Limited Coverage Drugs - Asenapine

Generic Name

asenapine

Strength

5 mg, 10 mg
Form tablet

Special Authority Criteria

Approval Period

Diagnosis of Bipolar I disorder

AND

Treatment failure or intolerance to lithium, carbamazepine or divalproex sodium

AND

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

Indefinite

Practitioner Exemptions

  • None

Special Notes

  • Criteria applicable for all plans including Plan G.

Special Authority Request Form(s)