CurrentAnthemPolicy N/A

Atypical antipsychotics formulary guidance

Guidance for prescribing and pharmacy coverage of atypical (second‑generation) antipsychotics for Anthem members, including which products are preferred vs nonpreferred, prior authorization requirements for pediatric patients, and generic substitution expectations. Affects prescribers and pharmacy staff verifying coverage and prescribing alternatives on the Anthem PDL.

Policy Summary

PayerAnthem

PolicyAtypical antipsychotics formulary guidance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all atypical antipsychotics in patients age 17 and under and document psychosocial care plus metabolic monitoring.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~20listed atypical antipsychotic products

children ≤17pediatric prior authorization

quarterlyPDL update frequency

Coverage and Formulary Preference

Formulary preference and pediatric prior authorization

Coverage and usage guidance summarized by product type and preference status.

General formulary guidance: Prescribe preferred products listed on the PDL when possible to avoid pharmacy claim rejections; verify coverage on the Anthem provider website since the PDL is subject to quarterly change.

Preferred products are often the generic versions; see PDL for current listings.

Brand vs generic expectation: When a generic equivalent exists and is listed as preferred, the brand-name product requires documentation of intolerance to or trial and failure of the generic agent before coverage of the brand is allowed.

This implies a generic-first or trial-of-generic expectation prior to covering brand formulations.

Pediatric prior authorization requirement: Prior authorization is required for all atypical antipsychotic products in children age 17 and under to assure psychosocial care and metabolic monitoring are in place.

Policy Summary

PayerAnthem

PolicyAtypical antipsychotics formulary guidance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all atypical antipsychotics in patients age 17 and under and document psychosocial care plus metabolic monitoring.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prescriber & Pharmacy Actions

Denial Risk

Claim rejection risk for nonpreferred products

Pharmacy claims for nonpreferred atypical antipsychotics may be rejected at the point of sale. To avoid delays or additional steps at the pharmacy, prescribe preferred products when possible and verify coverage on the Anthem Preferred Drug List (PDL). The PDL is updated quarterly.

Preferred products are listed on the Anthem PDL — review before prescribing.
Claims for nonpreferred products (see PDL) may be rejected at the pharmacy.

Step Therapy

Brand requires generic trial

When a generic version of an atypical antipsychotic exists and is listed as preferred, coverage of the brand-name product requires documentation of a medical intolerance to the generic or trial and failure of the generic agent.

Document trial and failure of the generic alternative or documented intolerance before requesting coverage for the brand-name product.
Check the PDL for current preferred generic alternatives.

Documentation Required

Pediatric prior authorization & documentation

Prior authorization is required for all atypical antipsychotic products in children age 17 and under. The PA request must document that appropriate psychosocial care is in place and that metabolic monitoring (baseline and ongoing) is planned or being performed.

PA required for patients age 17 and under for any atypical antipsychotic.
Include documentation of psychosocial interventions (e.g., therapy, care plan) and metabolic monitoring (baseline weight, BMI, fasting glucose/lipids and ongoing follow-up).
Provide clinical rationale and prior treatment history as applicable.

Initiation Guidance

Initiation guidance

When initiating atypical antipsychotic therapy, follow PDL preference and generic-first expectations.

Initiation guidance: Initiate therapy with preferred products listed on the Anthem PDL (typically generics) to avoid claim denials. If a brand-name product is requested and a generic equivalent is available, document intolerance to or trial and failure of the generic prior to approving the brand.

Verify current PDL on the Anthem provider website; PDL is subject to quarterly change.

Formulation exceptions: For patients unable to take oral medications, nonpreferred formulations such as Saphris SL or Secuado transdermal patch may be approved when clinically necessary.

Approval of non-oral formulations is considered on a case-by-case basis.

Requirement	Details
Generic-first (step) expectation
When a generic version exists and is listed as preferred, the brand-name product requires documented intolerance or trial and failure of the generic agent prior to coverage of the brand.

Key Definitions

Preferred product — definition and implications

DefinitionDrugs listed on the Anthem Preferred Drug List (PDL) — often generic equivalents — that are recommended to be prescribed when possible to avoid pharmacy claim rejections and additional prior‑authorization steps.

Practical implicationPrescribe PDL‑listed preferred products to reduce the risk of pharmacy claim rejections and avoid additional steps or delays at the pharmacy.

Relation to genericsWhen a generic equivalent is available and listed as preferred, the generic is the recommended product; brand may require documentation of intolerance or trial/failure of the generic.

VerificationVerify current coverage by reviewing the Anthem Preferred Drug List on the Anthem provider website, as the PDL is subject to change quarterly.

Interaction with prior authorization/step therapyPreferred products may still be subject to prior authorization or step‑therapy requirements in select cases; check PA rules for specifics.

Nonpreferred product — definition and authorization considerations

DefinitionBrand‑name or other products not listed as preferred on the Anthem PDL; these are identified as nonpreferred in the Hot Tip.

Possible prior authorizationNonpreferred products may require prior authorization, especially when a preferred/generic alternative exists or for patients age 17 and under where PA is required for all products.

Failure/intolerance documentationIf a generic preferred equivalent exists, coverage of the nonpreferred brand typically requires documentation of intolerance or trial and failure of the generic agent.

Claim rejection riskPrescribing nonpreferred products instead of preferred PDL items may result in pharmacy claim rejections or additional steps at the point of dispensing.

Exceptions for formulationCertain nonpreferred formulations (e.g., Saphris SL or Secuado transdermal) may be approved if the patient is unable to take oral medications — check PA guidance.

Background and Scope

This guidance summarizes formulary preferences for atypical (second‑generation) antipsychotics across oral, alternative, and injectable formulations to help prescribers and pharmacy staff select products likely to be covered without additional steps. When a generic equivalent is listed as preferred (for example, generic aripiprazole, clozapine, olanzapine, paliperidone ER, quetiapine, risperidone, and ziprasidone), clinicians are encouraged to prescribe the preferred generic to avoid claim rejections and extra prior authorization or step-therapy requirements. For patients who cannot take oral medications, certain non‑preferred formulations (such as sublingual or transdermal asenapine) may be approved when clinically necessary, and some long‑acting injectable products are listed as preferred in the injectable section; always confirm the specific product’s PDL status before prescribing.

OpenPayer