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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 00054252625 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 150 mg | Y | ||
| 00054852625 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 150 mg | Y | ||
| 31722054401 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 150 mg | Y | ||
| 62332001331 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 150 mg | Y | ||
| 68462022001 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 150 mg | Y | ||
| 00054252725 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 300 mg | Y | ||
| 00054252731 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 300 mg | Y | ||
| 00054852725 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 300 mg | Y | ||
| 31722054501 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 300 mg | Y | ||
| 31722054510 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 300 mg | Y | ||
| 60687080601 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 300 mg | Y | ||
| 60687080611 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 300 mg | Y | ||
| 62332001431 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 300 mg | Y | ||
| 62332001491 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 300 mg | Y | ||
| 68462022101 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 300 mg | Y | ||
| 68462022110 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 300 mg | Y | ||
| 00054253125 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 600 mg | Y | ||
| 31722054601 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 600 mg | Y | ||
| 62332001531 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 600 mg | Y | ||
| 68462022201 | LITHIUM CARBONATE | lithium carbonate | CAPSULE | 600 mg | Y | ||
| 00054452725 | LITHIUM CARBONATE | lithium carbonate | TABLET | 300 mg | Y | ||
| 00054452731 | LITHIUM CARBONATE | lithium carbonate | TABLET | 300 mg | Y | ||
| 00054852825 | LITHIUM CARBONATE | lithium carbonate | TABLET | 300 mg | Y | ||
| 62756043018 | LITHIUM CARBONATE | lithium carbonate | TABLET | 300 mg | Y | ||
| 62756043088 | LITHIUM CARBONATE | lithium carbonate | TABLET | 300 mg | Y | ||
| 00054002125 | LITHIUM CARBONATE ER | lithium carbonate | TABLET ER | 300 mg | Y | ||
| 00054002129 | LITHIUM CARBONATE ER | lithium carbonate | TABLET ER | 300 mg | Y | ||
| 23155076301 | LITHIUM CARBONATE ER | lithium carbonate | TABLET ER | 300 mg | Y | ||
| 64980020501 | LITHIUM CARBONATE ER | lithium carbonate | TABLET ER | 300 mg | Y | ||
| 64980020505 | LITHIUM CARBONATE ER | lithium carbonate | TABLET ER | 300 mg | Y | ||
| 68084064001 | LITHIUM CARBONATE ER | lithium carbonate | TABLET ER | 300 mg | Y | ||
| 68084064011 | LITHIUM CARBONATE ER | lithium carbonate | TABLET ER | 300 mg | Y | ||
| 68462022301 | LITHIUM CARBONATE ER | lithium carbonate | TABLET ER | 300 mg | Y | ||
| 62559028001 | LITHOBID | lithium carbonate | TABLET ER | 300 mg | Y | ||
| 00054002025 | LITHIUM CARBONATE ER | lithium carbonate | TABLET ER | 450 mg | Y | ||
| 64980027801 | LITHIUM CARBONATE ER | lithium carbonate | TABLET ER | 450 mg | Y | ||
| 68084065501 | LITHIUM CARBONATE ER | lithium carbonate | TABLET ER | 450 mg | Y | ||
| 68084065511 | LITHIUM CARBONATE ER | lithium carbonate | TABLET ER | 450 mg | Y | ||
| 68462022401 | LITHIUM CARBONATE ER | lithium carbonate | TABLET ER | 450 mg | Y | ||
| 71656007205 | LITHIUM CITRATE | lithium citrate | SOLUTION | 8 mEq/5 mL | Y | ||
| 71656007216 | LITHIUM CITRATE | lithium citrate | SOLUTION | 8 mEq/5 mL | Y | ||
| 71656007250 | LITHIUM CITRATE | lithium citrate | SOLUTION | 8 mEq/5 mL | Y | ||
| 72888017246 | LITHIUM CITRATE | lithium citrate | SOLUTION | 8 mEq/5 mL | Y | ||
| 00378033001 | PERPHENAZINE-AMITRIPTYLINE | perphenazine/amitriptyline HCl | TABLET | 2 mg-10 mg | Y | ||
| 59417040171 | TRIAVIL 10-2 | perphenazine/amitriptyline HCl | TABLET | 2 mg-10 mg | Y | ||
| 00378044201 | PERPHENAZINE-AMITRIPTYLINE | perphenazine/amitriptyline HCl | TABLET | 2 mg-25 mg | Y | ||
| 59417040271 | TRIAVIL 25-2 | perphenazine/amitriptyline HCl | TABLET | 2 mg-25 mg | Y | ||
| 00378004201 | PERPHENAZINE-AMITRIPTYLINE | perphenazine/amitriptyline HCl | TABLET | 4 mg-10 mg | Y | ||
| 00378057401 | PERPHENAZINE-AMITRIPTYLINE | perphenazine/amitriptyline HCl | TABLET | 4 mg-25 mg | Y | ||
| 59417040471 | TRIAVIL 25-4 | perphenazine/amitriptyline HCl | TABLET | 4 mg-25 mg | Y | ||
| 00378007301 | PERPHENAZINE-AMITRIPTYLINE | perphenazine/amitriptyline HCl | TABLET | 4 mg-50 mg | Y | ||
| 00904529052 | ST. JOHN'S WORT | St. John's wort | CAPSULE | 300 mg | Y | ||
| 10267050401 | ST. JOHN'S WORT | St. John's wort | TABLET | 300 mg | Y |