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PROTRIPTYLINE

VIVACTIL

Quetiapine Fumarate

Seroquel

TRAZODONE

DESYREL

Sertraline

Zoloft

Venlafaxine HCL

Effexor XR

AMITRIPTYLINE

ELAVIL

BUPROPION HYDROCHLORIDE

WELLBUTRIN,

Wellbutrin SR

CLOMIPRAMINE HCL

ANAFRANIL

DESIPRAMINE HCL

NORPRAMIN

DOXEPIN

SINEQUAN

IMIPRAMINE

TOFRANIL

NORTRIPTYLINE HCL

AVENTYL, PAMELOR

Therapeutic Class

SNRI

Other Anti- Depressants

Generic Name

Brand Name

Methylphenidate HCl

Concerta

PEMOLINE

CYLERT

LEVODOPA

DOPAR, LARODOPA

7

ANTI-HYPERKINETIC AMPHETAMINE/ DEXTROAMPHETAMINE

ADDERALL

DEXTROAMPHETAMINE SULFATE

DEXEDRINE

METHYLPHENIDATE HCL

RITALIN

BENZTROPINE MESYLATE

COGENTIN

CARBIDOPA/ LEVODOPA

SINEMET

ANTIMANIA AGENTS LITHIUM CARBONATE

ESKALITH, ESKALITH CR, LITHOBID

LITHIUM CITRATE VALPROIC ACID

ANTI-PARKINSON AGENTS AMANTADINE

DEPAKENE

SYMMETREL

VERSION 05/2004

Cap

25mg, 50mg,

x

Tab

75mg 10mg, 25mg,

x

50mg, 75mg,

Cap, Oral

100 10 10mg, 25mg,

x

Conc

50mg, 75mg,

Tab, Oral Conc

25mg, 50mg, 100mg, 20mg/mL

R

Tab

37.5mg, 75mg, 150mg

R

Tab

10mg, 25mg,

x

Cap, Soln

50mg 10mg, 25mg,

x

50mg, 75mg,

Tab

10 / 5mg, 10mg

x

Tab

25mg, 100mg,

R

Tab

50mg, 100mg, 200mg 300mg

x

Form

Strength

CHP

100mg, 150mg,

150mg 300mg

x

x

Tab

Tab, TabSR

10mg, 25mg,50mg, 75mg, 100mg, 75mg, 100mg, 150mg

Relative Cost

$$$

$$$$

$

$$$$

$$

$

$

$

$

$$ $$$$

$

CHP Restrictions

Restricted to failure or contraindication to preferred agent Prozac (fluoxetine) when

initiating SSRI therapy + generic Restricted to Psychiatry, patients

w/ minimal response/ contraindications to first line agents or patients currently

Restricted to therapy lasting up to 9 months from the dispensing date of the first prescription: Zyban (non- formulary): Wellbutrin XL non

Restricted to Psychiatry

Tab OSM

18mg, 36mg,

PA

$$$

Restricted to treatment failure on

Tab, Chew

54mg 18.75mg,

xAL

>$$$$$

Ritalin and Ritalin-SR Restricted to use in Attention

37.5mg, 75mg

Deficit Disorder individuals

bt

4

d 16

f

xAL

$$$$

xAL

$$

xAL

$$$

Tab

5mg, 7.5mg, 10mg, 12.5mg, 15mg, 20mg, 5mg, 10mg, 15mg

Tan, Spanules

Tab, TabSR

5mg, 10mg, 20mg

Tabs Only- Restricted to use in Attention Deficit Disorder individuals between 4 and 16 years

f Tabs Only- Restricted to use in

Attention Deficit Disorder individuals between 4 and 16 years

Restricted to use in Attention Deficit Disorder individuals between 4 and 16 years of age;

Cap, Liq

100mg,

xC

$

Restricted to Psychiatry

Tab

50mg/5mL 0.5mg, 1mg,

xC

$

Restricted to Psychiatry

Tab, TabSR

2mg 10/100mg,

x

$$

Tab, Cap, TabSR, TabCR

150mg, 300mg, 450mg, 600mg

xC

$$

Restricted to Psychiatry

Liq

300mg/5ml

x 90

$ $$$$

Restricted to Psychiatry

Cap, Syr

250mg, 250mg/5mL

$

Tab, Cap

25/100mg, 25/250mg,

25/100mg, 100mg, 250mg,

500mg

x

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