Antipsychotics, 2nd Gen

← Back to Class List

PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
ASENAPINE MALEATE SAPHRIS TAB SUBL Y    
CLOZAPINE CLOZAPINE TABLET Y    
LURASIDONE HCL LATUDA TABLET Y    
OLANZAPINE OLANZAPINE TABLET Y    
OLANZAPINE ZYPREXA TABLET Y    
QUETIAPINE FUMARATE SEROQUEL TABLET Y Quantity Limit  
QUETIAPINE FUMARATE QUETIAPINE FUMARATE TABLET Y Quantity Limit  
RISPERIDONE RISPERDAL SOLUTION Y    
RISPERIDONE RISPERIDONE SOLUTION Y    
RISPERIDONE RISPERIDONE TABLET Y    
RISPERIDONE RISPERDAL TABLET Y    
ARIPIPRAZOLE ARIPIPRAZOLE SOLUTION V    
ARIPIPRAZOLE ARIPIPRAZOLE ODT TAB RAPDIS V    
ARIPIPRAZOLE ABILIFY TABLET V    
ARIPIPRAZOLE ARIPIPRAZOLE TABLET V    
BREXPIPRAZOLE REXULTI TABLET V    
CARIPRAZINE HCL VRAYLAR CAP DS PK V    
CARIPRAZINE HCL VRAYLAR CAPSULE V    
CLOZAPINE VERSACLOZ ORAL SUSP V    
CLOZAPINE FAZACLO TAB RAPDIS V    
CLOZAPINE CLOZAPINE ODT TAB RAPDIS V    
OLANZAPINE OLANZAPINE ODT TAB RAPDIS V    
OLANZAPINE ZYPREXA ZYDIS TAB RAPDIS V    
PALIPERIDONE INVEGA TAB ER 24 V    
PALIPERIDONE PALIPERIDONE ER TAB ER 24 V    
PIMAVANSERIN TARTRATE NUPLAZID TABLET V PA Document Jan 26, 2017
QUETIAPINE FUMARATE SEROQUEL XR TAB ER 24H V Quantity Limit  
QUETIAPINE FUMARATE QUETIAPINE FUMARATE ER TAB ER 24H V Quantity Limit  
RISPERIDONE RISPERIDONE ODT TAB RAPDIS V    
RISPERIDONE RISPERDAL M-TAB TAB RAPDIS V    
ZIPRASIDONE HCL ZIPRASIDONE HCL CAPSULE V    
ZIPRASIDONE HCL GEODON CAPSULE V