Antipsychotics, 1st 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
FLUPHENAZINE HCL FLUPHENAZINE HCL ELIXIR Y    
FLUPHENAZINE HCL FLUPHENAZINE HCL ORAL CONC Y    
FLUPHENAZINE HCL FLUPHENAZINE HCL TABLET Y    
HALOPERIDOL HALOPERIDOL TABLET Y    
HALOPERIDOL LACTATE HALOPERIDOL LACTATE ORAL CONC Y    
LOXAPINE SUCCINATE LOXAPINE CAPSULE Y    
PERPHENAZINE PERPHENAZINE TABLET Y    
THIORIDAZINE HCL THIORIDAZINE HCL TABLET Y    
THIOTHIXENE THIOTHIXENE CAPSULE Y    
TRIFLUOPERAZINE HCL TRIFLUOPERAZINE HCL TABLET Y    
CHLORPROMAZINE HCL CHLORPROMAZINE HCL TABLET V    
PIMOZIDE ORAP TABLET V    
PIMOZIDE PIMOZIDE TABLET V