Limited coverage criteria – brexpiprazole

Last updated on March 17, 2025

 

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Generic name

brexpiprazole

Strength & form

0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg tablet

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 brexpiprazole automatically receive coverage for aripiprazole, olanzapine and ziprasidone

Special Authority request form(s)