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 about coverage of drugs for the treatment of opioid use disorder. |
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 not be covered under the Low Cost Alternative Program.
- 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 ® |
|
amitriptyline hydrochloride |
PMS-Amitriptyline |
|
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™, Metadol-D® |
|
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 ® |
