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Nuplazid Prior Authorization Criteria (with Quantity Limit) - Medicare Part D

Medicare Policy
Version Date: 01/01/2025

Prior Authorization Criteria for Approval

PA applies to new starts only

Nuplazid will be approved when BOTH of the following are met:

  1. The patient has an FDA labeled indication for the requested medication
    AND
  2. ONE of the following:
    1. The requested quantity (dose) does NOT exceed the program quantity limit
      OR
    2. BOTH of the following:
      1. The requested quantity (dose) is greater than the program quantity limit
        AND
      2. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months

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