Autonomic and CNS Medications
Anxiolytics

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
Atarax generic.gif (400 bytes)
hydroxyzine HCl		 10 mg tablet; 25 mg tablet; 50 mg tablet   approved.gif (510 bytes)  

$
Ativan generic.gif (400 bytes)
lorazepam		 1 mg tablet; 2 mg tablet; 0.5 mg tablet   approved.gif (510 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$
Ativan generic.gif (400 bytes)
lorazepam		 2 mg/mL Syringe   approved.gif (510 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$
Ativan generic.gif (400 bytes)
lorazepam		 4 mg/mL Solution; 2 mg/mL Solution   approved.gif (510 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$
BuSpar generic.gif (400 bytes)
buspirone		 10 mg tablet; 15 mg tablet; 30 mg tablet; 5 mg tablet; 7.5 mg tablet   approved.gif (510 bytes)  

$$$$
Chlordiazepoxide generic.gif (400 bytes)
Chlordiazepoxide		 Tab   nonform.gif (625 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

Not Applicable
estazolam generic.gif (400 bytes)
estazolam		 1 mg tablet; 2 mg tablet   approved.gif (510 bytes)  

Not Applicable
Librium generic.gif (400 bytes)
chlordiazepoxide HCl		 10 mg capsule; 5 mg capsule; 25 mg capsule   approved.gif (510 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$
Librium generic.gif (400 bytes)
chlordiazepoxide HCl		 100 mg Recon Soln   approved.gif (510 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$
Miltown generic.gif (400 bytes)
meprobamate		 tablet   nonform.gif (625 bytes)  

Not Applicable
Niravam generic.gif (400 bytes)
alprazolam		 0.25 mg tablet,disintegrating; 0.5 mg tablet,disintegrating; 1 mg tablet,disintegrating; 2 mg tablet,disintegrating   nonform.gif (625 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

Not Applicable
Serax generic.gif (400 bytes)
oxazepam		 15 mg capsule; 30 mg capsule; 10 mg capsule   approved.gif (510 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$$
Serax generic.gif (400 bytes)
oxazepam		 15 mg tablet   approved.gif (510 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$$
Tranxene T-Tab generic.gif (400 bytes)
clorazepate dipotassium		 7.5 mg tablet; 3.75 mg tablet; 15 mg tablet   approved.gif (510 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$
Tranxene-SD
clorazepate dipotassium		 22.5 mg tablet extended release; 11.25 mg tablet extended release   nonform.gif (625 bytes)

ql.gif mo.gif

NOTES_restrict.gif (377 bytes)

Not Applicable
Valium generic.gif (400 bytes)
diazepam		 2 mg tablet; 5 mg tablet; 10 mg tablet   approved.gif (510 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$
Valium generic.gif (400 bytes)
diazepam		 5 mg/mL Solution   approved.gif (510 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$
Vistaril generic.gif (400 bytes)
hydroxyzine pamoate		 capsule   approved.gif (510 bytes)  

$
Vistaril
hydroxyzine pamoate		 Suspension   approved.gif (510 bytes)  

$
Xanax generic.gif (400 bytes)
alprazolam		 0.5 mg tablet; 2 mg tablet; 0.25 mg tablet; 1 mg tablet   approved.gif (510 bytes)

mo.gif

NOTES_restrict.gif (377 bytes)

$
Xanax XR generic.gif (400 bytes)
alprazolam		 0.5 mg tablet extended release 24 hr; 1 mg tablet extended release 24 hr; 2 mg tablet extended release 24 hr; 3 mg tablet extended release 24 hr   approved.gif (510 bytes)

ql.gif mo.gif

NOTES_restrict.gif (377 bytes)

$$

Key for Product(s) Listed Above
Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary
(Third tier coverage applies for selected plans)		 Not Reimbursed
Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans.
Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

© 2002 Managed Markets Insight and Technology, LLC. All Rights Reserved