Concomitant Antipsychotic Treatment
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Defines medical necessity and prior authorization requirements for concomitant use of more than one second-generation (atypical) antipsychotic for Ambetter Nevada Medicaid members; applies to prescribers who are contracted behavioral health professionals.
No material clinical or coverage changes in this revision.
Coverage Criteria
Refractory Schizophrenia Spectrum Disorder (Initial)
Covered when ALL of the following are met
Provider must submit supporting documentation (office chart notes, labs) showing adherence and reasons for failure.
Refractory Bipolar Disorder with Psychosis/Severe Symptoms (Initial)
Covered when ALL of the following are met
Approval duration for initial: 6 months; provider must submit supporting documentation.
Continuation Therapy / Renewal
Covered when ALL of the following are met
Approval duration: 12 months.
Non‑FDA approved indications that are not specifically addressed in this policy are not authorized unless there is sufficient documentation of efficacy and safety in accordance with the off‑label use policy CP.PMN.53 or other applicable evidence of coverage documents.
Prescriptions written by providers who are not contracted behavioral health professionals are not authorized. In addition, non‑FDA indications lacking the required off‑label documentation per policy CP.PMN.53 are explicitly not authorized.
Provider Actions & Requirements
Prior authorization for continued concomitant use
Prior authorization is required for concomitant use beyond a 60‑day cross‑taper. Cross tapers will automatically be approved for 60 days; providers must submit a prior authorization request for continued utilization of concomitant use of any two atypical antipsychotics beyond the 60 days allowed for cross tapering. This includes oral dosage forms in combination with injectable dosage forms of the same agent (e.g., aripiprazole and aripiprazole long-acting injectable, risperidone and risperidone long-acting injectable). Prescribers must be contracted behavioral health professionals (BHMP).
- Cross-taper auto-approval: 60 days
- Continued concomitant use >60 days requires prior authorization
- Includes oral + injectable combinations (same agent)
- Prescriber requirement: contracted behavioral health professional
Required supporting documentation
Provider must submit documentation (including office chart notes and relevant laboratory results) demonstrating the member meets all approval criteria. Documentation must show: diagnostic information, prior medication trials (agents, doses, durations, and reasons for failure), evidence that adherence to treatment regimens was assessed and was not the cause of treatment failure, and any relevant symptom or functional status measures. Failure reasons should be noted (inadequate response at maximum tolerated dose, adverse reaction, or breakthrough symptoms).
- Include office chart notes and lab results
- Document prior trials with doses, durations (4–6 weeks at max tolerated dose), and reasons for failure
- Document assessment of adherence and that nonadherence did not contribute to failure
- For injectable+oral combinations, document agent identities and formulations
Required medication trials
Provider must document that required medication trials were conducted per policy (e.g., at least three antipsychotics for refractory schizophrenia-spectrum disorders or at least four evidence‑based options for refractory bipolar disorder with psychosis/severe symptoms), each at maximum tolerated doses for 4–6 weeks unless intolerant. Documentation must include trial dates, doses, response, and reason for discontinuation or augmentation.
- Trials: 4–6 weeks at maximum tolerated dose unless intolerant
- Refractory schizophrenia: ≥3 individual antipsychotic trials with failure reasons
- Refractory bipolar disorder with psychosis/severe symptoms: ≥4 evidence‑based treatment options or appropriate combination therapy
Not authorized conditions
Coverage is NOT authorized for non‑FDA approved indications that are not specifically addressed in this policy unless sufficient off‑label evidence is submitted per Ambetter Nevada off‑label policy (CP.PMN.53) or other evidence of coverage documents. Coverage is also not authorized for prescriptions written by non‑behavioral health professionals.
- Non‑FDA indications not addressed in this policy — require off‑label policy documentation (CP.PMN.53) or evidence of coverage
- Prescriptions written by non‑behavioral health professionals are not authorized
Level of Care Criteria
Treatment Modalities
Pharmacologic (atypical antipsychotics)
Dosage, administration, and product availability as listed in policy appendices.
Background
Concomitant use of more than one atypical (second‑generation) antipsychotic is considered in members with treatment‑refractory conditions such as schizophrenia spectrum disorders or bipolar disorder with psychosis/severe symptoms. Cross‑tapers are automatically approved for 60 days; continuation beyond a 60‑day cross‑taper requires prior authorization and oversight by a contracted behavioral health professional. Approval for initial refractory bipolar criteria is typically for 6 months, and members who previously met initial criteria or who are receiving medication via a Centene affiliate may be approved for 12 months. Required medication trials include multiple antipsychotic or evidence‑based treatment trials at maximum tolerated doses for 4–6 weeks with documentation of failure (inadequate response, adverse reaction, or breakthrough symptoms) and confirmation that nonadherence did not contribute to lack of response.
Definitions
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