Mercercountybhc.org
Exhibit A
MERCER COUNTY
MH/MR DRUG FORMULARY
Effective July 1, 2012
All forms of a drug listed on this formulary will be covered with the exception of injectables. Generic drugs must be substituted, if available. In order for a brand name to be dispensed, the prescriber must hand-write “brand necessary” or “brand medically necessary.” BRAND NAME
ABILIFY ……………………………………………. ARIPIPRAZOLE
ADAPIN, SINEQUAN……………………………… DOXEPIN
ADDERALL………………………………………….AMPHETAMINE & DEXTROAMPHETAMINE MIXTURE
ADDERALL XR……………………………………. AMPHETAMINE & DEXTROAMPHETAMINE MIXTURE
AKINETON…………………………………………. BIPERIDEN
AMBIEN………………………………………………ZOLPIDEM TARTRATE
ANAFRANIL…………………………………………CLOMIPRAMINE
ARTANE…………………………………………….TRIHEXYPHENIDYL
ASENDIN……………………………………………AMOXAPINE
ATARAX……………………………………………. HYDROXYZINE HYDROCHLORIDE
ATIVAN………………………………………………LORAZEPAM
BENADRYL………………………………………….DIPHENHYDRAMINE
BUSPAR…………………………………………….BUSPIRONE
CAMPRAL………………………………………….ACAMPROSATE
CELEXA…………………………………………….CITALOPRAM HYDROROMIDE
COGENTIN…………………………………………. BENZTROPINE
CONCERTA…………………………………………METHYLPHENIDATE HYDROCHLORIDE
CYLERT, ORAP…………………………………….PEMOLINE
CYLERT…………………………………………….PEMOLINE
CYMBALTA………………………………………….DULOXETINE HCI
DAYTRANA (Patch) ……………………………….METHYLPHENIDATE
DEPAKOTE …………………………………………DIVALPROEX
DEPAKOTE ER…………………………………….DIVALPROEX
DESYREL……………………………………………TRAZODONE
DEXEDRINE………………………………………. DEXTRO AMPHETAMINE
EFFEXOR…………………………………………. VENLAFAXINE HYDROCHLORIDE
EFFEXOR XR……………………………………….VENLAFAXINE HYDROCHLORIDE
* Denotes the addition of a new drug to the formulary list.
ELAVIL, ENDEP…………………………………….AMITRIPTYLINE
FOCALIN XR……………………………………… .DEXMETHYPHENIDATE
*FOCALIN…………………………………………….DEXMETHYPHENIDATE
GABITRIL……………………………………………TIAGABINE HCL
GEODON…………………………………………. ZIPRASIDONE
HALDOL……………………………………………. HALOPERIDOL
HALDOL DECANOATE……………………………HALOPERIDOL DECANOATE
INDERAL…………………………………………….PROPRANOLOL
INVEGA……………………………………………. PALIPERIDONE
KLONOPIN…………………………………………. CLONAZEPAM
KLONOPIN WAFERS…………………………… CLONAZEPAM
LAMICTAL………………………………………….LAMOTRIGINE
LEXAPRO……………………………………………ESCITALOPRAM OXALATE
LIBRIUM…………………………………………….CHLORDIAZEPOXIDE
LIMBITROL…………………………………………. CHLORDIAZEPOXIDE W/AMITRIPTYLINE
LITHOBID, ESKALITH……………………………. LITHIUM CARBONATE
LOXITANE…………………………………………. LOXAPINE
LUDIOMIL…………………………………………. MAPROTILINE
LUNESTA……………………………………………ESZOPICIONE
LUVOX……………………………………………….FLUVOXAMINE MALEATE
LUVOX CR………………………………………….FLUVOXAMINE
MELLARIL………………………………………….THIORIDAZINE
METADATE ER…………………………………….METHYLPHENIDATE HYDROCHLORIDE
METHYLIN ER…………………………………….METHYLPHENIDATE HYDROCHLORIDE
MOBAN………………………………………………MOLINDONE
MYSOLINE………………………………………….PRIMIDONE
NARDIL………………………………………………PHENELZINE
NAVANE…………………………………………….THIOTHIXENE
NEURONTIN……………………………………….GABAPENTIN
NORPRAMIN, PERTOFRANE…………………… DESIPRAMINE
ORAP………………………………………………. PIMOZIDE
PAMELOR, AVENTYL……………………………. NORTRIPTYLINE
PARLODEL………………………………………….BROMOCRIPTINE
PARNATE……………………………………………TRANYLCYPROMINE
PAXIL…………………………………………………PAROXETINE HYDROCHLORIDE
PAXIL CR ……………………………………………PAROXETINE
PEXEVA…………………………………… ……….PAROXETINE
PROLIXIN, PERMITIL…………………………….FLUPHENAZINE
* Denotes the addition of a new drug to the formulary list.
PROLIXIN DECANOATE………………………….FLUPHENAZINE DECANOATE
PROVIGIL ………………………………………….MODAFINIL
PROZAC…………………………………………….FLUOXETINE
PROZAC WEEKLY…………………………….….FLUOXETINE
REMERON………………………………………….MIRTAZAPINE
REMERON SOL TAB………………………………MIRTAZAPINE
RESTORIL…………………………………………. TEMAZEPAM
RISPERDAL………………………………………. RISPERIDONE
RISPERIDAL M TAB……………………………….RISPERIDONE
RITALIN………………………………………………METHYLPHENIDATE
SERAX……………………………………………….OXAZEPAM
SERZONE………………………………………… NEFAZODONE HYDROCHLORIDE
SEROQUEL…………………………………………QUETIAPINE
SONATA…………………………………………… ZALEPLON
STELAZINE………………………………………….TRIFLUOPERAZINE
STRATTERA…………………………………………ATOMOXETINE HCL
SURMONTIL……………………………………….TRIMIPRAMINE MALEATE
SYMMETREL……………………………………….AMANTADINE
TEGRETOL………………………………………….CARBAMAZEPINE
TEGRETOL XR…………………………………….CARBAMAZEPINE
THORAZINE…………………………………………CHLORPROMAZINE HYDROCHLORIDE
TOFRANIL……………………………………………IMIPRAMINE
TOPAMAX……………………………………………TOPIRAMATE
TRANXENE………………………………………….CLORAZEPATE DIPOTASSIUM
TRIAVIL, ETRAFON……………………………….AMITRIPTYLINE/PERPHENAZINE
TRILAFON…………………………………………. PERPHENAZINE
TRILEPTAL………………………………………….OXCARBAZEPINE
VALIUM……………………………………………. DIAZEPAM
VISTARIL…………………………………………….HYDROXYZINE PAMOATE
VIVACTIL…………………………………………….PROTRIPTYLINE
WELLBUTRIN……………………………………….BUPROPION HYDROCHLORIDE
WELLBUTRIN SR………………………………….BUPROPION HYDROCHLORIDE
WELLBUTRIN XL…………………………………. BUPROPION HYDROCHLORIDE
XANAX……………………………………………….ALPRAZOLAM
XANAX XR……………………………….………. ALPRAZOLAM XR
ZOLOFT……………………………………………. SERTRALINE HC1
ZYPREXA…………………………………………. OLANZAPINE
* Denotes the addition of a new drug to the formulary list.
Source: http://www.mercercountybhc.org/uploads/docs/Formulary_Jul_12.pdf
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