Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria
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1 Drug/Drug Class Antipsychotics Clinical Criteria Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules Logic diagram: a visual depiction of the clinical criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes) References: clinical publications and sources relevant to this clinical criteria 09/01/2018 1
2 Drugs Requiring Prior Authorization Antipsychotics First Generation Label Name GCN HIC4 AMITRIPTYLINE/PERPHENAZINE H2JB/H2GE AMITRIPTYLINE/PERPHENAZINE H2JB/H2GE AMITRIPTYLINE/PERPHENAZINE H2JB/H2GE AMITRIPTYLINE/PERPHENAZINE H2JB/H2GE AMITRIPTYLINE/PERPHENAZINE H2JB/H2GE CHLORPROMAZINE 10 MG TABLET H2GA CHLORPROMAZINE 25 MG TABLET H2GA CHLORPROMAZINE 50 MG TABLET H2GA CHLORPROMAZINE 100 MG TABLET H2GA CHLORPROMAZINE 200 MG TABLET H2GA CHLORPROMAZINE 30MG/ML CONC H2GA CHLORPROMAZINE 100MG/ML CONC H2GA FLUPHENAZINE 1 MG TABLET H2GD FLUPHENAZINE 2.5 MG TABLET H2GD FLUPHENAZINE 5 MG TABLET H2GD FLUPHENAZINE 10 MG TABLET H2GD FLUPHENAZINE 5 MG/ML CONC H2GD FLUPHENAZINE 2.5 MG/5 ML ELIX H2GD HALOPERIDOL 0.5 MG TABLET H2LH HALOPERIDOL 1 MG TABLET H2LH HALOPERIDOL 2 MG TABLET H2LH HALOPERIDOL 5 MG TABLET H2LH HALOPERIDOL 10 MG TABLET H2LH HALOPERIDOL 20 MG TABLET H2LH HALOPERIDOL 1MG/ML SOLUTION H2LH HALOPERIDOL LAC 2 MG/ML CONC H2LH LOXAPINE 5 MG CAPSULE H7UA LOXAPINE 10 MG CAPSULE H7UA LOXAPINE 25 MG CAPSULE H7UA LOXAPINE 50 MG CAPSULE H7UA MOLINDONE HCL 5 MG TABLET H7SA MOLINDONE HCL 10 MG TABLET H7SA MOLINDONE HCL 25 MG TABLET H7SA 09/01/2018 2
3 ORAP 1 MG TABLET H2LG ORAP 2 MG TABLET H2LG PERPHENAZINE 2 MG TABLET H2GE PERPHENAZINE 4 MG TABLET H2GE PERPHENAZINE 8 MG TABLET H2GE PERPHENAZINE 16 MG TABLET H2GE PIMOZIDE 1 MG TABLET H7RB PIMOZIDE 2 MG TABLET H7RB THIORIDAZINE 10 MG TABLET H2GH THIORIDAZINE 25 MG TABLET H2GH THIORIDAZINE 50 MG TABLET H2GH THIORIDAZINE 100 MG TABLET H2GH THIOTHIXENE 1 MG CAPSULE H2LT THIOTHIXENE 2 MG CAPSULE H2LT THIOTHIXENE 5 MG CAPSULE H2LT THIOTHIXENE 10 MG CAPSULE H2LT TRIFLUOPERAZINE 1 MG TABLET H2GG TRIFLUOPERAZINE 2 MG TABLET H2GG TRIFLUOPERAZINE 5 MG TABLET H2GG TRIFLUOPERAZINE 10 MG TABLET H2GG Antipsychotics Second Generation (Oral/Regular Acting Injectables) Label Name GCN HIC4 ABILIFY 1 MG/ML SOLUTION H7XA ABILIFY 2 MG TABLET H7XA ABILIFY 5 MG TABLET H7XA ABILIFY 10 MG TABLET H7XA ABILIFY 15 MG TABLET H7XA ABILIFY 20 MG TABLET H7XA ABILIFY 30 MG TABLET H7XA ABILIFY DISCMELT 10 MG TABLET H7XA ABILIFY DISCMELT 15 MG TABLET H7XA ARIPIPRAZOLE 1MG/ML SOLUTION H7XA ARIPIPRAZOLE 2MG TABLET H7XA ARIPIPRAZOLE 5MG TABLET H7XA ARIPIPRAZOLE 10MG TABLET H7XA ARIPIPRAZOLE 15MG TABLET H7XA 09/01/2018 3
4 ARIPIPRAZOLE 20MG TABLET H7XA ARIPIPRAZOLE 30MG TABLET H7XA ARIPIPRAZOLE ODT 10MG TABLET H7XA ARIPIPRAZOLE ODT 15MG TABLET H7XA CLOZAPINE 12.5MG TABLET H2LS CLOZAPINE 25 MG TABLET H2LS CLOZAPINE 50 MG TABLET H2LS CLOZAPINE 100 MG TABLET H2LS CLOZAPINE 200 MG TABLET H2LS CLOZAPINE ODT 12.5MG TABLET H2LS CLOZAPINE ODT 25MG TABLET H2LS CLOZAPINE ODT 100MG TABLET H2LS CLOZARIL 25 MG TABLET H2LS CLOZARIL 100 MG TABLET H2LS FANAPT 1 MG TABLET H7TK FANAPT 2 MG TABLET H7TK FANAPT 4 MG TABLET H7TK FANAPT 6 MG TABLET H7TK FANAPT 8 MG TABLET H7TK FANAPT 10 MG TABLET H7TK FANAPT 12 MG TABLET H7TK FANAPT TITRATION PACK H7TK FAZACLO 12.5 MG ODT H2LS FAZACLO 25 MG ODT H2LS FAZACLO 100 MG ODT H2LS FAZACLO 150 MG ODT H2LS FAZACLO 200 MG ODT H2LS GEODON 20 MG CAPSULE H2GD GEODON 40 MG CAPSULE H2GD GEODON 60 MG CAPSULE H2GD GEODON 80 MG CAPSULE H2GD GEODON 20 MG VIAL H2GD INVEGA ER 1.5 MG TABLET H7TH INVEGA ER 3 MG TABLET H7TH INVEGA ER 6 MG TABLET H7TH INVEGA ER 9 MG TABLET H7TH LATUDA 20 MG TABLET H7TL 09/01/2018 4
5 LATUDA 40 MG TABLET H7TL LATUDA 60 MG TABLET H7TL LATUDA 80 MG TABLET H7TL LATUDA 120 MG TABLET H7TL OLANZAPINE 2.5 MG TABLET H7TD OLANZAPINE 5 MG TABLET H7TD OLANZAPINE 7.5 MG TABLET H7TD OLANZAPINE 10 MG TABLET H7TD OLANZAPINE 10 MG VIAL H7TD OLANZAPINE 15 MG TABLET H7TD OLANZAPINE 20MG TABLET H7TD OLANZAPINE ODT 5MG TABLET H7TD OLANZAPINE ODT 10 MG TABLET H7TD OLANZAPINE ODT 15 MG TABLET H7TD OLANZAPINE ODT 20MG TABLET H7TD OLANZAPINE/FLUOXETINE 3-25 MG H7TD/H2JS OLANZAPINE/FLUOXETINE 6-25 MG H7TD/H2JS OLANZAPINE/FLUOXETINE 6-50 MG H7TD/H2JS OLANZAPINE/FLUOXETINE MG H7TD/H2JS OLANZAPINE/FLUOXETINE MG H7TD/H2JS PALIPERIDONE ER 1.5 MG TABLET H7TH PALIPERIDONE ER 3 MG TABLET H7TH PALIPERIDONE ER 6 MG TABLET H7TH PALIPERIDONE ER 9 MG TABLET H7TH QUETIAPINE 25 MG TABLET H7TF QUETIAPINE 50 MG TABLET H7TF QUETIAPINE 100 MG TABLET H7TF QUETIAPINE 200 MG TABLET H7TF QUETIAPINE 300 MG TABLET H7TF QUETIAPINE 400 MG TABLET H7TF REXULTI 0.25MG TABLET H7XB REXULTI 0.5MG TABLET H7XB REXULTI 1MG TABLET H7XB REXULTI 2MG TABLET H7XB REXULTI 3MG TABLET H7XB REXULTI 4MG TABLET H7XB RISPERDAL 1 MG/ML SOLUTION H7TA 09/01/2018 5
6 RISPERDAL 0.25 MG TABLET H7TA RISPERDAL 0.5 MG TABLET H7TA RISPERDAL 1 MG TABLET H7TA RISPERDAL 2 MG TABLET H7TA RISPERDAL 3 MG TABLET H7TA RISPERDAL 4 MG TABLET H7TA RISPERDAL M-TAB 0.5 MG ODT H7TA RISPERDAL M-TAB 1 MG ODT H7TA RISPERDAL M-TAB 2 MG ODT H7TA RISPERDAL M-TAB 3 MG ODT H7TA RISPERDAL M-TAB 4 MG ODT H7TA RISPERIDONE 0.25 MG ODT H7TA RISPERIDONE 0.5 MG ODT H7TA RISPERIDONE 1 MG ODT H7TA RISPERIDONE 2 MG ODT H7TA RISPERIDONE 3 MG ODT H7TA RISPERIDONE 4 MG ODT H7TA RISPERIDONE 1 MG/ML SOLUTION H7TA RISPERIDONE 0.25 MG TABLET H7TA RISPERIDONE 0.5 MG TABLET H7TA RISPERIDONE 1 MG TABLET H7TA RISPERIDONE 2 MG TABLET H7TA RISPERIDONE 3 MG TABLET H7TA RISPERIDONE 4 MG TABLET H7TA SAPHRIS 2.5 MG TABLET SUBLINGUAL H7TI SAPHRIS 5 MG TABLET SUBLINGUAL H7TI SAPHRIS 10 MG TAB SUBLINGUAL H7TI SEROQUEL 25 MG TABLET H7TF SEROQUEL 50 MG TABLET H7TF SEROQUEL 100 MG TABLET H7TF SEROQUEL 200 MG TABLET H7TF SEROQUEL 300 MG TABLET H7TF SEROQUEL 400 MG TABLET H7TF SEROQUEL XR 50 MG TABLET H7TF SEROQUEL XR 150 MG TABLET H7TF SEROQUEL XR 200 MG TABLET H7TF SEROQUEL XR 300 MG TABLET H7TF 09/01/2018 6
7 SEROQUEL XR 400 MG TABLET H7TF SYMBYAX 3-25 MG CAPSULE H7TD/H2JS SYMBYAX 6-25 MG CAPSULE H7TD/H2JS SYMBYAX MG CAPSULE H7TD/H2JS SYMBYAX 6-50 MG CAPSULE H7TD/H2JS SYMBYAX MG CAPSULE H7TD/H2JS VRAYLAR 1.5 MG CAPSULE H8WA VRAYLAR 1.5 MG-3 MG PACK H8WA VRAYLAR 3 MG CAPSULE H8WA VRAYLAR 4.5 MG CAPSULE H8WA VRAYLAR 6 MG CAPSULE H8WA VERSACLOZ 50MG/ML SUSPENSION H2LS ZIPRASIDONE 20 MG CAPSULE H7TG ZIPRASIDONE 40 MG CAPSULE H7TG ZIPRASIDONE 60 MG CAPSULE H7TG ZIPRASIDONE 80 MG CAPSULE H7TG ZYPREXA 2.5 MG TABLET H7TD ZYPREXA 5 MG TABLET H7TD ZYPREXA 7.5 MG TABLET H7TD ZYPREXA 10 MG TABLET H7TD ZYPREXA 10 MG VIAL H7TD ZYPREXA 15 MG TABLET H7TD ZYPREXA 20 MG TABLET H7TD ZYPREXA ZYDIS 5 MG TABLET H7TD ZYPREXA ZYDIS 10 MG TABLET H7TD ZYPREXA ZYDIS 15 MG TABLET H7TD ZYPREXA ZYDIS 20 MG TABLET H7TD Antipsychotics Second Generation (Long-Acting Injectables) Label Name GCN HIC4 ABILIFY MAINTENA ER 300MG SYR H7XA ABILIFY MAINTENA ER 300MG VL H7XA ABILIFY MAINTENA ER 400MG SYR H7XA ABILIFY MAINTENA ER 400MG VL H7XA ARISTADA ER 441MG/1.6ML SYRINGE H7XA ARISTADA ER 662MG/2.4ML SYRINGE H7XA ARISTADA ER 882MG/3.2ML SYRINGE H7XA 09/01/2018 7
8 INVEGA SUSTENNA 39 MG PREF SYR H7TH INVEGA SUSTENNA 78 MG PREF SYR H7TH INVEGA SUSTENNA 117 MG PREF SYR H7TH INVEGA SUSTENNA 156 MG PREF SYR H7TH INVEGA SUSTENNA 234 MG PREF SYR H7TH INVEGA TRINZA 273MG/0.875ML H7TH INVEGA TRINZA 410MG/1.315ML H7TH INVEGA TRINZA 546MG/1.75ML H7TH INVEGA TRINZA 819MG/2.625ML H7TH RISPERDAL CONSTA 12.5 MG SYR H7TA RISPERDAL CONSTA 25 MG SYR H7TA RISPERDAL CONSTA 37.5 MG SYR H7TA RISPERDAL CONSTA 50 MG SYR H7TA ZYPREXA RELPREVV 210 MG VIAL H7TD ZYPREXA RELPREVV 300 MG VIAL H7TD ZYPREXA RELPREVV 405 MG VIAL H7TD 09/01/2018 8
9 Clinical Edit Criteria Logic 1. Is the incoming claim for a first generation antipsychotic? Yes (Go to #5) No (Go to #2) 2. Is the client less than 3 years of age? Yes (Deny) No (Go to #3) 3. Is the client greater than 5 years of age? Yes (Go to #5) No (Go to #4) 4. Is the incoming request for aripiprazole or risperidone? Yes (Go to #5) No (Deny) 5. Does the client have 2 or more active claims for different antipsychotic agents (HIC4) in the last 30 days (excluding the incoming request)? Yes (Deny) No (Approve 365 days) 09/01/2018 9
10 Clinical Edit Criteria Logic Diagram DENY Yes Step 1: Is the incoming claim for a first generation antipsychotic? No Step 2: Is the client less than 3 years of age? No Step 3: Is the client greater than 5 years of age? Yes Yes No APPROVE (365 days) No Step 5: Does the client have 2 or more active claims for different antipsychotic agents (HIC4) in the last 30 days (excluding the incoming request)? Yes Step 4: Is the incoming request for aripiprazole or risperidone? No Yes DENY DENY 09/01/
11 Clinical Edit Criteria Supporting Tables Step 5 (2 active claims for different antipsychotic agents (HIC4) excluding the incoming request) Required quantity: 2 Look back timeframe: 30 days See the Antipsychotics table in the Drugs Requiring Prior Authorization section 09/01/
12 Clinical Edit Criteria References 1. Clinical Pharmacology [online database]. Tampa, FL: Elsevier / Gold Standard, Inc Available at Accessed on June 30, Micromedex [online database]. Available at Accessed on June 30, Practice Parameter For the Use of Atypical Antipsychotic Medications in Children and Adolescents. American Academy of Child and Adolescent Psychiatry Available at Publication History The Publication History records the publication iterations and revisions to this document. Publication Date Notes 06/14/2011 Initial publication and posting to website 10/13/2011 Added a new section to specify the drugs requiring prior authorization In the Clinical Edit Criteria Supporting Tables section, revised section to specify the drug names, GCNs, and HICLs pertinent to steps 2 and 3 of the logic diagram 12/31/2012 Added Latuda and amitriptyline/perphenazine to the Antipsychotics drug table 03/26/2014 Added additional criteria and expanded Clinical Edit Criteria Supporting Tables 10/30/2014 Revised Step 1 of Clinical Edit Criteria and Logic Diagram Removed Table C from Clinical Edit Supporting Tables 03/20/2015 Added GCNs for Abilify Maintena syringes to the Drugs Requiring Prior Authorization table 04/21/2015 Revised Clinical Edit Criteria and Logic Diagram to reflect duplicate therapy check through HIC4s 10/07/2015 Revised Clinical Edit Criteria and Logic Diagram - updated criteria to reflect when a patient is taking a first generation antipsychotic the logic then goes to Step 5 Updated Criteria Logic Diagram, Step 8 Does the client have a diagnosis found in Table A or B in the last 730 days? 12/18/2015 Added GCNs for Aristada ER injection, Rexulti tablets, Brintellix tablets and Fetzima capsules Updated and verified all ICD-9s and 10s 09/01/
13 02/01/2016 Added GCNs for Invega Trinza 02/26/2016 Updated HIC4 for quetiapine containing agents 03/08/2016 Reviewed and updated diagnoses for insomnia 03/23/2016 Added GCN for Saphris 2.5mg tablet 05/18/2016 Added GCN for Zyprexa/Olanzapine 10mg vial 07/19/2016 Added GCNs for Aristada 12/05/2016 Updated criteria logic, page 9. Amended answer for question 7 to If no, go to #8 01/30/2017 Updated ICD-10s, Table A, page 22 02/17/2017 Added GCNs for Vraylar to Drugs Requiring PA, page 7 03/19/2018 Added molindone and pimozide GCNs to Drugs Requiring PA, page 3 09/01/2018 Created Navitus specific edit Removed diagnosis based criteria Revised Clinical Edit Criteria and Logic Diagram Revised Clinical Edit criteria References 09/01/
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