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

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)

Log in to eForms
HLTH 5328 - General Special Authority request (PDF, 656KB)

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