Medication Brand Reference Age Prior Limit Required Quantity Name Additional Limitation Generic Name Authorization Information Formulation(s) oxcarbazepine Trileptal Tab Various Soln valproate sodium Cap / valproate sodium Depakene Syrup ANTIMANIC AGENTS lithium carbonate Various Cap Lithobid ER Tab lithium carbonate Various Soln lithium citrate ADHD DRUGS Amphetamines amphetamine- dextroamphetamine Adderall Tab X amphetamine- dextroamphetamine Adderall XR SR Cap X dextroamphetamine ER Cap X sulfate Dexedrine dextroamphetamine Tab X sulfate Various lisdexamfetamine dimesylate VYVANSE ER Cap X Stimulants Focalin Tab dexmethylphenidate hcl X FOCALIN XR ER Cap X dexmethylphenidate hcl Ritalin Tab X methylphenidate hcl Chew X methylphenidate hcl METHYLIN Tab Ritalin LA / Metadate CD ER Cap X methylphenidate hcl Ritalin SR SR Tab methylphenidate hcl X Concerta ER Tab X methylphenidate hcl DAYTRANA TD Patch methylphenidate hcl METHYLIN Soln X methylphenidate hcl methylphenidate hcl QUILLIVANT XR Susp X X Miscellaneous Agents STRATTERA Cap atomoxetine X Central Alpha-Agonists clonidine hcl Catapres Tab clonidine hcl KAPVAY ER Tab clonidine hcl Catapres TTS TD Patch guanfacine hcl Tenex Tab
Medication Generic Name Brand Reference Name Formulation(s) Age Limitation Prior Authorization Required Quantity Limit Additional Information oxcarbazepine Trileptal Tab valproate sodium Various Soln valproate sodium Depakene Cap / Syrup ANTIMANIC AGENTS lithium carbonate Various Cap lithium carbonate Lithobid ER Tab lithium citrate Various Soln ADHD DRUGS Amphetamines amphetamine- dextroamphetamine Adderall Tab X amphetamine- dextroamphetamine Adderall XR SR Cap X dextroamphetamine sulfate Dexedrine ER Cap X dextroamphetamine sulfate Various Tab X lisdexamfetamine dimesylate VYVANSE ER Cap X Stimulants dexmethylphenidate hcl Focalin Tab X dexmethylphenidate hcl FOCALIN XR ER Cap X methylphenidate hcl Ritalin Tab X methylphenidate hcl METHYLIN Chew Tab X methylphenidate hcl Ritalin LA / Metadate CD ER Cap X methylphenidate hcl Ritalin SR SR Tab X methylphenidate hcl Concerta ER Tab X methylphenidate hcl DAYTRANA TD Patch methylphenidate hcl METHYLIN Soln X methylphenidate hcl QUILLIVANT XR Susp X X Miscellaneous Agents atomoxetine STRATTERA Cap X Central Alpha-Agonists clonidine hcl Catapres Tab clonidine hcl KAPVAY ER Tab clonidine hcl Catapres TTS TD Patch guanfacine hcl Tenex Tab
ADHSDBHS%20BH%20Drug%20List.docx