MEDICATION FORMULARY

(Alphabetical by Brand Name)

Community Partnership of Southern Arizona (CPSA), with the approval of the ADHS/DBHS, has developed this formulary to be used by CPSA providers for CPSA members. CPSA and its Pharmacy & Therapeutics Committee will continue to update and revise this formulary, based on quality of care and sound pharmacoeconomic principles. CPSA requires mandatory generic substitution whenever an equivalent product is available, unless a Prior Authorization is obtained for a Brand name medication. Prior Authorizations must be requested by the prescriber by sending the Prior Authorization Request for Medication Form to CPSA, for the following: Prescriptions for non-formulary drugs Prescriptions for Brand name drugs when an equivalent product is available Prescriptions exceeding the maximum quantities Restricted items For all Prior Authorization procedures please refer to: CPSA Provider Manual Section 3.14, Securing Services and Prior Authorization CPSA Provider Manual Section 3.15, Psychotropic Medications: Prescribing and Monitoring Provider Manual Section 3.16, Medication Formulary Prior Authorization Request for Medication Form
Clicking on drug name will direct you to drug information on

If there are any comments, questions, concerns or requests for formulary additions or deletions please contact: Community Partnership of Southern Arizona (CPSA) Pharmacy Services Manager 535 N. Wilmot, Suite 201 Tucson, Arizona 85711 Phone: (520) 901-6800 Fax: (520) 318-6979

FORMULARY alpha by brand

Page 1 of 5

Effective: July 1, 2010 Revised: November 1, 2010

MEDICATION FORMULARY
(Alphabetical by Brand Name)

CPSA requires mandatory substitution whenever an equivalent product is available, unless a Prior Authorization is obtained for a Brand name medication.

Brand Medication
Abilify Adderall /Adderall XR Ambien Anafranil Antabuse Artane / Trihexane / Trihexy Asendin Atarax Ativan Benadryl/Genahist/Nordryl/Banophen Buprenex BuSpar Calan/Isoptin/Calan SR/IsoptinSR Campral Catapres Catapres-TSS Celexa Centrum / Theragram / One-A-Day Cibalith-S Clozaril Cogentin Colace Concerta Corgard Cymbalta Cytomel Daytrana Aripiprazole

Generic Medication
Amphetamine Dextroamphetamine Amphetamine Saccharate Amphetamine Aspartate / XR Zolpidem Clomipramine Disulfuram Trihexyphenidyl Amoxapine Hydroxyzine Lorazepam Diphenhydramine Buprenorphine Hydrochloride Injectable Buspirone Verapamil, Long Acting Acamprosate Clonidine Clonidine Transdermal Citalopram Multivitamin Lithium Citrate Clozapine Benztropine Docusate Methylphenidate Nadolol Duloxetine Liothyronine Methylphenidate Transdermal

FORMULARY alpha by brand

Page 2 of 5

Effective: July 1, 2010 Revised: November 1, 2010

MEDICATION FORMULARY
(Alphabetical by Brand Name)

Brand Medication
Depakene Depakote / Depakote ER / Depakote Sprinkle Desyrel Dexedrine/Dexedrine Spansule/Dextrostat Dolophine Effexor / Effexor XR Elavil/Endep Equetro / Carbatrol Fazaclo Focalin / Focalin XR Geodon Haldol / Haldol Concentrate Inderal Invega Klonopin Lamictal Lexapro Librium Lithobid/Lithotabs; Eskalith CR Lithonate / Eskalith CR Loxitane Luvox Mellaril Metamucil Minipress Moban Nardil Navane Neurontin Noctec Valproic Acid

Generic Medication
Divalproex (Devalproex) Trazodone Dextroamphetamine Methadone Venlafaxine Amitriptyline Carbamazepine extended-release Clozapine Dexmethylphenidate HCL/ Dexmethylphenidate Ziprasidone Haloperidol Propranonlol Paliperidone Clonazepam Lamotrigine Escitalopram Chlordiazepoxide Lithium Carbonate Long Acting Lithium Carbonate Loxapine Fluvoxamine Thioridazine Psyllium Powder Hydrophilic Metamucil Prazosin Molindone Phenelzine Thiothixene Gabapentin Chloral Hydrate

FORMULARY alpha by brand

Page 3 of 5

Effective: July 1, 2010 Revised: November 1, 2010

MEDICATION FORMULARY
(Alphabetical by Brand Name)

Brand Medication
Norpramin / Pertofrane One-A-Day / Theragram / Centrum Orap Pamelor Parlodel Parnate Paxil Periactin Prolixin /Permitil Prozac Remeron Restoril ReVia Risperdal / Risperdal M-TAB/Risperdal Consta Ritalin / Ritalin SR / Ritalin LA; Concerta; Metadate CD Rozerem Salivart / Saliva Substitute Serax Seroquel/Seroquel XR Sinequan /Sinequan Concentrate Stelazine / Stelazine Concentrate Strattera Subutex / Suboxone Symbyax Symmetrel Synthroid / Levothroid Tegretol/Epitol/Carbatrol Tenex Thorazine Desipramine Multivitamin Pimozide Nortriptyline

Generic Medication

Bromocriptine Mesylate Tranylcypromine Paroxetine Cyproheptadine Fluphenazine Fluoxetine Mirtazapine Temazepam Naltrexone Risperidone Methylphenidate Ramelteon Artificial Saliva Oxazepam Quetiapine Doxepin Trifluoperazine Atomoxetine Buprenorphine / Naloxone Olanzapine / Fluoxetine Amantadine Levothyroxine Carbamazepine Guanfacine Chlorpromazine

FORMULARY alpha by brand

Page 4 of 5

Effective: July 1, 2010 Revised: November 1, 2010

MEDICATION FORMULARY
(Alphabetical by Brand Name)

Brand Medication
Tofranil / Tipramine / Norfranil Tranxene Triavil Trilafon Trileptal Urecholine Valium Vistaril Vitamin B1 Vitamin B6 Vitamin E Vivactil Vyvanse Wellbutrin / Wellbutrin SR / Wellbutrin XL Xanax Zoloft Zyprexa, Zyprexa Zydis Imipramine Clorazepate

Generic Medication

Perphenazine / Amitriptyline Perphenazine Oxcarbazepine Bethanechol Diazepam Hydroxyzine Pamoate Thiamine Pyridoxine Alpha-Tocopherol Protriptyline Lisdexamfetamine Bupropion / Bupropion SR / Bupropion XL Alprazolam Sertraline Olanzapine

FORMULARY alpha by brand

Page 5 of 5

Effective: July 1, 2010 Revised: November 1, 2010