Limited Coverage Drugs - Ziprasidone

Generic Name

ziprasidone
Strength 20 mg, 40 mg, 60 mg, 80 mg

Form

capsule

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 requirements for ziprasidone automatically receive coverage for olanzapine and aripiprazole.

Special Authority Request Form(s)