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No-Charge Psychiatric Medication (Plan G) Formulary
Note: Table reformatted for ease of use.
The following list contains the brand and chemical names of drugs currently included in the Plan G formulary.
Most currently available generics that have been reviewed by PharmaCare are eligible for coverage; however, not all strengths are necessarily covered.
If a generic is available and is a PharmaCare benefit, the brand product is eligible for only partial coverage.
If a drug requires Special Authority approval, it is noted in the third column.
|
Brand Name |
Chemical Name |
Special Authority Approval Required |
Jump to names starting with:
A |
B | C | D |
E | F | G |
H | I | K |
L | M | N |
O | P |
R | S | T |
V | W | X |
Y | Z
|
|
Akineton |
biperiden |
|
|
Alprazolam |
alprazolam |
|
|
Amantadine |
amantadine |
|
|
Amantadine Syrup |
amantadine syrup |
|
|
Amitriptyline |
amitriptyline |
|
|
Anafranil |
clomipramine |
|
|
Androcur |
cyproterone |
Limited Coverage |
|
Atarax |
hydroxyzine |
Limited Coverage |
|
Atenolol |
atenolol |
|
|
Ativan |
lorazepam |
|
|
Aventyl |
nortriptyline |
|
|

| |
Bensylate |
benztropine |
|
|
Benztropine |
benztropine |
|
|
Bromazepam |
bromazepam |
|
|
Bromocriptine |
bromacriptine |
|
|
Bupropion |
bupropion |
Limited Coverage |
|
Buspar |
buspirone |
|
|
Buspirex |
busiprone |
|
|
Busiprone |
busiprone |
|
|
Bustab |
buspirone |
|
|

|
|
Carbamazepine |
carbamazepine |
|
|
Carbamazepine CR |
carbamazepine CR |
|
|
Carbidopa / Levodopa |
carbidopa / levodopa |
|
|
Carbolith |
lithium carbonate |
|
|
Catapres |
clonidine |
|
|
Celexa |
citalopram |
|
|
Chloral Hydrate |
chloral hydrate |
|
|
Chlordiazepoxide |
chlordiazepoxide |
|
|
Chlorpromanyl Syrup |
chlorpromazine syrup |
|
|
Chlorpromazine |
chlorpromazine |
|
|
Citalopram |
citalopram |
|
|
Clobazam |
clobazam |
Limited Coverage |
|
Clomipramine |
clomipramine |
|
|
Clonazepam |
clonazepam |
|
|
Clonidine |
clonidine |
|
|
Clopixol |
zuclopenthixol |
Limited Coverage |
|
Clorazepate |
clorazepate |
|
|
Clozapine |
clozapine |
|
|
Clozaril |
clozapine |
|
|
Cytomel |
liothyronine |
|
|

|
|
Dalmane |
flurazepam |
|
|
Depakene Capsules |
valproic acid |
|
|
Depakene Syrup |
valproate syrup |
|
|
Desipramine |
desipramine |
|
|
Desyrel |
trazodone |
|
|
Dexedrine Spansules |
dextroamphetamine |
|
|
Dexedrine Tablets |
dextroamphetamine |
|
|
Diazepam |
diazepam |
|
|
Diphenhydramine |
diphenhydramine injection |
|
|
Disulfiram |
disulfiram |
|
|
Divalproex |
divalproex |
|
|
Dixarit |
clonidine |
|
|
Doxepin |
doxepine |
|
|
Droperidol |
droperidol injection |
|
|
Duralith |
lithium carbonate |
|
|

|
|
Effexor |
venlafaxine |
|
|
Elavil |
amitriptyline |
|
|
Eltroxin |
levothyroxine |
|
|
Endantadine |
amantadine |
|
|
Epival |
divalproex |
|
|

|
|
Fluanxol Depot Injection |
flupenthixol decanoate |
|
|
Fluanxol Tablets |
flupenthixol |
|
|
Fluoxetine |
fluoxetine |
|
|
Fluphenazine |
fluphenazine |
|
|
Flurazepam |
flurazepam |
|
|
Fluvoxamine |
fluvoxamine |
|
|
Frisium |
clobazam |
Limited Coverage |
|
FXT 40 |
fluoxetine |
|
|

|
|
Gabapentin |
gabapentin |
Limited Coverage |
|

|
|
Halcion |
triazolam |
|
|
Haldol |
haloperidol injection |
|
|
Haloperidol |
haloperidol |
|
|
Haloperidol Liquid |
haloperidol liquid |
|
|
Hydroxyzine |
hydroxyzine |
Limited Coverage |
|
Hydroxyzine Syrup |
hydroxyzine syrup |
Limited Coverage |
|

|
|
Imipramine |
imipramine |
|
|
Imovane |
zopiclone |
Limited Coverage |
|
Impril |
imipramine |
|
|
Inderal |
propranolol |
|
|
Inderal LA |
propranolol |
|
|
Isoptin |
verapamil |
Limited Coverage |
|

|
|
Kemadrin |
procyclidine |
|
|

|
|
L-Tryptophan |
l-tryptophan |
|
|
Lamictal |
lamotrigine |
Limited Coverage |
|
Lamotrigine |
lamotrigine |
Limited Coverage |
|
Largactil |
chlorpromazine |
|
|
Lectopam |
bromazepam |
|
|
Levate |
amitriptyline |
|
|
Levodopa / Carbidopa |
levodopa / carbidopa |
|
|
Lithane |
lithium carbonate |
|
|
Lithium Carbonate |
lithium carbonate |
|
|
Lorazepam |
lorazepam |
|
|
Loxapine |
loxapine |
|
|
Lupron |
leuprolide |
Limited Coverage |
|
Luvox |
fluvoxamine |
|
|

|
|
Majeptil |
thioproperazine |
|
|
Manerix |
moclobemide |
|
|
Maprotiline |
maprotiline |
|
|
Mazepine |
carbamazepine |
|
|
Methotrimeprazine |
methotrimeprazine |
|
|
Methylphenidate |
methylphenidate |
|
|
Mirtazapine |
mirtazapin |
|
|
Moclobemide |
moclobemide |
|
|
Modecate Concentrate 100mg/ml |
fluphenazine decanoate |
|
|
Modecate Injection 25mg/ml |
fluphenazine decanoate |
|
|
Moditen Enanthate Injection 25mg/ml |
fluphenazine enanthate |
|
|
Mogadon |
nitrazepam |
|
|

|
|
Nardil |
phenelzine |
|
|
Navane |
thiothixene |
|
|
Neurontin |
gabapentin |
Limited Coverage |
|
Nitoman |
tetrabenazine |
|
|
Nitrazapam |
nitrazepam |
|
|
Norpramin |
desipramine |
|
|
Nortriptyline |
nortriptyline |
|
|
Norventyl |
nortriptyline |
|
|
Nozinan |
methotrimeprazine |
|
|

|
|
Omega Fluphenazine |
fluphenazine |
|
|
Omega Haloperidol LA |
haloperidol decanoate |
|
|
Orap |
pimozide |
|
|
Oxazepam |
oxazepam |
|
|

|
|
Parlodel |
bromocriptine |
|
|
Parnate |
tranylcypromine |
|
|
Paroxetine |
paroxetine |
|
|
Paxil |
paroxetine |
|
|
Peridol |
haloperidol |
|
|
Perphenazine |
perphenazine |
|
|
Pindolol |
pindolol |
|
|
Piportil-L4 Injection |
pipotiazine |
|
|
Procyclidine |
procyclidine |
|
|
Propranolol |
propranolol |
|
|
Prozac |
fluoxetine |
|
|

|
|
Remeron |
mirtazapine |
|
|
Restoril |
temazepam |
|
|
Risperdal Consta |
risperidone microspheres |
Limited Coverage |
| Risperdal |
risperidone tablets and suspension |
|
|
Ritalin |
methylphenidate |
|
|
Rivotril |
clonazepam |
|
|

|
|
Serax |
oxazepam |
|
|
Serentil |
mesoridazine |
|
Seroquel |
quetiapine |
|
|
Sertraline |
sertraline |
|
|
Sinemet |
carbidopa / levodopa |
|
|
Sinemet CR |
carbidopa / levodopa |
|
|
Sinequan |
doxepin |
|
|
Surmontil |
trimipramine |
|
|
Symmetrel |
amantadine |
|
|
Symmetrel Syrup |
amantadine syrup |
|
|
Synthroid |
levothyroxine |
|
|

|
|
Tegretol |
carbamazepine |
|
|
Tegretol CR |
carbamazepine CR |
|
|
Temazepam |
temazepam |
|
|
Tenormin |
atenolol |
|
|
Tofranil |
imipramine |
|
|
Trazodone |
trazodone |
|
|
Triazolam |
triazolam |
|
|
Trifluoperazine |
trifluoperazine |
|
|
Trihexyphenidyl |
trihexyphenidyl |
|
|
Trilafon |
perphenazine |
|
|
Trimipramine |
trimipramine |
|
|
Tryptan |
l-tryptophan |
|
|
Tryptan |
tryptophan |
|
|

|
|
Valium |
diazepam |
|
|
Valproic Acid |
valproic acid |
|
|
Verapamil |
verapamil |
Limited Coverage |
|
Verelan |
verapamil |
Limited Coverage |
|
Visken |
pindolol |
|
|
Vivol |
diazepam |
|
|

|
|
Wellbutrin SR |
bupropion |
Limited Coverage |
|

|
|
Xanax |
alprazolam |
|
|

|
|
Yocan |
yohimbine |
|
|
Yohimbine |
yohimbine |
|
|

|
|
Zeldox |
ziprasidone |
Limited Coverage |
|
Zoloft |
sertraline |
|
|
Zopiclone |
zopiclone |
Limited Coverage |
|
Zyprexa |
olanzapine |
Limited Coverage |

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