2. Did the patient receive this medication during a recent hospitalization? Y N

Transcription

1 Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS 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 Pennsylvania / Aetna Better Health Kids at 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 Please specify Quantity Frequency Strength Route of Administration Patient Information Patient ame: Patient ID: Patient Group o.: Patient DOB: Patient Phone: Prescribing Physician Expected Length of therapy 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. 1. Has Aetna Better Health authorized this medicine in the past for this patient (e.g. previous authorization is on file under this plan)? [If yes, then skip to question 6.] 2. Did the patient receive this medication during a recent hospitalization? [If no, then skip to question 4.] 3. Is this request being prescribed for labeled indications at FDA-approved doses? [o further questions.] Reference umber: C2321-A / Effective Date: 10/02/2017 1

2 4. Is the patient stable on the requested medication? [If no, then skip to question 11.] 5. Is this request being prescribed for labeled indications at FDA-approved doses? [o further questions.] 6. Did the patient have a clinical response to treatment and improvement in target symptoms? [If yes, then skip to question 8.] 7. Does the patient have a treatment plan for discontinuation or rationale for continued use? 8. Has the patient been evaluated for following: A) fasting lipids, B) blood pressure (BP), C) fasting glucose or A1c, D) tardive dyskinesia using the Abnormal Involuntary Movement Scale (AIMS) or Dyskinesia Identification System Condensed User Scale (DISCUS); E) Weight/BMI/waist circumference? [ote: Metabolic monitoring should be done at baseline, 3 months, 6 months then annually; Monitoring of tardive dyskinesia should be done at 3 months and annually thereafter.] If yes, please document results and date or submit records: 9. Is the patient 18 years of age or older? [If yes, then no further questions.] 10. Is the patient 6 years of age or older? [o further questions.] 11. Is this patient 18 years of age or older? [If no, then skip to question 20.] 12. Will the patient be using more than one antipsychotic? [If no, then go to question 14.] Reference umber: C2321-A / Effective Date: 10/02/2017 2

3 13. Is the patient transitioning from one antipsychotic to another (i.e., crosstitration)? [OTE: Dual antipsychotics may be authorized for up to 60 days to allow for cross-titration.] 14. Is the requested drug being prescribed by, or in consultation with a psychiatrist? 15. Is this request for the diagnosis of Bipolar Disorder or Schizophrenia? [If yes, then skip to question 18.] 16. Is this request for the diagnosis of Major Depressive Disorder? [If no, then no further question.] 17. Has the patient had failure or unresponsiveness to THREE different antidepressants from at least TWO different therapeutic subclasses (i.e., SSRI, SRI, mirtazapine, or bupropion)? If yes, please list antidepressants tried: [If no, then no further question.] 18. Has the patient had an inadequate response, or intolerable side effects, or contraindication of at least TWO preferred formulary atypical antipsychotics? (refer to plan formulary for a list of preferred agents) If yes, please list medications tried: [If yes, then skip to question 32.] 19. Was the patient stabilized on the requested medication during the most recent 90 days? If yes, please document where patient was receiving medication: [If yes, then skip to question 32.] Reference umber: C2321-A / Effective Date: 10/02/2017 3

4 20. Was patient s diagnosis based on comprehensive evaluation by or in consultation with a psychiatrist (members under 14 years must be seen by a child and adolescent psychiatrist) or neuropsychologist (or neurologist or developmental pediatrician for autism spectrum disorder or tic disorder)? 21. Do the patient s symptoms meet the Diagnostic and Statistical Manual of Mental Disorders (DSM5) criteria for that diagnosis? 22. Is the patient new to antipsychotics? [If no, then skip to question 24.] 23. Does the patient continue to have residual symptoms despite use of nonpharmacologic therapies such as evidence based behavioral, cognitive, and family based therapies? 24. Is this request for the diagnosis of Bipolar Disorder, Schizophrenia or chronic tic disorder (including Tourette s Syndrome)? [If yes, then skip to question 28.] 25. Is this request for the diagnosis of Major Depressive Disorder? [If no, then skip to question 27.] 26. Has the patient had an inadequate response, or intolerable side effects or contraindication to at least THREE different medication regimens for depression at an adequate dose and duration (at least 4 weeks): A) Antidepressant monotherapy, B) Antidepressant augmentation (SSRI or SRI plus any of the following: bupropion, lithium, buspirone, or liothyronine)? If yes, please list antidepressants tried: [If yes, then skip to question 28.] 27. Is this request for the diagnosis of psychomotor agitation, irritability, aggression, or self-injurious behavior associated with autistic disorder? [If no, then skip to question 31.] Reference umber: C2321-A / Effective Date: 10/02/2017 4

5 28. Is this request for a formulary preferred agent? (refer to the formulary for a list of preferred agents) [If yes, then skip to question 30.] 29. Has the patient had an inadequate response, or intolerable side effects, or contraindication of at least TWO preferred formulary atypical antipsychotics? (refer to plan formulary for a list of preferred agents)? If yes, please list medications tried: 30. Is the patient 6 years of age or older? [If yes, then skip to question 32.] 31. Is this request for the treatment of aggression associated with disruptive behavior disorders, conduct disorders, or intellectual disabilities? OTE: All requests for these indications require submission of the following with the request. Requests without this documentation will be denied. A) Treatment plan that comprehensively addresses all behaviors and conditions, B) Treatment history detailing previous use of more established medications to treat underlying/comorbid conditions, C) Documentation that aggressive behaviors continue and are not responding to non-pharmacologic therapies such as, but not limited to, evidence based behavioral, cognitive, and family based therapies despite compliance and participation with these interventions by the member and their parent/guardian. [o further questions.] 32. Is the requested drug being prescribed within FDA approved daily dosing, treatment guidelines or recognized compendia? Reference umber: C2321-A / Effective Date: 10/02/2017 5

6 33. Have baseline evaluations been documented for the following: A) weight or body mass index (BMI), waist circumference, B) blood pressure, B) fasting glucose or A1c, C) fasting lipid panel and extrapyramidal symptoms (EPS)/tardive dyskinesia using Abnormal Involuntary Movement Scale (AIMS) or Dyskinesia Identification System Condensed User Scale (DISCUS)? If yes, please document results and date or submit records: 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 Reference umber: C2321-A / Effective Date: 10/02/2017 6