Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
ziprasidone

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 ziprasidone automatically receive coverage for aripiprazole and olanzapine.

Forms

PharmaCare Special Authority Request (PDF)