Medication Brand Reference Age Prior Limit Quantity Required Name Additional Limitation Generic Name Authorization Information Formulation(s) Zyprexa Zydis ODT X olanzapine Seroquel Tab X quetiapine SEROQUEL XR Tab quetiapine X X Risperdal Tab X risperidone RISPERDAL CONSTA Inj X risperidone Risperdal M-TAB ODT X risperidone Risperdal Soln X risperidone SAPHRIS SL Tab X X asenapine maleate ziprasidone hcl Geodon Cap X Phenothiazine Antipsychotics Various Tab X chlorpromazine hcl Various Inj fluphenazine decanoate X Oral X fluphenazine hcl Various Conc Various Elix fluphenazine hcl X Various Tab X fluphenazine hcl Various Tab X perphenazine Various Tab X thioridazine hcl Various Tab X trifluoperazine hcl ANTICONVULSANTS Tab carbamazepine Tegretol, Epitol Chew Carbatrol, Equetro ER Cap carbamazepine Tegretol XR, ER Tab carbamazepine carbamazepine Tegretol Susp DR & ER divalproex Depakote Tab Depakote Sprinkles Cap divalproex Neurontin Cap gabapentin HORIZANT ER Tab X gabapentin gabapentin Neurontin Soln GRALISE Tab gabapentin X Tab Chew lamotrigine Lamictal ODT LAMICTAL XR ER Tab X lamotrigine Trileptal Susp oxcarbazepine
Medication Generic Name Brand Reference Name Formulation(s) Age Limitation Prior Authorization Required Quantity Limit Additional Information olanzapine Zyprexa Zydis ODT X quetiapine Seroquel Tab X quetiapine SEROQUEL XR Tab X X risperidone Risperdal Tab X risperidone RISPERDAL CONSTA Inj X risperidone Risperdal M-TAB ODT X risperidone Risperdal Soln X asenapine maleate SAPHRIS SL Tab X X ziprasidone hcl Geodon Cap X Phenothiazine Antipsychotics chlorpromazine hcl Various Tab X fluphenazine decanoate Various Inj X fluphenazine hcl Various Oral Conc X fluphenazine hcl Various Elix X fluphenazine hcl 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 gabapentin HORIZANT ER Tab X gabapentin Neurontin Soln gabapentin GRALISE Tab X lamotrigine Lamictal Tab Chew ODT lamotrigine LAMICTAL XR ER Tab X oxcarbazepine Trileptal Susp