CurrentAgency for Health Care AdministrationPolicy N/A

ANTIPSYCHOTIC POLYPHARMACY CRITERIA

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This policy establishes prior authorization criteria for antipsychotic polypharmacy for members with schizophrenia spectrum disorders or bipolar disorder with psychosis and/or severe symptoms. It governs initial approval, continuation of therapy, and a six-month authorization period.

Policy Summary

PayerAgency for Health Care Administration

PolicyANTIPSYCHOTIC POLYPHARMACY CRITERIA

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit documentation showing the required prior treatment trials and, for continuation, the patient's clinical response to therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsAuthorization length

3Schizophrenia trials required

1Clozapine trial required

4Bipolar treatment options required

4–6 weeks

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CurrentAgency for Health Care AdministrationPolicy N/A

ANTIPSYCHOTIC POLYPHARMACY CRITERIA

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Know when Agency for Health Care Administration releases new policies or updates existing guidance.

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Policy Summary

PayerAgency for Health Care Administration

PolicyANTIPSYCHOTIC POLYPHARMACY CRITERIA

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit documentation showing the required prior treatment trials and, for continuation, the patient's clinical response to therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsAuthorization length

3Schizophrenia trials required

1Clozapine trial required

4Bipolar treatment options required

4–6 weeks

Required trial duration

Coverage Criteria

Schizophrenia Spectrum Disorders

Coverage for schizophrenia spectrum disorders requires ALL of the following:

ALL of the following

Patient has a schizophrenia spectrum disorder.
Patient has tried at least 3 formulary antipsychotics, including clozapine.
Each required trial was administered at the maximum tolerated dose for 4 to 6 weeks.
Failure due to ONE or more of the following
- Inadequate response.
- Adverse reactions.
- Breakthrough symptoms.

Bipolar Disorder With Psychosis and/or Severe Symptoms

Coverage for bipolar disorder with psychosis and/or severe symptoms requires ALL of the following:

ALL of the following

Patient has bipolar disorder with psychosis and/or severe symptoms.
Patient has tried at least 4 evidence-based treatment options appropriate to the episode type: manic or depressive.
Each required trial was administered at the maximum tolerated dose for 4 to 6 weeks.
Failure due to ONE or more of the following
- Inadequate response.
- Adverse reactions.

Continuation Therapy

Continuation therapy requires ALL of the following:

ALL of the following

Patient met initial review requirements.
Clinical response to therapy is submitted.
Supporting documentation is required.

Provider Actions and Authorization Requirements

Prior Authorization

Schizophrenia Prerequisite Trials

Before antipsychotic polypharmacy authorization for schizophrenia spectrum disorders, the patient must complete trials of at least three formulary antipsychotics, including clozapine, at maximum tolerated doses for four to six weeks. Each trial must fail because of inadequate response, adverse reactions, and/or breakthrough symptoms.

At least 3 formulary antipsychotic trials are required.
One trial must be clozapine.
Each trial must last 4–6 weeks at the maximum tolerated dose.
Document failure due to inadequate response, adverse reactions, and/or breakthrough symptoms.

Prior Authorization

Bipolar Disorder Prerequisite Trials

Before authorization for bipolar disorder with psychosis and/or severe symptoms, the patient must complete at least four evidence-based treatment options appropriate to the episode type—manic or depressive—at maximum tolerated doses for four to six weeks. Each trial must fail because of inadequate response, adverse reactions, and/or breakthrough symptoms.

Policy Background

This policy establishes prior authorization criteria for antipsychotic polypharmacy. It applies to members with schizophrenia spectrum disorders or bipolar disorder with psychosis and/or severe symptoms. Initial approval requires documented failure of applicable prior treatments at maximum tolerated doses, and continuation requires documentation of the member’s clinical response. Authorizations are issued for six months.

Initial Therapy Criteria

Schizophrenia Initial Therapy

Initial therapy for schizophrenia spectrum disorders requires all of the following.

Schizophrenia initial therapy

The patient has tried at least three formulary antipsychotics, including clozapine.At least 3 formulary antipsychotics; 1 must be clozapine
Each required trial was administered at maximum tolerated doses for four to six weeks.4–6 weeks at maximum tolerated doses
Treatment failure was due to inadequate response, adverse reactions, and/or breakthrough symptoms.

Bipolar Initial Therapy

Continuation Criteria

Antipsychotic Polypharmacy Continuation

Continuation of therapy is approved when all of the following are met.

Antipsychotic polypharmacy continuation requirements

The patient met the initial review requirements.
The patient's clinical response to therapy is submitted with supporting documentation.

Step Therapy Requirements

Step	Indication	Required treatment trials	Dose and duration	Treatment failure
1	Schizophrenia spectrum disorders	At least 3 formulary antipsychotics, including clozapine	Maximum tolerated doses for 4–6 weeks	Inadequate response, adverse reactions, and/or breakthrough symptoms

Step	Indication	Required treatment trials	Episode appropriateness	Dose and duration	Treatment failure
1	Bipolar disorder with psychosis and/or severe symptoms	At least 4 evidence-based treatment options	Options must be appropriate to the manic or depressive episode	Maximum tolerated doses for 4–6 weeks	Inadequate response, adverse reactions, and/or breakthrough symptoms

Policy Summary

PayerAgency for Health Care Administration

PolicyANTIPSYCHOTIC POLYPHARMACY CRITERIA

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit documentation showing the required prior treatment trials and, for continuation, the patient's clinical response to therapy.

SourceLink

On This Page

Breakthrough symptoms.

At least 4 evidence-based treatment options are required.
Treatment options must be appropriate to the episode type: manic or depressive.
Each trial must last 4–6 weeks at the maximum tolerated dose.
Document failure due to inadequate response, adverse reactions, and/or breakthrough symptoms.

Step Therapy

Schizophrenia Formulary Step Therapy

For schizophrenia spectrum disorders, authorization requires completion of the formulary step-therapy sequence before antipsychotic polypharmacy is considered.

Step 1: Trial a formulary antipsychotic at the maximum tolerated dose for 4–6 weeks.
Step 2: Repeat with additional formulary antipsychotics until at least 3 formulary agents have been tried.
Step 3: Ensure that one of the 3 trials is clozapine.
Step 4: Document failure of the required trials due to inadequate response, adverse reactions, and/or breakthrough symptoms.

Step Therapy

Bipolar Evidence-Based Step Therapy

For bipolar disorder with psychosis and/or severe symptoms, authorization requires evidence-based treatment trials matched to the patient’s episode type before antipsychotic polypharmacy is considered.

Step 1: Identify the episode type: manic or depressive.
Step 2: Trial an evidence-based treatment option appropriate to that episode at the maximum tolerated dose for 4–6 weeks.
Step 3: Continue sequential trials until at least 4 appropriate evidence-based treatment options have been tried.
Step 4: Document failure due to inadequate response, adverse reactions, and/or breakthrough symptoms.

Documentation Required

Continuation Documentation Required

For continuation of therapy, submit documentation showing that the patient met the initial review requirements and has demonstrated a clinical response to therapy.

Document that initial review requirements were met.
Submit clinical response to therapy.
Include supporting clinical documentation with the continuation request.

Denial Risk

Prerequisite Criteria Not Met

Authorization may be denied when the required prerequisite treatment criteria are not met. This includes incomplete trials, failure to meet the required number or type of treatment trials, or lack of documented treatment failure.

Deny when fewer than 3 formulary antipsychotics were tried for schizophrenia spectrum disorders.
Deny when the schizophrenia prerequisite trials do not include clozapine.
Deny when fewer than 4 episode-appropriate evidence-based treatment options were tried for bipolar disorder with psychosis and/or severe symptoms.
Deny when required trials were not given for 4–6 weeks at maximum tolerated doses.
Deny when failure is not documented as inadequate response, adverse reactions, and/or breakthrough symptoms.

Denial Risk

Insufficient Continuation Documentation

Continuation authorization may be denied when the initial-review requirements are not documented or when the request does not establish clinical response with supporting documentation.

Deny when documentation does not show that the patient met initial review requirements.
Deny when clinical response to therapy is not submitted.
Deny when supporting clinical documentation is insufficient or absent.

Initial therapy for bipolar disorder with psychosis and/or severe symptoms requires all of the following.

Bipolar initial therapy

The patient has tried at least four evidence-based treatment options appropriate to the manic or depressive episode.At least 4 evidence-based treatment options
Treatment options depend on whether the episode is manic or depressive.
Each required trial was administered at maximum tolerated doses for four to six weeks.4–6 weeks at maximum tolerated doses
Treatment failure was due to inadequate response, adverse reactions, and/or breakthrough symptoms.