Medication Brand Reference Age Prior Limit Required Quantity Name Additional Limitation Generic Name Authorization Information Formulation(s) guanfacine hcl INTUNIV ER Tab X SUBSTANCE ABUSE Opiate Agonists/Partial Agonists Subutex SL Tab buprenorphine hcl buprenorphine hcl / SL Tab naloxone Suboxone buprenorphine hcl / Film X naloxone SUBOXONE FILM * methadone Dolophine Opiate Antagonists Revia Tab naltrexone VIVITROL Inj naltrexone X Miscellaneous Agents CAMPRAL DR Tab acamprosate Antabuse Tab disulferam ANXIOLYTICS AND HYPNOTICS Benzodiazepines Xanax Tab alprazolam Conc alprazolam intensol Alprazolam Intensol Soln alprazolam Xanax XR ER Tab Niravam ODT alprazolam Librium Cap chlordiazepoxide hcl Klonopin Tab clonazepam Various ODT clonazepam Tranxene-T Tab clorazepate dipotassium diazepam Valium Tab Conc diazepam intensol Diazepam Intensol Soln Various Tab estazolam Dalmane Cap flurazepam hcl lorazepam Ativan Tab Conc lorazepam Lorazepam Intensol Soln Serax Cap oxazepam Restoril Cap temazepam Miscellaneous Anxiolytics, Sedatives & Hypnotics Various Tab buspirone hcl
Medication Generic Name Brand Reference Name Formulation(s) Age Limitation Prior Authorization Required Quantity Limit Additional Information guanfacine hcl INTUNIV ER Tab X SUBSTANCE ABUSE Opiate Agonists/Partial Agonists buprenorphine hcl Subutex SL Tab buprenorphine hcl / naloxone Suboxone SL Tab buprenorphine hcl / naloxone SUBOXONE FILM Film X methadone Dolophine * Opiate Antagonists naltrexone Revia Tab naltrexone VIVITROL Inj X Miscellaneous Agents acamprosate CAMPRAL DR Tab disulferam Antabuse Tab ANXIOLYTICS AND HYPNOTICS Benzodiazepines alprazolam Xanax Tab alprazolam intensol Alprazolam Intensol Conc Soln alprazolam Xanax XR ER Tab alprazolam Niravam ODT chlordiazepoxide hcl Librium Cap clonazepam Klonopin Tab clonazepam Various ODT clorazepate dipotassium Tranxene-T Tab diazepam Valium Tab diazepam intensol Diazepam Intensol Conc Soln estazolam Various Tab flurazepam hcl Dalmane Cap lorazepam Ativan Tab lorazepam Lorazepam Intensol Conc Soln oxazepam Serax Cap temazepam Restoril Cap Miscellaneous Anxiolytics, Sedatives & Hypnotics buspirone hcl Various Tab
ADHSDBHS%20BH%20Drug%20List.docx