Limited coverage criteria – aripiprazole monohydrate
Last updated on March 5, 2025
Generic name |
aripiprazole monohydrate |
|
|---|---|---|
Strength & form |
300 mg, 400 mg vial for injection |
|
Special Authority criteria |
Approval period |
|---|---|
|
Management of the manifestations of schizophrenia or related psychotic disorders (not dementia-related) in: Patients who have tried oral aripiprazole, risperidone or paliperidone PLUS at least one other antipsychotic agent PLUS continue to be inadequately controlled at maximally-tolerated doses |
Indefinite |
|
Patients who are currently receiving a conventional depot antipsychotic PLUS experiencing significant side effects such as extrapyramidal symptoms or tardive dyskinesia |
|
| Patients with a history of non-adherence to antipsychotic medications resulting in important negative outcomes such as repeated hospitalizations |
Practitioner exemptions
- None
Special notes
- Criteria applicable to all plans including Plan G
- Coverage is not available for this formulation under Plan P