Limited coverage criteria – aripiprazole

Last updated on March 7, 2025

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Generic name	aripiprazole
Strength & form	2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg tablet

Special Authority criteria	Approval period
Patient specific diagnosis identified as schizophrenia or other psychosis (not dementia-related) AND Treatment failure or intolerance to at least one other specified anti-psychotic agent	Indefinite

Special Authority criteria

Approval period

Patient specific diagnosis identified as schizophrenia or other psychosis (not dementia-related)

AND

Treatment failure or intolerance to at least one other specified anti-psychotic agent

Indefinite

Practitioner exemptions

None

Special notes

Criteria applicable for all plans including Plan G
Patients who meet schizophrenia diagnosis criteria for aripiprazole automatically receive coverage for brexpiprazole, olanzapine and ziprasidone

Special Authority request form(s)

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HLTH 5328 - General Special Authority request (PDF, 656KB)

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