Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
aripiprazole
Criteria Approval Period

Patient specific diagnosis identified as schizophrenia or other psychosis (not dementia related)

PLUS

treatment failure or intolerance to another specified anti-psychotic agent.

 Indefinite

Practitioner Exemptions

  • No practitioner exemptions.

Special Notes

  • Criteria applicable for all plans including Plan G.
  • Patients who meet criteria for aripiprazole automatically receive coverage for olanzapine and ziprasidone

Special Authority Request Forms