Limited Coverage Drugs - Olanzapine

Generic Name

olanzapine (Zyprexa®)

Strength

2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg
Form tablet

Special Authority Criteria

Approval Period

1. 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

AND / OR

2. Diagnosis of Bipolar I disorder

AND

Treatment failure or intolerance to lithium, carbamazepine or divalproex sodium

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 requirements for olanzapine automatically receive coverage for aripiprazole and ziprasidone.

Special Authority Request Form(s)