Antipsychotics, Parenteral
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 ASIMTUFII | SUSER SYR | Y | Y | ||
| aripiprazole | ABILIFY MAINTENA | SUSER SYR | Y | Y | ||
| aripiprazole | ABILIFY MAINTENA | SUSER VIAL | Y | Y | ||
| aripiprazole lauroxil | ARISTADA | SUSER SYR | Y | Y | ||
| aripiprazole lauroxil,submicr. | ARISTADA INITIO | SUSER SYR | Y | Y | ||
| chlorpromazine HCl | CHLORPROMAZINE HCL | AMPUL | Y | Y | Oct 01, 2020 | |
| chlorpromazine HCl | THORAZINE | AMPUL | Y | Y | Oct 01, 2020 | |
| chlorpromazine HCl | CHLORPROMAZINE HCL | VIAL | Y | Y | Oct 01, 2020 | |
| fluphenazine decanoate | FLUPHENAZINE DECANOATE | VIAL | Y | Y | ||
| fluphenazine HCl | FLUPHENAZINE HCL | VIAL | Y | Y | ||
| haloperidol decanoate | HALOPERIDOL DECANOATE | AMPUL | Y | Y | ||
| haloperidol decanoate | HALOPERIDOL DECANOATE | VIAL | Y | Y | ||
| haloperidol lactate | HALOPERIDOL LACTATE | SYRINGE | Y | Y | ||
| haloperidol lactate | HALOPERIDOL LACTATE | VIAL | Y | Y | ||
| paliperidone palmitate | ERZOFRI | SYRINGE | Y | Y | ||
| paliperidone palmitate | INVEGA HAFYERA | SYRINGE | Y | Y | ||
| paliperidone palmitate | INVEGA SUSTENNA | SYRINGE | Y | Y | ||
| paliperidone palmitate | INVEGA TRINZA | SYRINGE | Y | Y | ||
| risperidone | PERSERIS | SUSER SYR | Y | Y | ||
| risperidone | UZEDY | SUSER SYR | Y | Y | ||
| risperidone microspheres | RISPERDAL CONSTA | VIAL | Y | Quantity Limit | Y | |
| risperidone microspheres | RYKINDO | VIAL | Y | Quantity Limit | Y | |
| risperidone microspheres | RISPERIDONE ER | VIAL | Y | Quantity Limit | Y | |
| olanzapine | ZYPREXA | VIAL | V | Y | ||
| olanzapine | OLANZAPINE | VIAL | V | Y | ||
| olanzapine pamoate | ZYPREXA RELPREVV | VIAL | V | Y | ||
| ziprasidone mesylate | ZIPRASIDONE MESYLATE | VIAL | V | Y | ||
| ziprasidone mesylate | GEODON | VIAL | V | Y |