Medication Brand Reference Age Prior Limit Generic Name Quantity Required Name Additional Limitation Authorization Information Formulation(s) Various venlafaxine hcl ER Tab Tricyclic Antidepressants & Related Non-Selective Reuptake Inhibitors Various Tab amitriptyline hcl amoxapine tab Various Tab Anafranil Cap clomipramine hcl Norpramin Tab desipramine hcl Various Cap doxepin hcl Various Conc doxepin hcl SILENOR Tab X doxepin hcl imipramine Various Tab Tofranil-PM Cap imipramine hcl maprotiline hcl Various Tab Pamelor Cap nortriptyline hcl Various Soln nortriptyline hcl Vivactil Tab protriptyline hcl trimipramine maleate Surmontil Cap Combination Medications Used for the Treatment of BPAD Symbyax Cap fluoxetine hcl /olanzapine X ANTIPSYCHOTICS 1st Generation Antipsychotics Various Tab X haloperidol haloperidol decanoate Haldol Inj X Various Conc haloperidol lactate X Loxitane Cap loxapine succinate X ORAP Tab X pimozide Navane Cap X thiothixene 2nd Generation Antipsychotics ABILIFY Tab aripiprazole X X ABILIFY DISCMELT ODT Tab X X aripiprazole ABILIFY MAINTENA Inj aripiprazole X X ABILIFY Soln X X aripiprazole Clozaril Tab X clozapine FazaClo ODT Tab X clozapine Iloperidone FANAPT Tab X X INVEGA ER Tab X X paliperiodone INVEGA SUSTENNA LA Susp paliperidone X X LATUDA Tab X X lurasidone hcl
Medication Generic Name Brand Reference Name Formulation(s) Age Limitation Prior Authorization Required Quantity Limit Additional Information venlafaxine hcl Various ER Tab Tricyclic Antidepressants & Related Non-Selective Reuptake Inhibitors amitriptyline hcl Various Tab amoxapine tab Various Tab clomipramine hcl Anafranil Cap desipramine hcl Norpramin Tab doxepin hcl Various Cap doxepin hcl Various Conc doxepin hcl SILENOR 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 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 aripiprazole ABILIFY Tab X X aripiprazole ABILIFY DISCMELT ODT Tab X X aripiprazole ABILIFY MAINTENA Inj X X aripiprazole ABILIFY Soln X X clozapine Clozaril Tab X clozapine FazaClo ODT Tab X Iloperidone FANAPT Tab X X paliperiodone INVEGA ER Tab X X paliperidone INVEGA SUSTENNA LA Susp X X lurasidone hcl LATUDA Tab X X
ADHSDBHS%20BH%20Drug%20List.docx