Medication Brand Reference Age Prior Limit Generic Name Quantity Required Name Additional Limitation Authorization Information Formulation(s) ANTIDEPRESSANTS Alpha-2 Receptor Antagonist Antidepressants Remeron Tab mirtazapine Remeron SolTab ODT Monoamine Oxidase Inhibitors (MAOIs) EMSAM TD Patch X seligilene isocarboxazid Marplan Tab phenelzine sulfate Nardil Tab Parnate Tab tranylcypromine sulfate Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs) APLENZIN ER Tab X bupropion hbr Wellbutrin IR Tab Wellbutrin SR ER Tab bupropion hcl Wellbutrin XL ER Tab Selective Serotonin Reuptake Inhibitors (SSRIs) Various Soln citalopram hbr Celexa Tab citalopram hbr Lexapro Soln escitalopram oxalate Lexapro Tab escitalopram oxalate Prozac Cap / Tab fluoxetine hcl Prozac Soln fluoxetine hcl Prozac Weekly DR Cap X fluoxetine hcl Luvox Tab fluvoxamine maleate Luvox CR ER Cap fluvoxamine maleate Paxil Susp paroxetine hcl Paxil Tab paroxetine hcl Paxil CR ER Tab paroxetine hcl tab PEXEVA Tab X Paroxetine mesylate Zoloft Conc sertraline hcl Zoloft Tab sertraline hcl VIIBRYD Tab X vilazodone hcl Sero tonin-2 Antagonist/Reuptake Inhibitors (SARIs) Various Tab nefazodone Various Tab trazodone hcl OLEPTRO ER Tab X trazodone hcl Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) PRISTIQ ER Tab X desvenlafaxine CYMBALTA Cap duloxetine hcl Effexor Tab venlafaxine hcl Effexor ER Cap venlafaxine hcl
Medication Generic Name Brand Reference Name Formulation(s) Age Limitation Prior Authorization Required Quantity Limit Additional Information ANTIDEPRESSANTS Alpha-2 Receptor Antagonist Antidepressants mirtazapine Remeron Remeron SolTab Tab ODT Monoamine Oxidase Inhibitors (MAOIs) seligilene EMSAM TD Patch X isocarboxazid Marplan Tab phenelzine sulfate Nardil Tab tranylcypromine sulfate Parnate Tab Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs) bupropion hbr APLENZIN ER Tab X bupropion hcl Wellbutrin Wellbutrin SR Wellbutrin XL IR Tab ER Tab ER Tab Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram hbr Various Soln citalopram hbr Celexa Tab escitalopram oxalate Lexapro Soln escitalopram oxalate Lexapro Tab fluoxetine hcl Prozac Cap / Tab fluoxetine hcl Prozac Soln fluoxetine hcl Prozac Weekly DR Cap X fluvoxamine maleate Luvox Tab fluvoxamine maleate Luvox CR ER Cap paroxetine hcl Paxil Susp paroxetine hcl Paxil Tab paroxetine hcl tab Paxil CR ER Tab Paroxetine mesylate PEXEVA Tab X sertraline hcl Zoloft Conc sertraline hcl Zoloft Tab vilazodone hcl VIIBRYD Tab X Sero tonin-2 Antagonist/Reuptake Inhibitors (SARIs) nefazodone Various Tab trazodone hcl Various Tab trazodone hcl OLEPTRO ER Tab X Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) desvenlafaxine PRISTIQ ER Tab X duloxetine hcl CYMBALTA Cap venlafaxine hcl Effexor Tab venlafaxine hcl Effexor ER Cap
ADHSDBHS%20BH%20Drug%20List.docx