Limited Coverage Drugs - aripiprazole monohydrate

Generic Name

aripiprazole monohydrate

Strength

300 mg, 400 mg

Form

vial for injection

Special Authority Criteria

Approval Period

Management of the manifestations of schizophrenia or related psychotic disorders (not dementia-related) in:

  1. Patients who have tried oral aripiprazole, risperidone or paliperidone

PLUS

at least one other antipsychotic agent

PLUS

continue to be inadequately controlled at maximally-tolerated doses

OR

  1. Patients who are currently receiving a conventional depot antipsychotic

PLUS

experiencing significant side effects such as extrapyramidal symptoms or tardive dyskinesia

OR

  1. Patients with a history of non-adherence to antipsychotic medications resulting in important negative outcomes such as repeated hospitalizations

Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • Coverage is not available for this formulation under Plan P

Special Authority Request Form