Prior Authorization. Physician Name: Specialty: NPI Number: Physician Fax: Physician Phone: Physician Address: City, State, Zip:

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1 12/16/2015 Prior Authorization AETA BETTER HEALTH OF TEXAS MEDICAID Antipsychotics (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Aetna Better Health of Texas Medicaid (Bexar and Tarrant) at Please contact Aetna Better Health of Texas Medicaid (Bexar) at or Aetna Better Health of Texas Medicaid (Tarrant) at with questions regarding the Prior Authorization process. When conditions are met, we will authorize the coverage of Antipsychotics (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (specify drug) Quantity Frequency Strength Route of Administration Expected Length of therapy Patient Information Patient ame: Patient ID: Patient Group o.: Patient DOB: Patient Phone: Prescribing Physician Physician ame: Specialty: PI umber: Physician Fax: Physician Phone: Physician Address: City, State, Zip: Diagnosis: ICD Code: Please circle the appropriate answer for each question. Question Circle es or o 1. Is the incoming claim for a first generation antipsychotic? [If yes, then skip to question 5.] 2. Is the patient less than 3 years of age? [If yes, then no further questions.] 3. Is the patient greater than 5 years of age? [If yes, then skip to question 5.]

2 Question 4. Is the incoming request for aripiprazole or risperidone (excluding long-acting preparations)? Circle es or o 5. Does the patient have a diagnosis of insomnia in the last 365 days? [If yes, then skip to question 8.] 6. Does the patient have a diagnosis of major depressive disorder (MDD) in the last 365 days? [If no, then skip to question 8.] 7. Does the patient have 1 claim for an antidepressant agent included in Table C (below) in the last 60 days? [If yes, then skip to question 9.] 8. Does the patient have a diagnosis included in Table A or Table B (below) in the last 730 days? 9. Does the patient have 2 or more active claims for different antipsychotic agents in the last 180 days (excluding the incoming request)? [If no, then skip to question 11.] 10. Does the patient have 2 or more active claims for different antipsychotic agents in the last 30 days with at least 30 days supply remaining (excluding the incoming request)? 11. Is this request for a non-preferred drug? The Texas Medicaid Preferred Drug List can be found at txvendordrug.com 12. Has the patient had a treatment failure with a preferred drug within any subclass or a contraindication or allergic reaction to any preferred drugs? If yes, PLEASE LIST which drug, dates tried, and describe treatment failure, contraindication or allergic reaction experienced.

3 Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Prescriber (Or Authorized) Signature Date Date Table A ICD-9 Code 295 SCHIZOPHREIC DISORDERS BIPOLOAR I DISORDER, SIGLE MAIC EPISODE BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MAIC BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) DEPRESSED BIPOLOAR I DIOSRDER, MOST RECET EPISODE (OR CURRET) MIXED BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) USPECIFIED BIPOLAR DISORDER, USPECIFIED OTHER BIPOLAR DISORDERS AUTISTIC DISORDER OTHER SPECIFIED EPISODIC MOOD DISORDER TOURETTE S DISORDER ICD-10 Code F20 SCHIZOPHREIA F31.0 BIPOLAR DISORDER, CURRET EPISODE HPOMAIC F31.1 BIPOLAR DISORDER, CURRET EPISODE MAIC WITHOUT PSCHOTIC FEATURES F31.6 BIPOLAR DISORDER, CURRET EPISODE MIXED F31.81 BIPOLAR II DISORDER F31.9 BIPOLAR DISORDER, USPECIFIED F34.8 OTHER PERSISTET MOOD DISORDER F84.0 AUTISTIC DISORDER F95.2 TOURETTE S DISORDER

4 Table B ICD-9 Code CODUCT DISORDER, CHILDHOOD OSET CODUCT DISORDER, ADOLESCET OSET CODUCT DISORDER, OSET USPECIFIED 297 DELUSIOAL DISORDERS PARAOID STATE, SIMPLE DELUSIOAL DISORDER PARAPHREIA SHARED PSCHOTIC DISORDER OTHER SPECIFIED PARAOID STATES USPECIFIED PARAOID STATE USPECIFIED EPISODIC MOOD DISORDER USPECIFIED PSCHOSIS 299 PERVASIVE DEVELOPMETAL DISORDERS CHILDHOOD DISITEGRATIVE DISORDER OTHER SPECIFIED PERVASIVE DEVELOPMETAL DISORDER USPECIFIED PERVASIVE DEVELOPMETAL DISORDER ITERMITTET EXPLOSIVE DISORDER OPPOSITIOAL DEFIAT DISORDER F91.1 CODUCT DISORDER, CHILDHOOD-OSET TPE F91.2 CODUCT DISORDER, ADOLESCET-OSET TPE F91.9 CODUCT DISORDER, USPECIFIED F22 F39 F09 F29 DELUSIOAL DISORDERS USPECIFIED MOOD DISORDER USPECIFIED METAL DISORDER DUE TO KOW PHSIOLOGICAL CODITIO USPECIFIED PSCHOSIS OT DUE TO A SUBSTACE OR KOW PHSIOLOGICAL CODITIO F84.8 OTHER PERVASIVE DEVELOPMETAL DISORDERS F84.9 PERVASIVE DEVELOPMETAL DISORDER, USPECIFIED F63.81 ITERMITTET EXPLOSIVE DISORDER F91.3 OPPOSITIOAL DEFIAT DISORDER

5 Table C Required quantity: 1 Look back timeframe: 60 days APLEZI ER BRISDELLE BUPROPIO ER BUPROPIO BUPROPIO SR BUPROPIO XL CELEXA CITALOPRAM EFFEXOR EMSAM PATCH ESCITALOPRAM FLUOXETIE FLUVOXAMIIE FLUVOXAMIE ER FORFIVO XL KHEDEZLA ER MARPLA MIRTAZAPIE EFAZODOE OLEPTRO ER PAROXETIE PAROXETIE CR PAXIL PEXEVA PHEELZIE PRISTIQ ER PROZAC SERTRALIE TRALCPROMIE TRAZODOE VELAFAXIE VELAFAXIE ER VIIBRD WELLBUTRI WELLBUTRI SR ZOLOFT