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Xxxxxx Antipsychotics
Xxxxxx
20
Name AETNA BCBSMA BMCHP FCHP HPHC HNE NHP NTWK MAHLTH THP
ARIPIPRAzOLE oral solution
[Abilify oral solution]
DL sT X* X X DL NC
ARIPIPRAzOLE orally disintegrating
tablet [Abilify Discmelt]
DL sT NC DL PA X DL DL PA NC
AsENAPINE [saphris] DL sT NC PA X PA NC
CHLORPROMAzINE X* X* X X X X X X X X
CLOzAPINE DL* X* X X X DL DL X X X
CLOzAPINE orally disintegrating
tablet [FazaClo]
DL FE NC PA PA X NC PA X
FLUPHENAzINE X* X* X X X X X X X X
HALOPERIDOL X* X* X X X X X X X X
ILOPERIDONE [Fanapt] DL sT NC X PA NC
LITHIUM CARBONATE/sR X* X* X X X X X X X X
LOXAPINE X* X* X X X X X X X X
MOLINDONE [Moban] X X* X X X X X
OLANzAPINE [zyprexa] DL* X* DL X X X DL DL DL X
OLANzAPINE injection [zyprexa IM] NC1 NC DL X2 X2 DL PA X
OLANzAPINE orally
disintegrating tablet [zyprexa zydis]
DL* X* DL PA X X DL DL PA X
PALIPERIDONE [Invega] DL FE
sT
NC DL PA PA X PA DL NC
PALIPERIDONE PALMITATE NC1 X X1 PA NC1 [Invega sustenna]
PERPHENAzINE X* X* X X X X X X X X
PERPHENAzINE/AMITRIPTyLINE X* X* X X X X X X X
PIMOzIDE [Orap] X X* X X X X X X X
PROCHLORPERAzINE X* X* X X X X X X X X
QUETIAPINE [seroquel] DL* X* DL X X X DL DL DL X
QUETIAPINE XR [seroquel XR] DL* X* DL X DL DL DL X
RIsPERIDONE DL* X* DL X X X X DL DL X
RIsPERIDONE [Risperdal] DL FE
sT
X DL PA DL X NC PA X
RIsPERIDONE injection NC1 X* DL X1 X1 X1 [Risperdal Consta]
DL DL X
1 Not covered under pharmacy benefit; may be covered under medical benefit
2 Covered under medical benefit