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Atypical Antipsychotics |
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Abilify |
Clozaril/clozapine |
Fazaclo |
Geodon |
Risperdal |
RisprdlConsta |
Risprdl MTab |
Seroquel |
Zyprexa |
Zyprexa Zydis |
| Plan |
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| Anthem BC BS |
2,ql |
3 (1) |
3 |
4 |
2 |
x |
x |
2 |
2 |
2 |
| Amerihealth Advntg Rx |
1,pa |
1 (1) |
x |
1 |
1 |
x |
x |
1 |
1 |
x |
| First Health Premier FH Premier 003 |
3,pa,ql |
x(1); 3pa |
3,pa |
3,pa,ql |
2;2,ql |
3,pa |
2,ql |
2,ql |
3,pa,ql |
3,pa,ql |
| Humana H Standard 003 |
2;2ql |
3(1) |
x |
2,ql |
2,ql |
2 |
x |
2,ql |
2,ql |
2,ql |
| Pacificare L&H PC Saver 207 |
3;4 |
x(1); pa |
x |
3,pa |
3 |
4 |
3 |
2 |
3 |
3 |
| SilverScript SilverScript |
2 |
x(1;2 |
x |
2 |
2 |
x |
2 |
2 |
2 |
2 |
| Unicare RX Rewards |
2;2,ql |
x(1) |
x |
2;3 |
2 |
x |
2 |
2 |
2 |
2 |
| United Health Care All three plans |
3 |
3(1) |
2 |
3 |
2 |
4 |
x |
2 |
2 |
2 |
| Wellcare Signature |
4,pa |
x(2) |
x |
4,pa |
4,pa |
4,pa |
x |
4,pa |
4,pa |
x |
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| # Tier level |
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| Brand (generic) if available |
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| pa=prior authorization |
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| ql=quantity limit |
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| x=not in formulary |
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| ;=listed in more than one manner |
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