ANTIDEPRESSANTS: TRICYCLIC | Vendor Drug Program

Brand Name/Generic Name	NDC/Manufacturer	FFS Clinical Prior Auth Required	PDL Prior Auth Required	Programs
AMITRIPTYLINE HCL 10 MG TAB amitriptyline HCl	16714025701 NORTHSTAR RX LL	No	No	Medicaid CHIP CSHCN
AMITRIPTYLINE HCL 10 MG TAB amitriptyline HCl	70710122500 ZYDUS PHARMACEU	No	No	Medicaid CHIP CSHCN
AMITRIPTYLINE HCL 10 MG TAB amitriptyline HCl	16714025702 NORTHSTAR RX LL	No	No	Medicaid CHIP CSHCN
AMITRIPTYLINE HCL 10 MG TAB amitriptyline HCl	70710122501 ZYDUS PHARMACEU	No	No	Medicaid CHIP CSHCN
AMITRIPTYLINE HCL 10 MG TAB amitriptyline HCl	00603221221 QUALITEST/PAR P	No	No	Medicaid CHIP CSHCN KHC
AMITRIPTYLINE HCL 10 MG TAB amitriptyline HCl	00603221232 QUALITEST/PAR P	No	No	Medicaid CHIP CSHCN KHC
AMITRIPTYLINE HCL 10 MG TAB amitriptyline HCl	50268003715 AVPAK	No	No	Medicaid CHIP CSHCN
AMITRIPTYLINE HCL 10 MG TAB amitriptyline HCl	29300041901 UNICHEM PHARMAC	No	No	Medicaid CHIP CSHCN KHC
AMITRIPTYLINE HCL 10 MG TAB amitriptyline HCl	29300041910 UNICHEM PHARMAC	No	No	Medicaid CHIP CSHCN KHC
AMITRIPTYLINE HCL 10 MG TAB amitriptyline HCl	16714044601 NORTHSTAR RX LL	No	No	Medicaid CHIP CSHCN