Limited coverage drugs – asenapine

Last updated on October 7, 2022

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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

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)

Log in to eForms
5328 - General Special Authority Request (PDF, 656KB)

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Limited coverage drugs – asenapine

Practitioner exemptions

Special notes

Special Authority request form(s)