Trustmark/Starmark Formulary Drug List April 2008 - Resource ...

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Brand Name Generic Name Tier Form TOFRANIL IMIPRAMINE HCL 3 Tablet IMIPRAMINE PAMOATE IMIPRAMINE PAMOATE 1 Capsule (Hard, Soft, etc.) TOFRANIL-PM IMIPRAMINE PAMOATE 3 Capsule (Hard, Soft, etc.) MAPROTILINE HCL MAPROTILINE HCL 1 Tablet MAPROTILINE HCL MAPROTILINE HCL 1 Tablet NORTRIPTYLINE HCL NORTRIPTYLINE HCL 1 Capsule (Hard, Soft, etc.) PAMELOR NORTRIPTYLINE HCL 3 Capsule (Hard, Soft, etc.) NORTRIPTYLINE HCL NORTRIPTYLINE HCL 1 Solution, Oral PAMELOR NORTRIPTYLINE HCL 3 Solution, Oral VIVACTIL PROTRIPTYLINE HCL 3 Tablet SURMONTIL TRIMIPRAMINE MALEATE 3 Capsule (Hard, Soft, etc.) TRIMIPRAMINE MALEATE TRIMIPRAMINE MALEATE 1 Capsule (Hard, Soft, etc.) TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINE COMBINATIONS PERPHENAZINE-AMITRIPTYLINE PERPHENAZINE/AMITRIPTYLINE HCL 1 Tablet TRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINE COMBINATIONS AMITRIPTYLINE/CHLORDIAZEPOXIDE AMITRIP HCL/CHLORDIAZEPOXIDE 1 Tablet AMITRIPTYLINE-CHLORDIAZEPOXIDE AMITRIP HCL/CHLORDIAZEPOXIDE 1 Tablet LIMBITROL AMITRIP HCL/CHLORDIAZEPOXIDE 3 Tablet LIMBITROL DS AMITRIP HCL/CHLORDIAZEPOXIDE 3 Tablet ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS MIRTAZAPINE MIRTAZAPINE 1 Tablet MIRTAZAPINE MIRTAZAPINE 3 Tablet REMERON MIRTAZAPINE 3 Tablet MIRTAZAPINE MIRTAZAPINE 1 Tablet, Rapid Dissolve REMERON MIRTAZAPINE 3 Tablet, Rapid Dissolve SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) CYMBALTA DULOXETINE HCL 3 Capsule,Delayed Release (Enteric Coated) EFFEXOR XR VENLAFAXINE HCL 2 Capsule, Sustained Release 24 Hr EFFEXOR VENLAFAXINE HCL 2 Tablet VENLAFAXINE HCL VENLAFAXINE HCL 1 Tablet NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUPROPION HCL BUPROPION HCL 1 Tablet WELLBUTRIN BUPROPION HCL 3 Tablet BUDEPRION SR BUPROPION HCL 1 Tablet, Sustained Action BUPROPION HCL SR BUPROPION HCL 1 Tablet, Sustained Action WELLBUTRIN SR BUPROPION HCL 3 Tablet, Sustained Action BUDEPRION XL BUPROPION HCL 1 Tablet, Sustained Release 24 Hr BUPROPION XL BUPROPION HCL 1 Tablet, Sustained Release 24 Hr WELLBUTRIN XL BUPROPION HCL 2 Tablet, Sustained Release 24 Hr SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) NEFAZODONE HCL NEFAZODONE HCL 1 Tablet DESYREL TRAZODONE HCL 3 Tablet TRAZODONE TRAZODONE HCL 1 Tablet TRAZODONE HCL TRAZODONE HCL 1 Tablet MAOIS - NON-SELECTIVE & IRREVERSIBLE MARPLAN ISOCARBOXAZID 3 Tablet NARDIL PHENELZINE SULFATE 3 Tablet PARNATE TRANYLCYPROMINE SULFATE 3 Tablet TRANYLCYPROMINE SULFATE TRANYLCYPROMINE SULFATE 1 Tablet ANTIPSYCHOTICS, DOPAMINE ANTAGONISTS, BUTYROPHENONES HALOPERIDOL HALOPERIDOL 1 Tablet HALOPERIDOL LACTATE HALOPERIDOL LACTATE 1 Concentrate, Oral ANTIPSYCHOTICS, DOPAMINE ANTAGONISTS, THIOXANTHENES NAVANE THIOTHIXENE 3 Capsule (Hard, Soft, etc.) THIOTHIXENE THIOTHIXENE 1 Capsule (Hard, Soft, etc.) ANTIPSYCHOTICS, DOPAMINE ANTAGONIST, DIPHENYLBUTYLPIPERIDINES ORAP PIMOZIDE 3 Tablet ANTIPSYCHOTICS, DOPAMINE ANTAGONIST, DIHYDROINDOLONES MOBAN MOLINDONE HCL 3 Tablet ANTIPSYCHOTICS, ATYPICAL, DOPAMINE, & SEROTONIN ANTAG CLOZAPINE CLOZAPINE 1 Tablet CLOZAPINE CLOZAPINE 2 Tablet FAZACLO CLOZAPINE 2 Tablet, Rapid Dissolve ZYPREXA OLANZAPINE 2 Tablet ZYPREXA ZYDIS OLANZAPINE 2 Tablet, Rapid Dissolve INVEGA PALIPERIDONE 2 Tablet, SR Osmotic Push 24 Hr Page 64
Brand Name Generic Name Tier Form SEROQUEL QUETIAPINE FUMARATE 2 Tablet SEROQUEL XR QUETIAPINE FUMARATE 2 Tablet, Sustained Release 24 Hr RISPERDAL RISPERIDONE 2 Solution, Oral RISPERDAL RISPERIDONE 2 Tablet RISPERDAL RISPERIDONE 2 Tablet, Rapid Dissolve RISPERDAL M-TAB RISPERIDONE 2 Tablet, Rapid Dissolve RISPERDAL CONSTA RISPERIDONE MICROSPHERES 2 Disposable Syringe (EA) GEODON ZIPRASIDONE HCL 2 Capsule (Hard, Soft, etc.) GEODON ZIPRASIDONE MESYLATE 2 Vial (SDV, MDV or Additive) (EA) ANTIPSYCHOTICS, DOPAMINE & SEROTONIN ANTAGONISTS LOXAPINE LOXAPINE SUCCINATE 1 Capsule (Hard, Soft, etc.) LOXAPINE SUCCINATE LOXAPINE SUCCINATE 1 Capsule (Hard, Soft, etc.) LOXITANE LOXAPINE SUCCINATE 3 Capsule (Hard, Soft, etc.) ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED ABILIFY ARIPIPRAZOLE 2 Solution, Oral ABILIFY ARIPIPRAZOLE 2 Tablet ABILIFY DISCMELT ARIPIPRAZOLE 2 Tablet, Rapid Dissolve TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE STRATTERA ATOMOXETINE HCL 2 Capsule (Hard, Soft, etc.) SEROTONIN-2 ANTAGONIST, REUPTAKE INH/DIETARY SUPP. COMB. TRAZAMINE TRAZODONE HCL/DIET8 3 Combination Package (EA) SELECTIVE SEROTONIN INHIB. (SSRIS)/DIET SUPP CMB. SENTROXATINE FLUOXETINE HCL/DIET. SUPP NO.8 3 Capsule (Hard, Soft, etc.) GABOXETINE FLUOXETINE HCL/DIET.SUPP NO.17 3 Capsule (Hard, Soft, etc.) NOREPINEPHRINE & DOPAMINE INHIB.(NDRIS)/DIET SUPP APPBUTAMONE-D BUPROPION HCL/DIET SUPP. NO.15 3 Combination Package (EA) APPBUTAMONE BUPROPION HCL/DIET SUPP. NO.16 3 Combination Package (EA) ANTI-ANXIETY DRUGS/DIETARY SUPPLEMENT COMBINATIONS GABAZOLAMINE ALPRAZOLAM/DIETARY SUPPL NO.17 3 Combination Package (EA) SEDATIVE/HYPNOTICS BARBITURATES BUTISOL SODIUM BUTABARBITAL SODIUM 3 Elixir BUTISOL SODIUM BUTABARBITAL SODIUM 3 Tablet PHENOBARBITAL PHENOBARBITAL 1 Elixir PHENOBARBITAL PHENOBARBITAL 1 Tablet PHENOBARBITAL PHENOBARBITAL 2 Tablet SECONAL SODIUM SECOBARBITAL SODIUM 3 Capsule (Hard, Soft, etc.) SEDATIVE-HYPNOTICS, NON-BARBITURATE SOMNOTE CHLORAL HYDRATE 3 Capsule (Hard, Soft, etc.) CHLORAL HYDRATE CHLORAL HYDRATE 3 Suppository, Rectal CHLORAL HYDRATE CHLORAL HYDRATE 1 Syrup CHLORAL HYDRATE CHLORAL HYDRATE 3 Syrup ESTAZOLAM ESTAZOLAM 1 Tablet LUNESTA ESZOPICLONE 3 Tablet DALMANE FLURAZEPAM HCL 3 Capsule (Hard, Soft, etc.) FLURAZEPAM HCL FLURAZEPAM HCL 1 Capsule (Hard, Soft, etc.) MIDAZOLAM HCL MIDAZOLAM HCL 1 Syrup MIDAZOLAM HCL MIDAZOLAM HCL 3 Syrup DORAL QUAZEPAM 3 Tablet RESTORIL TEMAZEPAM 3 Capsule (Hard, Soft, etc.) RESTORIL TEMAZEPAM 3 Capsule (Hard, Soft, etc.) TEMAZEPAM TEMAZEPAM 1 Capsule (Hard, Soft, etc.) HALCION TRIAZOLAM 3 Tablet TRIAZOLAM TRIAZOLAM 1 Tablet SONATA ZALEPLON 3 Capsule (Hard, Soft, etc.) AMBIEN ZOLPIDEM TARTRATE 3 Tablet ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE 1 Tablet ZOLPIDEM TARTRATE ZOLPIDEM TARTRATE 3 Tablet AMBIEN CR ZOLPIDEM TARTRATE 3 Tablet, Multiphasic Release ANTI-NARCOLEPSY & ANTI-CATAPLEXY, SEDATIVE-TYPE AGT XYREM SODIUM OXYBATE 2 Solution, Oral HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTS ROZEREM RAMELTEON 3 Tablet SEDATIVE-HYPNOTICS, NON-BARBITURATE/DIETARY SUPP. STRAZEPAM TEMAZEPAM/DIET8 3 Capsule (Hard, Soft, etc.) Page 65
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Trustmark/Starmark Formulary Drug List April 2008 - Resource ...

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