Title 19/21 GMH/SA &
Non-Title 19/21 SMI
Behavioral Health Drug List
Updated 01/01/2016
Effective April 1, 2014, Mercy Maricopa Integrated Care began operations as the Regional Behavioral Health
Authority for Maricopa County. Funds for services are provided through a contract with the Arizona
Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) and the Arizona Health
Care Cost Containment System (AHCCCS).
Updated 01/01/2016 | 1
About the Behavioral Health Drug List
The Mercy Maricopa behavioral health drug list includes all of the behavioral health medications listed on the
ADHS/DBHS 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 Maricopa.
 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.MercyMaricopa.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
Chew = chewable
Conc = concentrate
DR = Delayed Release
Elix = Elixir
ER = extended release
hbr = hydrobromide
hcl = hydrochloride
IM = intramuscular
Inj = injectable
IR = Immediate release
LA = long acting
ODT = orally disintegrating tablet
SL = sublingual
SOLN = solution
SR = sustained release
Susp = suspension
Syr = Syrup
Tab = tablet
TD = transdermal
XL = extended release
The behavioral health drug list begins on page 3.
Updated 01/01/2016 | 2
Covered Drug
Reference Drug
Name
ANTIDEPRESSANTS
Alpha-2 Receptor Antagonist Antidepressants
Remeron Remeron
mirtazapine
SolTab
Monoamine Oxidase Inhibitors (MAOIs)
EMSAM
selegiline
isocarboxazid
Marplan
Formulation(s)
< 6 requires PA
Wellbutrin
Wellbutrin SR
Wellbutrin XL
Selective Serotonin Reuptake Inhibitors (SSRIs)
citalopram hbr
Various
citalopram hbr
Celexa
escitalopram oxalate
Lexapro
escitalopram oxalate
Lexapro
Prior
Authorization
Required
Tab ODT
TD Patch
Quantity Limit
(all are based on
30-day supply)
Additional
Information
#30
X
Tab
phenelzine sulfate
Nardil
Tab
tranylcypromine
Parnate
Tab
sulfate and Dopamine Reuptake Inhibitors (NDRIs)
Norepinephrine
APLENZIN
bupropion hbr
ER Tab
bupropion hcl
Age
Limitation
X
IR Tab
ER Tab
ER Tab
Soln
Tab
Soln
Tab
fluoxetine hcl
Prozac
Cap/Tab
fluoxetine hcl
fluoxetine hcl weekly
Prozac
Prozac Weekly
Soln
DR Cap
fluvoxamine maleate
Luvox
Tab
fluvoxamine maleate
paroxetine hcl
Luvox CR
Paxil
ER Cap
Susp
#30
IR:75/100mg = #60
SR:100/150/200mg = #60
XL: 300mg = #30
XL: 150mg = #90
300ml
#30
300ml
#30
10mg and 60mg = #30
20 mg = #120
40mg = # 60
X
600 ml
#1 pack
60mg
25mg = #30
50mg = #60
100mg = #90
#60
900ml
Updated 01/01/2016 | 3
Covered Drug
Reference Drug
Name
Formulation(s)
paroxetine hcl
Paxil
Tab
paroxetine hcl tab
Paxil CR
ER Tab
PEXEVA
paroxetine mesylate
Tab
sertraline hcl
Zoloft
Conc
sertraline hcl
Zoloft
Tab
VIIBRYD
vilazodone hcl
Serotonin- 2 Antagonist/Reuptake Inhibitors (SARIs)
nefazodone
Various
trazodone ER
Various
trazodone hcl
Various
Age
Limitation
< 6 requires PA
Tab
Tab
Tab
Tab
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
desvenlafaxine
Pristiq
ER Tab
duloxetine hcl
Cymbalta
Cap
venlafaxine hcl
Effexor
IR Tab
venlafaxine hcl XR
Effexor
ER Cap
venlafaxine hcl ER
Various
ER Tab
Tricyclic Antidepressants & Related Non-Selective Reuptake Inhibitors
amitriptyline hcl
Various
Tab
amoxapine tab
Various
Tab
Prior
Authorization
Required
X
X
Quantity Limit
(all are based on
30-day supply)
#60
40mg = #45
12.5/37.5mg = #30
25mg = #60
10 MG= #180
20 MG=#90
30 MG=#60
40 MG=#45
300ml
25= #30
50mg, 100mg =#60
Additional
Information
10mg, 20mg = #60
40mg = #30
Starter kit = #1
#30
50mg, 100mg, 150mg =
#120
300mg= #60
#30
#60
#90
#60
#60
Updated 01/01/2016 | 4
Covered Drug
Reference Drug
Name
Formulation(s)
< 6 requires PA
clomipramine hcl
Anafranil
Cap
desipramine hcl
Norpramin
Tab
doxepin hcl
Various
Cap
doxepin hcl
Various
Conc
SILENOR
doxepin hcl
Tab
imipramine
Various
Tab
imipramine hcl
Tofranil-PM
Cap
maprotiline hcl
Various
Tab
nortriptyline hcl
Pamelor
Cap
nortriptyline hcl
Various
Soln
protriptyline hcl
Vivactil
Tab
trimipramine maleate
Surmontil
Cap
Combination Medications Used for the Treatment of BPAD
fluoxetine hcl
Symbyax
Cap
/olanzapine
ANTIPSYCHOTICS
1st Generation Antipsychotics
haloperidol
Various
Tab
haloperidol decanoate
Haldol
Inj
haloperidol lactate
Various
Conc
loxapine succinate
Loxitane
Cap
pimozide
Orap
Tab
thiothixene
Navane
Cap
2nd Generation Antipsychotics
ABILIFY
aripiprazole
Tab
aripiprazole
ABILIFY DISCMELT
ODT Tab
ABILIFY MAINTENA
aripiprazole
aripiprazole
Abilify
Age
Limitation
Prior
Authorization
Required
Quantity Limit
(all are based on
30-day supply)
Additional
Information
X
X
#30
X
X
X
X
X
X
X
#30
X
X
Inj
X
X
Soln
X
X
#30
480ml
Updated 01/01/2016 | 5
Covered Drug
Age
Limitation
Reference Drug
Name
Formulation(s)
clozapine
Clozaril
Tab
X
clozapine
FazaClo
ODT Tab
X
< 6 requires PA
Prior
Authorization
Required
Quantity Limit
(all are based on
30-day supply)
25mg = #360, 50mg = #90,
100mg = #270, 200mg =
#90
12.5mg, #270
25mg = #360,
Additional
Information
100mg = #270, 150mg,
200mg = #90
X
1mg,2mg,4mg #60
6mg,8mg,10mg, 12mg #30
Titration pack = #1
FANAPT
Iloperidone
Tab
X
paliperiodone I
Invega
ER Tab
X
INVEGA SUSTENNA
paliperiodone
LA Susp
X
X
LATUDA
lurasidone hcl
Tab
X
X
olanzapine
Zyprexa, Zydis
ODT
X
quetiapine
Seroquel
Tab
X
SEROQUEL XR
quetiapine
Tab
X
risperidone
Risperdal
Tab
X
0.25/0.5/1/2 mg= #90
3mg, 4mg = #60
RISPERDAL CONSTA
risperidone
Inj
X
#2/28days
risperidone ODT
Risperdal M-TAB
ODT
X
0.25mg, 0.5mg, 1mg = #90
2mg, 3mg 4mg = #60
Risperidone soln
SAPHRIS
ziprasidone hcl
Risperdal
asenapine
Geodon
Soln
SL Tab
Cap
X
X
X
240ml
#60
#60
#60
120mg = #30
#30
25/50mg = #30
100/200/300/400mg = #60
X
X
#30
Updated 01/01/2016 | 6
Covered Drug
Age
Limitation
Reference Drug
Name
Formulation(s)
Various
Tab
X
Various
Inj
X
fluphenazine oral conc
Various
Oral Conc
fluphenazine hcl elix
Various
Elix
fluphenazine hcl tab
Various
Tab
Various
Various
Various
Tab
Tab
Tab
Tegretol, Epitol
Carbatrol, Equetro
Tegretol XR,
Tegretol
Depakote
Tab Chew
ER Cap
ER Tab
Susp
DR & ER Tab
divalproex
Depakote Sprinkles
Cap
gabapentin
HORIZANT
gabapentin
GRALISE
Neurontin
gabapentin
Neurontin
gabapentin
Cap
ER Tab
Soln
Tab
lamotrigine
Lamictal
Tab Chew ODT
LAMICTAL XR
oxcarbazepine
oxcarbazepine
topiramate
lamotrigine
Trileptal
Trileptal
Topamax
ER Tab
Susp
Tab
Cap/tab
nothiazine Antipsychotics
chlorpromazine hcl
fluphenazine
decanoate
perphenazine
thioridazine hcl
trifluoperazine hcl
ANTICONVULSANTS
carbamazepine
carbamazepine
carbamazepine
carbamazepine
divalproex
< 6 requires PA
Prior
Authorization
Required
Quantity Limit
(all are based on
30-day supply)
Additional
Information
X
X
X
X
X
X
X
X
#60
X
Updated 01/01/2016 | 7
Covered Drug
valproate sodium soln
valproate sodium
cap/syrup
ANTIMANIC AGENTS
lithium carbonate cap
lithium carbonate tab
lithium citrate
ADHD DRUGS
Amphetamines
amphetaminedextroamphetamine IR
amphetaminedextroamphetamine
XR
Dextroamphetamine
sulfate
Dextroamphetamine
sulfate
VYVANSE
Stimulants
dexmethylphenidate
hcl
dexmethylphenidate
hcl ER
FOCALIN XR 25mg and
35mg
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
Age
Limitation
Prior
Authorization
Required
Quantity Limit
(all are based on
30-day supply)
Reference Drug
Name
Formulation(s)
Various
Soln
Depakene
Cap /Syrup
Various
Lithobid
Various
Cap
ER Tab
Soln
Adderall
Tab
X
5/10/12.5mg= #90
15/20/30mg = #60
Adderall XR
SR Cap
X
#30
Dexedrine
ER Cap
X
#60
Various
Tab
X
#90
Lisdexamfetamine
ER Cap
X
#30
Focalin
Tab
X
#60
FocalinXR
ER Cap
X
#30
ER Cap
X
#30
Tab
Chew Tab
ER Cap
X
X
X
#90
#90
#30
dexmethylphenidate
hcl ER
Ritalin
Methylin
Ritalin LA/Metadate
CD
< 6 requires PA
Additional
Information
Updated 01/01/2016 | 8
Reference Drug
Name
Formulation(s)
methylphenidate hcl
Ritalin SR
SR Tab
X
methylphenidate hcl
Concerta
ER Tab
X
Quantity Limit
(all are based on
30-day supply)
#30
36mg = #90
All other strengths = #30
TD Patch
Soln
Susp
X
X
X
900ml
900ml
Cap
X
Covered Drug
DAYTRANA
methylphenidate hcl
methylphenidate hcl
Methylin
QUILLIVANT XR
methylphenidate hcl
Miscellaneous Agents
STRATTERA
atomoxetine
Central Alpha-Agonists
clonidine hcl tab
Catapres
clonidine ER
Kapvay
clonidine patch
Catapres TTS
guanfacine hcl
Tenex
guanfacine hcl ER
Intuniv
SUBSTANCE ABUSE
Opiate Agonists/Partial Agonists
buprenorphine hcl
Subutex
buprenorphine hcl
Suboxone
/naloxone
SUBOXONE FILM
buprenorphine hcl
/naloxone
Age
Limitation
< 6 requires PA
Tab
ER Tab
TD Patch
Tab
ER Tab
Prior
Authorization
Required
X
#30
#120
#4
X
#30
SL Tab
#90
SL Tab
#90
Film
Additional
Information
X
#90
* medication can
methadone
only be obtained
from an Opioid
Treatment
Program (OTP)
provider
Dolophine
Opiate Antagonists
naltrexone
Revia
Tab
VIVITROL
naltrexone
Inj
#30
X
Updated 01/01/2016 | 9
Covered Drug
Reference Drug
Name
Miscellaneous Agents
acamprosate
Campral
disulfiram
Antabuse
ANXIOLYTICS AND HYPNOTICS
Benzodiazepines
Formulation(s)
Age
Limitation
< 6 requires PA
Prior
Authorization
Required
Quantity Limit
(all are based on
30-day supply)
Additional
Information
DR Tab
Tab
alprazolam
Xanax
Tab
0.25/0.5/1mg= #120
2mg = #60
alprazolam intensol
Alprazolam Intensol
Conc Soln
120ml
alprazolam
Xanax XR
ER Tab
alprazolam
Niravam
ODT
chlordiazepoxide hcl
Librium
Cap
clonazepam
Klonopin
Tab
clonazepam
Various
ODT
clorazepate
dipotassium
diazepam
diazepam intensol
estazolam
flurazepam hcl
Tranxene-T
Valium
Diazepam Intensol
Various
Dalmane
Tab
Tab
Conc Soln
Tab
Cap
lorazepam
Ativan
Tab
lorazepam Intensol
lorazepam
Conc Soln
90ml
oxazepam
temazepam
Serax
Restoril
Cap
Cap
#30
0.5/1mg= #120
2/3mg = #60
0.25/0.5/1mg= #120
2mg = #60
0.5/1mg =#120
2mg = #60
0.125/0.25/0.5/1mg=#120
2mg = #60
2/5/10 mg =#120
240ml
#30
#30
0.5/1 mg =#120
2mg = #90
Updated 01/01/2016 | 10
Covered Drug
Reference Drug
Name
Miscellaneous Anxiolytics, Sedatives & Hypnotics
buspirone hcl
Various
eszopiclone
Lunesta
meprobamate
Various
ramelteon
Rozerem
triazolam
Halcion
zaleplon capsule
Sonata
zolpidem
Ambien
Zolpidem ER
Ambien CR
INTERMEZZO SL,
zolpidem
EDULAR
ZOLPIMIST
zolpidem
ANTIHISTAMINES
cyproheptadine hcl
Various
diphenhydramine
Various
diphenhydramine hcl
Various
hydroxyzine hcl
Atarax
hydroxyzine pamoate
Vistaril
DOPAMINE AGONISTS
amantadine hcl
Various
AUTONOMIC AGONISTS
Parasympathomimetic (Cholinergic) Agents
bethanechol chloride
Urecholine
Anticholinergic Agents
benztropine mesylate
Cogentin
trihexyphenidyl hcl
Artane
CARDIOVASCULAR DRUG
Formulation(s)
Age
Limitation
< 6 requires PA
Prior
Authorization
Required
Tab
Tab
Tab
Tab
Tab
Cap
Tab
ER Tab
X
SL Tab
X
Soln
X
Quantity Limit
(all are based on
30-day supply)
Additional
Information
#30
#30
#30
#30
#30
Tab
Cap/Tab
Elix/Syr
TaB/Syr
Cap
Cap/Tab
Tab
Tab
Tab
Alpha-1 Adrenergic Blocking Agents
prazosin hcl
Minipres
Cap
Updated 01/01/2016 | 11
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
Beta-Adrenergic Blocking Agents
nadolol tab
Corgard
propranolol hcl
Inderal
THYROID AGENTS
levothyroxine sodium Levothroid/Synthroid
liothyronine
Cytomel
VITAMINS AND OTHER MISCELLANEOUS AGENTS
alpha-tocopherol
Vitamin E -Various
Tab
Tab
Tab
Tab
Cap
folic acid
omega 3 fatty acids
Vitamin B12 Various
Various
Various
Tab
Cap
pyridoxine hcl
Vitamin B6 - Various
Tab
thiamine hcl
Vitamin B1 - Various
Tab
cyanocobalamin
multiple vitamin
Various
multiple vitamin /
Various
minerals
Miscellaneous Ear, Nose & Throat Drug
saliva substitute
Salivart
Cathartics and Laxative
docusate sodium
Colace
psyllium
Metamucil
Tab
Tab
Tab
Spray
Cap
Powder
Updated 01/01/2016 | 12