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�� &#x/Att;¬he; [/;ott;&#xom ];&#x/BBo;&#xx [6;.44;i 3;.55;U 3;".4;Җ ;c.7;g ];&#x/Sub;&#xtype;&#x /Fo;&#xoter;&#x /Ty;&#xpe /;&#xPagi;&#xnati;&#xon 0;&#x/Att;¬he; [/;ott;&#xom ];&#x/BBo;&#xx [6;.44;i 3;.55;U 3;".4;Җ ;c.7;g ];&#x/Sub;&#xtype;&#x /Fo;&#xoter;&#x /Ty;&#xpe /;&#xPagi;&#xnati;&#xon 0;1 &#x/MCI; 0 ;&#x/MCI; 0 ;CDCR DAPO FormularyEffective Date 9/01/2018 Generic Name Brand Name Strength Dosage Form Restrictions Amantadine Symmetrel 100 MG Capsule Amantadine Symmetrel 100 MG Tablet AmantadineSymmetrel50 MG/ 5 ML Syrup Amitriptyline HCLElavilTablet Amitriptyline HCLElavilTablet Amitriptyline HCLElavilTablet Amitriptyline HCLElavilTablet Amitriptyline HCL Elavil Tablet Amitriptyline HCL Elavil 75 MG Tablet AripiprazoleAbilify2 MGTablet Does not include orally dissolvable tablets Aripiprazole Abilify 5 MGTablet Does not include orally dissolvable tablets Aripiprazole Abilify 10 MGTablet Does not include orally dissolvable tablets Aripiprazole Abilify 15 MGTablet Does not include orally dissolvable tablets Aripiprazole Abilify 20 MGTablet Does not include orally dissolvable tablets Aripiprazole Abilify 30 MG Does not include orally dissolvable tablets Benztropine Mesylate Cogentin 0.5 MG Tablet Benztropine Mesylate Cogentin 1 MG Tablet Benztropine Mesylate Cogentin 2 MG Tablet Buspirone HCL Buspar 7.5 MG Tablet Buspirone HCLBusparTablet Buspirone HCLBusparTablet Buspirone HCLBusparTablet Buspirone HCL Buspar 30 MG Tablet Carbamazep

2 ine Carbatrol 300 MG CPMP 12HR
ine Carbatrol 300 MG CPMP 12HR Carbamazepine Carbatrol 100 MG CPMP 12HR Carbamazepine Tegretol 200 MG Tablet Carbamazepine Tegretol 100 MG Chewable Tablet Carbamazepine Tegretol 100 MG/5ml Oral Susp Carbamazepine XR Carbatrol 200 MG CPMP 12HR Carbamazepine XRTegretol XR Tablet, Sustained Release 24H 2 Generic Name Brand Name Strength Dosage Form Restrictions Carbamazepine XRTegretol XR Tablet, Sustained Release 24H Carbamazepine XRTegretol XR Tablet, Sustained Release 24H Chlorpromazine HCLThorazine100 MG/MLOral CONC Chlorpromazine HCL Thorazine 10 MG Tablet Chlorpromazine HCL Thorazine 25 MG Tablet Chlorpromazine HCL Thorazine 50 MG Tablet Chlorpromazine HCL Thorazine 100 MG Tablet Chlorpromazine HCL Thorazine 200 MG Tablet Citalopram HBR Celexa 20 MG Tablet Citalopram HBRCelexaTablet Citalopram HBRCelexa10 MG/5MLSolution Citalopram HBRCelexaTablet ClomipramineAnafranilTablet Clomipramine Anafranil 50 MG Tablet Clomipramine Anafranil 75 MG Tablet Clozapine Clozapine 25 MG Tablet Clozapine Clozapine 100 MG Tablet Clozapine Clozapine 50 MG Tablet Clozapine Clozapine 200 MG Tablet Desipramine HCLNorpraminTablet Desipramine HCLNorpraminTablet Desipramine HCLNorpraminTablet Desipramine HCL Norpramin 25 MG Tablet Desipramine HCL Norpramin 50 MG Tablet Desipramine HCL Norpramin 75 MG Tablet Diphenhydramine HCL Benadryl 25 MG Capsule Diphenhydramine HCL Benadryl 50mg Capsule Diphenhydramine HCL Benadryl 12.5mg

3 /5ml Elixir Diphenhydramine HCLB
/5ml Elixir Diphenhydramine HCLBenadrylTablet Diphenhydramine HCLBenadrylTablet Diphenhydramine HCLBenadryl12.5 MG/5MLElixir Diphenhydramine HCLNytolCapsule Diphenhydramine HCL Sominex 50 MG Tablet Diphenhydramine HCL Sominex 25 MG Tablet Disulfiram Antabuse 250 MG Tablet Disulfiram Antabuse 500 MG Tablet Divalproex SodiumDepakote DR Tablet Delayed Release Divalproex SodiumDepakote DR Tablet Delayed Release Divalproex SodiumDepakote DR Tablet Delayed Release 3 Generic Name Brand Name Strength Dosage Form Restrictions Divalproex Sodium Depakote Sprinkle Sprinkle Capsule Divalproex Sodium Depakote ER Tablet Sustained Release 24 H Divalproex Sodium Depakote ER Tablet, Sustained Release 24 H Donepezil HCL Aricept 10 MG Tablet Donepezil HCL Aricept 5 MG Tablet Donepezil HCLAricept ODT Tablet, orally disintegrating Donepezil HCLAricept ODT Tablet, orally disintegrating Doxepin HCLSinequanCapsule Doxepin HCLSinequanCapsule Doxepin HCLSinequanCapsule Doxepin HCL Sinequan 25 MG Capsule Doxepin HCL Sinequan 50 MG Capsule Doxepin HCL Sinequan 75 MG Capsule Doxepin HCL Sinequan 10 MG/ML Oral Conc Fluoxetine HCL Prozac 40 MG Pulvule Fluoxetine HCL Prozac 20 MG Tablet Fluoxetine HCLProzac Pulvule Fluoxetine HCLProzac Pulvule Fluoxetine HCLProzac Tablet Fluoxetine HCLProzac 20 MG/5MLSolution Fluoxetine HCL Weekly Prozac Weekly 90 MG Pulvule Fluphenazine Decanoate Prolixin25 MG/MLInjection Fluphenazine HCL Prolixin 2.5 MG/ML Injection Fluphenazine HCLProlixin2.5 MG/5MLElixir Fluphenazi

4 ne HCLProlixin5 MG/MLOral Conc Fluphenaz
ne HCLProlixin5 MG/MLOral Conc Fluphenazine HCLProlixinTablet Fluphenazine HCL Prolixin 10 MG Tablet Fluphenazine HCL Prolixin 2.5 MG Tablet Fluphenazine HCL Prolixin 5 MG Tablet Fluvoxamine Maleate Luvox 25 MG Tablet Fluvoxamine Maleate Luvox 50 MG Tablet Fluvoxamine Maleate Luvox 100 MG Tablet Haloperidol Haldol 0.5 MG Tablet HaloperidolHaldolTablet HaloperidolHaldolTablet HaloperidolHaldolTablet Haloperidol Haldol 20 MG Tablet Haloperidol Haldol 5 MG Tablet 4 Generic Name Brand Name Strength Dosage Form Restrictions Haloperidol Decanoate Haldol 50 MG/ML IM Injection Haloperidol Decanoate Haldol 100 MG/ML IM Injection Hydroxyzine HCL Atarax 10 MG/5ML Syrup Hydroxyzine HCL Atarax 10 MG Tablet Hydroxyzine HCL Atarax 25 MG Tablet Hydroxyzine HCL Atarax 50 MG Tablet Hydroxyzine PamoateVistarilCapsule Hydroxyzine PamoateVistarilCapsule Hydroxyzine PamoateVistarilCapsule Imipramine HCLTofranilTablet Imipramine HCL Tofranil 25 MG Tablet Imipramine HCL Tofranil 50 MG Tablet Isocarboxazid Marplan 10 MG Tablet Lamotrigine Lamictal 25 MG Tablet Starter Kit Lamotrigine Lamictal 100 MG Tablet Lamotrigine Lamictal 25 MG Tablet Lamotrigine Lamictal Chewable dispersable Tablet Lamotrigine Lamictal Chewable dispersable Tablet Lamotrigine LamictalTablet Lamotrigine LamictalTablet Lithium CarbonateEskalith Capsule Lithium CarbonateEskalith Capsule Lithium Carbonate Eskalith 600 MG Capsule Lithium Carbonate Eskalith 300 MG Tablet

5 Lithium CarbonateLlithobid Tablet,
Lithium CarbonateLlithobid Tablet, Sustained Release Lithium Carbonate EREskalith CRTablet Lithium CitrateLithium8 MEQ/5MLOral Solution Loxapine SuccinateLoxitaneCapsule Loxapine Succinate Loxitane 25 MG Capsule Loxapine Succinate Loxitane 5 MG Capsule Loxapine Succinate Loxitane 50 MG Capsule Mirtazapine Remeron 7.5 MG Tablet Mirtazapine Remeron 15 MG Tablet Mirtazapine Remeron 30 MG Tablet Mirtazapine Remeron 45 MG Tablet MirtazapineRemeron Solutab Tablet, orally disintegrating MirtazapineRemeron Solutab Tablet, orally disintegrating 5 Generic Name Brand Name Strength Dosage Form Restrictions MirtazapineRemeron Solutab Tablet, orally disintegrating Nefazodone HCL Serzone 50 MG Tablet Nefazodone HCLSerzoneTablet Nefazodone HCLSerzoneTablet Nefazodone HCLSerzoneTablet Nefazodone HCLSerzoneTablet Nortriptyline HCL Pamelor 10 MG Capsule Nortriptyline HCL Pamelor 25 MG Capsule Nortriptyline HCL Pamelor 50 MG Capsule Nortriptyline HCL Pamelor 75 MG Capsule Nortriptyline HCL Pamelor 10 MG/5ML Solution Olanzapine Zyprexa 7.5 MG Tablet Olanzapine Zyprexa 10 MG Tablet OlanzapineZyprexaTablet OlanzapineZyprexa2.5 MGTablet OlanzapineZyprexaTablet OlanzapineZyprexaTablet OlanzapineZyprexa ODT Tablet, orally disintegrating OlanzapineZyprexa ODT Tablet, orally disintegrating OlanzapineZyprexa ODT Tablet, orally disintegrating OlanzapineZyprexa ODT Tablet, orally disintegrating Olanzapine/Fluoxetine HCL Symbyax6 MG/25MGCapsule Olanzapine/Fluoxetine HCL Symbyax6 MG/50MGCapsule

6 Olanzapine/Fluoxetine HCL
Olanzapine/Fluoxetine HCL SymbyaxMG/25MGCapsule Olanzapine/Fluoxetine HCL Symbyax12 MG/50MGCapsule Olanzapine/Fluoxetine HCL Symbyax3 MG/25Capsule OxcarbazepineTrileptalTablet OxcarbazepineTrileptalTablet OxcarbazepineTrileptal300 MG/5MLOral Susp OxcarbazepineTrileptalTablet Paroxetine HCL Paxil 30 MG Tablet Paroxetine HCL Paxil 40 MG Tablet Paroxetine HCLPaxil37.5MG Tablet, Sustained Released Paroxetine HCLPaxilTablet Paroxetine HCLPaxilTablet 6 Generic Name Brand Name Strength Dosage Form Restrictions Paroxetine HCLPaxil Tablet, Sustained Released Paroxetine HCLPaxil12.5MG Tablet, Sustained Released Perphenazine TrilafonTablet Perphenazine Trilafon 2 MG Tablet Perphenazine Trilafon 4 MG Tablet Perphenazine Trilafon 8 MG Tablet Perphenazine/ Amitriptyline TriavilTablet Perphenazine/ Amitriptyline TriavilTablet Perphenazine/ Amitriptyline TriavilTablet Perphenazine/ Amitriptyline TriavilTablet Perphenazine/ Amitriptyline TriavilTablet Phenelzine SulfateNardilTablet Pramipexole Di - HCL Mirapex 1 MG Tablet Pramipexole Di - HCL Mirapex 1.5 MG Tablet Pramipexole Di - HCL Mirapex 0.125 MG Tablet Pramipexole Di - HCL Mirapex 0.25 MG Tablet Pramipexole Di - HCL Mirapex 0.5 MG Tablet Pramipexole Di - HCL Mirapex 0.75 MG Tablet Propranolol HCL Inderal 10 MG Tablet Propranolol HCLInderalTablet Propranolol HCLInderalTablet Propranolol HCLInderalTablet Propranolol HCL Inderal 80 MG Tablet Propranolol HCL Inderal 20 MG/5ML Solution Propranolol HCL Inderal 40 MG/5ML Solution

7 Propranolol HCL ERInderal LA Tablet, Ext
Propranolol HCL ERInderal LA Tablet, Extended Release Propranolol HCL ERInderal LA Tablet, Extended Release Protriptyline HCL Vivactil 10 MG Tablet Protriptyline HCL Vivactil 5 MG Tablet Ramelteon Rozerem 8 MG Tablet RisperidoneRisperdal0.25 MGTablet RisperidoneRisperdal0.5 MGTablet RisperidoneRisperdal 1 MG/MLOral Solution RisperidoneRisperdal Tablet Risperidone Risperdal 2 MG Tablet Risperidone Risperdal 3 MG Tablet Risperidone Risperdal 4 MG Tablet 7 Generic Name Brand Name Strength Dosage Form Restrictions Risperidone Risperdal Mtab Tablet, orally disintegrating Risperidone Risperdal Mtab Tablet, orally disintegrating Risperidone Risperdal Mtab Tablet, orally disintegrating Risperidone Risperdal Mtab Tablet, orally disintegrating Risperidone Risperdal Mtab 0.5 MG Tablet, orally disintegrating Ropinirole HCL Requip 0.25 MG Tablet Ropinirole HCL Requip 1 MG Tablet Ropinirole HCLRequipTablet Ropinirole HCLRequipTablet Ropinirole HCLRequip0.5 MGTablet Ropinirole HCL Requip 4 MG Tablet Ropinirole HCL Requip 3 MG Tablet Sertraline HCL Zoloft 25 MG Tablet Sertraline HCL Zoloft 50 MG Tablet Sertraline HCL Zoloft 100 MG Tablet Sertraline HCL Zoloft 20 MG/ML Oral Conc. ThiothixeneNavaneCapsule ThiothixeneNavaneCapsule ThiothixeneNavaneCapsule ThiothixeneNavaneCapsule Thiothixene Navane 5 MG Capsule Tiagabine HCL Gabitril 4 MG Tablet Tiagabine HCL Gabitril 12 MG Tablet Tiagabine HCL Gabitril 16 MG Tablet Tiagabine HCL Gabitril 2 MG Tab

8 let Topiramate Topamax 50 MG
let Topiramate Topamax 50 MG Tablet Topiramate Topamax 100 MG Tablet TopiramateTopamaxTablet TopiramateTopamaxTablet TopiramateTopamaxSprinkle Capsule Topiramate Topamax 25 MG Sprinkly Capsule Tranylcypromine Sulfate ParnateTablet Trazodone HCL Desyrel 50 MG Tablet Trazodone HCLDesyrelTablet Trazodone HCLDesyrelTablet Trazodone HCLDesyrelTablet Trifluoperazine HCL Stelazine 1 MG Tablet Trifluoperazine HCL Stelazine 10 MG Tablet 8 Generic Name Brand Name Strength Dosage Form Restrictions Trifluoperazine HCL Stelazine 2 MG Tablet Trifluoperazine HCL Stelazine 5 MG Tablet Valproic Acid Depakene 250 MG Capsule Valproic Acid Depakene 250 MG/5ML Oral Solution Venlafaxine EREffexor Xr37.5mg Tablet Extended Release Limit of #30 per month Venlafaxine EREffexor Xr75mg Tablet Extended Release Limit of #30 per month Venlafaxine EREffexor Xr150mg Tablet Extended Release Limit of #30 per month Venlafaxine HCLEffexorTablet Venlafaxine HCLEffexor37.5 MGTablet Venlafaxine HCL Effexor 50 MG Tablet Venlafaxine HCL Effexor 75 MG Tablet Venlafaxine HCL Effexor 100 MG Capsule Venlafaxine HCL EREffexor XR37.5 MG Capsule, Extended Release Limit of #30 per month Venlafaxine HCL EREffexor XR Capsule, Extended Release Limit of #30 per month Venlafaxine HCL EREffexor XR Capsule, Extended Release Limit of #30 per month Venlafaxine HCL EREffexor XR Tablet Extended Release Limit of #30 per month ZiprazidoneGeodonCapsule Ziprazidone Geodon 40 MG Capsule Ziprazidone Geodon 60 MG Capsule Ziprazidone Geodon 80 MG Cap