Psychiatric Medications Plan (Plan G)

PharmaCare covers Methadose™, buprenorphine/naloxone, and Kadian® 24-hour slow-release oral morphine for opioid use disorder treatment under Plan G. Read more…

To request Plan G coverage, an individual and their prescriber must complete an Application for Psychiatric Medication Coverage. For more information see Getting Plan Coverage for Your Patients.

Plan G Drugs that Require Special Authority Approval

For a list of Plan G drugs that require Special Authority approval, please see the Special Authority Drug List. Plan G drugs are indicated as LCD—Psychiatric Medications Plan in the Special Authority Category column.

Plan G Regular Benefits

The table below lists Plan G regular benefits. PharmaCare fully or partially covers these benefits.

Important Notes

  • PharmaCare Plan G may not cover all available formulations and strengths of the drugs listed below.
    • examples of drug formulation include tablet, capsule, liquid, and injection
    • examples of drug strength include 5 mg and 10 mg/ml
  • If PharmaCare covers a generic version of a drug, PharmaCare generally covers only part of the cost of the brand product. Some generic versions may also be only partially covered (depending on the price of the competing generic brands).
  • This list is intended as a general reference only of the products covered by Plan G. It may not reflect the most recent changes to the formulary.
  • PharmaCare formularies are not a replacement for professional medical judgment and advice.

Generic Drug Name

Brand Drug Name

alprazolam

Xanax ®

amantadine

Symmetrel ®

amitriptyline

Elavil ®

atenolol

Tenormin ®

benztropine

Bensylate®

bromazepam

Lectopam ®

bromocriptine

Parlodel ®

buprenorphine/naloxone

Suboxone ®

busiprone

Buspar®

carbamazepine

Tegretol ®

chloral hydrate

Noctec ®

chlordiazepoxide

Librium ®

chlorpromazine

Largactil ®

citalopram

Celexa®

clomipramine

Anafranil®

clonazepam

Rivotril ®

clonidine

Catapres®

clonidine

Dixarit®

clorazepate

Tranxene ®

clozapine

Clozaril®

desipramine

Norpramin ®

dextroamphetamine

Dexedrine®

diazepam

Valium ®

diazepam

Vivol ®

diphenhydramine injection

diphenhydramine injection USP

disulfiram

Antabuse®

divalproex

Epival ®

doxepin

Sinequan ®

droperidol

Inapsine ®

escitalopram

Cipralex®

fluoxetine

FXT 40 ®

fluoxetine

Prozac ®

flupenthixol

Fluanxol ®

flupenthixol decanoate

Fluanxol Depot ®

fluphenazine

Moditen ®

fluphenazine decanoate

Modecate Concentrate ®

fluphenazine decanoate

Modecate Injection ®

flurazepam

Dalmane®

fluvoxamine

Luvox ®

imipramine

Impril ®

imipramine

Tofranil ®

levodopa / carbidopa combination tablet

Sinemet ®

levothyroxine

Eltroxin ®

levothyroxine

Synthroid ®

liothyronine

Cytomel®

lithium carbonate

Carbolith®

lithium carbonate

Duralith®

lithium carbonate

Lithane ®

lorazepam

Ativan®

loxapine

Loxapac ®

maprotiline

Ludiomil ®

methadone

Methadose

methotrimeprazine

Nozinan ®

methylphenidate

Ritalin ®

mirtazapine

Remeron ®

moclobemide

Manerix ®

morphine (24-hour slow-release)

Kadian ®

nitrazapam

Mogadon ®

nortriptyline

Aventyl®

oxazepam

Serax ®

paliperidone

Invega ®

paroxetine

Paxil ®

pericyazine

Neuleptil ®

perphenazine

Trilafon ®

phenelzine

Nardil ®

pimozide

Orap ®

pindolol

Visken ®

pipotiazine

Piportil-L4 Injection ®

procyclidine

Kemadrin ®

propranolol

Inderal ®

quetiapine

Seroquel ®

risperidone

Risperdal ®

sertraline

Zoloft ®

temazepam

Restoril ®

tetrabenazine

Nitoman ®

thiothixene

Navane ®

tranylcypromine

Parnate ®

trazodone

Desyrel®

triazolam

Halcion ®

trifluoperazine

Stelazine ®

trihexyphenidyl

Artane®

trimipramine

Surmontil ®

tryptophan

Tryptan ®

valproic acid

Depakene®

venlafaxine

Effexor®

yohimbine

Yocan ®

zuclopenthixol

Clopixol®

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