Prior Authorization Criteria for Approval

The following products are included in this PA program:

Basic formulary: aripiprazole, asenapine, clozapine, Fanapt, lurasidone, Lybalvi, olanzapine, paliperidone ER, quetiapine, Rexulti, risperidone 1 mg/mL oral solution, risperidone ODT, Secuado, Versacloz, ziprasidone injection, Zyprexa Relprevv

HC Enhanced, MAPD Classic formularies: aripiprazole, asenapine, clozapine, Fanapt, lurasidone, Lybalvi, olanzapine, paliperidone ER, quetiapine, quetiapine ER, Rexulti, risperidone 1 mg/mL oral solution, risperidone ODT, Secuado, Versacloz, ziprasidone injection, Zyprexa Relprevv

PA applies to new starts only and only to patients who are 65 YEARS OF AGE AND OVER. Quantity limitations apply to all patients.

Formulary atypical antipsychotics will be approved when ALL of the following are met:

1. The patient has an FDA labeled indication or an indication that is supported in CMS approved compendia for the requested medication
   AND
2. ONE of the following:
   1. There is evidence of a claim that indicates the patient is currently being treated with the requested medication within the past 180 days
      OR
   2. The prescriber states the patient is currently being treated with the requested medication
      OR
   3. ONE of the following:
      1. The patient has a diagnosis other than dementia-related psychosis or dementia-related behavioral symptoms
         OR
      2. The patient has dementia-related psychosis or dementia related behavioral symptoms AND BOTH of the following:
         1. Dementia-related psychosis is determined to be severe or the associated behavior puts the patient or others in danger
            AND
         2. Prescriber has documented that s/he has discussed the risk of increased mortality with the patient and/or the patient’s surrogate decision maker
            AND
3. ONE of the following:
   1. The requested quantity (dose) does NOT exceed the program quantity limit
      OR
   2. ALL of the following:
      1. The requested quantity (dose) is greater than the program quantity limit
         AND
      2. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit
         AND
      3. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of approval: 12 months