Antidepressants, Misc. and Lithium
Drug Use Review Documents
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | New Drug Evaluation & Updates |
|---|---|---|---|---|---|
| lithium carbonate | LITHIUM CARBONATE | CAPSULE | Oct 01, 2020 | ||
| lithium carbonate | LITHIUM CARBONATE | TABLET | Oct 01, 2020 | ||
| lithium carbonate | LITHIUM CARBONATE ER | TABLET ER | Oct 01, 2020 | ||
| lithium carbonate | LITHOBID | TABLET ER | Oct 01, 2020 | ||
| lithium citrate | LITHIUM CITRATE | SOLUTION | |||
| perphenazine/amitriptyline HCl | TRIAVIL 10-2 | TABLET | |||
| perphenazine/amitriptyline HCl | TRIAVIL 25-4 | TABLET | |||
| perphenazine/amitriptyline HCl | TRIAVIL 25-2 | TABLET | |||
| perphenazine/amitriptyline HCl | PERPHENAZINE-AMITRIPTYLINE | TABLET | |||
| St. John's wort | ST. JOHN'S WORT | CAPSULE | |||
| St. John's wort | ST. JOHN'S WORT | TABLET |