Limited coverage criteria – ziprasidone

Last updated on March 24, 2025

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Generic name	ziprasidone
Strength & form	20 mg, 40 mg, 60 mg, 80 mg 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

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 request form(s)

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

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