Antipsychotics, 2nd Gen

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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    
clozapine CLOZARIL TABLET Y    
lurasidone HCl LATUDA TABLET Y    
olanzapine ZYPREXA TABLET Y    
olanzapine OLANZAPINE TABLET Y    
quetiapine fumarate QUETIAPINE FUMARATE TABLET Y Quantity Limit  
quetiapine fumarate SEROQUEL TABLET Y Quantity Limit  
risperidone RISPERDAL SOLUTION Y    
risperidone RISPERIDONE SOLUTION Y    
risperidone RISPERDAL TABLET Y    
risperidone RISPERIDONE 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 CLOZAPINE ODT TAB RAPDIS V    
clozapine FAZACLO TAB RAPDIS V    
olanzapine ZYPREXA ZYDIS TAB RAPDIS V    
olanzapine OLANZAPINE ODT 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 QUETIAPINE FUMARATE ER TAB ER 24H V Quantity Limit  
quetiapine fumarate SEROQUEL XR TAB ER 24H V Quantity Limit  
risperidone RISPERDAL M-TAB TAB RAPDIS V    
risperidone RISPERIDONE ODT TAB RAPDIS V    
ziprasidone HCl GEODON CAPSULE V    
ziprasidone HCl ZIPRASIDONE HCL CAPSULE V