Title 19/ 21 GMH/SA & Non-Title 19/ SMI Behavioral Health ......2018/10/01 · ER = extended...

Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 10/01/2018

Updated 10/01/2018 | 2

About the Behavioral Health Drug List

The Mercy Care behavioral health drug list includes all of the behavioral health medications listed on the AHCCCS Behavioral Health Drug List (BHDL). The list specifies which medications require:

Prior authorization

Quantity limits

Age restriction o If a medication has an age restriction and is being prescribed outside the age limits, the

prescribing provider will need to submit a prior authorization to Mercy Care.

Any additional information

All formulary medications available in generic form are supplied in generic form. Requests for brand name preparations must get prior authorization. For more information about your prescription drug coverage, please refer to your Member Handbook. If you have questions, please call Member Services at 1-800-564-5465 or visit www.MercyCareAZ.org.

Key Drugs listed in Bold/Italic CAPITAL LETTERS indicate the medication is only available as a brand name

product

(*) Indicates that medication can only be obtained from an Opioid Treatment Program (OTP) provider

(X) Indicates that the medication is only available through the (T)RBHA prior authorization process

Abbreviations Cap = capsule LA = long acting Chew = chewable ODT = orally disintegrating tablet Conc = concentrate SL = sublingual DR = Delayed Release SOLN = solution Elix = Elixir SR = sustained release ER = extended release Susp = suspension hbr = hydrobromide Syr = Syrup hcl = hydrochloride Tab = tablet IM = intramuscular TD = transdermal Inj = injectable XL = extended release IR = Immediate release

The behavioral health drug list begins on page 3.

http://www.mercycareaz.org/

Updated 10/01/2018 | 3

Covered Drug

Reference Drug Name Formulation(s)

Age Limitation

< 6 requires

PA

Prior Authorization

Required

Quantity Limit (all are based on

30-day supply)

Additional Information

ANTIDEPRESSANTS

Alpha-2 Receptor Antagonist Antidepressants

mirtazapine Remeron Remeron

SolTab Tab ODT X #30

Monoamine Oxidase Inhibitors (MAOIs)

EMSAM selegiline TD Patch X

isocarboxazid Marplan Tab X

phenelzine sulfate Nardil Tab X

tranylcypromine sulfate Parnate Tab X

Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs)

bupropion hcl Wellbutrin

Wellbutrin SR Wellbutrin XL

IR Tab ER Tab ER Tab

X IR:75/100mg = #120

SR:100/150/200mg = #60 XL: 150mg/300mg = #30

Selective Serotonin Reuptake Inhibitors (SSRIs)

citalopram hbr Various Soln X 600ml

citalopram hbr Celexa Tab X 10mg = #60

#30

1

escitalopram oxalate Lexapro Soln X 600ml

escitalopram oxalate Lexapro Tab X #30

5mg = #60

fluoxetine hcl Prozac Cap X 10mg = #60

20 mg = #120 40mg = #60

Updated 10/01/2018 | 4

Covered Drug


Age Limitation

< 6 requires

PA

Prior Authorization

Required


30-day supply)


fluoxetine hcl Prozac Soln X 600ml

fluoxetine hcl weekly Prozac Weekly DR Cap X

fluvoxamine maleate Luvox Tab X 25mg = #60

50mg = #180 100mg = #90

fluvoxamine maleate Luvox CR ER Cap X 100mg = #90 150mg = #60

PAXIL paroxetine Susp X #900ml

paroxetine hcl Paxil Tab X #30

40mg = #45

paroxetine hcl tab Paxil CR ER Tab X #90

PEXEVA paroxetine mesylate Tab X

sertraline hcl Zoloft Conc X 300ml

sertraline hcl Zoloft Tab X 25mg = #90

50mg = #120 100mg =#60

VIIBRYD vilazodone hcl Tab X

VIIBRYD Starter Pack vilazodone hcl Tab X

Serotonin- 2 Antagonist/Reuptake Inhibitors (SARIs)

nefazodone Various Tab X

50mg = #60

100mg = #60

150mg = #120

200mg = #90

Updated 10/01/2018 | 5

Covered Drug


Age Limitation

< 6 requires

PA

Prior Authorization

Required


30-day supply)


250mg = #60

trazodone hcl Various Tab X

50mg = #90

100mg = #120

150mg = #60

300mg = #30

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

desvenlafaxine Pristiq ER Tab X

#120

duloxetine 20mg, 30mg and 60mg only

Cymbalta Cap X 20mg and 30mg = #120

60mg = #60

SAVELLA Tab X ST

venlafaxine hcl Effexor IR Tab X

25mg = #120 37.5mg = #90 50mg = #90

75mg = #150 100mg = #90

venlafaxine hcl XR Effexor ER Cap X

37.5mg = #90

75mg = #90

150mg = #30

Tricyclic Antidepressants & Related Non-Selective Reuptake Inhibitors

amitriptyline hcl Various Tab X

amoxapine tab Various Tab X

clomipramine hcl Anafranil Cap X

desipramine hcl Norpramin Tab X

Updated 10/01/2018 | 6

Covered Drug


Age Limitation

< 6 requires

PA

Prior Authorization

Required


30-day supply)


doxepin hcl Various Cap X #90

doxepin hcl Various Conc X #180ml

imipramine Various Tab X

imipramine hcl Tofranil-PM Cap X

maprotiline hcl Various Tab X

nortriptyline hcl Pamelor Cap X

nortriptyline hcl Various Soln X

protriptyline hcl Vivactil Tab X

trimipramine maleate Surmontil Cap X

ANTIPSYCHOTICS

1st Generation Antipsychotics

haloperidol Various Tab X

haloperidol decanoate Haldol Inj X PA for <18 years of age

haloperidol lactate Various Conc X

loxapine succinate Loxitane Cap X

pimozide Orap Tab X PA for <12 years of age

thiothixene Navane Cap X

2nd Generation Antipsychotics

aripiprazole Abilify Tab, ODT X

AHCCCS Preferred Drug;

#30

aripiprazole Abilify Solution X AHCCCS Preferred Drug;

#150

Updated 10/01/2018 | 7

Covered Drug


Age Limitation

< 6 requires

PA

Prior Authorization

Required


30-day supply)


ABILIFY MAINTENA

aripiprazole

Inj X

AHCCCS Preferred Drug; PA

for <18 years of age

#1/ 28 days

ARISTADA

X



QLL: #1/ 28 days;

1064mg:#1/56 days

ARISTADA INITIO X



QLL: #2/ 365 days;

clozapine Clozaril Tab X AHCCCS Preferred Drug PA for <18 years of age

#150

clozapine FazaClo ODT Tab X AHCCCS Preferred Drug

#150

INVEGA SUSTENNA paliperidone LA Susp X



#1/ 28 days

INVEGA TRINZA paliperidone LA Susp X



#1/ 84days

Updated 10/01/2018 | 8

Covered Drug


Age Limitation

< 6 requires

PA

Prior Authorization

Required


30-day supply)


LATUDA lurasidone hcl Tab X

AHCCCS Preferred Drug #30

olanzapine Zyprexa, Zydis ODT, Tab X

AHCCCS Preferred Drug 5MG = #60

10mg = #60

15MG = #30

20mg = #30

quetiapine Seroquel Tab X AHCCCS Preferred Drug

#60

risperidone Risperdal Tab X AHCCCS Preferred Drug

#60

RISPERDAL CONSTA risperidone Inj X AHCCCS Preferred Drug

#2/30days

risperidone ODT Risperdal M-TAB ODT X AHCCCS Preferred Drug

#60

Risperidone soln Risperdal Soln X AHCCCS Preferred Drug

240ml

SAPHRIS asenapine SL Tab X

AHCCCS Preferred Drug #60

ziprasidone hcl Geodon Cap X AHCCCS Preferred Drug #60

Phenothiazine Antipsychotics

chlorpromazine hcl Various Tab X

Updated 10/01/2018 | 9

Covered Drug


Age Limitation

< 6 requires

PA

Prior Authorization

Required


30-day supply)


fluphenazine decanoate Various Inj X

PA for <18 years of age

fluphenazine oral conc Various Oral Conc X

fluphenazine hcl elix Various Elix X

fluphenazine hcl tab Various Tab X

perphenazine Various Tab X

thioridazine hcl Various Tab X

trifluoperazine hcl Various Tab X

ANTICONVULSANTS

carbamazepine Tegretol, Epitol Tab Chew

carbamazepine Carbatrol, Equetro ER Cap

carbamazepine Tegretol XR, ER Tab

carbamazepine Tegretol Susp

divalproex Depakote DR & ER Tab

divalproex Depakote Sprinkles Cap

gabapentin Neurontin Cap Cumulative Daily Dose=

3600mg/day

HORIZANT gabapentin ER Tab X Cumulative Daily Dose=

3600mg/day

gabapentin Neurontin Soln Cumulative Daily Dose=

3600mg/day

GRALISE gabapentin Tab X Cumulative Daily Dose=

3600mg/day

Updated 10/01/2018 | 10

Covered Drug


Age Limitation

< 6 requires

PA

Prior Authorization

Required


30-day supply)


lamotrigine Lamictal Tab Chew ODT

LAMICTAL XR lamotrigine ER Tab

oxcarbazepine Trileptal Susp

oxcarbazepine Trileptal Tab

topiramate Topamax Cap/tab

valproate sodium soln Various Soln

valproate sodium cap/syrup

Depakene Cap /Syrup

ANTIMANIC AGENTS

lithium carbonate cap Various Cap X

lithium carbonate tab Lithobid ER Tab X

lithium citrate Various Soln X

CNS STIMULANT DRUGS

ADDERALL (BRAND) X AHCCCS Preferred Drug

#60

ADDERALL XR (BRAND)

SR Cap X AHCCCS Preferred Drug #30

APTENSIO XR Methylphenidate XR Cap X AHCCCS Preferred Drug

#30

amphetamine- dextroamphetamine Salts (DEXTROAMP-

AMPHETAM)

Adderall Tab X AHCCCS Preferred Drug #60

15/20/30mg = #60

atomoxetine STRATTERA Cap X AHCCCS Preferred Drug

#30

Updated 10/01/2018 | 11

Covered Drug


Age Limitation

< 6 requires

PA

Prior Authorization

Required


30-day supply)


DAYTRANA methylphenidate hcl TD Patch X AHCCCS Preferred Drug

#30

Dextroamphetamine sulfate

Dexedrine ER Cap X AHCCCS Preferred Drug #60

Dextroamphetamine sulfate

Various Tab X AHCCCS Preferred Drug #60

FOCALIN (BRAND)

Tab X AHCCCS Preferred Drug #60

FOCALIN XR (BRAND)

ER Cap X AHCCCS Preferred Drug #60

clonidine hcl tab Catapres Tab X

clonidine patch Catapres TTS TD Patch X #4

guanfacine hcl Tenex Tab X

guanfacine hcl ER Intuniv ER Tab X AHCCCS Preferred Drug

#30

KAPVAY ER (BRAND) Kapvay ER Tab X AHCCCS Preferred Drug #120

methylphenidate CD METADATE CD X AHCCCS Preferred Drug

#30

METHYLIN Soln X AHCCCS Preferred Drug

300ml

methylphenidate hcl Ritalin Tab X AHCCCS Preferred Drug #90

methylphenidate hcl Ritalin /CD LA Cap X AHCCCS Preferred Drug #30

Updated 10/01/2018 | 12

Covered Drug


Age Limitation

< 6 requires

PA

Prior Authorization

Required


30-day supply)


methylphenidate hcl Concerta ER Tab X AHCCCS Preferred Drug

#60

QUILLICHEW ER X AHCCCS Preferred Drug

#30

QUILLIVANT XR methylphenidate hcl Susp X

AHCCCS Preferred Drug 150ml

RITALIN LA 10MG CAP X AHCCCS Preferred Drug

#30

VYVANSE Lisdexamfetamine ER Cap X AHCCCS Preferred Drug #30

VYVANSE Lisdexamfetamine Chew tab X AHCCCS Preferred Drug #30

SUBSTANCE ABUSE

Opiate Agonists/Partial Agonists

SUBOXONE FILM buprenorphine hcl

/naloxone Film

AHCCCS Preferred Drug

methadone Dolophine

* medication can only be

obtained from an Opioid

Treatment Program

(OTP) provider

Opiate Antagonists

naltrexone Revia Tab #30

Updated 10/01/2018 | 13

Covered Drug


Age Limitation

< 6 requires

PA

Prior Authorization

Required


30-day supply)


NARCAN Naloxone Nasal Spray AHCCCS Preferred Drug

naloxone Syringe Inj AHCCCS Preferred Drug

naloxone vial In AHCCCS Preferred Drug

VIVITROL naltrexone Inj

AHCCCS Preferred Drug

Miscellaneous Agents

acamprosate Campral DR Tab

disulfiram Antabuse Tab

ANXIOLYTICS AND HYPNOTICS

Benzodiazepines

alprazolam Xanax Tab X 0.25/0.5/1mg= #120

2mg = #60

alprazolam intensol Alprazolam Intensol Conc Soln X 120ml

alprazolam ER Xanax XR ER Tab X #30

alprazolam Niravam ODT X 0.25/0.5/1mg= #120

2mg = #60

chlordiazepoxide hcl Librium Cap X #60

clonazepam Klonopin Tab X 0.5/1mg =#120

2mg = #60

Updated 10/01/2018 | 14

Covered Drug


Age Limitation

< 6 requires

PA

Prior Authorization

Required


30-day supply)


clonazepam Various ODT X 0.125/0.25/0.5/1mg=#120

2mg = #60

clorazepate dipotassium Tranxene-T Tab X 3.75mg/7.5mg = #120

15mg= #60

diazepam Valium Tab X #120

diazepam 5mg/ml Conc X 60ml

diazepam 1mg/ml

Soln X 300ml

lorazepam Ativan Tab X 0.5/1 mg =#120

2mg = #60

lorazepam Intensol lorazepam Conc Soln X 60ml

oxazepam Serax Cap X #60

Miscellaneous Anxiolytics, Sedatives & Hypnotics

buspirone hcl Various Tab X #120

30mg = #60

ramelteon Rozerem Tab

AHCCCS Preferred Drug, ST #30

ST through zolpidem

and temazepam

Temazepam 15mg and 30mg

Restoril Cap X AHCCCS Preferred Drug

#30

zolpidem Ambien Tab X AHCCCS Preferred Drug

5mg = #60 10mg = #30

Updated 10/01/2018 | 15

Covered Drug


Age Limitation

< 6 requires

PA

Prior Authorization

Required


30-day supply)


ANTIHISTAMINES

cyproheptadine hcl Various Tab

diphenhydramine Various Cap/Tab

diphenhydramine hcl Various Elix/Syr

hydroxyzine hcl Atarax Tab #240

hydroxyzine Various Syr 300ml

hydroxyzine pamoate Vistaril Cap #120

DOPAMINE AGONISTS

amantadine hcl Various Cap/Tab

AUTONOMIC AGONISTS

Parasympathomimetic (Cholinergic) Agents

bethanechol chloride Urecholine Tab

Anticholinergic Agents

benztropine mesylate Cogentin Tab

trihexyphenidyl hcl Artane Tab

CARDIOVASCULAR DRUG

Alpha-1 Adrenergic Blocking Agents

prazosin hcl Minipres Cap

Beta-Adrenergic Blocking Agents

nadolol tab Corgard Tab

propranolol hcl Inderal Tab

Updated 10/01/2018 | 16

Covered Drug


Age Limitation

< 6 requires

PA

Prior Authorization

Required


30-day supply)


THYROID AGENTS

levothyroxine sodium Levothroid/Synthroid Tab

liothyronine Cytomel Tab

VITAMINS AND OTHER MISCELLANEOUS AGENTS

alpha-tocopherol Vitamin E -Various Cap, chew tab

cyanocobalamin Vitamin B12 - Various Tab

folic acid Various Tab

Niacin Tab, cap, ER tab

omega 3 fatty acids Various Cap

pyridoxine hcl Vitamin B6 - Various Tab

thiamine hcl Vitamin B1 - Various Tab

multiple vitamin Various Tab

multiple vitamin/minerals

Various Tab

Miscellaneous Ear, Nose & Throat Drug

saliva substitute Salivart Sol, loz, tab

Cathartics and Laxative

bisacodyl Enema, supp,tab

cascara sagrada cap

docusate Colace Cap, tab, liq

Fiber Powder, tab, cap

Updated 10/01/2018 | 17

Covered Drug


Age Limitation

< 6 requires

PA

Prior Authorization

Required


30-day supply)


Magnesium citrate soln

Magnesium oxide tab

Methylcellulose Powder, tab

psyllium Metamucil Powder, cap

Senna Tab, syr, liq

Title 19/ 21 GMH/SA & Non-Title 19/ SMI Behavioral Health ......2018/10/01 · ER = extended...

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