Prior Authorization Criteria for Approval

The following medications are included in this PA program:

Chlorpromazine tablets, fluphenazine, haloperidol, loxapine, molindone, perphenazine, pimozide, thioridazine, thiothixene, trifluoperazine

PA applies to new starts only

Prior Authorization applies only to patients who are 65 YEARS OF AGE AND OVER.

Formulary typical 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 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. The prescriber has documented that s/he has discussed the risk of increased mortality with the patient and/or the patient’s surrogate decision maker

Length of approval: 12 months