Limited Coverage Drugs - Psychiatric Medications Program - Hydroxyzine

Generic Name / Strength / Form

Atarax Syrup 2mg/Ml 10 MG/5 ML Solution
Apo Hydroxyzine Cap 50mg 50 MG Capsule
Apo Hydroxyzine Cap 25mg 25 MG Capsule
Apo Hydroxyzine Cap 10mg 10 MG Capsule
Novo-Hydroxyzin 10 MG Capsule
Novo-Hydroxyzin 25 MG Capsule
Novo-Hydroxyzin 50 MG Capsule
Pms Hydroxyzine Syr 10mg/5ml 10 MG/5 ML Solution

Criteria

Approval Period

For the treatment of anxiety.

Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • None

Special Authority Request Form(s)