Texas Standard Prior Authorization Form Addendum

Size: px
Start display at page:

Download "Texas Standard Prior Authorization Form Addendum"

Transcription

1 Texas Standard Prior Authorization Form Addendum Molina Healthcare of Texas 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 Molina Pharmacy Prior Authorization Department at Please contact Molina Pharmacy Prior Authorization Department at with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of Antipsychotics (Medicaid). Drug ame (select from list of drugs shown) Antipsychotics - First Generation Antipsychotics 2 nd Generation Patient ame: Patient ID: Patient DOB: Amitriptyline/Perphenazine Abilify Olanzapine Ziprasidone Physician ame: Physician Phone: Physician Fax: Physician Address: City, State, Zip: Chlorpromazine Abilify Maintena ER Olanzapine/Fluoxetine Zyprexa Fluphenazine Aristada ER Quetiapine Zyprexa Relprevv Haloperidol Clozapine Rexulti Zyprexa Zydis Loxapine Clozaril Risperdal Aripiprazole Loxitane Fanapt Risperdal Consta Vraylar Moban Fazaclo Risperidone Orap Geodon Saphris Perphenazine Invega ER Seroquel Thioridazine Invega Sustenna Seroquel XR Thiothixene Invega Trinza Symbyax Trifluoperazine Latuda Versacloz Patient Information Prescribing Physician Diagnosis: ICD Code: Directions for administration: Please circle the appropriate answer for each question. 1. Is the incoming claim for a first generation antipsychotic? If the answer to this question is yes, go to question 5. If the answer to this question is no, go to question 2.

2 2. Is the patient less than (<) 3 years of age? If the answer to this question is yes, denied. If the answer to this question is no, go to question Is the patient greater than (>) 5 years of age? If the answer to this question is yes, go to question 5. If the answer to this question is no, go to question Is the incoming request for aripiprazole or risperidone? If the answer to this question is yes, go to question 5. If the answer to this question is no, deny. 5. Does the patient have a diagnosis of insomnia in the last 365 days? If the answer to this question is yes, go to question 8. If the answer to this question is no, go to question Does the patient have a diagnosis of depression or major depressive disorder (MDD) in the last 365 days? If the answer to this question is yes, go to question 7. If the answer to this question is no, go to question Does the patient have 1 claim for an antidepressant agent in the last 60 days? If the answer to this question is yes, go to question 9. If the answer to this question is no, go to question Does the patient have a diagnosis included in Table A or B in the last 730 days? If the answer to this question is yes, go to question 9. If the answer to this question is no, deny. 9. Does the patient have 2 or more active claims for different antipsychotic agents in the last 180 days (excluding the incoming request)? If the answer to this question is yes, go to question 10. If the answer to this question is no, go to question Does the patient have 2 or more active claims for different antipsychotic agents in the last 30 days with (excluding the incoming request)? If the answer to this question is yes, deny. If the answer to this question is no, go to question Is this request for a non-preferred drug? The Texas Medicaid Preferred Drug List can be found at txvendordrug.com If the answer to this question is yes, go to question 12. If the answer to this question is no, approve for 365 days. 12. Has the patient been stable on 1 non-preferred agent for 30-days in the past 180 days? If the answer to this question is yes, approve for 365 days. If the answer to this question is no, go to question Has the patient failed a 14-day treatment with at least 1 preferred agent(s) within the past 180 days? If the answer to this question is yes, approve for 365 days. If the answer to this question is no, go to question Is there a documented allergy or contraindication to preferred agents in this class? If yes, please list which drug, dates tried, and describe treatment failure, contraindication or allergy. If no, deny.

3 Table A ICD-10 Code Description SIMPLE TPE SCHIZOPHREIA, USPECIFIED SIMPLE TPE SCHIZOPHREIA, SUBCHROIC SIMPLE TPE SCHIZOPHREIA, CHROIC SIMPLE TPE SCHIZOPHREIA, SUBCHROIC WITH ACUTE EXACERBATIO SIMPLE TPE SCHIZOPHREIA, CHROIC WITH ACUTE EXACERBATIO SIMPLE TPE SCHIZOPHREIA, I REMISSIO DISORGAIZED TPE SCHIZOPHREIA, USPECIFIED DISORGAIZED TPE SCHIZOPHREIA, SUBCHROIC DISORGAIZED TPE SCHIZOPHREIA, CHROIC DISORGAIZED TPE SCHIZOPHREIA, SUBCHROIC WITH ACUTE EXACERBATIO DISORGAIZED TPE SCHIZOPHREIA, CHROIC WITH ACUTE EXACERBATIO DISORGAIZED TPE SCHIZOPHREIA, I REMISSIO CATATOIC TPE SCHIZOPHREIA, USPECIFIED CATATOIC TPE SCHIZOPHREIA, SUBCHROIC CATATOIC TPE SCHIZOPHREIA, CHROIC CATATOIC TPE SCHIZOPHREIA, SUBCHROIC WITH ACUTE EXACERBATIO CATATOIC TPE SCHIZOPHREIA, CHROIC WITH ACUTE EXACERBATIO CATATOIC TPE SCHIZOPHREIA, I REMISSIO PARAOID TPE SCHIZOPHREIA, USPECIFIED PARAOID TPE SCHIZOPHREIA, SUBCHROIC PARAOID TPE SCHIZOPHREIA, CHROIC PARAOID TPE SCHIZOPHREIA, SUBCHROIC WITH ACUTE EXACERBATIO PARAOID TPE SCHIZOPHREIA, CHROIC WITH ACUTE EXACERBATIO PARAOID TPE SCHIZOPHREIA, I REMISSIO SCHIZOPHREIFORM DISORDER, USPECIFIED SCHIZOPHREIFORM DISORDER, SUBCHROIC SCHIZOPHREIFORM DISORDER, CHROIC SCHIZOPHREIFORM DISORDER, SUBCHROIC WITH ACUTE EXACERBATIO SCHIZOPHREIFORM DISORDER, CHROIC WITH ACUTE EXACERBATIO SCHIZOPHREIFORM DISORDER, I REMISSIO LATET SCHIZOPHREIA, USPECIFIED LATET SCHIZOPHREIA, SUBCHROIC LATET SCHIZOPHREIA, CHROIC LATET SCHIZOPHREIA, SUBCHROIC WITH ACUTE EXACERBATIO LATET SCHIZOPHREIA, CHROIC WITH ACUTE EXACERBATIO LATET SCHIZOPHREIA, I REMISSIO SCHIZOPHREIC DISORDERS, RESIDUAL TPE, USPECIFIED SCHIZOPHREIC DISORDERS, RESIDUAL TPE, SUBCHROIC SCHIZOPHREIC DISORDERS, RESIDUAL TPE, CHROIC SCHIZOPHREIC DISORDERS, RESIDUAL TPE, SUBCHROIC WITH ACUTE EXACERBATIO SCHIZOPHREIC DISORDERS, RESIDUAL TPE, CHROIC WITH ACUTE EXACERBATIO SCHIZOPHREIC DISORDERS, RESIDUAL TPE, I REMISSIO SCHIZOAFFECTIVE DISORDER, USPECIFIED SCHIZOAFFECTIVE DISORDER, SUBCHROIC SCHIZOAFFECTIVE DISORDER, CHROIC

4 29573 SCHIZOAFFECTIVE DISORDER, SUBCHROIC WITH ACUTE EXACERBATIO SCHIZOAFFECTIVE DISORDER, CHROIC WITH ACUTE EXACERBATIO SCHIZOAFFECTIVE DISORDER, I REMISSIO OTHER SPECIFIED TPES OF SCHIZOPHREIA, USPECIFIED OTHER SPECIFIED TPES OF SCHIZOPHREIA, SUBCHROIC OTHER SPECIFIED TPES OF SCHIZOPHREIA, CHROIC OTHER SPECIFIED TPES OF SCHIZOPHREIA, SUBCHROIC WITH ACUTE EXACERBATIO OTHER SPECIFIED TPES OF SCHIZOPHREIA, CHROIC WITH ACUTE EXACERBATIO OTHER SPECIFIED TPES OF SCHIZOPHREIA, I REMISSIO USPECIFIED SCHIZOPHREIA, USPECIFIED USPECIFIED SCHIZOPHREIA, SUBCHROIC USPECIFIED SCHIZOPHREIA, CHROIC USPECIFIED SCHIZOPHREIA, SUBCHROIC WITH ACUTE EXACERBATIO USPECIFIED SCHIZOPHREIA, CHROIC WITH ACUTE EXACERBATIO USPECIFIED SCHIZOPHREIA, I REMISSIO BIPOLAR I DISORDER, SIGLE MAIC EPISODE, USPECIFIED BIPOLAR I DISORDER, SIGLE MAIC EPISODE, MILD BIPOLAR I DISORDER, SIGLE MAIC EPISODE, MODERATE BIPOLAR I DISORDER, SIGLE MAIC EPISODE, SEVERE, WITHOUT METIO OF PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, SIGLE MAIC EPISODE, SEVERE, SPECIFIED AS WITH PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, SIGLE MAIC EPISODE, I PARTIAL OR USPECIFIED REMISSIO BIPOLAR I DISORDER, SIGLE MAIC EPISODE, I FULL REMISSIO BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MAIC, USPECIFIED BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MAIC, MILD BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MAIC, MODERATE BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MAIC, SEVERE, WITHOUT METIO OF PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MAIC, SEVERE, SPECIFIED AS WITH PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MAIC, I PARTIAL OR USPECIFIED REMISSIO BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MAIC, I FULL REMISSIO BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) DEPRESSED, USPECIFIED BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) DEPRESSED, MILD BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) DEPRESSED, MODERATE BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) DEPRESSED, SEVERE, WITHOUT METIO OF PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) DEPRESSED, SEVERE, SPECIFIED AS WITH PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) DEPRESSED, SEVERE, SPECIFIED AS WITH PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) DEPRESSED, I FULL REMISSIO BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MIXED, USPECIFIED

5 BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MIXED, MILD BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MIXED, MODERATE BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MIXED, SEVERE, WITHOUT METIO OF PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MIXED, SEVERE, SPECIFIED AS WITH PSCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MIXED, I PARTIAL OR USPECIFIED REMISSIO BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) MIXED, I FULL REMISSIO 2967 BIPOLAR I DISORDER, MOST RECET EPISODE (OR CURRET) USPECIFIED BIPOLAR DISORDER, USPECIFIED ATPICAL MAIC DISORDER OTHER BIPOLAR DISORDER USPECIFIED EPISODIC MOOD DISORDER OTHER SPECIFIED EPISODIC MOOD DISORDER AUTISTIC DISORDER, CURRET OR ACTIVE STATE AUTISTIC DISORDER, RESIDUAL STATE CHILDHOOD DISITEGRATIVE DISORDER, CURRET OR ACTIVE STATE CHILDHOOD DISITEGRATIVE DISORDER, RESIDUAL STATE OTHER SPECIFIED PERVASIVE DEVELOPMETAL DISORDERS, CURRET OR ACTIVE STATE OTHER SPECIFIED PERVASIVE DEVELOPMETAL DISORDERS, RESIDUAL STATE USPECIFIED PERVASIVE DEVELOPMETAL DISORDER, CURRET OR ACTIVE STATE USPECIFIED PERVASIVE DEVELOPMETAL DISORDER, RESIDUAL STATE TOURETTE S DISORDER ICD-10 Code Description F200 PARAOID SCHIZOPHREIA F201 DISORGAIZED SCHIZOPHREIA F202 CATATOIC SCHIZOPHREIA F203 UDIFFERETIATED SCHIZOPHREIA F205 RESIDUAL SCHIZOPHREIA F2081 SCHIZOPHREIFORM DISORDER F2089 OTHER SCHIZOPHREIA F209 SCHIZOPHREIA, USPECIFIED F21 SCHIZOTPAL DISORDER F22 DELUSIOAL DISORDERS F23 BRIEF PSCHOTIC DISORDER F24 SHARED PSCHOTIC DISORDER F250 SCHIZOAFFECTIVE DISORDER, BIPOLAR TPE F251 SCHIZOAFFECTIVE DISORDER, DEPRESSIVE TPE F258 OTHER SCHIZOAFFECTIVE DISORDERS F259 SCHIZOAFFECTIVE DISORDER, USPECIFIED F28 OTHER PSCHOTIC DISORDER OT DUE TO A SUBSTACE OR KOW PHSIOLOGICAL CODITIO F29 USPECIFIED PSCHOSIS OT DUE TO A SUBSTACE OR KOW PHSIOLOGICAL CODITIO F3010 MAIC EPISODE WITHOUT PSCHOTIC SMPTOMS USPECIFIED F3011 MAIC EPISODE WITHOUT PSCHOTIC SMPTOMS MILD F3012 MAIC EPISODE WITHOUT PSCHOTIC SMPTOMS MODERATE F3013 MAIC EPISODE, SEVERE, WITHOUT PSCHOTIC SMPTOMS F302 MAIC EPISODE, SEVERE WITH PSCHOTIC SMPTOMS F303 MAIC EPISODE I PARTIAL REMISSIO

6 F304 F308 F309 F310 F3110 F3111 F3112 F3113 F312 F3130 F3131 F3132 F314 F315 F3160 F3161 F3162 F3163 F3164 F3170 F3171 F3172 F3173 F3174 F3175 F3176 F3177 F3178 F3181 F3189 F319 F340 F341 F3481 F3489 F349 F39 F840 F842 F843 F845 F848 F849 F952 MAIC EPISODE I FULL REMISSIO OTHER MAIC EPISODES MAIC EPISODE, USPECIFIED BIPOLAR DISORDER, CURRET EPISODE HPOMAIC BIPOLAR DISORDER, CURRET EPISODE MAIC WITHOUT PSCHOTIC FEATURES USPECIFIED BIPOLAR DISORDER, CURRET EPISODE MAIC WITHOUT PSCHOTIC FEATURES MILD BIPOLAR DISORDER, CURRET EPISODE MAIC WITHOUT PSCHOTIC FEATURES MODERATE BIPOLAR DISORDER, CURRET EPISODE MAIC WITHOUT PSCHOTIC FEATURES SEVERE BIPOLAR DISORDER, CURRET EPISODE MAIC SEVERE WITH PSCHOTIC FEATURES BIPOLAR DISORDER, CURRET EPISODE DEPRESSED, MILD OR MODERATE SEVERIT USPECIFIED BIPOLAR DISORDER, CURRET EPISODE DEPRESSED, MILD BIPOLAR DISORDER, CURRET EPISODE DEPRESSED, MODERATE BIPOLAR DISORDER, CURRET EPISODE DEPRESSED, SEVERE, WITHOUT PSCHOTIC FEATURES BIPOLAR DISORDER, CURRET EPISODE DEPRESSED, SEVERE, WITH PSCHOTIC FEATURES BIPOLAR DISORDER, CURRET EPISODE MIXED USPECIFIED BIPOLAR DISORDER, CURRET EPISODE MIXED MILD BIPOLAR DISORDER, CURRET EPISODE MIXED MODERATE BIPOLAR DISORDER, CURRET EPISODE MIXED SEVERE, WITHOUT PSCHOTIC FEATURES BIPOLAR DISORDER, CURRET EPISODE MIXED SEVERE, WITH PSCHOTIC FEATURES BIPOLAR DISORDER, CURRETL I REMISSIO MOST RECET EPISODE USPECIFIED BIPOLAR DISORDER, I PARTIAL REMISSIO, MOST RECET EPISODE HPOMAIC BIPOLAR DISORDER, I FULL REMISSIO, MOST RECET EPISODE HPOMAIC BIPOLAR DISORDER, I PARTIAL REMISSIO, MOST RECET EPISODE MAIC BIPOLAR DISORDER, I FULL REMISSIO, MOST RECET EPISODE MAIC BIPOLAR DISORDER, I PARTIAL REMISSIO, MOST RECET EPISODE DEPRESSED BIPOLAR DISORDER, I FULL REMISSIO, MOST RECET EPISODE DEPRESSED BIPOLAR DISORDER, I PARTIAL REMISSIO, MOST RECET EPISODE MIXED BIPOLAR DISORDER, I FULL REMISSIO, MOST RECET EPISODE MIXED BIPOLAR II DISORDER OTHER BIPOLAR DISORDER BIPOLAR DISORDER, USPECIFIED CCLOTHMIC DISORDER DSTHMIC DISORDER DISRUPTIVE MOOD DSREGULATIO DISORDER OTHER SPECIFIED PERSISTET MOOD DISORDERS PERSISTET MOOD [AFFECTIVE] DISORDER, USPECIFIED USPECIFIED MOOD [AFFECTIVE] DISORDER AUTISTIC DISORDER RETT'S SDROME OTHER CHILDHOOD DISITEGRATIVE DISORDER ASPERGER'S SDROME OTHER PERVASIVE DEVELOPMETAL DISORDERS PERVASIVE DEVELOPMETAL DISORDER, USPECIFIED TOURETTE S DISORDER

7 ICD-9 Code Description 2970 PARAOID STATE, SIMPLE 2971 DELUSIOAL DISORDER 2972 PARAPHREIA 2973 SHARED PSCHOTIC DISORDER Table B 2978 OTHER SPECIFIED PARAOID STATES 2979 USPECIFIED PARAOID STATE 2989 USPECIFIED PSCHOSIS ITERMITTET EXPLOSIVE DISORDER CODUCT DISORDER, CHILDHOOD OSET CODUCT DISORDER, ADOLESCET OSET CODUCT DISORDER, OSET USPECIFIED OPPOSITIOAL DEFIAT DISORDER ICD-10 Code Description F22 F23 F24 F29 F6381 F911 F912 F913 F919 DELUSIOAL DISORDERS BRIEF PSCHOTIC DISORDER SHARED PSCHOTIC DISORDER USPECIFIED PSCHOSIS OT DUE TO A SUBSTACE OR KOW PHSIOLOGICAL CODITIO ITERMITTET EXPLOSIVE DISORDER CODUCT DISORDER, CHILDHOOD-OSET TPE CODUCT DISORDER, ADOLESCET-OSET TPE OPPOSITIOAL DEFIAT DISORDER CODUCT DISORDER, USPECIFIED Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (or Authorized) Signature Date

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

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

More information

Antipsychotics Prior Authorization Criteria for Louisiana Fee for Service and MCO Medicaid Recipients

Antipsychotics Prior Authorization Criteria for Louisiana Fee for Service and MCO Medicaid Recipients Antipsychotics Prior Authorization Criteria for Louisiana Fee for Service and MCO Medicaid Recipients Preferred Agents (Oral) a Amitriptyline/Perphenazine (Generic) Aripiprazole Tablet (Generic) b Chlorpromazine

More information

Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria

Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria 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

More information

Texas Prior Authorization Program Clinical Edit Criteria

Texas Prior Authorization Program Clinical Edit Criteria Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization

More information

Pharmacy Medical Necessity Guidelines: Antipsychotic Medications

Pharmacy Medical Necessity Guidelines: Antipsychotic Medications Pharmacy Medical Necessity Guidelines: Effective: October 1, 2016 Prior Authorization Required Type of Review Care Management Not Covered Type of Review Clinical Review Pharmacy (RX) or Medical (MED) Benefit

More information

Antipsychotic Medications Age and Step Therapy

Antipsychotic Medications Age and Step Therapy Market DC *- Florida Healthy Kids Antipsychotic Medications Age and Step Therapy Override(s) Approval Duration Prior Authorization 1 year Quantity Limit *Virginia Medicaid See State Specific Mandates *Indiana

More information

Pharmacy Benefit Management (PBM) Program FORMULARY/PRODUCT RESTRICTIONS

Pharmacy Benefit Management (PBM) Program FORMULARY/PRODUCT RESTRICTIONS Workforce Safety & Insurance Revised Document Date: 07/21/2015 1600 E Century Ave Ste 1 PO Box 5585 Bismarck, ND 58506-5585 701.328.3800 1.800.777.5033 www.workforcesafety.com Pharmacy Benefit Management

More information

HOSPITAL BASED INPATIENT PSYCHIATRIC SERVICES (HBIPS) MEASURE SET

HOSPITAL BASED INPATIENT PSYCHIATRIC SERVICES (HBIPS) MEASURE SET HOSPITAL BASED INPATIENT PSYCHIATRIC SERVICES (HBIPS) MEASURE SET Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: February, 2013 Most recently revised: December 2018 The Psychiatric Measure Set CMS

More information

See Important Reminder at the end of this policy for important regulatory and legal information.

See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: (Invega Sustenna, Invega Trinza) Reference Number: CP.PHAR.291 Effective Date: 12.01.16 Last Review Date: 08.18 Line of Business: Medicaid See Important Reminder at the end of this policy

More information

Pharmacy Medical Necessity Guidelines: Antipsychotic Medications

Pharmacy Medical Necessity Guidelines: Antipsychotic Medications Pharmacy Medical Necessity Guidelines: Effective: April 1, 2018 Prior Authorization Required Type of Review Care Management Not Covered Type of Review Clinical Review Pharmacy (RX) or Medical (MED) Benefit

More information

Pharmacy Medical Necessity Guidelines: Antipsychotic Medications

Pharmacy Medical Necessity Guidelines: Antipsychotic Medications Pharmacy Medical Necessity Guidelines: Antipsychotic Medications Effective: July. 1, 2016 Prior Authorization Required Type of Review Care Management Not Covered Type of Review Clinical Review Pharmacy

More information

Clinical Policy: Olanzapine Long-Acting Injection (Zyprexa Relprevv) Reference Number: CP.PHAR.292 Effective Date: Last Review Date: 08.

Clinical Policy: Olanzapine Long-Acting Injection (Zyprexa Relprevv) Reference Number: CP.PHAR.292 Effective Date: Last Review Date: 08. Clinical Policy: (Zyprexa Relprevv) Reference Number: CP.PHAR.292 Effective Date: 12.01.16 Last Review Date: 08.18 Line of Business: Medicaid See Important Reminder at the end of this policy for important

More information

See Important Reminder at the end of this policy for important regulatory and legal information.

See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: (Abilify Maintena, Aristada, Aristada Initio) Reference Number: CP.PHAR.290 Effective Date: 12.01.16 Last Review Date: 08.18 Line of Business: Medicaid Coding Implications Revision Log

More information

Nebraska Medicaid Criteria. Abilify Maintena

Nebraska Medicaid Criteria. Abilify Maintena Nebraska Medicaid Criteria All initial and renewal authorizations are for 12 months in duration. Abilify Maintena *Criteria for Authorization for Abilify Maintena The individual has a current DSM diagnosis

More information

Commissioner for the Department for Medicaid Services Selections for Preferred Products

Commissioner for the Department for Medicaid Services Selections for Preferred Products Commissioner for the Department for Medicaid Services Selections for Preferred Products This is a summary of the final Preferred Drug List (PDL) selections made by the Commissioner for the Department for

More information

Rexulti (brexpiprazole)

Rexulti (brexpiprazole) Market DC Rexulti (brexpiprazole) Override(s) Approval Duration Prior Authorization 1 year Quantity Limit *Indiana see State Specific Mandates below *Maryland see State Specific Mandates below *Virginia

More information

Molina Healthcare of Texas

Molina Healthcare of Texas Texas Standard Prior Authorization Form Addendum Molina Healthcare of Texas Ingrezza (Marketplace) This fax machine is located in a secure location as required by HIPAA Regulations. Complete / Review information,

More information

ABILIFY INJ. Products Affected Step 2: ABILIFY MAINTENA PREFILLED SYRINGE 300 MG INTRAMUSCULAR ABILIFY MAINTENA PREFILLED SYRINGE 400 MG INTRAMUSCULAR

ABILIFY INJ. Products Affected Step 2: ABILIFY MAINTENA PREFILLED SYRINGE 300 MG INTRAMUSCULAR ABILIFY MAINTENA PREFILLED SYRINGE 400 MG INTRAMUSCULAR ABILIFY INJ ABILIFY MAINTENA PREFILLED SYRINGE 300 MG ABILIFY MAINTENA PREFILLED SYRINGE 400 MG ABILIFY MAINTENA SUSPENSION RECONSTITUTED ER 300 MG Claim will pay automatically for ABILIFY MAINTENA if

More information

Step Therapy Group. Atypical Antipsychotic Agents

Step Therapy Group. Atypical Antipsychotic Agents Atypical Antipsychotic Agents Any beneficiary newly enrolled into Community Care, Inc. currently receiving aripiprazole, aripiprazole ODT, risperidone, risperidone ODT, olanzapine, olanzapine ODT, quetiapine,

More information

Pharmacy Medical Necessity Guidelines: Atypical Antipsychotic Medications. Effective: December 12, 2017

Pharmacy Medical Necessity Guidelines: Atypical Antipsychotic Medications. Effective: December 12, 2017 Pharmacy Medical Necessity Guidelines: Effective: December 12, 2017 Prior Authorization Required Type of Review Care Management Not Covered Type of Review Clinical Review Pharmacy (RX) or Medical (MED)

More information

REXULTI (brexpiprazole) oral tablet

REXULTI (brexpiprazole) oral tablet REXULTI (brexpiprazole) oral tablet Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy

More information

Medications and Children Disorders

Medications and Children Disorders Mental Health Comprehensive Services Providing Family Stability and Developing Life Coping Skills Medications and Children Disorders Psychiatric medications can be an effective part of the treatment for

More information

Literature Scan: Parenteral Antipsychotics

Literature Scan: Parenteral Antipsychotics Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119

More information

Pharmacy Medical Necessity Guidelines: Atypical Antipsychotic Medications. Effective: February 20, 2017

Pharmacy Medical Necessity Guidelines: Atypical Antipsychotic Medications. Effective: February 20, 2017 Pharmacy Medical Necessity Guidelines: Effective: February 20, 2017 Prior Authorization Required Type of Review Care Management Not Covered Type of Review Clinical Review Pharmacy (RX) or Medical (MED)

More information

INJECTABLE ANTIPSYCHOTICS AUTHORIZATION FORM

INJECTABLE ANTIPSYCHOTICS AUTHORIZATION FORM SUBMIT TO Utilization Management Department Phone: 1.866.912.6285 Fax: 1.866.694.3649 MEMBER INFORMATION INJECTABLE ANTIPSYCHOTICS AUTHORIZATION FORM Fax completed form to Cepatico at 866.694.3649. Upon

More information

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

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

More information

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

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

More information

Debra Brown, PharmD, FASCP Pharmaceutical Consultant II Specialist. HMS Training Webinar January 27, 2017

Debra Brown, PharmD, FASCP Pharmaceutical Consultant II Specialist. HMS Training Webinar January 27, 2017 Debra Brown, PharmD, FASCP Pharmaceutical Consultant II Specialist HMS Training Webinar January 27, 2017 1 Describe nationwide prevalence and types of elderly dementia + define BPSD Define psychotropic

More information

A Brief Overview of Psychiatric Pharmacotherapy. Joel V. Oberstar, M.D. Chief Executive Officer

A Brief Overview of Psychiatric Pharmacotherapy. Joel V. Oberstar, M.D. Chief Executive Officer A Brief Overview of Psychiatric Pharmacotherapy Joel V. Oberstar, M.D. Chief Executive Officer Disclosures Some medications discussed are not approved by the FDA for use in the population discussed/described.

More information

STEP THERAPY CRITERIA

STEP THERAPY CRITERIA DRUG CLASS PRODUCTS) BRAND NAME (BRAND ONLY) (generic) STEP THERAPY CRITERIA ATYPICAL ANTIPSYCHOTICS (BRAND ONLY ABILIFY (AL TABLET & AL SOLUTION ONLY) (aripiprazole) FANAPT (BRAND ONLY) (iloperidone)

More information

Judges Reference Table for the March 2016 Psychotropic Medication Utilization Parameters for Foster Children

Judges Reference Table for the March 2016 Psychotropic Medication Utilization Parameters for Foster Children Judges Reference Table for the Psychotropic Medication Utilization Parameters for Foster Children Stimulants for treatment of ADHD Preschool (Ages 3-5 years) Child (Ages 6-12 years) Adolescent (Ages 13-17

More information

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. I. Requirements for Prior Authorization of Antipsychotics

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES. I. Requirements for Prior Authorization of Antipsychotics MEDICAL ASSISTANCE HBOOK PRI AUTHIZATION OF PHARMACEUTICAL SERVICES I. Requirements for Prior Authorization of Antipsychotics A. Prescriptions That Require Prior Authorization Prescriptions for Antipsychotics

More information

Objectives. Antipsychotics 7/25/2016. LeadingAge Florida 53rd Annual Convention & Exposition

Objectives. Antipsychotics 7/25/2016. LeadingAge Florida 53rd Annual Convention & Exposition Reducing the Use of Antipsychotics in Long Term Care Communities Alan W. Obringer RPh, CPh, CGP Executive Director Senior Care Pharmacy Objectives Recognize the clinical evidence for the need to change

More information

Antipsychotics and stroke risk

Antipsychotics and stroke risk Integrating Sentinel into Routine Regulatory Drug Review: A Snapshot of the First Year Antipsychotics and stroke risk Lockwood G. Taylor, PhD, MPH Division of Epidemiology II Office of Pharmacovigilance

More information

LATUDA Commercial Update

LATUDA Commercial Update LATUDA Commercial Update LATUDA Meeting (Tokyo) January 2011 Mark Iwicki President and Chief Operating Officer Sunovion Pharmaceuticals Inc. Sunovion Is Uniquely Positioned to Deliver Strong Performance

More information

Slide 1. Slide 2. Slide 3. About this module. About this module. Antipsychotics: The Essentials Module 5 A Primer on Selected Antipsychotics

Slide 1. Slide 2. Slide 3. About this module. About this module. Antipsychotics: The Essentials Module 5 A Primer on Selected Antipsychotics Slide 1 Antipsychotics: The Essentials Module 5 A Primer on Selected Antipsychotics Flavio Guzmán, MD Slide 2 About this module 13 antipsychotics will be studied 3 first generation antipsychotics 10 second

More information

Michael J. Bailey, M.D. OptumHealth Public Sector

Michael J. Bailey, M.D. OptumHealth Public Sector Michael J. Bailey, M.D. OptumHealth Public Sector LIHP Quality Charter To ensure the quality of care delivered to enrollees in San Diego County Assistance Programs, such as County Medical Services (CMS)

More information

What Team Members Other Than Prescribers Need To Know About Antipsychotics

What Team Members Other Than Prescribers Need To Know About Antipsychotics What Team Members Other Than Prescribers Need To Know About Antipsychotics The Care Transitions Network National Council for Behavioral Health Montefiore Medical Center Northwell Health New York State

More information

U T I L I Z A T I O N E D I T S

U T I L I Z A T I O N E D I T S I N D I A N A H E A L T H C O V E R A G E P R O G R A M S U T I L I Z A T I O N E D I T S A P R I L 1 9, 2 0 1 2 s for s Refer to Provider Bulletin BT200709 for additional information regarding the Mental

More information

Kelly E. Williams, Pharm.D. PGY2 Psychiatric Pharmacy Resident April 16,2009

Kelly E. Williams, Pharm.D. PGY2 Psychiatric Pharmacy Resident April 16,2009 Kelly E. Williams, Pharm.D. PGY2 Psychiatric Pharmacy Resident April 16,2009 List the antipsychotics most often prescribed Compare and contrast the use and adverse effects experienced in the pediatric

More information

Quarterly Pharmacy Formulary Change Notice

Quarterly Pharmacy Formulary Change Notice MEDICAID PROVIDER BULLETIN February 26, 2015 Quarterly Pharmacy Formulary Change Notice Summary of Change: The formulary changes listed in the table below were reviewed and approved at our September 24,

More information

ANTIPSYCHOTICS/ NEUROLEPTICS

ANTIPSYCHOTICS/ NEUROLEPTICS Pharmacological Interventions Tutorial Antipsychotic medications First Generation (Typicals) Includes phenothiazines, thioxanthenes, butyrophenones ANTIPSYCHOTICS/ NEUROLEPTICS Second Generation (Atypicals)

More information

Pharmacy Prior Authorization

Pharmacy Prior Authorization Pharmacy Prior Authorization MERC CARE (MEDICAID) Promacta (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax

More information

IOWA MEDICAID DRUG UTILIZATION REVIEW COMMISSION 100 Army Post Road (515)

IOWA MEDICAID DRUG UTILIZATION REVIEW COMMISSION 100 Army Post Road (515) IOWA MEDICAID DRUG UTILIZATION REVIEW COMMISSION 100 Army Post Road (515) 974-3131 -866-626-0216 Brett Faine, Pharm.D. Larry Ambroson, R.Ph. Casey Clor, M.D. Professional Staff: Mark Graber, M.D., FACEP

More information

Appendix: Psychotropic Medication Reference Tables

Appendix: Psychotropic Medication Reference Tables Appendix: Psychotropic Medication Reference Tables How to Use these Tables These reference tables are designed to provide clinic staff with specific medication related criteria for the Polypharmacy, Cardiometabolic

More information

Drug Use Criteria: Atypical Antipsychotics (oral)

Drug Use Criteria: Atypical Antipsychotics (oral) Texas Vendor Drug Program Drug Use Criteria: Atypical Antipsychotics (oral) Publication History 1. Developed: February 1997 2. Revised: September 2017; September 2015; December 2013; February 2012; June

More information

2. Is the patient responding to medication? Y N

2. Is the patient responding to medication? Y N Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS ADD-ADHD Stimulants (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

2019 STEP THERAPY CRITERIA UCare Individual & Family Plans UCare Individual & Family Plans with Fairview

2019 STEP THERAPY CRITERIA UCare Individual & Family Plans UCare Individual & Family Plans with Fairview 2019 STEP THERAPY CRITERIA UCare Individual & Family Plans UCare Individual & Family Plans with Fairview In some cases, UCare requires you to first try certain drugs to treat your medical condition before

More information

Implementation of Performance Improvement Projects

Implementation of Performance Improvement Projects Implementation of Performance Improvement Projects Mary Marlatt-Dumas, Quality Manager, NMRE, Region 2 Diane L. Bennett, QI Coordinator/Compliance Officer, NorthCare Network, Region 1 Bill Phelps, Quality

More information

3. Does the patient meet ALL of the following requirements? Y N

3. Does the patient meet ALL of the following requirements? Y N Pharmacy Prior Authorization AETA BETTER HEALTH FLORIDA Procrit - Retacrit (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign

More information

Proposed Changes to Existing Measure for HEDIS : Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA)

Proposed Changes to Existing Measure for HEDIS : Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA) Proposed Changes to Existing Measure for HEDIS 1 2020: Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA) NCQA seeks comments on proposed modifications to the HEDIS Health

More information

2. Does the patient have a diagnosis of chronic idiopathic thrombocytopenic purpura (ITP)?

2. Does the patient have a diagnosis of chronic idiopathic thrombocytopenic purpura (ITP)? Pharmacy Prior Authorization MERC CARE (MEDICAID) Promacta (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax

More information

Antipsychotics. Something Old, Something New, Something Used to Treat the Blues

Antipsychotics. Something Old, Something New, Something Used to Treat the Blues Antipsychotics Something Old, Something New, Something Used to Treat the Blues Objectives To provide an overview of the key differences between first and second generation agents To an overview the newer

More information

2017 HEDIS Pediatric Toolkit

2017 HEDIS Pediatric Toolkit 2017 HEDIS Pediatric Toolkit Prepared By: Quality Improvement Department, Molina Healthcare of Washington MolinaHealthcare.com HEDIS 2017 TABLE OF CONTENTS Welcome to 2017 HEDIS TIPS...2 Molina Provider

More information

Measure #383 (NQF 1879): Adherence to Antipsychotic Medications For Individuals with Schizophrenia National Quality Strategy Domain: Patient Safety

Measure #383 (NQF 1879): Adherence to Antipsychotic Medications For Individuals with Schizophrenia National Quality Strategy Domain: Patient Safety Measure #383 (NQF 1879): Adherence to Antipsychotic Medications For Individuals with Schizophrenia National Quality Strategy Domain: Patient Safety 2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY

More information

Table of Contents. 1.0 Policy Statement...1

Table of Contents. 1.0 Policy Statement...1 Division of Medical Assistance General Clinical Policy No. A-6 Table of Contents 1.0 Policy Statement...1 2.0 Policy Guidelines...1 2.1 Eligible Recipients...1 2.1.1 General Provisions...1 2.1.2 EPSDT

More information

See Important Reminder at the end of this policy for important regulatory and legal information.

See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: Reference Number: AZ.CP.PHAR.10.11.10 Effective Date: 07.16 Last Review Date: 09.12.18 Line of Business: Medicaid Arizona Revision Log See Important Reminder at the end of this policy

More information

Drug Class Literature Scan: Oral and Parenteral Antipsychotics

Drug Class Literature Scan: Oral and Parenteral Antipsychotics Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-2596

More information

2. Does the patient have chronic urticaria? Y N

2. Does the patient have chronic urticaria? Y N Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Xolair (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

Comparison of Atypical Antipsychotics

Comparison of Atypical Antipsychotics PL Detail-Document #281006 This PL Detail-Document gives subscribers additional insight related to the Recommendations published in PHARMACIST S LETTER / PRESCRIBER S LETTER October 2012 Comparison of

More information

3. Has the member received the requested drug for less than 2 years? Y N

3. Has the member received the requested drug for less than 2 years? Y N Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Zoladex (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign

More information

Policy Evaluation: Low Dose Quetiapine Safety Edit

Policy Evaluation: Low Dose Quetiapine Safety Edit Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University 500 Summer Street NE, E35, Salem, Oregon 97301 1079 Phone 503 947 5220 Fax 503

More information

Ativan and geodon compatibility

Ativan and geodon compatibility P ford residence southampton, ny Ativan and geodon compatibility In this case, a patient developed severe hypotension (66/30 mm Hg) after receiving intramuscular olanzapine and intramuscular lorazepam

More information

Antipsychotic Medication

Antipsychotic Medication Antipsychotic Medication Mary Knutson, RN 3-7-12 Mosby items and derived items 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 1 Clinical Uses of Antipsychotics Short-term: in severe depression and

More information

Attention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Preferred Drug List Changes - UPDATE

Attention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Preferred Drug List Changes - UPDATE Attention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Drug List Changes - UPDATE Note: This article was previously published in the December 2014 Medicaid

More information

Measure #383 (NQF 1879): Adherence to Antipsychotic Medications For Individuals with Schizophrenia National Quality Strategy Domain: Patient Safety

Measure #383 (NQF 1879): Adherence to Antipsychotic Medications For Individuals with Schizophrenia National Quality Strategy Domain: Patient Safety Measure #383 (NQF 1879): Adherence to Antipsychotic Medications For Individuals with Schizophrenia National Quality Strategy Domain: Patient Safety 2017 OPTIONS F INDIVIDUAL MEASURES: REGISTRY ONLY MEASURE

More information

3. Have baseline A1c or fasting glucose, thyroid-stimulating hormone (TSH), and electrocardiography (EKG) been checked?

3. Have baseline A1c or fasting glucose, thyroid-stimulating hormone (TSH), and electrocardiography (EKG) been checked? Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Somatostatin Analogs (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

3. Has the member received the requested drug for less than 2 years? Y N

3. Has the member received the requested drug for less than 2 years? Y N Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Zoladex (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

2. Does the patient have a diagnosis of Crohn s disease? Y N

2. Does the patient have a diagnosis of Crohn s disease? Y N Pharmacy Prior Authorization MERC CARE PLA (MEDICAID) Stelara (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax

More information

Pharmacy Prior Authorization

Pharmacy Prior Authorization Pharmacy Prior Authorization AETA BETTER HEALTH ILLIOIS (MEDICAID) CS Stimulants (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

Riding the Waves: Tools for the Management of Bipolar Disorder

Riding the Waves: Tools for the Management of Bipolar Disorder Riding the Waves: Tools for the Management of Bipolar Disorder Jacintha S. Cauffield, Pharm.D., BCPS, CDE Associate Professor of Pharmacy Practice Palm Beach Atlantic University Lloyd L. Gregory School

More information

2. Is this request for a preferred medication? Y N

2. Is this request for a preferred medication? Y N Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Opioids Long-Acting and Short-Acting (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

2. Does the member have a diagnosis of central precocious puberty? Y N

2. Does the member have a diagnosis of central precocious puberty? Y N Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Leuprolide (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

IMPORTANT NOTICE. Changes to dispensing of some Behavioral Health Medications for DC Healthcare Alliance members

IMPORTANT NOTICE. Changes to dispensing of some Behavioral Health Medications for DC Healthcare Alliance members IMPORTANT NOTICE Changes to dispensing of some Behavioral Health Medications for DC Healthcare Alliance members These changes apply only to members covered under the DC Healthcare Alliance program Alliance

More information

Pharmacy Prior Authorization

Pharmacy Prior Authorization Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Promacta (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

10/2/2017. Evaluate existing data in regards to the appropriate treatment of schizophrenia

10/2/2017. Evaluate existing data in regards to the appropriate treatment of schizophrenia Evaluate existing data in regards to the appropriate treatment of schizophrenia Review risks and benefits of antipsychotic therapy in the management of acute psychosis Rebecca L. Jones, Pharm.D., B.C.P.P.

More information

Antipsychotic Prior Authorization Request

Antipsychotic Prior Authorization Request Antipsychotic Prior Authorization Request Commonwealth of Massachusetts MassHealth Drug Utilization Review Program P.O. Box 2586, Worcester, MA 01613-2586 Fax: 1-877-208-7428 Phone: 1-800-745-7318 MassHealth

More information

Steps for Initiating Electroconvulsive Therapy Treatment

Steps for Initiating Electroconvulsive Therapy Treatment Steps for Initiating Electroconvulsive Therapy Treatment PSYCHIATRISTS CAN REFER PATIENTS FOR ECT TREATMENT AT EL CAMINO HOSPITAL BY CALLING THE ECT NURSE COORDINATOR AT 650-962-5795. Once the referral

More information

Treat Schizophrenia Schizoaffective disorder Bipolar disorder Psychotic depression Off-label uses Insomnia Tics Delirium Stuttering

Treat Schizophrenia Schizoaffective disorder Bipolar disorder Psychotic depression Off-label uses Insomnia Tics Delirium Stuttering Robert M. Millay RN MSN Ed Professor, Napa Valley College Psychiatric Technician Programs Copyright 2015, 2011, 2007, 2003, 1999, 1995, 1991 by Mosby, an imprint of Elsevier Inc. Treat Schizophrenia Schizoaffective

More information

3. Has the patient had a sustained improvement in Pain or Function (e.g. PEG scale with a 30 percent response from baseline)?

3. Has the patient had a sustained improvement in Pain or Function (e.g. PEG scale with a 30 percent response from baseline)? Pharmacy Prior Authorization AETA BETTER HEALTH KETUCK Opioids Long-Acting and Short-Acting (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

Table of Contents Introduction... 3

Table of Contents Introduction... 3 Table of Contents Introduction... 3 Diabetes Care Overview - General HEDIS Tips to Improve Scores... 4 HEDIS Tip Sheets... 5 Comprehensive Diabetes Care Medical Record Documentation... 6 Comprehensive

More information

Drug Class Review Second Generation Antipsychotic Drugs

Drug Class Review Second Generation Antipsychotic Drugs Drug Class Review Second Generation Antipsychotic Drugs Final Update 4 Report November 2013 The purpose of reports is to make available information regarding the comparative clinical effectiveness and

More information

Table of Contents Introduction... 3

Table of Contents Introduction... 3 Table of Contents Introduction... 3 Diabetes Care Overview - General HEDIS Tips to Improve Scores... 4 HEDIS Tip Sheets... 5 Comprehensive Diabetes Care Medical Record Documentation... 6 Comprehensive

More information

Current Non-Preferred Agents

Current Non-Preferred Agents Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35, Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119

More information

Nuplazid (pimavanserin)

Nuplazid (pimavanserin) Texas Prior Authorization Program Clinical Criteria Drug/Drug Class This criteria was recommended for review by the Texas Medicaid Vendor Drug Program to ensure appropriate and safe utilization. Additional

More information

1. Has this plan authorized this medication in the past for this patient (i.e., previous authorization is on file under this plan)?

1. Has this plan authorized this medication in the past for this patient (i.e., previous authorization is on file under this plan)? 09/07/2016 Prior Authorization AETA BETTER HEALTH OF KETUCK (MEDICAID) PCSK9 Inhibitors (K88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,

More information

$"% & '( ) " * +, !"##!""$ !*$-!+*" % $&

$% & '( )  * +, !##!$ !*$-!+* % $& ! """# # $"% & '( ')&# '( ) " * +, '( )(*!*$-!+*"!"##!""$ % $& &. / 011 12 ' 32 3 456 3. 3 0 11 32! 71 829:1 1' 3,3 12/ 2 31:181' 337)1 / 111 3 : 39.21)2 231 1 1 13' 223 333 23) 3;3 2 1 1' 11 3 31 333

More information

Abbreviated Class Review: Long-Acting Injectable Antipsychotics

Abbreviated Class Review: Long-Acting Injectable Antipsychotics Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35, Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119

More information

CONTRAINDICATIONS TABLE

CONTRAINDICATIONS TABLE CONTRAINDICATIONS TABLE Generic Name Brand Name Contraindications Amphetamine Salts Adderall, Adderall XR Hypersensitivity to amphetamine, dextroamphetamine, or other sympathomimetic amines Advanced arteriosclerosis

More information

Aripiprazole Lauroxil: Preparing for Commercial Success

Aripiprazole Lauroxil: Preparing for Commercial Success Aripiprazole Lauroxil: Preparing for Commercial Success Mark Stejbach Chief Commercial Officer Alkermes R&D Day July 17, 2013 Forward-Looking Statements This presentation contains forward-looking statements

More information

Abbreviated Class Review: Long-Acting Injectable Antipsychotics

Abbreviated Class Review: Long-Acting Injectable Antipsychotics Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35, Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119

More information

3. Does the patient continue to receive nutritional or psychological counseling? Y N

3. Does the patient continue to receive nutritional or psychological counseling? Y N Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS CS Stimulants (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review

More information

Regier 1993; Kessler 2005; Stevens 2016; Parellada 206; Mohr 2012; Prajapati 2016;

Regier 1993; Kessler 2005; Stevens 2016; Parellada 206; Mohr 2012; Prajapati 2016; Regier 1993; Kessler 2005; Stevens 2016; Parellada 206; Mohr 2012; Prajapati 2016; Miyamoto 2017 Risperdal Consta (risperidone) Zyprexa Relprevv (olanzapine pamoate) Invega Sustenna (paliperidone palmiate)

More information

See Important Reminder at the end of this policy for important regulatory and legal information.

See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: Reference Number: HIM.PA.59 Effective Date: 12/14 Last Review Date: 08/17 Line of Business: Health Insurance Marketplace Coding Implications Revision Log See Important Reminder at the

More information

Follow-up to Previous Reviews. Buprenorphine and benzodiazepine

Follow-up to Previous Reviews. Buprenorphine and benzodiazepine 14 April 2016 1 Follow-up to Previous Reviews Buprenorphine and benzodiazepine 2 Buprenorphine and Benzodiazepine DUR Payment block went in to effect 1/6/16 requiring prior authorization for payment for

More information

Drug Use Evaluation: Low Dose Quetiapine

Drug Use Evaluation: Low Dose Quetiapine Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 Fax 503-947-1119

More information

South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina

South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206 Pharmacy and Therapeutics (P&T) Committee Meeting MINUTES 1. Call to Order A meeting of the

More information