Arizona Department of Health Services/ Division of Behavioral Health Services
Behavioral Health Drug List
Effective 01/01/2014
The Arizona Department of Health Services, Division of Behavioral Health Services, the “Department”, is
pleased to provide the Behavioral Health Drug List (BHDL) which will serve as the foundation for the
medications prescribed by our Contractors’ Providers throughout the State. The BHDL contains all of the
behavioral health medications listed on each (Tribal) Regional Behavioral Health Authority’s ((T)RBHA)
behavioral health drug list and specifies which medications require prior authorization. The BHDL also specifies
that there are age restrictions for some medications. Providers prescribing medications outside of the age limit
parameters are required to submit a prior authorization to the recipient’s (T)RBHA.
The drugs listed in the BHDL are intended to provide clinically appropriate, evidenced-based, cost-effective
medication options, for all eligible recipients receiving services through the Department and its Contractors. The
drugs listed on the BHDL have been reviewed and approved by our Pharmacy and Therapeutics (P&T)
Committee.
However, the BHDL is not intended as a comprehensive listing of all drugs that may be reimbursed by the
Department. If a drug is not listed on the BHDL and is determined to be medically necessary for a behavioral
health diagnosis, it may be requested through the (T)RBHA Prior Authorization process. Providers and
recipients may contact the (T)RBHA that is responsible for their pharmacy benefit to request more information
about the process for medications not listed on the BHDL.
Pharmacy and Therapeutics (P&T) Committee
The P & T Committee is composed of clinical staff from the Department and each of its Contractors. This
committee meets at least quarterly to discuss a variety of clinical issues, which pertain to drug selections,
including formulary additions, deletions and changes as well as pharmacy program management.
The P&T Committee evaluates clinical information for newly marketed drugs within 180 days of market launch.
Current medications are reviewed on an annual basis. The evaluation may include, but is not limited to, the
following review categories:

Safety
Efficacy
Comparative data and studies
FDA approved indications
Treatment and consensus guidelines
Adverse events
Contraindications/Warnings/Precautions
Pharmacokinetics
Dosage frequency and formulations
Patient administration/compliance considerations
Medical outcome and pharmacoeconomic studies
When a new drug is considered for inclusion on the BHDL, it will be reviewed relative to similar drugs that are
currently included on the BHDL. The review process of a therapeutic class continually promotes the most
clinically appropriate, useful, and cost-effective agents. All of the information in the BHDL is provided as a
reference for drug therapy selection. Specific drug selection for an individual member rests solely with the
prescribing clinician. As a reminder, the (T)RBHA Providers are required to utilize the most cost-effective
(least costly) clinically appropriate pharmaceutical treatment.
1
revised 8/5/2013
Generic Drugs
The Department supports the use of generic medications. As a general rule, brand name medications will require
Prior Authorization as noted in the BHDL and when a generic equivalent is available for a branded drug.
The BHDL is organized by sections. Each section includes therapeutic groups identified by drug class. Products
are listed with the generic name in lower case and brand name medications are listed in bold capitals. Generics
drugs are to be considered as the first line of prescribing. The Department and its Contractors are required to use
the most cost-effective (least costly) clinically appropriate pharmaceutical treatment.
Quantity Limits
The BHDL does not specify medication Quantity Limits. The Department allows its Contractors to develop their
own Quantity Limit parameters, and these can be located on each Contractor’s website. The Department, in
consultation with its Contractors, has developed prior authorization criteria for evaluation of medication dosages
that exceed the FDA Allowable Maximum.
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
2
revised 8/5/2013
ANTIDEPRESSANTS
Alpha-2 Receptor Antagonist Antidepressants
Remeron
mirtazapine
Remeron SolTab
Monoamine Oxidase Inhibitors (MAOIs)
EMSAM
seligilene
Marplan
isocarboxazid
Nardil
phenelzine sulfate
Parnate
tranylcypromine sulfate
Norepinephrine and Dopamine Reuptake Inhibitors (NDRIs)
APLENZIN
bupropion hbr
Wellbutrin
Wellbutrin SR
Wellbutrin XL
bupropion hcl
Selective Serotonin Reuptake Inhibitors (SSRIs)
Various
citalopram hbr
Celexa
citalopram hbr
Lexapro
escitalopram oxalate
Lexapro
escitalopram oxalate
Prozac
fluoxetine hcl
Prozac
fluoxetine hcl
Prozac Weekly
fluoxetine hcl
Luvox
fluvoxamine maleate
Luvox
CR
fluvoxamine maleate
Paxil
paroxetine hcl
Paxil
paroxetine hcl
Paxil
CR
paroxetine hcl tab
PEXEVA
Paroxetine mesylate
Zoloft
sertraline hcl
Zoloft
sertraline hcl
VIIBRYD
vilazodone hcl
Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs)
Various
nefazodone
Various
trazodone hcl
OLEPTRO
trazodone hcl
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
PRISTIQ
desvenlafaxine
CYMBALTA
duloxetine hcl
Effexor
venlafaxine hcl
Effexor
venlafaxine hcl
3
Additional
Information
Quantity
Limit
Prior
Authorization
Required
Brand Reference
Name
Age
Limitation
Generic Name
Formulation(s)
Medication
Tab
ODT
TD Patch
Tab
Tab
Tab
X
ER Tab
IR Tab
ER Tab
ER Tab
X
Soln
Tab
Soln
Tab
Cap / Tab
Soln
DR Cap
Tab
ER Cap
Susp
Tab
ER Tab
Tab
Conc
Tab
Tab
Tab
Tab
ER Tab
ER Tab
Cap
Tab
ER Cap
X
X
X
X
X
revised 8/5/2013
Various
venlafaxine hcl
ER Tab
Tricyclic Antidepressants & Related Non-Selective Reuptake Inhibitors
Various
Tab
amitriptyline hcl
Various
Tab
amoxapine tab
Anafranil
Cap
clomipramine hcl
Norpramin
Tab
desipramine hcl
Various
Cap
doxepin hcl
Various
Conc
doxepin hcl
SILENOR
Tab
doxepin hcl
Various
Tab
imipramine
Tofranil-PM
Cap
imipramine hcl
Various
Tab
maprotiline hcl
Pamelor
Cap
nortriptyline hcl
Various
Soln
nortriptyline hcl
Vivactil
Tab
protriptyline hcl
Surmontil
Cap
trimipramine maleate
Combination Medications Used for the Treatment of BPAD
Symbyax
Cap
fluoxetine hcl /olanzapine
ANTIPSYCHOTICS
1st Generation Antipsychotics
Various
Tab
haloperidol
Haldol
Inj
haloperidol decanoate
Various
Conc
haloperidol lactate
Loxitane
Cap
loxapine succinate
ORAP
Tab
pimozide
Navane
Cap
thiothixene
2nd Generation Antipsychotics
ABILIFY
Tab
aripiprazole
ABILIFY
DISCMELT
ODT
Tab
aripiprazole
ABILIFY MAINTENA
Inj
aripiprazole
ABILIFY
Soln
aripiprazole
Clozaril
Tab
clozapine
FazaClo
ODT
Tab
clozapine
FANAPT
Tab
Iloperidone
INVEGA
ER Tab
paliperiodone
INVEGA SUSTENNA
LA Susp
paliperidone
LATUDA
Tab
lurasidone hcl
4
Additional
Information
Quantity
Limit
Prior
Authorization
Required
Brand Reference
Name
Age
Limitation
Generic Name
Formulation(s)
Medication
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
revised 8/5/2013
olanzapine
quetiapine
quetiapine
risperidone
risperidone
risperidone
risperidone
asenapine maleate
ziprasidone hcl
Phenothiazine Antipsychotics
chlorpromazine hcl
fluphenazine decanoate
fluphenazine hcl
fluphenazine hcl
fluphenazine hcl
perphenazine
thioridazine hcl
trifluoperazine hcl
ANTICONVULSANTS
Various
Various
Tab
Inj
Oral
Conc
Elix
Tab
Tab
Tab
Tab
X
X
Various
Various
Various
Various
Various
Various
Tegretol, Epitol
Carbatrol, Equetro
Tegretol XR,
Tegretol
divalproex
divalproex
gabapentin
gabapentin
gabapentin
gabapentin
Depakote
Depakote Sprinkles
Neurontin
HORIZANT
Neurontin
GRALISE
Lamictal
LAMICTAL XR
Trileptal
Tab
Chew
ER Cap
ER Tab
Susp
DR & ER
Tab
Cap
Cap
ER Tab
Soln
Tab
Tab
Chew
ODT
ER Tab
Susp
Additional
Information
X
X
X
X
X
X
X
X
X
Quantity
Limit
ODT
Tab
Tab
Tab
Inj
ODT
Soln
SL Tab
Cap
Prior
Authorization
Required
Zyprexa Zydis
Seroquel
SEROQUEL XR
Risperdal
RISPERDAL CONSTA
Risperdal M-TAB
Risperdal
SAPHRIS
Geodon
carbamazepine
carbamazepine
carbamazepine
carbamazepine
lamotrigine
lamotrigine
oxcarbazepine
5
Age
Limitation
Generic Name
Brand Reference
Name
Formulation(s)
Medication
X
X
X
X
X
X
X
X
X
X
X
revised 8/5/2013
oxcarbazepine
valproate sodium
Trileptal
Various
valproate sodium
ANTIMANIC AGENTS
lithium carbonate
lithium carbonate
lithium citrate
ADHD DRUGS
Amphetamines
amphetaminedextroamphetamine
amphetaminedextroamphetamine
dextroamphetamine
sulfate
dextroamphetamine
sulfate
lisdexamfetamine
dimesylate
Stimulants
dexmethylphenidate hcl
dexmethylphenidate hcl
methylphenidate hcl
Depakene
Tab
Soln
Cap /
Syrup
Various
Lithobid
Various
Cap
ER Tab
Soln
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
Miscellaneous Agents
atomoxetine
Central Alpha-Agonists
clonidine hcl
clonidine hcl
clonidine hcl
guanfacine hcl
6
Adderall
Adderall XR
Tab
SR Cap
ER Cap
Dexedrine
Tab
Various
Additional
Information
Quantity
Limit
Prior
Authorization
Required
Age
Limitation
Generic Name
Brand Reference
Name
Formulation(s)
Medication
X
X
X
X
VYVANSE
ER Cap
X
Focalin
FOCALIN XR
Ritalin
X
X
X
METHYLIN
Ritalin LA / Metadate CD
Ritalin SR
Concerta
DAYTRANA
METHYLIN
QUILLIVANT XR
Tab
ER Cap
Tab
Chew
Tab
ER Cap
SR Tab
ER Tab
TD Patch
Soln
Susp
STRATTERA
Cap
X
Catapres
KAPVAY
Catapres TTS
Tenex
Tab
ER Tab
TD Patch
Tab
X
X
X
X
X
X
X
revised 8/5/2013
guanfacine hcl
SUBSTANCE ABUSE
Opiate Agonists/Partial Agonists
buprenorphine hcl
buprenorphine hcl /
naloxone
buprenorphine hcl /
naloxone
methadone
Opiate Antagonists
naltrexone
naltrexone
Miscellaneous Agents
acamprosate
disulferam
ANXIOLYTICS AND HYPNOTICS
Benzodiazepines
alprazolam
Subutex
Additional
Information
X
SL Tab
SL Tab
Suboxone
Film
SUBOXONE FILM
X
*
Dolophine
Revia
VIVITROL
Tab
Inj
CAMPRAL
Antabuse
DR Tab
Tab
Xanax
Tab
Conc
Soln
ER Tab
ODT
Cap
Tab
ODT
Tab
Tab
Conc
Soln
Tab
Cap
Tab
Conc
Soln
Cap
Cap
alprazolam intensol
alprazolam
alprazolam
chlordiazepoxide hcl
clonazepam
clonazepam
clorazepate dipotassium
diazepam
Alprazolam Intensol
Xanax XR
Niravam
Librium
Klonopin
Various
Tranxene-T
Valium
diazepam intensol
estazolam
flurazepam hcl
lorazepam
Diazepam Intensol
Various
Dalmane
Ativan
lorazepam
Lorazepam Intensol
Serax
oxazepam
Restoril
temazepam
Miscellaneous Anxiolytics, Sedatives & Hypnotics
Various
buspirone hcl
7
Quantity
Limit
ER Tab
Prior
Authorization
Required
INTUNIV
Age
Limitation
Generic Name
Brand Reference
Name
Formulation(s)
Medication
X
Tab
revised 8/5/2013
eszopiclone
meprobamate
ramelteon
triazolam
zaleplon capsule
zolpidem
zolpidem
LUNESTA
Various
ROZEREM
Halcion
Sonata
Ambien
Ambien CR
INTERMEZZO SL /
EDULAR
ZOLPIMIST
zolpidem
zolpidem
ANTIHISTAMINES
Various
cyproheptadine hcl
Various
diphenhydramine
Various
diphenhydramine hcl
Atarax
hydroxyzine hcl
Vistaril
hydroxyzine pamoate
DOPAMINE AGONISTS
Various
amantadine hcl
AUTONOMIC AGONISTS
Parasympathomimetic (Cholinergic) Agents
Urecholine
bethanechol chloride
Anticholinergic Agents
Cogentin
benzotropine mesylate
Artane
trihexyphenidyl hcl
CARDIOVASCULAR DRUGS
Alpha-1 Adrenergic Blocking Agents
Minipres
prazosin hcl
Beta-Adrenergic Blocking Agents
Corgard
nadolol tab
Inderal
propranolol hcl
THYROID AGENTS
Levothroid / Synthroid
levothyroxine sodium
Cytomel
liothyronine
VITAMINS AND OTHER MISCELLANEOUS AGENTS
Vitamin E – Various
alpha-tocopherol
Vitamin
B12 - Various
cyanocobalamin
Various
folic acid
Various
omega 3 fatty acids
Vitamin B6 - Various
pyridoxine hcl
8
Tab
Tab
Tab
Tab
Cap
Tab
ER Tab
SL Tab
Soln
Additional
Information
Quantity
Limit
Prior
Authorization
Required
Age
Limitation
Generic Name
Brand Reference
Name
Formulation(s)
Medication
X
X
X
X
Tab
Cap / Tab
Elix / Syr
Tab / Syr
Cap
Cap / Tab
Tab
Tab
Tab
Cap
Tab
Tab
Tab
Tab
Cap
Tab
Tab
Cap
Tab
revised 8/5/2013
Vitamin B1 - Various
thiamine hcl
Various
multiple vitamin
multiple vitamin /
Various
minerals
Miscellaneous Ear, Nose & Throat Drug
Salivart
saliva substitute
Cathartics and Laxatives
Colace
docusate sodium
Metamucil
psyllium
9
Additional
Information
Quantity
Limit
Prior
Authorization
Required
Age
Limitation
Generic Name
Brand Reference
Name
Formulation(s)
Medication
Tab
Tab
Tab
Spray
Cap
Powder
revised 8/5/2013