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 HALDOL DECANOATE 100 AMPUL Y    
haloperidol decanoate HALDOL DECANOATE 50 AMPUL Y    
haloperidol decanoate HALOPERIDOL DECANOATE AMPUL Y    
haloperidol decanoate HALOPERIDOL DECANOATE 100 AMPUL Y    
haloperidol decanoate HALOPERIDOL DECANOATE VIAL Y    
haloperidol lactate HALDOL AMPUL Y    
haloperidol lactate HALOPERIDOL 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