FDA LABELED INDICATIONS AND DOSAGE
Agent(s) |
FDA Indication(s) |
Notes |
Ref# |
Abilify Asimtufii® (aripiprazole ER) Intramuscular injection |
For the treatment of schizophrenia in adults As maintenance monotherapy treatment of bipolar I disorder in adults |
|
13 |
Abilify Maintena® (aripiprazole ER) Intramuscular injection |
Treatment of schizophrenia in adults Maintenance monotherapy treatment of bipolar I disorder in adults |
|
1 |
Aristada® (aripiprazole lauroxil ER) Intramuscular injection |
Treatment of schizophrenia in adults |
|
2 |
Aristada Initio® (aripiprazole lauroxil ER) Intramuscular injection |
In combination with oral aripiprazole, is indicated for the initiation of Aristada when used for the treatment of schizophrenia in adults |
|
3 |
Erzofri® (paliperidone palmitate ER) Intramuscular injection |
Treatment of schizophrenia in adults Treatment of schizoaffective disorder in adults as monotherapy and as an adjunct to mood stabilizers or antidepressants |
|
16 |
Invega Sustenna® (paliperidone palmitate ER) Intramuscular injection |
Treatment of schizophrenia in adults Treatment of schizoaffective disorder in adults as monotherapy and as an adjunct to mood stabilizers or antidepressants |
|
4 |
Invega Hafyera® (paliperidone palmitate ER) Intramuscular injection |
Treatment of schizophrenia in adults after they have been adequately treated with: · A once-a-month paliperidone palmitate extended-release injectable suspension (e.g., Invega Sustenna) for at least four months OR · An every-three-month paliperidone palmitate extended-release injectable suspension (e.g., Invega Trinza) for at least one three-month cycle |
|
12 |
Invega Trinza® (paliperidone palmitate ER) Intramuscular injection |
Treatment of schizophrenia in patients after they have been adequately treated with Invega Sustenna (1-month paliperidone palmitate extended-release injectable suspension) for at least four months |
|
5 |
Perseris® (risperidone ER) Subcutaneous injection |
Treatment of schizophrenia in adults |
|
6 |
Risperdal Consta® (risperidone ER) Intramuscular injection* |
Treatment of schizophrenia As monotherapy or as adjunctive therapy to lithium or valproate for the maintenance treatment of Bipolar I Disorder |
*generic available |
7 |
Rykindo® (risperidone ER) Intramuscular injection |
Treatment of schizophrenia in adults As monotherapy or as adjunctive therapy to lithium or valproate for the maintenance treatment of bipolar I disorder in adults |
|
15 |
Uzedy® (risperidone ER) Subcutaneous injection |
Treatment of schizophrenia in adults As monotherapy or as adjunctive therapy to lithium or valproate for the maintenance treatment of Bipolar I Disorder in adults |
|
14 |
Zyprexa® Relprevv™ (olanzapine ER) Intramuscular injection |
Treatment of schizophrenia |
|
8 |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
STEP THERAPY CLINICAL CRITERIA FOR APPROVAL
|
Module |
Clinical Criteria for Approval |
||||||||||||||||
|
|
*generic available Target Agent(s) will be approved when ONE of the following is met: 1. The patient has been treated with the requested agent within the past 180 days OR 2. The prescriber states the patient has been treated with the requested agent within the past 180 days AND is at risk if therapy is changed OR 3. The patient has ONE of the following: A. A medication history of use in the past 365 days to ONE prerequisite agent OR B. An intolerance or hypersensitivity to ONE prerequisite agent that is NOT expected to occur with the requested agent OR C. An FDA labeled contraindication to ALL prerequisite agent(s) that is NOT expected to occur with the requested agent Length of Approval: 12 months NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria. |
STEP THERAPY CLINICAL CRITERIA OPERATIONAL LEVEL OF EVIDENCE REQUIREMENTS
|
Module |
Ops Set Up |
Validation Options |
Other Explanation |
|
|
Validation: Apply Baseline and go to Validation Options |
Continuation of Therapy;Contraindication, intolerance, hypersensitivity;Prerequisites |
|
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
|
Module |
Clinical Criteria for Approval |
|
Universal QL |
Quantity Limit for the Target Agent(s) will be approved when ONE of the following is met: 1. The requested quantity (dose) does NOT exceed the program quantity limit OR 2. The requested quantity (dose) exceeds the program quantity limit AND ONE of the following: A. BOTH of the following: 1. The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND 2. There is support for therapy with a higher dose for the requested indication OR B. BOTH of the following: 1. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND 2. There is support for why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit OR C. BOTH of the following: 1. The requested quantity (dose) exceeds the maximum FDA labeled dose for the requested indication AND 2. There is support for therapy with a higher dose for the requested indication Length of Approval: up to 12 months |
QUANTITY LIMIT CLINICAL CRITERIA OPERATIONAL LEVEL OF EVIDENCE REQUIREMENTS
|
Module |
Ops Set Up |
Validation Options |
Other Explanation |
|
Universal QL |
Validation: Apply Baseline and go to Validation Options |
|
|
Safety |
The Atypical Antipsychotics – Extended Maintenance Agents carry a boxed warning for increased mortality in elderly patients with dementia-related psychosis. The warning states that elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. These agents are not approved for the treatment of patients with dementia-related psychosis. Additionally, these agents have a contraindication of known hypersensitivity to the active ingredient.(1-7,12-16) Zyprexa Relprevv contains the following boxed warnings:(8) · Post-injection delirium/sedation syndrome. The warning states that patients are at risk for severe sedation (including coma) and/or delirium after each injection and must be observed for at least 3 hours in a registered facility with ready access to emergency response services. Because of this risk, Zyprexa Relprevv is available only through a restricted distribution program called Zyprexa Relprevv Patient Care Program and requires, prescriber, healthcare facility, patient, and pharmacy enrollment. · Increased mortality in elderly patients with dementia-related psychosis. The warning states that elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Zyprexa Relprevv is not approved for the treatment of patients with dementia-related psychosis. |
Number |
Reference |
1 |
Abilify Maintena prescribing information. Otsuka America Pharmaceutical, Inc. March 2025. |
2 |
Aristada prescribing information. Alkermes, Inc. January 2025. |
3 |
Aristada Initio prescribing information. Alkermes, Inc. January 2025. |
4 |
Invega Sustenna prescribing information. Janssen Pharmaceuticals, Inc. January 2025. |
5 |
Invega Trinza prescribing information. Janssen Pharmaceuticals, Inc. January 2025. |
6 |
Perseris prescribing information. Indivior, Inc. January 2025. |
7 |
Risperdal Consta prescribing information. Janssen Pharmaceuticals, Inc. January 2025. |
8 |
Zyprexa Relprevv prescribing information. Eli Lilly and Company. January 2025. |
9 |
Reference no longer used. |
10 |
Reference no longer used. |
11 |
Reference no longer used. |
12 |
Invega Hafyera prescribing information. Janssen Pharmaceuticals, Inc. January 2025. |
13 |
Abilify Asimtufii prescribing information. Otsuka Pharmaceutical Co., Ltd. March 2025. |
14 |
Uzedy prescribing information. Teva Neuroscience, Inc. October 2025. |
15 |
Rykindo prescribing information. Shandong Luye Pharmaceutical Co, Ltd. January 2025. |
16 |
Erzofri prescribing information. Shandong Luye Pharmaceutical Co., Ltd. March 2025. |
POLICY AGENT SUMMARY STEP THERAPY
Final Module |
Target Agent GPI |
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Targeted MSC |
Available MSC |
Final Age Limit |
Preferred Status |
Effective Date |
Targeted NDCs When Exclusions Exist |
|
||||||||||
|
5925001500E4 |
Abilify asimtufii ; Abilify maintena |
aripiprazole im er susp prefilled syringe ; aripiprazole im for er susp prefilled syringe |
300 MG ; 400 MG ; 720 MG/2.4ML ; 960 MG/3.2ML |
M ; N ; O ; Y |
N |
|
|
|
|
|
5925001500G2 |
Abilify maintena |
aripiprazole im for extended release susp |
300 MG ; 400 MG |
M ; N ; O ; Y |
N |
|
|
|
|
|
5925001520E4 |
Aristada ; Aristada initio |
aripiprazole lauroxil im er susp prefilled syr |
1064 MG/3.9ML ; 441 MG/1.6ML ; 662 MG/2.4ML ; 675 MG/2.4ML ; 882 MG/3.2ML |
M ; N ; O ; Y |
N |
|
|
|
|
|
5907005010E639 |
Erzofri |
paliperidone palmitate er susp pref syr |
351 MG/2.25ML |
M ; N ; O ; Y |
N |
|
|
11-15-2024 |
|
|
5907005010E632 |
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 117 MG/0.75ML |
117 MG/0.75ML |
M ; N ; O ; Y |
N |
|
|
|
|
|
5907005010E635 |
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 156 MG/ML |
156 MG/ML |
M ; N ; O ; Y |
N |
|
|
|
|
|
5907005010E638 |
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 234 MG/1.5ML |
234 MG/1.5ML |
M ; N ; O ; Y |
N |
|
|
|
|
|
5907005010E626 |
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 39 MG/0.25ML |
39 MG/0.25ML |
M ; N ; O ; Y |
N |
|
|
|
|
|
5907005010E629 |
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 78 MG/0.5ML |
78 MG/0.5ML |
M ; N ; O ; Y |
N |
|
|
|
|
|
5907005010E670 |
Invega hafyera |
Paliperidone Palmitate ER Susp Pref Syr |
1092 MG/3.5ML |
M ; N ; O ; Y |
N |
|
|
|
|
|
5907005010E675 |
Invega hafyera |
Paliperidone Palmitate ER Susp Pref Syr |
1560 MG/5ML |
M ; N ; O ; Y |
N |
|
|
|
|
|
5907005010E643 |
Invega trinza |
Paliperidone Palmitate ER Susp Pref Syr 273 MG/0.875ML |
273 MG/0.88ML |
M ; N ; O ; Y |
N |
|
|
|
|
|
5907005010E647 |
Invega trinza |
Paliperidone Palmitate ER Susp Pref Syr 410 MG/1.315ML |
410 MG/1.32ML |
M ; N ; O ; Y |
N |
|
|
|
|
|
5907005010E651 |
Invega trinza |
Paliperidone Palmitate ER Susp Pref Syr 546 MG/1.75ML |
546 MG/1.75ML |
M ; N ; O ; Y |
N |
|
|
|
|
|
5907005010E655 |
Invega trinza |
Paliperidone Palmitate ER Susp Pref Syr 819 MG/2.625ML |
819 MG/2.63ML |
M ; N ; O ; Y |
N |
|
|
|
|
|
5907007000E4 |
Perseris |
risperidone subcutaneous for er susp prefilled syr |
120 MG ; 90 MG |
M ; N ; O ; Y |
N |
|
|
|
|
|
5907007010G2 |
Risperdal consta |
risperidone microspheres for im extended rel susp |
12.5 MG ; 25 MG ; 37.5 MG ; 50 MG |
M ; N ; O ; Y |
O ; Y |
|
|
|
|
|
5907007000G2 |
Rykindo |
risperidone for im extended release suspension |
25 MG ; 37.5 MG ; 50 MG |
M ; N ; O ; Y |
N |
|
|
09-08-2023 |
|
|
5907007000E6 |
Uzedy |
risperidone subcutaneous er susp pref syr |
100 MG/0.28ML ; 125 MG/0.35ML ; 150 MG/0.42ML ; 200 MG/0.56ML ; 250 MG/0.7ML ; 50 MG/0.14ML ; 75 MG/0.21ML |
M ; N ; O ; Y |
N |
|
|
05-19-2023 |
|
|
591570601019 |
Zyprexa relprevv |
olanzapine pamoate for extended rel im susp |
210 MG ; 300 MG ; 405 MG |
M ; N ; O ; Y |
N |
|
|
|
|
POLICY AGENT SUMMARY QUANTITY LIMIT
Target Agent GPI |
Target Brand Name(s) |
Target Generic Name(s) |
Strength |
QL Amount |
Dose Form |
Days Supply |
Duration |
Targeted NDCs When Exclusions Exist |
Age Limit |
Effective Date |
Term Date |
|
|||||||||||
5925001500E455 |
Abilify asimtufii |
aripiprazole im er susp prefilled syringe |
720 MG/2.4ML |
1 |
Syringe |
56 |
DAYS |
|
|
05-12-2023 |
|
5925001500E465 |
Abilify asimtufii |
aripiprazole im er susp prefilled syringe |
960 MG/3.2ML |
1 |
Syringe |
56 |
DAYS |
|
|
05-12-2023 |
|
5925001500E430 |
Abilify maintena |
Aripiprazole IM For ER Susp Prefilled Syringe 300 MG |
300 MG |
1 |
Syringe |
28 |
DAYS |
|
|
05-12-2023 |
|
5925001500E440 |
Abilify maintena |
Aripiprazole IM For ER Susp Prefilled Syringe 400 MG |
400 MG |
1 |
Syringe |
28 |
DAYS |
|
|
05-12-2023 |
|
5925001500G230 |
Abilify maintena |
Aripiprazole IM For Extended Release Susp 300 MG |
300 MG |
1 |
Vial |
28 |
DAYS |
|
|
02-15-2024 |
|
5925001500G240 |
Abilify maintena |
Aripiprazole IM For Extended Release Susp 400 MG |
400 MG |
1 |
Vial |
28 |
DAYS |
|
|
02-15-2024 |
|
5925001520E450 |
Aristada |
Aripiprazole Lauroxil IM ER Susp Prefilled Syr 1064 MG/3.9ML |
1064 MG/3.9ML |
1 |
Syringe |
56 |
DAYS |
|
|
|
|
5925001520E420 |
Aristada |
Aripiprazole Lauroxil IM ER Susp Prefilled Syr 441 MG/1.6ML |
441 MG/1.6ML |
1 |
Syringe |
28 |
DAYS |
|
|
|
|
5925001520E430 |
Aristada |
Aripiprazole Lauroxil IM ER Susp Prefilled Syr 662 MG/2.4ML |
662 MG/2.4ML |
1 |
Syringe |
28 |
DAYS |
|
|
|
|
5925001520E440 |
Aristada |
Aripiprazole Lauroxil IM ER Susp Prefilled Syr 882 MG/3.2ML |
882 MG/3.2ML |
1 |
Syringe |
28 |
DAYS |
|
|
|
|
5925001520E435 |
Aristada initio |
Aripiprazole Lauroxil IM ER Susp Prefilled Syr 675 MG/2.4ML |
675 MG/2.4ML |
1 |
Kit |
180 |
DAYS |
|
|
|
|
5907005010E639 |
Erzofri |
paliperidone palmitate er susp pref syr |
351 MG/2.25ML |
1 |
Syringe |
180 |
DAYS |
|
|
11-15-2024 |
|
5907005010E632 |
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 117 MG/0.75ML |
117 MG/0.75ML |
1 |
Kit |
28 |
DAYS |
|
|
|
|
5907005010E635 |
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 156 MG/ML |
156 MG/ML |
1 |
Kit |
28 |
DAYS |
|
|
|
|
5907005010E638 |
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 234 MG/1.5ML |
234 MG/1.5ML |
1 |
Kit |
28 |
DAYS |
|
|
|
|
5907005010E626 |
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 39 MG/0.25ML |
39 MG/0.25ML |
1 |
Kit |
28 |
DAYS |
|
|
|
|
5907005010E629 |
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 78 MG/0.5ML |
78 MG/0.5ML |
1 |
Kit |
28 |
DAYS |
|
|
|
|
5907005010E670 |
Invega hafyera |
Paliperidone Palmitate ER Susp Pref Syr |
1092 MG/3.5ML |
1 |
Syringe |
180 |
DAYS |
|
|
|
|
5907005010E675 |
Invega hafyera |
Paliperidone Palmitate ER Susp Pref Syr |
1560 MG/5ML |
1 |
Syringe |
180 |
DAYS |
|
|
|
|
5907005010E643 |
Invega trinza |
Paliperidone Palmitate ER Susp Pref Syr 273 MG/0.875ML |
273 MG/0.88ML |
1 |
Syringe |
90 |
DAYS |
|
|
|
|
5907005010E647 |
Invega trinza |
Paliperidone Palmitate ER Susp Pref Syr 410 MG/1.315ML |
410 MG/1.32ML |
1 |
Syringe |
90 |
DAYS |
|
|
|
|
5907005010E651 |
Invega trinza |
Paliperidone Palmitate ER Susp Pref Syr 546 MG/1.75ML |
546 MG/1.75ML |
1 |
Syringe |
90 |
DAYS |
|
|
|
|
5907005010E655 |
Invega trinza |
Paliperidone Palmitate ER Susp Pref Syr 819 MG/2.625ML |
819 MG/2.63ML |
1 |
Syringe |
90 |
DAYS |
|
|
|
|
5907007000E430 |
Perseris |
Risperidone Subcutaneous For ER Susp Prefilled Syr 120 MG |
120 MG |
1 |
Kit |
30 |
DAYS |
|
|
02-15-2024 |
|
5907007000E420 |
Perseris |
Risperidone Subcutaneous For ER Susp Prefilled Syr 90 MG |
90 MG |
1 |
Kit |
30 |
DAYS |
|
|
02-15-2024 |
|
5907007010G210 |
Risperdal consta |
Risperidone Microspheres For IM Extended Rel Susp 12.5 MG |
12.5 MG |
2 |
Vials |
28 |
DAYS |
|
|
02-15-2024 |
|
5907007010G220 |
Risperdal consta |
Risperidone Microspheres For IM Extended Rel Susp 25 MG |
25 MG |
2 |
Vials |
28 |
DAYS |
|
|
02-15-2024 |
|
5907007010G230 |
Risperdal consta |
Risperidone Microspheres For IM Extended Rel Susp 37.5 MG |
37.5 MG |
2 |
Vials |
28 |
DAYS |
|
|
02-15-2024 |
|
5907007010G240 |
Risperdal consta |
Risperidone Microspheres For IM Extended Rel Susp 50 MG |
50 MG |
2 |
Vials |
28 |
DAYS |
|
|
02-15-2024 |
|
5907007000G220 |
Rykindo |
risperidone for im extended release suspension |
25 MG |
2 |
Vials |
28 |
DAYS |
|
|
09-08-2023 |
|
5907007000G230 |
Rykindo |
risperidone for im extended release suspension |
37.5 MG |
2 |
Vials |
28 |
DAYS |
|
|
09-08-2023 |
|
5907007000G240 |
Rykindo |
risperidone for im extended release suspension |
50 MG |
2 |
Vials |
28 |
DAYS |
|
|
09-08-2023 |
|
5907007000E610 |
Uzedy |
risperidone subcutaneous er susp pref syr |
50 MG/0.14ML |
1 |
Syringe |
28 |
DAYS |
|
|
05-19-2023 |
|
5907007000E618 |
Uzedy |
risperidone subcutaneous er susp pref syr |
75 MG/0.21ML |
1 |
Syringe |
28 |
DAYS |
|
|
05-19-2023 |
|
5907007000E626 |
Uzedy |
risperidone subcutaneous er susp pref syr |
100 MG/0.28ML |
1 |
Syringe |
28 |
DAYS |
|
|
05-19-2023 |
|
5907007000E634 |
Uzedy |
risperidone subcutaneous er susp pref syr |
125 MG/0.35ML |
1 |
Syringe |
28 |
DAYS |
|
|
05-19-2023 |
|
5907007000E642 |
Uzedy |
risperidone subcutaneous er susp pref syr |
150 MG/0.42ML |
1 |
Syringe |
56 |
DAYS |
|
|
05-19-2023 |
|
5907007000E658 |
Uzedy |
risperidone subcutaneous er susp pref syr |
200 MG/0.56ML |
1 |
Syringe |
56 |
DAYS |
|
|
05-19-2023 |
|
5907007000E674 |
Uzedy |
risperidone subcutaneous er susp pref syr |
250 MG/0.7ML |
1 |
Syringe |
56 |
DAYS |
|
|
05-19-2023 |
|
59157060101950 |
Zyprexa relprevv |
Olanzapine Pamoate For Extended Rel IM Susp 210 MG (Base Eq) |
210 MG |
2 |
Vials |
28 |
DAYS |
|
|
|
|
59157060101960 |
Zyprexa relprevv |
Olanzapine Pamoate For Extended Rel IM Susp 300 MG (Base Eq) |
300 MG |
2 |
Vials |
28 |
DAYS |
|
|
|
|
59157060101970 |
Zyprexa relprevv |
Olanzapine Pamoate For Extended Rel IM Susp 405 MG (Base Eq) |
405 MG |
1 |
Vial |
28 |
DAYS |
|
|
|
|
CLIENT SUMMARY – STEP THERAPY
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
|||
Abilify asimtufii ; Abilify maintena |
aripiprazole im er susp prefilled syringe ; aripiprazole im for er susp prefilled syringe |
300 MG ; 400 MG ; 720 MG/2.4ML ; 960 MG/3.2ML |
|
Abilify maintena |
aripiprazole im for extended release susp |
300 MG ; 400 MG |
|
Aristada ; Aristada initio |
aripiprazole lauroxil im er susp prefilled syr |
1064 MG/3.9ML ; 441 MG/1.6ML ; 662 MG/2.4ML ; 675 MG/2.4ML ; 882 MG/3.2ML |
|
Erzofri |
paliperidone palmitate er susp pref syr |
351 MG/2.25ML |
|
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 117 MG/0.75ML |
117 MG/0.75ML |
|
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 156 MG/ML |
156 MG/ML |
|
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 234 MG/1.5ML |
234 MG/1.5ML |
|
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 39 MG/0.25ML |
39 MG/0.25ML |
|
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 78 MG/0.5ML |
78 MG/0.5ML |
|
Invega hafyera |
Paliperidone Palmitate ER Susp Pref Syr |
1092 MG/3.5ML |
|
Invega hafyera |
Paliperidone Palmitate ER Susp Pref Syr |
1560 MG/5ML |
|
Invega trinza |
Paliperidone Palmitate ER Susp Pref Syr 273 MG/0.875ML |
273 MG/0.88ML |
|
Invega trinza |
Paliperidone Palmitate ER Susp Pref Syr 410 MG/1.315ML |
410 MG/1.32ML |
|
Invega trinza |
Paliperidone Palmitate ER Susp Pref Syr 546 MG/1.75ML |
546 MG/1.75ML |
|
Invega trinza |
Paliperidone Palmitate ER Susp Pref Syr 819 MG/2.625ML |
819 MG/2.63ML |
|
Perseris |
risperidone subcutaneous for er susp prefilled syr |
120 MG ; 90 MG |
|
Risperdal consta |
risperidone microspheres for im extended rel susp |
12.5 MG ; 25 MG ; 37.5 MG ; 50 MG |
|
Rykindo |
risperidone for im extended release suspension |
25 MG ; 37.5 MG ; 50 MG |
|
Uzedy |
risperidone subcutaneous er susp pref syr |
100 MG/0.28ML ; 125 MG/0.35ML ; 150 MG/0.42ML ; 200 MG/0.56ML ; 250 MG/0.7ML ; 50 MG/0.14ML ; 75 MG/0.21ML |
|
Zyprexa relprevv |
olanzapine pamoate for extended rel im susp |
210 MG ; 300 MG ; 405 MG |
|
CLIENT SUMMARY – QUANTITY LIMITS
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
|||
Abilify asimtufii |
aripiprazole im er susp prefilled syringe |
720 MG/2.4ML |
|
Abilify asimtufii |
aripiprazole im er susp prefilled syringe |
960 MG/3.2ML |
|
Abilify maintena |
Aripiprazole IM For ER Susp Prefilled Syringe 300 MG |
300 MG |
|
Abilify maintena |
Aripiprazole IM For ER Susp Prefilled Syringe 400 MG |
400 MG |
|
Abilify maintena |
Aripiprazole IM For Extended Release Susp 300 MG |
300 MG |
|
Abilify maintena |
Aripiprazole IM For Extended Release Susp 400 MG |
400 MG |
|
Aristada |
Aripiprazole Lauroxil IM ER Susp Prefilled Syr 1064 MG/3.9ML |
1064 MG/3.9ML |
|
Aristada |
Aripiprazole Lauroxil IM ER Susp Prefilled Syr 441 MG/1.6ML |
441 MG/1.6ML |
|
Aristada |
Aripiprazole Lauroxil IM ER Susp Prefilled Syr 662 MG/2.4ML |
662 MG/2.4ML |
|
Aristada |
Aripiprazole Lauroxil IM ER Susp Prefilled Syr 882 MG/3.2ML |
882 MG/3.2ML |
|
Aristada initio |
Aripiprazole Lauroxil IM ER Susp Prefilled Syr 675 MG/2.4ML |
675 MG/2.4ML |
|
Erzofri |
paliperidone palmitate er susp pref syr |
351 MG/2.25ML |
|
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 117 MG/0.75ML |
117 MG/0.75ML |
|
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 156 MG/ML |
156 MG/ML |
|
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 234 MG/1.5ML |
234 MG/1.5ML |
|
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 39 MG/0.25ML |
39 MG/0.25ML |
|
Erzofri ; Invega sustenna |
Paliperidone Palmitate ER Susp Pref Syr 78 MG/0.5ML |
78 MG/0.5ML |
|
Invega hafyera |
Paliperidone Palmitate ER Susp Pref Syr |
1092 MG/3.5ML |
|
Invega hafyera |
Paliperidone Palmitate ER Susp Pref Syr |
1560 MG/5ML |
|
Invega trinza |
Paliperidone Palmitate ER Susp Pref Syr 273 MG/0.875ML |
273 MG/0.88ML |
|
Invega trinza |
Paliperidone Palmitate ER Susp Pref Syr 410 MG/1.315ML |
410 MG/1.32ML |
|
Invega trinza |
Paliperidone Palmitate ER Susp Pref Syr 546 MG/1.75ML |
546 MG/1.75ML |
|
Invega trinza |
Paliperidone Palmitate ER Susp Pref Syr 819 MG/2.625ML |
819 MG/2.63ML |
|
Perseris |
Risperidone Subcutaneous For ER Susp Prefilled Syr 120 MG |
120 MG |
|
Perseris |
Risperidone Subcutaneous For ER Susp Prefilled Syr 90 MG |
90 MG |
|
Risperdal consta |
Risperidone Microspheres For IM Extended Rel Susp 12.5 MG |
12.5 MG |
|
Risperdal consta |
Risperidone Microspheres For IM Extended Rel Susp 25 MG |
25 MG |
|
Risperdal consta |
Risperidone Microspheres For IM Extended Rel Susp 37.5 MG |
37.5 MG |
|
Risperdal consta |
Risperidone Microspheres For IM Extended Rel Susp 50 MG |
50 MG |
|
Rykindo |
risperidone for im extended release suspension |
25 MG |
|
Rykindo |
risperidone for im extended release suspension |
37.5 MG |
|
Rykindo |
risperidone for im extended release suspension |
50 MG |
|
Uzedy |
risperidone subcutaneous er susp pref syr |
50 MG/0.14ML |
|
Uzedy |
risperidone subcutaneous er susp pref syr |
75 MG/0.21ML |
|
Uzedy |
risperidone subcutaneous er susp pref syr |
100 MG/0.28ML |
|
Uzedy |
risperidone subcutaneous er susp pref syr |
125 MG/0.35ML |
|
Uzedy |
risperidone subcutaneous er susp pref syr |
150 MG/0.42ML |
|
Uzedy |
risperidone subcutaneous er susp pref syr |
200 MG/0.56ML |
|
Uzedy |
risperidone subcutaneous er susp pref syr |
250 MG/0.7ML |
|
Zyprexa relprevv |
Olanzapine Pamoate For Extended Rel IM Susp 210 MG (Base Eq) |
210 MG |
|
Zyprexa relprevv |
Olanzapine Pamoate For Extended Rel IM Susp 300 MG (Base Eq) |
300 MG |
|
Zyprexa relprevv |
Olanzapine Pamoate For Extended Rel IM Susp 405 MG (Base Eq) |
405 MG |
|
