Antipsychotics, Parenteral

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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
ARIPIPRAZOLE ABILIFY MAINTENA SUSER SYR Y    
ARIPIPRAZOLE ABILIFY MAINTENA SUSER VIAL Y    
ARIPIPRAZOLE LAUROXIL ARISTADA SUSER SYR Y    
CHLORPROMAZINE HCL CHLORPROMAZINE HCL AMPUL Y    
FLUPHENAZINE DECANOATE FLUPHENAZINE DECANOATE VIAL Y    
FLUPHENAZINE HCL FLUPHENAZINE HCL VIAL Y    
HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE AMPUL Y    
HALOPERIDOL DECANOATE HALDOL DECANOATE 50 AMPUL Y    
HALOPERIDOL DECANOATE HALDOL DECANOATE 100 AMPUL Y    
HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100 AMPUL Y    
HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE VIAL Y    
HALOPERIDOL LACTATE HALOPERIDOL AMPUL Y    
HALOPERIDOL LACTATE HALDOL AMPUL Y    
HALOPERIDOL LACTATE HALOPERIDOL LACTATE VIAL Y    
RISPERIDONE MICROSPHERES RISPERDAL CONSTA SYRINGE Y Quantity Limit  
OLANZAPINE OLANZAPINE VIAL V    
OLANZAPINE ZYPREXA VIAL V    
OLANZAPINE PAMOATE ZYPREXA RELPREVV VIAL V    
PALIPERIDONE PALMITATE INVEGA SUSTENNA SYRINGE V    
PALIPERIDONE PALMITATE INVEGA TRINZA SYRINGE V    
ZIPRASIDONE MESYLATE GEODON VIAL V