPIN HCL CONCENTRATE	DOXEPIN HCL			PA Required for ages < 6 years			
IMIPRAMINE PAMOATE CAPSULES	TORFRANIL-PM			PA Required for ages < 6 years			
IMIPRAMINE HCL TABLETS	TOFRANIL			PA Required for ages < 6 years			
IMIPRAMINE PAMOATE CAPSULES	TOFRANIL-PM			PA Required for ages < 6 years			
NORTRIPTYLINE HCL CAPSULES	PAMELOR			PA Required for ages < 6 years			
NORTRIPTYLINE HCL SOLUTION	NORTRIPTYLINE HCL			PA Required for ages < 6 years			
PROTRIPTYLINE HCL TABLETS	VIVACTIL			PA Required for ages < 6 years			
TRIMIPRAMINE MALEATE	SURMONTIL			PA Required for ages < 6 years			
ANTIPSYCHOTICS	

Drug Class/Drug Name	
Reference Brand Name	
Use Brand Only	Preferred Drug
Status	
Prior Authorization Required	
Quantity Limits	
Days Supply	
ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL ORAL AGENTS		
ARIPIPRAZOLE TABLETS	ABILIFY		Preferred Drug	PA Required for Ages < 6 years	30	30	

ARIPIPRAZOLE ORALLY DISPERABLE TABLETS (ODT)	
ABILIFY		
Preferred Drug	
PA Required for Ages < 6 years	
30	
30	
ARIPIPRAZOLE SOLUTION	ABILIFY		Preferred Drug	PA Required for Ages < 6 years	150	30	
ASENAPINE MALEATE SUBLINGUAL	SAPHRIS	Brand Only	Preferred Drug	PA Required for Ages < 6 years	60	30	
CLOZAPINE ORALLY DISPERSABLE TABLET	FAZACLO		Preferred Drug	PA Required for Ages < 18 years	150	30	
CLOZAPINE TABLETS	CLOZARIL		Preferred Drug	PA Required for Ages < 18 years	150	30	
LURASIDONE HCL TABS	LATUDA	Brand Only	Preferred Drug	PA Required for Ages < 6 years	30	30	

OLANZAPINE TABLET	

ZYPREXA		

Preferred Drug	

PA Required for Ages < 6 years	5MG :60
10mg: 60
15MG: 30
20mg: 30	30
30
30
30	

OLANZAPINE ORALLY DISPERSABLE TABLET	

ZYPREXA ZYDIS		

Preferred Drug	

PA Required for Ages < 6 years	5MG :60
10mg: 60
15MG: 30
20mg: 30	30
30
30
30	
QUETIAPINE FUMARATE TABLETS	SEROQUEL		Preferred Drug	PA Required for Ages < 6 years	60	30	
RISPERIDONE ORALLY DISPERSABLE TABLET	RISPERIDONE ODT		Preferred Drug	PA Required for Ages < 6 years	60	30	
RISPERIDONE ORAL SOLUTION	RISPERDAL		Preferred Drug	PA Required for Ages < 6 years	240	30	
RISPERIDONE TABLETS	RISPERDAL		Preferred Drug	PA Required for Ages < 6 years	60	30	
ZIPRASIDONE HCL CAPSULES	GEODON		Preferred Drug	PA Required for Ages < 6 years	60	30	
ANTIPSYCHOTICS - SECOND GENERATION - ATYPICAL LONG ACTING INJECTABLES		
ARIPIPRAZOLE LAUROXIL	ARISTADA	Brand Only	Preferred Drug	PA Required for Ages < 18 years	1	30	
ARIPIPRAZOLE SUSPENSION	ABILIFY MAINTENA	Brand Only	Preferred Drug	PA Required for Ages < 18 years	1	30	
PALIPERIDONE PALMITATE SUSPENSION	INVEGA SUSTENNA	Brand Only	Preferred Drug	PA Required for Ages < 18 years	1	30	
PALIPERIDONE PALMITATE SUSPENSION	INVEGA TRINZA	Brand Only	Preferred Drug	PA Required for Ages < 18 years	1	90	
RISPERIDONE MICROSPHERES SUSPENSION	RISPERDAL CONSTA	Brand Only	Preferred Drug	PA Required for Ages < 18 years	2	30	
ANTIPSYCHOTICS - FIRST GENERATION -TYPICAL ORAL AGENTS	

Drug Class/Drug Name	
Reference Brand Name	
Use Brand Only	Preferred Drug
Status	
Prior Authorization Required	
Quantity Limits	
Days Supply	
CHLORPROMAZINE HCL SOLUTION	VARIOUS			PA Required for Ages < 6 years			
CHLORPROMAZINE HCL TABLETS	VARIOUS			PA Required for Ages < 6 years			
FLUPHENAZINE HCL CONCENTRATE	VARIOUS			PA Required for Ages < 6 years			
FLUPHENAZINE HCL ELIXIR	VARIOUS			PA Required for Ages < 6 years			
FLUPHENAZINE HCL TABLETS	VARIOUS			PA Required for Ages < 6 years			
HALOPERIDOL LACTATE CONCENTRATE	VARIOUS			PA Required for Ages < 6 years			
HALOPERIDOL TABLETS	VARIOUS			PA Required for Ages < 6 years			
LOXAPINE SUCCINATE CAPSULES	LOXITANE			PA Required for Ages < 6 years			
PERPHENAZINE TABLETS	VARIOUS			PA Required for Ages < 6 years			
PIMOZIDE	ORAP			PA Required for Ages < 6 years			
THIORIDAZINE HCL TABLETS	VARIOUS			PA Required for Ages < 6 years			
THIOTHIXENE CAPSULES	VARIOUS			PA Required for Ages < 6 years			
TRIFLUOPERAZINE HCL TABLETS	VARIOUS			PA Required for Ages < 6 years			
ANTIPSYCHOTICS - FIRST GENERATION -TYPICAL -LONG ACTING INJECTIONS		
FLUPHENAZINE DECANOATE SOLUTION	FLUPHENAZINE DECANOATE			PA Required for Ages < 18 years			
HALOPERIDOL DECANOATE SOLUTION	HALDOL DECANOATE			PA Required for Ages < 18 years			
ANTICONVULSANTS	
CARBAMAZEPINE	TEGRETOL, EPITROL						
CARBAMAZEPINE	TEGRETOL, EPITROL						
CARBAMAZEPINE	CARBATROL, EQUETRO						
CARBAMAZEPINE	TEGRETOL XR,						
CARBAMAZEPINE	TEGRETOL						
DIVALPROEX	DEPAKOTE						
DIVALPROEX	DEPAKOTE SPRINKLES						
GABAPENTIN	NEURONTIN						
GABAPENTIN	HORIZANT			PA Required			
GABAPENTIN	NEURONTIN						
GABAPENTIN	GRALISE			PA Required			
LAMOTRIGINE CHEWABLE TABLETS	LAMICTAL CHEWABLE TABLETS						

Drug Class/Drug Name	
Reference Brand Name	
Use Brand Only	Preferred Drug
Status	
Prior Authorization Required	
Quantity Limits	
Days Supply	
LAMOTRIGINE	LAMICTAL						
LAMOTRIGINE	LAMICTAL XR						
OXCARBAZEPINE	TRILEPTAL						
OXCARBAZEPINE	TRILEPTAL						
TOPIRAMATE	TOPAMAX						
VALPROATE SODIUM	VARIOUS						
VALPROATE SODIUM	DEPAKENE						
ANTIMANIC AGENTS	
LITHIUM CARBONATE	VARIOUS						
LITHIUM CARBONATE	LITHOBID						
LITHIUM CITRATE	VARIOUS						
ADHD AGENTS	
AMPHETAMINES	
AMPHETAMINE-DEXTROAMPHETAMINE CAPSULE
24-HOUR	
ADDERALL XR	
Brand Only	
Preferred Drug	
PA Required for Ages < 6 years	
30	
30	

AMPHETAMINE-DEXTROAMPHETAMINE TABLETS	
ADDERALL	BRAND AND
GENERIC	
Preferred Drug	
PA Required for Ages < 6 years	
60	
30	
DEXTROAMPHETAMINE SULFATE CAPSULE 24-
HOUR	
VARIOUS		
Preferred Drug	
PA Required for Ages < 6 years	
60	
30	
DEXTROAMPHETAMINE SULFATE TABLETS	VARIOUS		Preferred Drug	PA Required for Ages < 6 years	60	30	
LISDEXAMFETAMINE DIMESYLATE CAPSULES	VYVANSE	Brand Only	Preferred Drug	PA Required for Ages < 6 years	30	30	
STIMULANTS	
DEXMETHYLPHENIDATE HCL CAPSULE 24-HOUR	FOCALIN XR	Brand Only	Preferred Drug	PA Required for Ages < 6 years	60	30	
DEXMETHYLPHENIDATE HCL TABLETS	FOCALIN	Brand Only	Preferred Drug	PA Required for Ages < 6 years	60	30	
METHYLPHENIDATE HCL CHEWABLE TABLETS	METHYLIN		Preferred Drug	PA Required for Ages < 6 years	90	30	
METHYLPHENIDATE HCL CHEWABLE TABLETS
EXTENDED RELEASE	
QUILLICHEW ER	
Brand Only	
Preferred Drug	
PA Required for Ages < 6 years	
30	
30	
METHYLPHENIDATE HCL CAPSULE 24-HOUR	RITALIN LA 10MG	Brand Only	Preferred Drug	PA Required for Ages < 6 years	30	30	
METHYLPHENIDATE HCL CAPSULE 24-HOUR	APTENSIO XR	Brand Only	Preferred Drug	PA Required for Ages < 6 years	30	30	

Drug Class/Drug Name	
Reference Brand Name	
Use Brand Only	Preferred Drug
Status	
Prior Authorization Required	
Quantity Limits	
Days Supply	
METHYLPHENIDATE HCL CAPSULE CONTROLLED
RELEASE	
METADATE CD		
Preferred Drug	
PA Required for Ages < 6 years	
30	
30	
METHYLPHENIDATE PATCH	DAYTRANA	Brand Only	Preferred Drug	PA Required for Ages < 6 years	30	30	
METHYLPHENIDATE HCL SOLUTION	METHYLIN	Brand Only	Preferred Drug	PA Required for Ages < 6 years	300	30	
METHYLPHENIDATE HCL SUSPENSION	QUILLIVANT XR	Brand Only	Preferred Drug	PA Required for Ages < 6 years	150	30	
METHYLPHENIDATE HCL TABLETS	VARIOUS		Preferred Drug	PA Required for Ages < 6 years	90	30	
METHYLPHENIDATE HCL TABLET 24-HOUR	METHYLPHENIDATE HCL ER		Preferred Drug	PA Required for Ages < 6 years	60	30	
METHYLPHENIDATE HCL TABLET CONTROLLED
RELEASE	
METHYLPHENIDATE HCL ER		
Preferred Drug	
PA Required for Ages < 6 years	
60	
30	
MISCELLANEOUS AGENTS	
ATOMOXETINE HCL CAPSULES	STRATTERA	Brand Only	Preferred Drug	PA Required for Ages < 6 years	30	30	
CENTRAL ALPHA-AGONISTS	
CLONIDINE HCL	CATAPRES			PA Required for Ages < 6 years			
CLONIDINE HCL Transdermal Patch	CATAPRES PATCHES			PA Required for Ages < 6 years	4	28	
CLONIDINE HCL (ADHD) TABLET 12-HOUR	KAPVAY	Brand Only	Preferred Drug	PA Required for Ages < 6 years	120	30	
GUANFACINE HCL (ADHD) TABLET 24-HOUR	GUANFACINE ER		Preferred Drug	PA Required for Ages < 6 years	30	30	
GUANFACINE HCL	TENEX			PA Required for Ages < 6 years			
SUBSTANCE USE DISORDER TREATMENT	
OPIOID AGONISTS/PARTIAL AGONISTS	

Drug Class/Drug Name	
Reference Brand Name	
Use Brand Only	Preferred Drug
Status	
Prior Authorization Required	
Quantity Limits	
Days Supply	

BUPRENORPHINE	

VARIOUS			
PA Required unless the member is pregnant- the prescriber must note the following ICD- 10 codes on the prescription:
O09.91- Supervision of high risk preganancy, 1st Trimester.
O09.92- Supervision of high risk preganancy, 2nd Trimester.
O09.93- Supervision of high risk preganancy, 3rd Trimester.
O09.91- Supervision of high risk preganancy- use for Post-Partum Nursing Mothers.			
BUPRENORPHINE/NALOXONE	SUBOXONE FILM	Brand Only	Preferred Drug				
METHADONE*	DOLOPHINE*						
OPIOID AGONISTS	
NALOXONE VIAL & SYRINGE	VARIOUS		Preferred Drug				
NALOXONE NASAL SPRAY	NARCAN NASAL SPRAY		Preferred Drug				
NALTREXONE	REVIA		Preferred Drug				
NALTREXONE	VIVITROL		Preferred Drug				
MISCELLANEOUS AGENTS	
ACAMPROSATE	CAMPRAL						
DISULFIRAM	ANTABUSE						
ANXIOLYTICS AND HYPNOTICS	
BENZODIAZEPINES	

ALPRAZOLAM CONC 1 MG/ML	

ALPRAZOLAM INTENSOL			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

60	

15	

Drug Class/Drug Name	
Reference Brand Name	
Use Brand Only	Preferred Drug
Status	
Prior Authorization Required	
Quantity Limits	
Days Supply	

ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.25 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

120	

30	

ALPRAZOLAM ORALLY DISINTEGRATING TAB 0.5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

120	

30	

ALPRAZOLAM ORALLY DISINTEGRATING TAB 1 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

120	

30	

ALPRAZOLAM ORALLY DISINTEGRATING TAB 2 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

60	

30	

ALPRAZOLAM TAB 0.25 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in
a 30-day time period.	

120	

30	

ALPRAZOLAM TAB 0.5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

120	

30	

ALPRAZOLAM TAB 1 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

120	

30	

ALPRAZOLAM TAB 2 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

60	

30	

ALPRAZOLAM TAB SR 24HR 0.5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

30	

30	

Drug Class/Drug Name	
Reference Brand Name	
Use Brand Only	Preferred Drug
Status	
Prior Authorization Required	
Quantity Limits	
Days Supply	

ALPRAZOLAM TAB SR 24HR 1 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

30	

30	

ALPRAZOLAM TAB SR 24HR 2 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

30	

30	

ALPRAZOLAM TAB SR 24HR 3 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

30	

30	

CHLORDIAZEPOXIDE HCL CAP 10 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

60	

30	

CHLORDIAZEPOXIDE HCL CAP 25 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in
a 30-day time period.	

60	

30	

CHLORDIAZEPOXIDE HCL CAP 5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

60	

30	

CLONAZEPAM 0.5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	
120	
30	

CLONAZEPAM 1.0 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	
120	
30	

CLONAZEPAM 2 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	
60	
30	

Drug Class/Drug Name	
Reference Brand Name	
Use Brand Only	Preferred Drug
Status	
Prior Authorization Required	
Quantity Limits	
Days Supply	

CLONAZEPAM ODT 0.125MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	
120	
30	

CLONAZEPAM ODT 0.25MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	
120	
30	

CLONAZEPAM ODT 0.5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	
120	
30	

CLONAZEPAM ODT 1MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	
120	
30	

CLONAZEPAM ODT 2MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in
a 30-day time period.	
60	
30	

CLORAZEPATE DIPOTASSIUM TAB 15 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

60	

30	

CLORAZEPATE DIPOTASSIUM TAB 3.75 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

120	

30	

CLORAZEPATE DIPOTASSIUM TAB 7.5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

120	

30	

DIAZEPAM CONC 5 MG/ML	

DIAZEPAM INTENSOL			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

60	

30	

Drug Class/Drug Name	
Reference Brand Name	
Use Brand Only	Preferred Drug
Status	
Prior Authorization Required	
Quantity Limits	
Days Supply	

DIAZEPAM SOLN 1 MG/ML	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

300	

30	

DIAZEPAM TAB 10 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

120	

30	

DIAZEPAM TAB 2 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

120	

30	

DIAZEPAM TAB 5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

120	

30	

LORAZEPAM CONC 2 MG/ML	

LORAZEPAM INTENSOL			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in
a 30-day time period.	

60	

30	

LORAZEPAM TAB 0.5 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

120	

30	

LORAZEPAM TAB 1 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

120	

30	

LORAZEPAM TAB 2 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

60	

30	

OXAZEPAM CAP 10 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

60	

30	

Drug Class/Drug Name	
Reference Brand Name	
Use Brand Only	Preferred Drug
Status	
Prior Authorization Required	
Quantity Limits	
Days Supply	

OXAZEPAM CAP 15 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

60	

30	

OXAZEPAM CAP 30 MG	

VARIOUS			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

60	

30	
MISCELLANEOUS ANXIOLYTICS	

BUSPIRONE HCL TAB 5 MG	

BUSPIRONE HCL			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

120	

30	

BUSPIRONE HCL TAB 7.5 MG	

BUSPIRONE HCL			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

120	

30	

BUSPIRONE HCL TAB 10 MG	

BUSPIRONE HCL			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

120	

30	

BUSPIRONE HCL TAB 15 MG	

BUSPIRONE HCL			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in a 30-day time period.	

120	

30	

BUSPIRONE HCL TAB 30 MG	

BUSPIRONE HCL			PA Required for Ages < 6 years.
PA Required for > 1 Anxiolytic Medication in
a 30-day time period.	

60	

30	
HYDROXYZINE HCL SYRUP	HYDROXYZINE HCL SYRUP				300ml	30	
HYDROXYZINE HCL TABLETS	HYDROXYZINE HCL TABLETS				240	30	
HYDROXYZINE PAMOATE	VISTARIL				120	30	
MISCELLANEOUS SEDATIVES & HYPNOTICS	
RAMELTEON	ROZEREM			Step Therapy Required - Patient must have
tried Temazepam and Zolpidem	
30	
30	

Drug Class/Drug Name	
Reference Brand Name	
Use Brand Only	Preferred Drug
Status	
Prior Authorization Required	
Quantity Limits	
Days Supply	
TEMAZEPAM 15MG & 30MG	RESTORIL			PA Required for Ages < 6 years
PA Required for > 1 Hypnotic	
30	
30	
ZOLPIDEM TARTRATE TABLETS 5MG	AMBIEN			PA Required for Ages < 6 years
PA Required for > 1 Hypnotic	
60	
30	
ZOLPIDEM TARTRATE TABLETS 10MG	AMBIEN			PA Required for Ages < 6 years
PA Required for > 1 Hypnotic	
30	
30	
ANTIHISTAMINES	
CYPROHEPTADINE HCL	VARIOUS						
DIPHENHYDRAMINE HCL CAPSULES	VARIOUS						
DIPHENHYDRAMINE HCL CHEWABLE TABLETS	VARIOUS						
DIPHENHYDRAMINE HCL ELIXIR	VARIOUS						
DIPHENHYDRAMINE HCL LIQUID	VARIOUS						
DIPHENHYDRAMINE HCL SYRUP	VARIOUS						
DIPHENHYDRAMINE HCL TABLETS	VARIOUS						
DOPAMINE AGONISTS	
AMANTADINE HCL	VARIOUS						
AUTONOMIC AGONISTS	
PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS	
BETHANECHOL CHLORIDE	URECHOLINE						
ANTICHOLINERGIC AGENTS	
BENZOTROPINE MESYLATE	COGENTIN						
TRIHEXYPHENIDYL HCL	ARTANE						
CARDIOVASCULAR DRUGS	
ALPHA-1 ADRENERGIC BLOCKING AGENTS	
PRAZOSIN HCL	MINIPRESS						
BETA-ADRENERGIC BLOCKING AGENTS	
NADOLOL TAB	CORGARD						
PROPRANOLOL HCL	INDERAL						
THYROID AGENTS	

Drug Class/Drug Name	
Reference Brand Name	
Use Brand Only	Preferred Drug
Status	
Prior Authorization Required	
Quantity Limits	
Days Supply	
LEVOTHYROXINE SODIUM	LEVOTHROID/SYNTHROID						
LIOTHYRONINE	CYTOMEL						
VITAMINS AND OTHER MISCELLANEOUS AGENTS	
ALPHA-TOCOPHEROL	VITAMIN E – VARIOUS						
CYANOCOBALAMIN	VITAMIN B12 - VARIOUS						
FOLIC ACID	VARIOUS						
OMEGA 3 FATTY ACIDS	VARIOUS						
PYRIDOXINE HCL	VITAMIN B6 - VARIOUS						
THIAMINE HCL	VITAMIN B1 - VARIOUS						
MULTIPLE VITAMIN	VARIOUS						
MULTIPLE VITAMIN / MINERALS	VARIOUS						
SALIVA SUBSTITUTE	SALIVART						
DOCUSATE SODIUM	COLACE						
PSYLLIUM	METAMUCIL						
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