Antipsychotics, 2nd Gen

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria New Drug Evaluation
aripiprazole ABILIFY TABLET Y Age Restriction  
aripiprazole ARIPIPRAZOLE TABLET Y Age Restriction  
asenapine maleate ASENAPINE MALEATE TAB SUBL Y Age Restriction  
asenapine maleate SAPHRIS TAB SUBL Y Age Restriction  
cariprazine HCl VRAYLAR CAP DS PK Y Age Restriction  
cariprazine HCl VRAYLAR CAPSULE Y Age Restriction  
clozapine CLOZARIL TABLET Y Age Restriction  
clozapine CLOZAPINE TABLET Y Age Restriction  
lurasidone HCl LURASIDONE HCL TABLET Y Age Restriction  
lurasidone HCl LATUDA TABLET Y Age Restriction  
olanzapine ZYPREXA TABLET Y Age Restriction  
olanzapine OLANZAPINE TABLET Y Age Restriction  
quetiapine fumarate QUETIAPINE FUMARATE ER TAB ER 24H Y Age and Quantity Limits  
quetiapine fumarate SEROQUEL XR TAB ER 24H Y Age and Quantity Limits  
quetiapine fumarate SEROQUEL XR TAB24HDSPK Y Age and Quantity Limits  
quetiapine fumarate QUETIAPINE FUMARATE TABLET Y Age and Quantity Limits  
quetiapine fumarate SEROQUEL TABLET Y Age and Quantity Limits  
risperidone RISPERDAL SOLUTION Y Age Restriction  
risperidone RISPERIDONE SOLUTION Y Age Restriction  
risperidone RISPERIDONE TABLET Y Age Restriction  
risperidone RISPERDAL TABLET Y Age Restriction  
ziprasidone HCl ZIPRASIDONE HCL CAPSULE Y Age Restriction  
ziprasidone HCl GEODON CAPSULE Y Age Restriction  
aripiprazole ARIPIPRAZOLE SOLUTION V Age Restriction  
aripiprazole ARIPIPRAZOLE ODT TAB RAPDIS V Age Restriction  
aripiprazole ABILIFY MYCITE TABSENSSTR V Age Restriction  
aripiprazole ABILIFY MYCITE TABSENSTPD V Age Restriction  
asenapine SECUADO PATCH TD24 V Age Restriction  
brexpiprazole REXULTI TAB DS PK V Age Restriction  
brexpiprazole REXULTI TABLET V Age Restriction  
clozapine VERSACLOZ ORAL SUSP V Age Restriction  
clozapine CLOZAPINE ODT TAB RAPDIS V Age Restriction  
iloperidone FANAPT TAB DS PK V Age Restriction  
iloperidone FANAPT TABLET V Age Restriction  
lumateperone tosylate CAPLYTA CAPSULE V Age Restriction  
olanzapine ZYPREXA ZYDIS TAB RAPDIS V Age Restriction  
olanzapine OLANZAPINE ODT TAB RAPDIS V Age Restriction  
olanzapine/samidorphan malate LYBALVI TABLET V Age Restriction  
paliperidone PALIPERIDONE ER TAB ER 24 V Age Restriction  
paliperidone INVEGA TAB ER 24 V Age Restriction  
pimavanserin tartrate NUPLAZID CAPSULE V PA Document  
pimavanserin tartrate NUPLAZID TABLET V PA Document Jan 26, 2017
quetiapine fumarate QUETIAPINE FUMARATE TABLET V Age and Quantity Limits  
risperidone RISPERIDONE ODT TAB RAPDIS V Age Restriction  
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