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2020-2021 Crisis Medicaion List

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2020-2021 Crisis Medicaion List 2020-2021 Crisis Medicaion List Health Choice AZ Crisis List effective: 07/01/2021 Drug Name Requirements/Limits ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS atomoxetine hcl cap 10 mg (base equiv) (generic QL (Max 7 days) of STRATTERA) atomoxetine hcl cap 18 mg (base equiv) (generic QL (Max 7 days) of STRATTERA) atomoxetine hcl cap 25 mg (base equiv) (generic QL (Max 7 days) of STRATTERA) atomoxetine hcl cap 40 mg (base equiv) (generic QL (Max 7 days) of STRATTERA) atomoxetine hcl cap 60 mg (base equiv) (generic QL (Max 7 days) of STRATTERA) atomoxetine hcl cap 80 mg (base equiv) (generic QL (Max 7 days) of STRATTERA) atomoxetine hcl cap 100 mg (base equiv) (generic QL (Max 7 days) of STRATTERA) ANALGESICS - OPIOID OPIOID PARTIAL AGONISTS buprenorphine hcl-naloxone hcl sl film 2-0.5 mg QL (Max 7 days) (base equiv) (generic of SUBOXONE) buprenorphine hcl-naloxone hcl sl film 4-1 mg QL (Max 7 days) (base equiv) (generic of SUBOXONE) buprenorphine hcl-naloxone hcl sl film 8-2 mg QL (Max 7 days) (base equiv) (generic of SUBOXONE) buprenorphine hcl-naloxone hcl sl film 12-3 mg QL (Max 7 days) (base equiv) (generic of SUBOXONE) buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg QL (Max 7 days) (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 mg QL (Max 7 days) (base equiv) ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC. hydroxyzine hcl syrup 10 mg/5ml QL (Max 7 days) hydroxyzine hcl tab 10 mg QL (Max 7 days) hydroxyzine hcl tab 25 mg QL (Max 7 days) hydroxyzine hcl tab 50 mg QL (Max 7 days) hydroxyzine pamoate cap 25 mg (generic of QL (Max 7 days) VISTARIL) hydroxyzine pamoate cap 50 mg (generic of QL (Max 7 days) VISTARIL) hydroxyzine pamoate cap 100 mg QL (Max 7 days) BENZODIAZEPINES alprazolam tab 0.5 mg (generic of XANAX) QL (Max 7 days) alprazolam tab 0.25 mg (generic of XANAX) QL (Max 7 days) alprazolam tab 1 mg (generic of XANAX) QL (Max 7 days) OTC - Over the counter QL - Quantity Limits 1 Drug Name Requirements/Limits alprazolam tab 2 mg (generic of XANAX) QL (Max 7 days) chlordiazepoxide hcl cap 5 mg QL (Max 7 days) chlordiazepoxide hcl cap 10 mg QL (Max 7 days) chlordiazepoxide hcl cap 25 mg QL (Max 7 days) clorazepate dipotassium tab 3.75 mg QL (Max 7 days) clorazepate dipotassium tab 7.5 mg QL (Max 7 days) clorazepate dipotassium tab 15 mg QL (Max 7 days) diazepam tab 2 mg (generic of VALIUM) QL (Max 7 days) diazepam tab 5 mg (generic of VALIUM) QL (Max 7 days) diazepam tab 10 mg (generic of VALIUM) QL (Max 7 days) lorazepam tab 0.5 mg (generic of ATIVAN) QL (Max 7 days) lorazepam tab 1 mg (generic of ATIVAN) QL (Max 7 days) lorazepam tab 2 mg (generic of ATIVAN) QL (Max 7 days) oxazepam cap 10 mg QL (Max 7 days) oxazepam cap 15 mg QL (Max 7 days) oxazepam cap 30 mg QL (Max 7 days) ANTICONVULSANTS ANTICONVULSANTS - BENZODIAZEPINES clonazepam tab 0.5 mg (generic of KLONOPIN) QL (Max 7 days) clonazepam tab 1 mg (generic of KLONOPIN) QL (Max 7 days) clonazepam tab 2 mg (generic of KLONOPIN) QL (Max 7 days) ANTICONVULSANTS - MISC. carbamazepine chew tab 100 mg QL (Max 7 days) carbamazepine susp 100 mg/5ml (generic of QL (Max 7 days) TEGRETOL) carbamazepine tab 200 mg (generic of TEGRETOL) QL (Max 7 days) carbamazepine tab er 12hr 100 mg (generic of QL (Max 7 days) TEGRETOL-XR) carbamazepine tab er 12hr 200 mg (generic of QL (Max 7 days) TEGRETOL-XR) carbamazepine tab er 12hr 400 mg (generic of QL (Max 7 days) TEGRETOL-XR) oxcarbazepine susp 300 mg/5ml (60 mg/ml) QL (Max 7 days) (generic of TRILEPTAL) oxcarbazepine tab 150 mg (generic of TRILEPTAL) QL (Max 7 days) oxcarbazepine tab 300 mg (generic of TRILEPTAL) QL (Max 7 days) oxcarbazepine tab 600 mg (generic of TRILEPTAL) QL (Max 7 days) VALPROIC ACID divalproex sodium tab delayed release 125 mg QL (Max 7 days) (generic of DEPAKOTE) divalproex sodium tab delayed release 250 mg QL (Max 7 days) (generic of DEPAKOTE) divalproex sodium tab delayed release 500 mg QL (Max 7 days) (generic of DEPAKOTE) divalproex sodium tab er 24 hr 250 mg (generic of QL (Max 7 days) DEPAKOTE ER) OTC - Over the counter QL - Quantity Limits 2 Drug Name Requirements/Limits divalproex sodium tab er 24 hr 500 mg (generic of QL (Max 7 days) DEPAKOTE ER) valproate sodium oral soln 250 mg/5ml (base QL (Max 7 days) equiv) valproic acid cap 250 mg QL (Max 7 days) ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS) mirtazapine tab 15 mg (generic of REMERON) QL (Max 7 days) mirtazapine tab 30 mg (generic of REMERON) QL (Max 7 days) mirtazapine tab 45 mg QL (Max 7 days) ANTIDEPRESSANTS - MISC. bupropion hcl tab 75 mg QL (Max 7 days) bupropion hcl tab 100 mg QL (Max 7 days) bupropion hcl tab er 12hr 100 mg (generic of QL (Max 7 days) WELLBUTRIN SR) bupropion hcl tab er 12hr 150 mg (generic of QL (Max 7 days) WELLBUTRIN SR) bupropion hcl tab er 12hr 200 mg (generic of QL (Max 7 days) WELLBUTRIN SR) SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram hydrobromide oral soln 10 mg/5ml QL (Max 7 days) citalopram hydrobromide tab 10 mg (base equiv) QL (Max 7 days) (generic of CELEXA) citalopram hydrobromide tab 20 mg (base equiv) QL (Max 7 days) (generic of CELEXA) citalopram hydrobromide tab 40 mg (base equiv) QL (Max 7 days) (generic of CELEXA) fluoxetine hcl cap 10 mg (generic of PROZAC) QL (Max 7 days) fluoxetine hcl cap 20 mg (generic of PROZAC) QL (Max 7 days) fluoxetine hcl cap 40 mg (generic of PROZAC) QL (Max 7 days) fluoxetine hcl solution 20 mg/5ml QL (Max 7 days) fluoxetine hcl tab 60 mg (generic of FLUOXETINE QL (Max 7 days) HYDROCHLORIDE) FLUOXETINE TAB 60MG QL (Max 7 days) fluvoxamine maleate tab 25 mg QL (Max 7 days) fluvoxamine maleate tab 50 mg QL (Max 7 days) fluvoxamine maleate tab 100 mg QL (Max 7 days) paroxetine hcl tab 10 mg (generic of PAXIL) QL (Max 7 days) paroxetine hcl tab 20 mg (generic of PAXIL) QL (Max 7 days) paroxetine hcl tab 30 mg (generic of PAXIL) QL (Max 7 days) paroxetine hcl tab 40 mg (generic of PAXIL) QL (Max 7 days) sertraline hcl oral concentrate for solution 20 QL (Max 7 days) mg/ml (generic of ZOLOFT) sertraline hcl tab 25 mg (generic of ZOLOFT) QL (Max 7 days) sertraline hcl tab 50 mg (generic of ZOLOFT) QL (Max 7 days) sertraline hcl tab 100 mg (generic of ZOLOFT) QL (Max 7 days) OTC - Over the counter QL - Quantity Limits 3 Drug Name Requirements/Limits SEROTONIN MODULATORS trazodone hcl tab 50 mg QL (Max 7 days) trazodone hcl tab 100 mg QL (Max 7 days) trazodone hcl tab 150 mg QL (Max 7 days) trazodone hcl tab 300 mg QL (Max 7 days) SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) venlafaxine hcl cap er 24hr 37.5 mg (base QL (Max 7 days) equivalent) (generic of EFFEXOR XR) venlafaxine hcl cap er 24hr 75 mg (base QL (Max 7 days) equivalent) (generic of EFFEXOR XR) venlafaxine hcl cap er 24hr 150 mg (base QL (Max 7 days) equivalent) (generic of EFFEXOR XR) venlafaxine hcl tab 25 mg (base equivalent) QL (Max 7 days) venlafaxine hcl tab 50 mg (base equivalent) QL (Max 7 days) venlafaxine hcl tab 75 mg (base equivalent) QL (Max 7 days) venlafaxine hcl tab 100 mg (base equivalent) QL (Max 7 days) ANTIDOTES AND SPECIFIC ANTAGONISTS OPIOID ANTAGONISTS naltrexone hcl tab 50 mg QL (Max 7 days) ANTIHISTAMINES ANTIHISTAMINES - ETHANOLAMINES diphenhydramine hcl cap 25 mg QL (Max 7 days), OTC diphenhydramine hcl cap 50 mg QL (Max 7 days), OTC diphenhydramine hcl tab 25 mg QL (Max 7 days), OTC ANTIHISTAMINES - PIPERIDINES cyproheptadine hcl tab 4 mg QL (Max 7 days) ANTIHYPERTENSIVES ANTIADRENERGIC ANTIHYPERTENSIVES clonidine hcl tab 0.1 mg QL (Max 7 days) clonidine hcl tab 0.2 mg QL (Max 7 days) clonidine hcl tab 0.3 mg QL (Max 7 days) guanfacine hcl tab 1 mg QL (Max 7 days) guanfacine hcl tab 2 mg QL (Max 7 days) ANTIPARKINSON AND RELATED THERAPY AGENTS ANTIPARKINSON ANTICHOLINERGICS benztropine mesylate tab 0.5 mg QL (Max 7 days) benztropine mesylate tab 1 mg QL (Max 7 days) benztropine mesylate tab 2 mg QL (Max 7 days) trihexyphenidyl hcl tab 2 mg QL (Max 7 days) trihexyphenidyl hcl tab 5 mg QL (Max 7 days) ANTIPSYCHOTICS/ANTIMANIC AGENTS ANTIMANIC AGENTS lithium carbonate cap 150 mg QL (Max 7 days) lithium carbonate cap 300 mg QL (Max 7 days) OTC - Over the counter QL - Quantity Limits 4 Drug Name Requirements/Limits lithium carbonate cap 600 mg QL (Max 7 days) lithium carbonate tab er 300 mg (generic of QL (Max 7 days) LITHOBID) lithium carbonate tab er 450 mg QL (Max 7 days) LITHIUM SOL 8MEQ/5ML QL (Max 7 days) BENZISOXAZOLES risperidone orally disintegrating tab 0.5 mg QL (Max 7 days) risperidone orally disintegrating tab 0.25 mg QL (Max 7 days) risperidone orally disintegrating tab 1 mg QL (Max 7 days) risperidone orally disintegrating tab 2 mg QL (Max 7 days) risperidone orally disintegrating tab 3 mg QL (Max 7 days) risperidone orally disintegrating tab 4 mg QL (Max 7 days) risperidone soln 1 mg/ml (generic of RISPERDAL) QL (Max 7 days) risperidone tab 0.5 mg (generic of RISPERDAL) QL (Max 7 days) risperidone tab 0.25 mg QL (Max 7 days) risperidone tab 1 mg (generic of RISPERDAL) QL (Max 7 days) risperidone tab 2 mg (generic of RISPERDAL) QL (Max 7 days) risperidone tab 3 mg (generic of RISPERDAL) QL (Max 7 days) risperidone tab 4 mg (generic of RISPERDAL) QL (Max 7 days) BUTYROPHENONES haloperidol decanoate im soln 50 mg/ml (generic QL (Max 7 days) of HALDOL DECANOATE 50) haloperidol decanoate im soln 100 mg/ml (generic QL (Max 7 days) of HALDOL DECANOATE 100) haloperidol tab 0.5 mg QL (Max 7 days) haloperidol tab 1 mg QL (Max 7 days) haloperidol tab 2 mg QL (Max 7 days) haloperidol tab 5 mg QL (Max 7 days) haloperidol tab 10 mg QL (Max 7 days) haloperidol tab 20 mg QL (Max 7 days) DIBENZAPINES
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