Limited coverage drugs – brexpiprazole

Last updated on August 7, 2024

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Generic name	brexpiprazole
Strength	0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
Form	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 requirements for brexpiprazole automatically receive coverage for aripiprazole, olanzapine and ziprasidone

Special Authority request form(s)

Log in to eForms
5328 - General Special Authority Request (PDF, 656KB)

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Limited coverage drugs – brexpiprazole

Practitioner exemptions

Special notes

Special Authority request form(s)