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Antipsychotic Drugs

PHARM-13 Statement of Medical Necessity for Quantity Limits Override.

Antipsychotic Drugs

Drugs

Quantity Limits

Abilify (Aripiprazole) 2mg, 5mg, 10mg, 15mg, 20mg and 30mg Tablets

 1 Tablet Daily up to 100 Days
Abilify Discmelt (Aripiprazole) 10mg and 15mg, Rapdis Tablets  1 Rapdis Tablet Daily up to 100 Days

Geodon (Ziprasidone HCL) 20mg, 40mg, 60mg and 80mg Capsules 

 2 Capsules daily up to 100 capsules
Invega (Paliperidone) 3mg, 6mg and 9mg Tablets  3mg and 9mg - 1 Tablet daily up to 100 tablets                 6mg - 2 Tablets daily up to 100 tablets

Risperdal (Risperidone) 0.25mg, 0.5mg, 1mg, 2mg, 3mg and 4mg Tablets 

 2 Tablets per day up to 100 Tablets
Risperdal Consta (Risperidone Microspheres) 12.5mg/2ml, 25mg/2ml, 37.5mg/2ml and 50mg/2ml Disposable Syringes  2 Injection Kits per 28 days

Risperdal M-Tab (Risperidone) 0.25mg, 0.5mg, 1mg, 2mg, 3mg and 4mg RapdisTablets 

 2 Rapdis Tablets per day up to 100 Tablets
Seroquel (Quetiapine Fumarate) 25mg, 50mg, 100mg, 200mg, 300mg and 400mg Tablets  3 Tablets per day up to 34 days

Seroquel XR (Quetiapine Fumarate) 50mg, 150mg, 200mg, 300mg and 400mg SR Tablets 

 50mg, 150mg and 200mg - 1 Tablet daily up to 100 tablets   200mg and 300mg - 2 Tablets daily up to 100 Tablets

Symbyax (Olanzapine/Fluoxetine HCL) 3mg/25mg, 6mg/25mg, 6mg/50mg, 12mg/25mg and 12mg/50mg Capsules 

 1 Capsule daily up to 100 capsules
Zyprexa (Olanzapine) 2.5mg, 5mg, 7.5mg, 10mg, 15mg and 20mg Tablets  1 Tablet daily up to 100 tablets

Zyprexa Zydis (Olanzapine) 5mg, 10mg, 15mg and 20mg Tablets 

 1 Rapdis Tablet daily up to 100 tablets
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Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

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