Antidepressants, Misc. and Lithium
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 00378033001 | PERPHENAZINE-AMITRIPTYLINE | perphenazine/amitriptyline HCl | TABLET | 2 mg-10 mg | Y | Y | ||
| 59417040171 | TRIAVIL 10-2 | perphenazine/amitriptyline HCl | TABLET | 2 mg-10 mg | Y | Y | ||
| 00378044201 | PERPHENAZINE-AMITRIPTYLINE | perphenazine/amitriptyline HCl | TABLET | 2 mg-25 mg | Y | Y | ||
| 59417040271 | TRIAVIL 25-2 | perphenazine/amitriptyline HCl | TABLET | 2 mg-25 mg | Y | Y | ||
| 00378004201 | PERPHENAZINE-AMITRIPTYLINE | perphenazine/amitriptyline HCl | TABLET | 4 mg-10 mg | Y | Y | ||
| 00378057401 | PERPHENAZINE-AMITRIPTYLINE | perphenazine/amitriptyline HCl | TABLET | 4 mg-25 mg | Y | Y | ||
| 59417040471 | TRIAVIL 25-4 | perphenazine/amitriptyline HCl | TABLET | 4 mg-25 mg | Y | Y | ||
| 00378007301 | PERPHENAZINE-AMITRIPTYLINE | perphenazine/amitriptyline HCl | TABLET | 4 mg-50 mg | Y | Y | ||
| 00904529052 | ST. JOHN'S WORT | St. John's wort | CAPSULE | 300 mg | Y | Y | ||
| 10267050401 | ST. JOHN'S WORT | St. John's wort | TABLET | 300 mg | Y | Y |