Medication Brand Reference Age Prior Limit Required Quantity Name Additional Limitation Generic Name Authorization Information Formulation(s) eszopiclone LUNESTA Tab X Various Tab meprobamate ROZEREM Tab ramelteon Halcion Tab triazolam Sonata Cap zaleplon capsule zolpidem Ambien Tab zolpidem Ambien CR ER Tab X INTERMEZZO SL / X zolpidem EDULAR SL Tab ZOLPIMIST Soln X zolpidem ANTIHISTAMINES Various Tab cyproheptadine hcl Various Cap / Tab diphenhydramine Various Elix / Syr diphenhydramine hcl Atarax Tab / Syr hydroxyzine hcl Vistaril Cap hydroxyzine pamoate DOPAMINE AGONISTS Various Cap / Tab amantadine hcl AUTONOMIC AGONISTS Parasympathomimetic (Cholinergic) Agents Urecholine Tab bethanechol chloride Anticholinergic Agents Cogentin Tab benzotropine mesylate trihexyphenidyl hcl Artane Tab CARDIOVASCULAR DRUGS Alpha-1 Adrenergic Blocking Agents Minipres Cap prazosin hcl Beta-Adrenergic Blocking Agents Corgard Tab nadolol tab Inderal Tab propranolol hcl THYROID AGENTS Levothroid / Synthroid Tab levothyroxine sodium Cytomel Tab liothyronine VITAMINS AND OTHER MISCELLANEOUS AGENTS alpha-tocopherol Vitamin E – Various Cap cyanocobalamin Vitamin B12 - Various Tab Various Tab folic acid Various Cap omega 3 fatty acids Vitamin B6 - Various Tab pyridoxine hcl
Medication Generic Name Brand Reference Name Formulation(s) Age Limitation Prior Authorization Required Quantity Limit Additional Information eszopiclone LUNESTA Tab X meprobamate Various Tab ramelteon ROZEREM Tab triazolam Halcion Tab zaleplon capsule Sonata Cap zolpidem Ambien Tab zolpidem Ambien CR ER Tab X zolpidem INTERMEZZO SL / EDULAR SL Tab X zolpidem ZOLPIMIST Soln X ANTIHISTAMINES cyproheptadine hcl Various Tab diphenhydramine Various Cap / Tab diphenhydramine hcl Various Elix / Syr hydroxyzine hcl Atarax Tab / Syr hydroxyzine pamoate Vistaril Cap DOPAMINE AGONISTS amantadine hcl Various Cap / Tab AUTONOMIC AGONISTS Parasympathomimetic (Cholinergic) Agents bethanechol chloride Urecholine Tab Anticholinergic Agents benzotropine mesylate Cogentin Tab trihexyphenidyl hcl Artane Tab CARDIOVASCULAR DRUGS Alpha-1 Adrenergic Blocking Agents prazosin hcl Minipres Cap Beta-Adrenergic Blocking Agents nadolol tab Corgard Tab propranolol hcl Inderal Tab THYROID AGENTS levothyroxine sodium Levothroid / Synthroid Tab liothyronine Cytomel Tab VITAMINS AND OTHER MISCELLANEOUS AGENTS alpha-tocopherol Vitamin E – Various Cap cyanocobalamin Vitamin B12 - Various Tab folic acid Various Tab omega 3 fatty acids Various Cap pyridoxine hcl Vitamin B6 - Various Tab
ADHSDBHS%20BH%20Drug%20List.docx