MERCER COUNTY Exhibit A
MH/MR FORMULARY (Revised)
Effective January 1, 2006
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
|
GENERIC 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
|
DEPAKOTE
|
DIVALPROEX
|
DEPAKOTE ER
|
DIVALPROEX
|
DESYREL
|
TRAZODONE
|
DEXEDRINE
|
DEXTRO AMPHETAMINE
|
EFFEXOR
|
VENLAFAXINE HYDROCHLORIDE
|
EFFEXOR XR
|
VENLAFAXINE HYDROCHLORIDE
|
ELAVIL, ENDEP
|
AMITRIPTYLINE
|
*FOCALIN XR
|
DEXMETHYPHENIDATE
|
GABITRIL
|
TIAGABINE HCL
|
*GEODON
|
ZIPRASIDONE
|
HALDOL
|
HALOPERIDOL
|
HALDOL DECANOATE
|
HALOPERIDOL DECANOATE
|
INDERAL
|
PROPRANOLOL
|
KLONOPIN
|
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
|
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
|
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
|
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
|
Effective 1/1/06
*Denotes the addition of a new drug to the formulary list.