Limited coverage drugs – asenapine

Last updated on August 7, 2024

Generic name

asenapine

Strength

5 mg, 10 mg
Form

tablet

Special Authority criteria

Approval period

Diagnosis of Bipolar I disorder

AND

Treatment failure or intolerance to lithium, carbamazepine or divalproex sodium

AND

Treatment failure to at least one other anti-psychotic agent

Indefinite

Practitioner exemptions

  • None

Special notes

  • Criteria applicable for all plans including Plan G

Special Authority request form(s)