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

Requesting Plan G Coverage for Your Patient

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

clomipramine

Anafranil®

disulfiram

Antabuse®

trihexyphenidyl

Artane®

lorazepam

Ativan®

nortriptyline

Aventyl®

benztropine

Bensylate®

busiprone

Buspar®

lithium carbonate

Carbolith®

clonidine

Catapres®

citalopram

Celexa®

escitalopram

Cipralex®

zuclopenthixol

Clopixol®

clozapine

Clozaril®

liothyronine

Cytomel®

flurazepam

Dalmane®

valproic acid

Depakene®

trazodone

Desyrel®

dextroamphetamine

Dexedrine®

diphenhydramine injection

diphenhydramine injection USP

clonidine

Dixarit®

lithium carbonate

Duralith®

venlafaxine

Effexor®

amitriptyline

Elavil ®

levothyroxine

Eltroxin ®

divalproex

Epival ®

flupenthixol decanoate

Fluanxol Depot ®

flupenthixol

Fluanxol ®

fluoxetine

FXT 40 ®

triazolam

Halcion ®

imipramine

Impril ®

droperidol

Inapsine ®

propranolol

Inderal ®

paliperidone

Invega ®

morphine (24-hour slow release)

Kadian ®

procyclidine

Kemadrin ®

chlorpromazine

Largactil ®

bromazepam

Lectopam ®

chlordiazepoxide

Librium ®

lithium carbonate

Lithane ®

loxapine

Loxapac ®

maprotiline

Ludiomil ®

fluvoxamine

Luvox ®

moclobemide

Manerix ®

methadone

Methadose

fluphenazine decanoate

Modecate Concentrate ®

fluphenazine decanoate

Modecate Injection ®

fluphenazine

Moditen ®

nitrazapam

Mogadon ®

phenelzine

Nardil ®

thiothixene

Navane ®

pericyazine

Neuleptil ®

tetrabenazine

Nitoman ®

chloral hydrate

Noctec ®

desipramine

Norpramin ®

methotrimeprazine

Nozinan ®

pimozide

Orap ®

bromocriptine

Parlodel ®

tranylcypromine

Parnate ®

paroxetine

Paxil ®

pipotiazine

Piportil-L4 Injection ®

fluoxetine

Prozac ®

mirtazapine

Remeron ®

temazepam

Restoril ®

risperidone

Risperdal ®

methylphenidate

Ritalin ®

clonazepam

Rivotril ®

oxazepam

Serax ®

quetiapine

Seroquel ®

levodopa / carbidopa combination tablet

Sinemet ®

doxepin

Sinequan ®

trifluoperazine

Stelazine ®

buprenorphine/naloxone

Suboxone®

trimipramine

Surmontil ®

amantadine

Symmetrel ®

levothyroxine

Synthroid ®

carbamazepine

Tegretol ®

atenolol

Tenormin ®

imipramine

Tofranil ®

clorazepate

Tranxene ®

perphenazine

Trilafon ®

tryptophan

Tryptan ®

diazepam

Valium ®

pindolol

Visken ®

diazepam

Vivol ®

alprazolam

Xanax ®

yohimbine

Yocan ®

sertraline

Zoloft ®