Limited coverage criteria – asenapine

Last updated on March 17, 2025

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Generic name	asenapine
Strength & form	5 mg, 10 mg 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
HLTH 5328 - General Special Authority request (PDF, 656KB)

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