Effective Date

Date of Origin   

07-01-2025           

Abilify®

(aripiprazole)*

Tablet

Oral solution

Orally disintegrating tablet

• Schizophrenia
• Acute Treatment of Manic and Mixed Episodes associated with Bipolar I Disorder
• Adjunctive Treatment of Major Depressive Disorder
• Irritability Associated with Autistic Disorder
• Treatment of Tourette's Disorder

*generic available

6

Abilify MyCite®

(aripiprazole)

Tablet with sensor, strips, and pod (Starter kit)

Tablet with sensor and strips (Maintenance kit)

Treatment of adults with schizophrenia

Treatment of bipolar I disorder

• Acute treatment of adults with manic and mixed episodes as monotherapy and as adjunct to lithium or valproate
• Maintenance treatment of adults as monotherapy and as adjunct to lithium or valproate

Adjunctive treatment of adults with major depressive disorder (MDD)

Limitations of Use:

• The ability of Abilify MyCite to improve patient compliance or modify aripiprazole dosage has not been established
• The use of Abilify MyCite to track drug ingestion in “real-time” or during an emergency is not recommended because detection may be delayed or not occur

30

CAPLYTA®

(lumateperone)

Capsule

Treatment of:

• Schizophrenia in adults
• Depressive episodes associated with bipolar I or II disorder (bipolar depression) in adults, as monotherapy and as adjunctive therapy with lithium or valproate

32

Clozapine ODT, Clozaril®

(clozapine)

Tablet*

Orally disintegrating tablet*^

Treatment-resistant schizophrenia

Reducing suicidal behavior in patients with schizophrenia or schizoaffective disorder

*generic available

^12.5mg ODT brand name only

1; 12

COBENFY™

(xanomeline and trospium chloride)

Capsule

Treatment of schizophrenia in adults

34

Fanapt®

(iloperidone)

Tablet

Treatment of schizophrenia in adults

Acute treatment of manic or mixed episodes associated with bipolar I disorder in adults

10

Geodon®

(ziprasidone)

Capsule*

Treatment of schizophrenia in adults

Acute treatment of adults as monotherapy of manic or mixed episodes associated with bipolar I disorder

Maintenance treatment of bipolar I disorder as an adjunct to lithium or valproate in adults

*generic available

5

INVEGA®

(paliperidone ER)

Tablet*

Treatment of schizophrenia

Treatment of schizoaffective disorder as monotherapy and as an adjunct to mood stabilizers and/or antidepressants

*generic available

7

Latuda®

(lurasidone HCl)

Tablet*

Treatment of:

• Schizophrenia in adults and adolescents (13 to 17 years)
• Depressive episode associated with Bipolar I Disorder (bipolar depression) in adults and pediatric patients (10 to 17 years) as monotherapy
• Depressive episode associated with Bipolar I Disorder (bipolar depression) in adults as adjunctive therapy with lithium or valproate

*generic available

11

LYBALVI®

(olanzapine and samidorphan)

Tablet

Treatment of:

• Schizophrenia in adults
• Bipolar I disorder in adults
  • Acute treatment of manic or mixed episodes as monotherapy and as adjunct to lithium or valproate
  • Maintenance monotherapy treatment

33

OPIPZA™

(aripiprazole)

Oral film

Treatment of schizophrenia in patients ages 13 years and older

Adjunctive treatment of major depressive disorder (MDD) in adults

Irritability associated with autistic disorder in pediatric patients 6 years and older

Treatment of Tourette’s disorder in pediatric patients 6 years and older

35

REXULTI®

(brexpiprazole)

Tablet

Use as an adjunctive therapy to antidepressants for the treatment of major depressive disorder (MDD)

Treatment of schizophrenia in adults and pediatric patients ages 13 years and older

Treatment of agitation associated with dementia due to Alzheimer’s disease

Limitations of Use: REXULTI is not indicated as an as needed (“prn”) treatment for agitation associated with dementia due to Alzheimer’s disease

14

Risperdal®, Risperidone ODT

(risperidone)

Tablet*

Orally disintegrating tablet*^

Oral solution*

Treatment of schizophrenia

As monotherapy or adjunctive therapy with lithium or valproate, for the treatment of acute manic or mixed episodes associated with Bipolar I Disorder

Treatment of irritability associated with autistic disorder

*generic available

^0.25mg tablet brand name only

2

Saphris®

(asenapine)

Sublingual tablet*

Schizophrenia in adults

Bipolar I disorder

• Acute monotherapy treatment of manic or mixed episodes, in adults and pediatric patients 10 to 17 years of age
• Adjunctive treatment to lithium or valproate in adults
• Maintenance monotherapy treatment in adults

*generic available

9

Secuado®

(asenapine)

Transdermal system

Treatment of adults with schizophrenia

31

Seroquel®

(quetiapine)

Tablet*

Treatment of:

• Schizophrenia
• Bipolar I disorder manic episodes
• Bipolar disorder, depressive episodes

*generic available

4

Seroquel XR®

(quetiapine ER)

Tablet*

Treatment of:

• Schizophrenia
• Bipolar I disorder, manic, or mixed episodes
• Bipolar disorder, depressive episodes
• Major depressive disorder, adjunctive therapy with antidepressants

*generic available

8

Versacloz®

(clozapine)

Oral suspension

Treatment-resistant schizophrenia

Reducing suicidal behavior in patients with schizophrenia or schizoaffective disorder

13

Vraylar®

(cariprazine)

Capsule

Treatment of schizophrenia in adults

Acute treatment of manic or mixed episodes associated with bipolar I disorder in adults

Treatment of depressive episodes associated with bipolar I disorder (bipolar depression) in adults

Adjunctive therapy to antidepressants for the treatment of major depressive disorder (MDD) in adults

15

ZyPREXA®, Zyprexa® Zydis®

(olanzapine)*

Tablet

Orally disintegrating tablet

Treatment of schizophrenia

Acute treatment of manic or mixed episodes associated with bipolar I disorder and maintenance treatment of bipolar I disorder

Adjunct to valproate or lithium in the treatment of manic or mixed episodes associated with bipolar I disorder.

As Zyprexa and fluoxetine in combination for the:

• Treatment of depressive episodes associated with bipolar I disorder
• Treatment of treatment resistant depression

*generic available

3

Schizophrenia

Schizophrenia is a psychiatric disorder that involves chronic or recurrent psychosis. Antipsychotic medications are the first-line treatment for schizophrenia. However, antipsychotic medications have significant side effects and therapy selection is dependent on tolerability. Antipsychotics have been shown to reduce positive symptoms of schizophrenia. Positive symptoms refers to symptoms that are in ​excess or added to normal mental functioning, such as hallucinations, delusions, and suspiciousness. On the contrary, negative symptoms of schizophrenia, include a decrease in expressed emotions, disinterest in usual activities and hobbies, and lack of motivation. Positive symptoms are generally effectively managed with available antipsychotic medications, while treatment of negative symptoms remains a challenge. Clozapine is generally considered the most effective antipsychotic medication for the treatment of schizophrenia. However, due to adverse effects such as agranulocytosis and seizures, its use is reserved for patients with treatment-resistant disease, suicide risk, or risk of aggressive behavior despite other treatments. Antipsychotic medications are commonly grouped into two categories. First-generation antipsychotics (FGAs), also known as “typical antipsychotics,” were developed in the 1950s. Second-generation antipsychotics (SGAs), also known as “atypical antipsychotics,” emerged in the 1980s. Atypical antipsychotics tend to cause fewer extrapyramidal side effects than first generation antipsychotics. Elderly patients, in particular, are at increased risk of chronic confusion and disorientation during treatment with first generation antipsychotic medications.(16,17)

Bipolar Disorder

Bipolar disorder is a mood disorder that is characterized by episodes of mania, hypomania, and major depression. Initiation of maintenance pharmacotherapy is recommended to prevent relapse, minimize suicide attempts, and may be associated with reduced rates of violent behavior. First line maintenance therapy is recommended, if possible, to consist of the same regimen that successfully treated the acute bipolar mood episode. Lithium, quetiapine, divalproex, and lamotrigine monotherapy are considered first-line treatments. Second line therapy is reserved for those who do not tolerate first-line maintenance pharmacotherapy. Olanzapine, risperidone, carbamazepine, paliperidone, ziprasidone, and lurasidone are all considered second-line therapies. Additionally, combining pharmacotherapy with psychotherapy has shown to reduce the rate of recurrent mood episodes and enhance medication adherence.(18,19)

Major Depressive Disorder

Major depressive disorder (MDD), also known as unipolar major depression, is diagnosed when a patient has suffered at least one major depressive episode and have no history of mania or hypomania. The goal of initial treatment for depression is symptom remission and restoring baseline functioning. Selective serotonin reuptake inhibitors (SSRIs) along with serotonin norepinephrine reuptake inhibitors (SNRIs), bupropion, and mirtazapine are considered first line treatment options for adults with major depressive disorder (MDD). Guidelines do not consider antipsychotics as a first line treatment of major depressive disorder without psychosis. However, they suggest that psychotic depression typically responds better to the combination of an antipsychotic and an antidepressant medication rather than either component alone. Although, some research has shown comparable responses with antidepressant or antipsychotic monotherapy treatment.(21)

Autism Spectrum Disorder

Autism spectrum disorder (ASD) can be characterized by patterns of delay and deviance in the development of social, communicative, and cognitive skills. The Practice Parameters American Academy of Child and Adolescent Psychiatry suggest pharmacotherapy may be offered when there is a specific target symptom or comorbid condition. The benefits of pharmacotherapy are increasing educational opportunity and allowing for less restrictive environments through management of severe and challenging behaviors. Frequent targets for pharmacologic intervention include associated comorbid conditions (e.g., anxiety, depression) and other features (e.g., aggression, self-injurious behavior, hyperactivity, inattention, compulsive-like behaviors, repetitive or stereotypic behaviors, and sleep disturbances). Various considerations (e.g., adverse effects) should guide pharmacologic treatment. Risperidone and aripiprazole have been FDA approved for the treatment of irritability (e.g., physical aggression, severe tantrum behavior) associated with autism. There is a growing body of controlled evidence for pharmacologic intervention.(22)

Practice Parameters American Academy of Child and Adolescent Psychiatry:(22)

• Antipsychotics supported by randomized control trials (RCTs) showing positive effects on various target symptoms in ASD include aripiprazole, haloperidol, olanzapine, and risperidone.
• Combining medication with parent training is moderately more efficacious than medication alone for decreasing serious behavioral disturbance and modestly more efficacious for adaptive functioning. Individuals with ASD may be nonverbal, so treatment response is often judged by caregiver report and observation of specific behaviors. Although this may help document the effectiveness of the selected medication, an overall goal of treatment is to facilitate the child’s adjustment and engagement with educational intervention.

Despite many randomized trials, confidence in reported improvements remains low for most interventions. Risperidone and aripiprazole improved challenging behavior in the short term (less than 6 months) but also carry significant risks including weight gain, appetite changes, and extrapyramidal symptoms (EPS).(22,23)

Dementia-Related Psychosis (off-label use)

The American Psychiatric Association (APA) recommends that nonpharmacologic interventions be attempted before a trial of antipsychotic drug therapy and that the interventions attempted be guided by the patient’s level of distress and the risk to the patients and caregiver. In addition, the FDA states that physicians who prescribe antipsychotics to elderly patients with dementia-related psychosis should discuss the risk of increased mortality with their patients, patients’ families, and caregivers. Evidence indicates that antipsychotics provide weak benefits for the treatment of psychosis and agitation in patients with dementia. Adverse effects of antipsychotics include sedation, metabolic effects, and cognitive impairment. For many patients with Alzheimer’s disease, antipsychotics can be tapered and discontinued without significant signs of withdrawal or return of behavioral symptoms.(24,25)

Antipsychotic drug therapy generally is reserved for patients who have severe symptoms or when associated agitation, combativeness, or violent behavior puts the patient or others in danger. Current evidence indicates that the atypical antipsychotics can provide modest improvement in behavioral manifestations; some evidence suggests that efficacy may be better for psychosis than for other manifestations. Antipsychotic drug efficacy appears to be similar among available agents and therefore the choice of agent should be based on adverse effect profile and other patient considerations. The goal of therapy is to minimize adverse effects and the lowest possible effective dose should be used.(24,25)

Tourette's Disorder

Tourette's disorder (TD) is a neuropsychiatric disorder characterized by involuntary motor and vocal tics. Although the etiology of Tourette's disorder is unknown, evidence suggests that pathophysiology of this disorder involves an abnormality in the central dopaminergic system. Currently, the medications that are FDA approved for the treatment of Tourette’s disorder are aripiprazole, haloperidol, and pimozide. Most clinicians use atypical antipsychotics prior to these agents and clonidine and guanfacine are considered first line agents due to their low side effect profile. The level of evidence for their effectiveness is less than antipsychotics and they lack an FDA approval. Atypical neuroleptics (aripiprazole or risperidone) are typically used if the alpha-2 agonists are ineffective or intolerable.(28)

According to the American Academy of Neurology guidelines, there was moderate confidence that haloperidol, risperidone, aripiprazole, tiapride, clonidine, onabotulinumtoxin A injections were probably more likely than placebo to reduce tics. There was low confidence that pimozide, ziprasidone, metoclopramide, guanfacine, topiramate, and tetrahydrocannabinol were possibly more likely than placebo to reduce tics. There is high confidence that the patients need to be counseled and monitored for adverse events such as weight gain, drug-induced movement disorders, elevated prolactin levels, sedation, and effects on the heart rate, blood pressure, and ECGs. The class of medicine is selected based on the severity of the tics and the side effect profile of the medicine based on other comorbidities such as depression, anxiety, and sleep disturbance. The American Academy of Child & Adolescent Psychiatry states that atypical antipsychotics are effective in TD. At the time the guidelines were published, no atypical antipsychotics were FDA approved, and only haloperidol and pimozide had been approved for TD. The guidelines found that risperidone is the most well studied non-FDA labeled atypical antipsychotic for the treatment of TD. Risperidone was found to be at least as effective as clonidine, haloperidol, and pimozide; with less frequent and severe side effects. The most common adverse reaction with risperidone therapy was mild to moderate sedation. No clinically significant extrapyramidal symptoms were observed.(27-29)

Safety

The atypical antipsychotic agents carry a boxed warning for increased mortality in elderly patients with dementia-related psychosis. The warning states that elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. These agents are not approved for the treatment of patients with dementia-related psychosis.(1-15,30-33,35) 

Abilify, Caplyta, Latuda, Rexulti, Risperdal, and Seroquel/Seroquel XR have an additional boxed warning for an increased risk of suicidal thoughts and behaviors in pediatric and young adult patients. Closely monitor all antidepressant-treated patients for worsening and emergence of suicidal thoughts and behaviors.(2,4,6,8,11,14,30,32)

All atypical antipsychotics have the following contraindication:(1-15,30-35)

• Known hypersensitivity to the active ingredient

All clozapine agents including Versacloz, have the following boxed warnings:(1,12,13)

• Severe Neutropenia: Clozaril can cause severe neutropenia, which can lead to serious and fatal infections. Patients initiating and continuing treatment with Clozaril must have a baseline blood absolute neutrophil count (ANC) measured before treatment initiation and regular ANC monitoring during treatment.
• Clozaril is available only through a restricted program called the Clozapine Risk Evaluation and Mitigation Strategy (REMS).
• Orthostatic Hypotension, Bradycardia, and Syncope: Risk is dose related. Starting dose is 12.5 mg. Titrate gradually and use divided dosages.
• Seizure: Risk is dose related. Titrate gradually and use divided doses. Use with caution in patients with history of seizure or risk factors for seizure.
• Myocarditis, Cardiomyopathy and Mitral Valve Incompetence: Can be fatal. Discontinue and obtain cardiac evaluation if findings suggest these cardiac reactions.
• Increased Mortality in Elderly Patients with Dementia-Related Psychosis: Clozaril is not approved for this condition. 

Geodon has the following contraindications:(5)

• Do not use in patients with a known history of QT prolongation
• Do not use in patients with recent acute myocardial infarction
• Do not use in patients with uncompensated heart failure
• Do not use in combination with other drugs that have demonstrated QT prolongation
• Do not use in patients with known hypersensitivity to ziprasidone

Saphris has the following contraindications:(9)

• Severe hepatic impairment (Child-Pugh C)
• Known hypersensitivity to Saphris (asenapine), or to any components in the formulation 

Latuda has the following contraindications:(11)

• Known hypersensitivity to Latuda or any components in the formulation
• Concomitant use with a strong CYP3A4 inhibitor (e.g., ketoconazole)
• Concomitant use with a strong CYP3A4 inducer (e.g., rifampin)

Secuado has the following contraindications:(31)

• Severe hepatic impairment
• A history of hypersensitivity reactions to asenapine or any components of the transdermal system

LYBALVI has the following contraindications:(33)

• Patients using opioids
• Patients undergoing acute opioid withdrawal
• If LYBALVI is administered with lithium or valproate, refer to the lithium or valproate Prescribing Information for the contraindications for those products

COBENFY has the following contraindications:(34)​​​

• urinary retention
• moderate or severe hepatic impairment
• gastric retention
• history of hypersensitivity to COBENFY or trospium chloride
• untreated narrow-angle glaucoma

1

Clozaril tablets prescribing information. Novartis Pharmaceuticals Co. November 2024.

2

Risperdal prescribing information. Janssen Pharmaceuticals, Inc. December 2022.

3

ZyPREXA and Zyprexa Zydis prescribing information. Eli Lilly and Company. April 2021.

4

Seroquel prescribing information. AstraZeneca Pharmaceuticals LP. January 2022.

5

Geodon prescribing information. Roerig – Pfizer Inc. February 2022.

6

Abilify prescribing information. Otsuka America Pharmaceutical, Inc. June 2024.

7

INVEGA prescribing information. Janssen Pharmaceuticals, Inc. March 2022.

8

Seroquel XR prescribing information. AstraZeneca Pharmaceuticals LP. January 2022.

9

Saphris prescribing information. Allergan USA, Inc. June 2024.

10

Fanapt prescribing information. Vanda Pharmaceuticals Inc. April 2024.

11

Latuda prescribing information. Sumitomo Pharma America, Inc. July 2023.

12

Clozapine ODT prescribing information. Teva Pharmaceuticals USA, Inc. May 2023.

13

Versacloz prescribing information. TruPharma, LLC. March 2023.

14

REXULTI prescribing information. Otsuka Pharmaceutical Co., Ltd. May 2024.

15

Vraylar prescribing information. Allergan USA, Inc. November 2024.

16

Patel KR, Cherian J, Gohil K, Atkinson D. Schizophrenia: overview and treatment options. Published September 1, 2014. https://pmc.ncbi.nlm.nih.gov/articles/PMC4159061/

17

Keepers GA, Fochtmann LJ, Anzia JM, et al. The American Psychiatric Association Practice Guideline for the Treatment of Patients with Schizophrenia. American Journal of Psychiatry. 2020;177(9):868-872. doi:10.1176/appi.ajp.2020.177901

18

Hirschfield, Robert M. Guideline Watch: Practice Guideline for the Treatment of Patients with Bipolar Disorder. American Psychiatric Association. Second edition. November 2005. Available at: Guideline Watch: Practice Guideline for the Treatment of Patients With Bipolar Disorder, 2nd Edition

19

Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders. 2018;20:97-170. doi:10.1111/bdi.12609

20

Reference no longer used.

21

Gelenberg AJ, Freeman MP, Markowitz JC, et al. PRACTICE GUIDELINE FOR THE Treatment of Patients With Major Depressive Disorder Third Edition. American Psychiatric Association; 2010. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd-1410197717630.pdf

22

Volkmar F, Siegel M, Woodbury-Smith M, King B, McCracken J, State M. Practice parameter for the assessment and treatment of children and adolescents with autism spectrum Disorder. Journal of the American Academy of Child & Adolescent Psychiatry. 2014;53(2):237-257. doi:10.1016/j.jaac.2013.10.013

23

Weitlauf AS, McPheeters ML, Peters B, et al. Therapies for Children With Autism Spectrum Disorder: Behavioral Interventions Update. Agency for Healthcare Research and Quality; 2014. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/autism-update_research.pdf

24

Rabins PV, Blacker D, Rovner BW, et al. PRACTICE GUIDELINE FOR THE treatment of patients with Alzheimer’s disease and other dementias. American Psychiatric Association; 2007. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Clinical%20Practice%20Guidelines/alzheimers.pdf

25

Reus VI, Fochtmann LJ, Eyler AE, et al. The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. American Journal of Psychiatry. 2016;173(5):543-546. doi:10.1176/appi.ajp.2015.173501

26

Reference no longer used.

27

Murphy TK, Lewin AB, Storch EA, Stock S. Practice parameter for the assessment and treatment of children and adolescents with TIC disorders. Journal of the American Academy of Child & Adolescent Psychiatry. 2013;52(12):1341-1359. doi:10.1016/j.jaac.2013.09.015

28

Pringsheim T, Okun MS, Müller-Vahl K, et al. Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology. 2019;92(19):896-906. doi:10.1212/wnl.0000000000007466

29

Padala PR, Qadri SF, Madaan V. Brief report. The Primary Care Companion for CNS Disorders. 2005;7(6). doi:10.4088/pcc.v07n0605

30

Abilify MyCite prescribing information. Otsuka America Pharmaceutical, Inc. February 2023.

31

Secuado prescribing information. Hisamitsu Pharmaceutical Co, Inc. December 2023.

32

CAPLYTA prescribing information. Intra-Cellular Therapies, Inc. June 2023.

33

LYBALVI prescribing information. Alkermes, Inc. January 2024.

34

COBENFY prescribing information. Bristol-Myers Squibb Company. September 2024.

35

OPIPZA prescribing information. Carwin Pharmaceutical Associates, LLC. August 2024.

Abilify

10 MG ; 15 MG ; 2 MG ; 20 MG ; 30 MG ; 5 MG

M ; N ; O

O ; Y

Abilify mycite maintenanc ; Abilify mycite starter ki

10 MG ; 15 MG ; 2 MG ; 20 MG ; 30 MG ; 5 MG

M ; N ; O

N

Caplyta

10.5 MG ; 21 MG ; 42 MG

M ; N ; O

N

Clozapine odt ; Clozaril ; Versacloz

100 MG ; 12.5 MG ; 150 MG ; 200 MG ; 25 MG ; 50 MG ; 50 MG/ML

M ; N ; O

N ; O ; Y

Cobenfy ; Cobenfy starter pack

100-20 MG ; 125-30 MG ; 50-20 & 100-20 MG ; 50-20 MG

M ; N ; O

N

Fanapt ; Fanapt titration pack

1 & 2 & 4 & 6 MG ; 1 MG ; 10 MG ; 12 MG ; 2 MG ; 4 MG ; 6 MG ; 8 MG

M ; N ; O

N

Geodon

20 MG ; 40 MG ; 60 MG ; 80 MG

M ; N ; O

O ; Y

Invega

1.5 MG ; 3 MG ; 6 MG ; 9 MG

M ; N ; O

O ; Y

Latuda

120 MG ; 20 MG ; 40 MG ; 60 MG ; 80 MG

M ; N ; O

O ; Y

Lybalvi

10-10 MG ; 15-10 MG ; 20-10 MG ; 5-10 MG

M ; N ; O

N

Opipza

aripiprazole oral film

10 MG ; 2 MG ; 5 MG

M ; N ; O ; Y

N

Quetiapine fumarate ; Seroquel

100 MG ; 150 MG ; 200 MG ; 25 MG ; 300 MG ; 400 MG ; 50 MG

M ; N ; O

N ; O ; Y

Quetiapine fumarate ; Seroquel ; Seroquel xr

100 MG ; 150 MG ; 200 MG ; 25 MG ; 300 MG ; 400 MG ; 50 MG

M ; N ; O

N ; O ; Y

Risperdal

0.25 MG ; 0.5 MG ; 1 MG ; 2 MG ; 3 MG ; 4 MG

M ; N ; O

O ; Y

Risperdal

1 MG/ML

M ; N ; O

O ; Y

Risperidone odt

0.25 MG ; 0.5 MG ; 1 MG ; 2 MG ; 3 MG ; 4 MG

M ; N ; O

N ; Y

Saphris ; Secuado

10 MG ; 2.5 MG ; 3.8 MG/24HR ; 5 MG ; 5.7 MG/24HR ; 7.6 MG/24HR

M ; N ; O

N ; O ; Y

Seroquel xr

150 MG ; 200 MG ; 300 MG ; 400 MG ; 50 MG

M ; N ; O

O ; Y

Zyprexa

10 MG ; 15 MG ; 2.5 MG ; 20 MG ; 5 MG ; 7.5 MG

M ; N ; O

O ; Y

Zyprexa zydis

10 MG ; 15 MG ; 20 MG ; 5 MG

M ; N ; O

O ; Y

Aripiprazole Oral Solution 1 MG/ML

1 MG/ML

900

mLs

30

DAYS

aripiprazole orally disintegrating tab

10 MG ; 15 MG

60

Tablets

30

DAYS

Clozapine Orally Disintegrating Tab 150 MG

150 MG

180

Tablets

30

DAYS

Clozapine Orally Disintegrating Tab 200 MG

200 MG

120

Tablets

30

DAYS

Clozapine Orally Disintegrating Tab 25 MG

25 MG

270

Tablets

30

DAYS

Risperidone Orally Disintegrating Tab 4 MG

4 MG

120

Tablets

30

DAYS

Abilify

aripiprazole tab

10 MG ; 15 MG ; 2 MG ; 20 MG ; 30 MG ; 5 MG

30

Tablets

30

DAYS

Abilify mycite maintenanc ; Abilify mycite starter ki

aripiprazole tab

10 MG ; 15 MG ; 2 MG ; 20 MG ; 30 MG ; 5 MG

30

Tablets

30

DAYS

Caplyta

lumateperone tosylate cap

10.5 MG ; 21 MG ; 42 MG

30

Capsules

30

DAYS

Clozapine odt ; Clozaril ; Versacloz

clozapine orally disintegrating tab  ; clozapine susp  ; clozapine tab

100 MG ; 12.5 MG ; 150 MG ; 200 MG ; 25 MG ; 50 MG ; 50 MG/ML

90

Tablets

30

DAYS

Clozaril

Clozapine Tab 100 MG

100 MG

270

Tablets

30

DAYS

Clozaril

Clozapine Tab 200 MG

200 MG

120

Tablets

30

DAYS

Cobenfy

xanomeline tartrate-trospium chloride cap

50-20 MG

60

Capsules

30

DAYS

Cobenfy

xanomeline tartrate-trospium chloride cap

100-20 MG

60

Capsules

30

DAYS

Cobenfy

xanomeline tartrate-trospium chloride cap

125-30 MG

60

Capsules

30

DAYS

Cobenfy starter pack

xanomeline-trospium chloride cap pack

50-20 & 100-20 MG

56

Capsules

180

DAYS

Erzofri ; Invega ; Invega hafyera ; Invega sustenna ; Invega trinza

paliperidone palmitate er susp pref syr  ; paliperidone tab er

1.5 MG ; 1092 MG/3.5ML ; 117 MG/0.75ML ; 156 MG/ML ; 1560 MG/5ML ; 234 MG/1.5ML ; 273 MG/0.88ML ; 3 MG ; 351 MG/2.25ML ; 39 MG/0.25ML ; 410 MG/1.32ML ; 546 MG/1.75ML ; 6 MG ; 78 MG/0.5ML ; 819 MG/2.63ML ; 9 MG

30

Tablets

30

DAYS

Fanapt

iloperidone tab

1 MG ; 10 MG ; 12 MG ; 2 MG ; 4 MG ; 6 MG ; 8 MG

60

Tablets

30

DAYS

Fanapt titration pack

Iloperidone Tab 1 MG & 2 MG & 4 MG & 6 MG Titration Pak

1 & 2 & 4 & 6 MG

1

Pack

180

DAYS

Geodon

ziprasidone hcl cap

20 MG ; 40 MG ; 60 MG ; 80 MG

60

Capsules

30

DAYS

Invega

Paliperidone Tab ER 24HR 6 MG

6 MG

60

Tablets

30

DAYS

Latuda

lurasidone hcl tab

120 MG ; 20 MG ; 40 MG ; 60 MG ; 80 MG

30

Tablets

30

DAYS

Latuda

Lurasidone HCl Tab 80 MG

80 MG

60

Tablets

30

DAYS

Lybalvi

olanzapine-samidorphan l-malate tab

10-10 MG ; 15-10 MG ; 20-10 MG ; 5-10 MG

30

Tablets

30

DAYS

Opipza

aripiprazole oral film

2 MG

30

Films

30

DAYS

Opipza

aripiprazole oral film

5 MG

90

Films

30

DAYS

Opipza

aripiprazole oral film

10 MG

90

Films

30

DAYS

Quetiapine fumarate

Quetiapine Fumarate Tab

150 MG

30

Tablets

30

DAYS

Quetiapine fumarate ; Seroquel

quetiapine fumarate tab

100 MG ; 150 MG ; 200 MG ; 25 MG ; 300 MG ; 400 MG ; 50 MG

90

Tablets

30

DAYS

Rexulti

brexpiprazole tab

0.25 MG ; 0.5 MG ; 1 MG ; 2 MG ; 3 MG ; 4 MG

30

Tablets

30

DAYS

Rexulti

brexpiprazole tab

0.25 MG ; 0.5 MG ; 1 MG ; 2 MG ; 3 MG ; 4 MG

30

Tablets

30

DAYS

Risperdal

Risperidone Soln 1 MG/ML

1 MG/ML

480

mLs

30

DAYS

Risperdal

Risperidone Tab 4 MG

4 MG

120

Tablets

30

DAYS

Risperidone odt

risperidone orally disintegrating tab

0.25 MG ; 0.5 MG ; 1 MG ; 2 MG ; 3 MG ; 4 MG

60

Tablets

30

DAYS

Saphris ; Secuado

asenapine maleate sl tab  ; asenapine td patch

10 MG ; 2.5 MG ; 3.8 MG/24HR ; 5 MG ; 5.7 MG/24HR ; 7.6 MG/24HR

60

Tablets

30

DAYS

Secuado

asenapine td patch

3.8 MG/24HR ; 5.7 MG/24HR ; 7.6 MG/24HR

30

Patches

3

DAYS

Seroquel

Quetiapine Fumarate Tab 300 MG

300 MG

60

Tablets

30

DAYS

Seroquel

Quetiapine Fumarate Tab 400 MG

400 MG

60

Tablets

30

DAYS

Seroquel xr

Quetiapine Fumarate Tab ER 24HR 150 MG

150 MG

30

Tablets

30

DAYS

Seroquel xr

Quetiapine Fumarate Tab ER 24HR 200 MG

200 MG

30

Tablets

30

DAYS

Seroquel xr

Quetiapine Fumarate Tab ER 24HR 300 MG

300 MG

60

Tablets

30

DAYS

Seroquel xr

Quetiapine Fumarate Tab ER 24HR 400 MG

400 MG

60

Tablets

30

DAYS

Seroquel xr

Quetiapine Fumarate Tab ER 24HR 50 MG

50 MG

60

Tablets

30

DAYS

Versacloz

Clozapine Susp 50 MG/ML

50 MG/ML

540

mLs

30

DAYS

Vraylar

cariprazine hcl cap  ; cariprazine hcl cap therapy pack

1.5 & 3 MG ; 1.5 MG ; 3 MG ; 4.5 MG ; 6 MG

30

Capsules

30

DAYS

Vraylar

Cariprazine HCl Cap Therapy Pack 1.5 MG (1) & 3 MG (6)

1.5 & 3 MG

7

Capsules

180

DAYS

Zyprexa

olanzapine tab

10 MG ; 15 MG ; 2.5 MG ; 20 MG ; 5 MG ; 7.5 MG

30

Tablets

30

DAYS

Zyprexa zydis

olanzapine orally disintegrating tab

10 MG ; 15 MG ; 20 MG ; 5 MG

30

Tablets

30

DAYS

Abilify

10 MG ; 15 MG ; 2 MG ; 20 MG ; 30 MG ; 5 MG

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Abilify mycite maintenanc ; Abilify mycite starter ki

10 MG ; 15 MG ; 2 MG ; 20 MG ; 30 MG ; 5 MG

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Caplyta

10.5 MG ; 21 MG ; 42 MG

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Clozapine odt ; Clozaril ; Versacloz

100 MG ; 12.5 MG ; 150 MG ; 200 MG ; 25 MG ; 50 MG ; 50 MG/ML

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Cobenfy ; Cobenfy starter pack

100-20 MG ; 125-30 MG ; 50-20 & 100-20 MG ; 50-20 MG

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Fanapt ; Fanapt titration pack

1 & 2 & 4 & 6 MG ; 1 MG ; 10 MG ; 12 MG ; 2 MG ; 4 MG ; 6 MG ; 8 MG

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Geodon

20 MG ; 40 MG ; 60 MG ; 80 MG

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Invega

1.5 MG ; 3 MG ; 6 MG ; 9 MG

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Latuda

120 MG ; 20 MG ; 40 MG ; 60 MG ; 80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lybalvi

10-10 MG ; 15-10 MG ; 20-10 MG ; 5-10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; SourceRx

Opipza

aripiprazole oral film

10 MG ; 2 MG ; 5 MG

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Quetiapine fumarate ; Seroquel

100 MG ; 150 MG ; 200 MG ; 25 MG ; 300 MG ; 400 MG ; 50 MG

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Quetiapine fumarate ; Seroquel ; Seroquel xr

100 MG ; 150 MG ; 200 MG ; 25 MG ; 300 MG ; 400 MG ; 50 MG

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Risperdal

1 MG/ML

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Risperdal

0.25 MG ; 0.5 MG ; 1 MG ; 2 MG ; 3 MG ; 4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Risperidone odt

0.25 MG ; 0.5 MG ; 1 MG ; 2 MG ; 3 MG ; 4 MG

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Saphris ; Secuado

10 MG ; 2.5 MG ; 3.8 MG/24HR ; 5 MG ; 5.7 MG/24HR ; 7.6 MG/24HR

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Seroquel xr

150 MG ; 200 MG ; 300 MG ; 400 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zyprexa

10 MG ; 15 MG ; 2.5 MG ; 20 MG ; 5 MG ; 7.5 MG

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Zyprexa zydis

10 MG ; 15 MG ; 20 MG ; 5 MG

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Aripiprazole Oral Solution 1 MG/ML

1 MG/ML

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aripiprazole orally disintegrating tab

10 MG ; 15 MG

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Clozapine Orally Disintegrating Tab 150 MG

150 MG

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Clozapine Orally Disintegrating Tab 200 MG

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Clozapine Orally Disintegrating Tab 25 MG

25 MG

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Risperidone Orally Disintegrating Tab 4 MG

4 MG

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Abilify

aripiprazole tab

10 MG ; 15 MG ; 2 MG ; 20 MG ; 30 MG ; 5 MG

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Abilify mycite maintenanc ; Abilify mycite starter ki

aripiprazole tab

10 MG ; 15 MG ; 2 MG ; 20 MG ; 30 MG ; 5 MG

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Caplyta

lumateperone tosylate cap

10.5 MG ; 21 MG ; 42 MG

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Clozapine odt ; Clozaril ; Versacloz

clozapine orally disintegrating tab  ; clozapine susp  ; clozapine tab

100 MG ; 12.5 MG ; 150 MG ; 200 MG ; 25 MG ; 50 MG ; 50 MG/ML

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Clozaril

Clozapine Tab 100 MG

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Clozaril

Clozapine Tab 200 MG

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Cobenfy

xanomeline tartrate-trospium chloride cap

125-30 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Cobenfy

xanomeline tartrate-trospium chloride cap

100-20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Cobenfy

xanomeline tartrate-trospium chloride cap

50-20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Cobenfy starter pack

xanomeline-trospium chloride cap pack

50-20 & 100-20 MG

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Erzofri ; Invega ; Invega hafyera ; Invega sustenna ; Invega trinza

paliperidone palmitate er susp pref syr  ; paliperidone tab er

1.5 MG ; 1092 MG/3.5ML ; 117 MG/0.75ML ; 156 MG/ML ; 1560 MG/5ML ; 234 MG/1.5ML ; 273 MG/0.88ML ; 3 MG ; 351 MG/2.25ML ; 39 MG/0.25ML ; 410 MG/1.32ML ; 546 MG/1.75ML ; 6 MG ; 78 MG/0.5ML ; 819 MG/2.63ML ; 9 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Fanapt

iloperidone tab

1 MG ; 10 MG ; 12 MG ; 2 MG ; 4 MG ; 6 MG ; 8 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Fanapt titration pack

Iloperidone Tab 1 MG & 2 MG & 4 MG & 6 MG Titration Pak

1 & 2 & 4 & 6 MG

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Geodon

ziprasidone hcl cap

20 MG ; 40 MG ; 60 MG ; 80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Invega

Paliperidone Tab ER 24HR 6 MG

6 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Latuda

lurasidone hcl tab

120 MG ; 20 MG ; 40 MG ; 60 MG ; 80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Latuda

Lurasidone HCl Tab 80 MG

80 MG

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Lybalvi

olanzapine-samidorphan l-malate tab

10-10 MG ; 15-10 MG ; 20-10 MG ; 5-10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Opipza

aripiprazole oral film

10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Opipza

aripiprazole oral film

5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Opipza

aripiprazole oral film

2 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Quetiapine fumarate

Quetiapine Fumarate Tab

150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Quetiapine fumarate ; Seroquel

quetiapine fumarate tab

100 MG ; 150 MG ; 200 MG ; 25 MG ; 300 MG ; 400 MG ; 50 MG

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Rexulti

brexpiprazole tab

0.25 MG ; 0.5 MG ; 1 MG ; 2 MG ; 3 MG ; 4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Rexulti

brexpiprazole tab

0.25 MG ; 0.5 MG ; 1 MG ; 2 MG ; 3 MG ; 4 MG

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Risperdal

Risperidone Soln 1 MG/ML

1 MG/ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Risperdal

Risperidone Tab 4 MG

4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Risperidone odt

risperidone orally disintegrating tab

0.25 MG ; 0.5 MG ; 1 MG ; 2 MG ; 3 MG ; 4 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Saphris ; Secuado

asenapine maleate sl tab  ; asenapine td patch

10 MG ; 2.5 MG ; 3.8 MG/24HR ; 5 MG ; 5.7 MG/24HR ; 7.6 MG/24HR

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Secuado

asenapine td patch

3.8 MG/24HR ; 5.7 MG/24HR ; 7.6 MG/24HR

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Seroquel

Quetiapine Fumarate Tab 300 MG

300 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Seroquel

Quetiapine Fumarate Tab 400 MG

400 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Seroquel xr

Quetiapine Fumarate Tab ER 24HR 150 MG

150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Seroquel xr

Quetiapine Fumarate Tab ER 24HR 200 MG

200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Seroquel xr

Quetiapine Fumarate Tab ER 24HR 300 MG

300 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Seroquel xr

Quetiapine Fumarate Tab ER 24HR 400 MG

400 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Seroquel xr

Quetiapine Fumarate Tab ER 24HR 50 MG

50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Versacloz

Clozapine Susp 50 MG/ML

50 MG/ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Vraylar

cariprazine hcl cap  ; cariprazine hcl cap therapy pack

1.5 & 3 MG ; 1.5 MG ; 3 MG ; 4.5 MG ; 6 MG

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Vraylar

Cariprazine HCl Cap Therapy Pack 1.5 MG (1) & 3 MG (6)

1.5 & 3 MG

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Zyprexa

olanzapine tab

10 MG ; 15 MG ; 2.5 MG ; 20 MG ; 5 MG ; 7.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zyprexa zydis

olanzapine orally disintegrating tab

10 MG ; 15 MG ; 20 MG ; 5 MG

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*-generic available

^-branded generic product(s) available

Target Agent(s) will be approved when ONE of the following is met:

1. The patient has been treated with the requested agent within the past 180 days OR
2. The prescriber states the patient has been treated with the requested agent within the past 180 days AND is at risk if therapy is changed OR
3. ONE of the following:
   1. The patient has ONE of the following:
      1. Has a medication history to ONE prerequisite agent OR
      2. Has an intolerance or hypersensitivity to ONE prerequisite agent OR
   2. The patient has an FDA labeled contraindication to ALL prerequisite agent(s)

Length of Approval: For dementia-related psychosis: 3 months for initial approval; 6 months for renewals

                                For all other indications: 12 months

NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria.

Quantity limit for the Target Agent(s) will be approved when ONE of the following is met:

1. The requested quantity (dose) does NOT exceed the program quantity limit OR
2. The requested quantity (dose) exceeds the program quantity limit AND ONE of the following:
   1. BOTH of the following:
      1. The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND
      2. There is support for therapy with a higher dose for the requested indication OR
   2. BOTH of the following:
      1. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
      2. There is support for why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR
   3. BOTH of the following:
      1. The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND
      2. There is support for therapy with a higher dose for the requested indication

Length of Approval: up to 12 months