Antipsychotics, 1st 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 | New Drug Evaluation & Updates |
|---|---|---|---|---|---|
| chlorpromazine HCl | CHLORPROMAZINE HCL | ORAL CONC | Y | Age Restriction | Oct 01, 2020 |
| 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 | Oct 01, 2020 |
| chlorpromazine HCl | CHLORPROMAZINE HCL | TABLET | V | Age Restriction | Oct 01, 2020 |
| loxapine | ADASUVE | AER POW BA | V | Age Restriction | |
| pimozide | PIMOZIDE | TABLET | V | Age Restriction |