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Limited coverage criteria – olanzapine

Last updated on March 20, 2025

 

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Generic name

 olanzapine (Zyprexa®)

Strength & form

 2.5 mg/5 mg/7.5 mg/10 mg/15 mg/20 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

AND/OR

Diagnosis of bipolar I disorder

AND

Treatment failure or intolerance to lithium, carbamazepine or divalproex sodium

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 olanzapine automatically receive coverage for aripiprazole, brexpiprazole and ziprasidone

Special Authority request form(s)