Antidepressants, Misc. and Lithium

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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 but eligible patients will encounter a co-pay at the pharmacy.
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
esketamine HCl SPRAVATO SPRAY V    
lithium carbonate LITHIUM CARBONATE CAPSULE    
lithium carbonate LITHIUM CARBONATE TABLET    
lithium carbonate LITHIUM CARBONATE TABLET ER    
lithium carbonate LITHIUM CARBONATE ER TABLET ER    
lithium carbonate LITHOBID TABLET ER    
lithium citrate LITHIUM SOLUTION    
perphenazine/amitriptyline HCl PERPHENAZINE-AMITRIPTYLINE TABLET    
perphenazine/amitriptyline HCl TRIAVIL 10-2 TABLET    
perphenazine/amitriptyline HCl TRIAVIL 25-2 TABLET    
perphenazine/amitriptyline HCl TRIAVIL 25-4 TABLET    
St. John's wort ST. JOHN'S WORT CAPSULE    
St. John's wort ST. JOHN'S WORT TABLET