Antipsychotics, 1st 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
chlorpromazine HCl CHLORPROMAZINE HCL ORAL CONC Y Age Restriction  
fluphenazine HCl FLUPHENAZINE HCL ELIXIR Y Age Restriction  
fluphenazine HCl FLUPHENAZINE HCL ORAL CONC Y Age Restriction  
fluphenazine HCl PROLIXIN TABLET Y Age Restriction  
fluphenazine HCl FLUPHENAZINE HCL TABLET Y Age Restriction  
haloperidol HALOPERIDOL TABLET Y Age Restriction  
haloperidol lactate HALOPERIDOL LACTATE ORAL CONC Y Age Restriction  
loxapine succinate LOXAPINE CAPSULE Y Age Restriction  
perphenazine PERPHENAZINE TABLET Y Age Restriction  
thioridazine HCl THIORIDAZINE HCL ORAL CONC Y Age Restriction  
thioridazine HCl THIORIDAZINE HCL TABLET Y Age Restriction  
thiothixene THIOTHIXENE CAPSULE Y Age Restriction  
thiothixene HCl THIOTHIXENE HCL ORAL CONC Y Age Restriction  
trifluoperazine HCl TRIFLUOPERAZINE HCL TABLET Y Age Restriction  
chlorpromazine HCl THORAZINE TABLET V Age Restriction  
chlorpromazine HCl CHLORPROMAZINE HCL TABLET V Age Restriction  
loxapine ADASUVE AER POW BA V Age Restriction  
pimozide PIMOZIDE TABLET V Age Restriction