Limited Coverage Drugs - Aripiprazole

Generic Name

aripiprazole                                                                                                                                               
Strength 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg

Form

tablet

Special Authority Criteria

Approval Period

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

AND

Treatment failure or intolerance to at least one other specified anti-psychotic agent.

Indefinite

Practitioner Exemptions

  • None

Special Notes

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

Special Authority Request Form(s)