Antipsychotics, 2nd Gen
PDL Reference Documents
Drug Use Review Documents
Newsletters
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| aripiprazole | ABILIFY | TABLET | Y | Age Restriction | Y | |
| asenapine maleate | SAPHRIS | TAB SUBL | Y | Age Restriction | Y | |
| lurasidone HCl | LATUDA | TABLET | Y | Age Restriction | Y | |
| quetiapine fumarate | QUETIAPINE FUMARATE ER | TAB ER 24H | Y | Age and Quantity Limits | Y | |
| quetiapine fumarate | QUETIAPINE FUMARATE | TABLET | Y | Age and Quantity Limits | Y | Sep 24, 2015 |
| risperidone | RISPERDAL | SOLUTION | Y | Age Restriction | Y | |
| risperidone | RISPERIDONE | SOLUTION | Y | Age Restriction | Y | |
| ziprasidone HCl | ZIPRASIDONE HCL | CAPSULE | Y | Age Restriction | Y | |
| aripiprazole | ARIPIPRAZOLE | SOLUTION | V | Age Restriction | Y | |
| aripiprazole | ARIPIPRAZOLE ODT | TAB RAPDIS | V | Age Restriction | Y | |
| asenapine | SECUADO | PATCH TD24 | V | Age Restriction | Y | |
| brexpiprazole | REXULTI | TAB DS PK | V | Age Restriction | Y | |
| clozapine | VERSACLOZ | ORAL SUSP | V | Age Restriction | Y | |
| clozapine | CLOZAPINE ODT | TAB RAPDIS | V | Age Restriction | Y | |
| iloperidone | FANAPT | TAB DS PK | V | Age Restriction | Y | |
| iloperidone | FANAPT | TABLET | V | Age Restriction | Y | |
| lumateperone tosylate | CAPLYTA | CAPSULE | V | Age Restriction | Y | |
| olanzapine | ZYPREXA ZYDIS | TAB RAPDIS | V | Age Restriction | Y | |
| olanzapine | OLANZAPINE ODT | TAB RAPDIS | V | Age Restriction | Y | |
| olanzapine/samidorphan malate | LYBALVI | TABLET | V | Age Restriction | Y | |
| paliperidone | PALIPERIDONE ER | TAB ER 24 | V | Age Restriction | Y | |
| paliperidone | INVEGA | TAB ER 24 | V | Age Restriction | Y | |
| pimavanserin tartrate | NUPLAZID | TABLET | V | Pharmacy PA | Y | Jan 26, 2017 |