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
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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