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State Health Plan Atypical Antipsychotic Step Therapy Program



With the recent and expected release of several generic atypical antipsychotics (Zyprexa®, Geodon® and Seroquel®), non-preferred brand atypical antipsychotics will be subject to a step therapy program for NEW USERS ONLY who are 18 years of age or older starting on April 2, 2012.

For the State Health Plan to maintain an affordable prescription drug benefit and to promote the use of generics and preferred brand name medications, new users of non-preferred atypical antipsychotics will be required to complete a coverage review and will need to have experienced intolerance or treatment failure with at least one of the following: olanzapine (Zyprexa), risperidone (Risperdal®), quetiapine (Seroquel), ziprasidone (Geodon) or clozapine (Clozaril®). This program has been reviewed by the Plan Pharmacy and Therapeutics Committee.

Please consider whether a generic or preferred brand atypical antipsychotic would be appropriate for your patients starting on therapy.

Atypical Antipsychotics

Tier One ($12 copay)

Generic Medications
risperidone, olanzapine and clozapine

Tier Two ($40 copay)

Preferred Brand Name Medications

Seroquel®*, Seroquel XR® and Geodon®*

(*expected to become available as generics in early 2012)

Tier Three ($64 copay)

Non-preferred Brands without a generic equivalent

Requires a coverage review
Abilify®, Invega®, Latuda®, Saphris®, Fanapt®

Brand with Generic Equivalent

($12 plus the difference in the Plan’s cost for the

brand and generic, up to a max of $100 per 30-day supply)
Brand Risperdal, Zyprexa and Clozaril
Benefit coverage is provided (regardless of age) for any patient who is currently receiving a non- preferred atypical antipsychotic. Also, if a patient has a generic or preferred drug claim in his/her prescription history in the previous 2 years, the coverage of the non-preferred medication will automatically be approved. For Abilify, benefit coverage is provided if the drug is being used for adjunctive treatment of major depressive disorder.

To request a coverage review, providers may call Medco toll-free at 1-800-417-1764 from 8:00 a.m. to 9:00 p.m., Eastern Time, Monday through Friday, or log on to to request a review. Members will be responsible for the full cost of the prescription if the provider does not receive approval during the coverage review.