Limited coverage drugs – ziprasidone

Last updated on September 27, 2024

Generic name

ziprasidone
Strength 20 mg, 40 mg, 60 mg, 80 mg

Form

capsule

Special Authority criteria

Approval period

Diagnosis of schizophrenia or other psychosis (not dementia-related)

AND

Treatment failure or intolerance to at least one other 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 ziprasidone automatically receive coverage for aripiprazole, brexpiprazole and olanzapine.

Special Authority requests