Concomitant Antipsychotic Treatment
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Policy governing prior authorization and medical necessity criteria for concomitant use of two second-generation (atypical) antipsychotics for Arizona Complete Health members (Arizona Medicaid/AzCH-CCP). Applies to prescribers and behavioral health providers managing antipsychotic therapy.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Initial therapy — Refractory Schizophrenia Spectrum Disorder
Concomitant antipsychotic therapy is medically necessary when ALL of the following are met for Refractory Schizophrenia Spectrum Disorder:
Approval duration = 6 months
Initial therapy — Refractory Bipolar Disorder
Concomitant antipsychotic therapy is medically necessary when ALL of the following are met for Refractory Bipolar Disorder with Psychosis and/or Severe Symptoms:
Approval duration = 6 months
Initial therapy — Other diagnoses
Other diagnoses/indications:
Continued therapy
Continued therapy criteria (must meet ALL listed per category):
Concomitant LAI + oral antipsychotic review
When concomitant use involves a long‑acting injectable (LAI) second‑generation antipsychotic and an oral second‑generation antipsychotic:
Follow AHCCCS FFS PA Criteria for LAI agents and AZ.CP.PMN.10 for the oral agent
Prescriptions for concomitant antipsychotic treatment that are written by clinicians who are not Behavioral Health Medical Professionals (BHMP) are not authorized for coverage. Providers must ensure the prescriber meets the behavioral health credentialing requirement in order for coverage to be considered.
Non‑FDA approved (off‑label) indications that are not specifically addressed in this policy are not authorized for coverage unless the provider submits sufficient documentation of efficacy and safety consistent with the AHCCCS FFS Prior Authorization Guideline — Coverage of Off‑Label Non‑FDA Approved Indications. Follow that guideline when requesting coverage for off‑label uses.
Administrative updates to this policy removed references to the Care1st Health plan and its logos. The removal is administrative only and does not change clinical criteria or coverage requirements.
For clarity, coverage is not authorized for non‑FDA approved indications that are not addressed in this policy unless the provider supplies the required off‑label documentation per the AHCCCS FFS Prior Authorization Guideline.
This clinical policy is intended to serve as a guide to medical necessity to assist in coverage determinations and benefit administration. It is not a contract, a guarantee of payment, nor a substitute for professional medical judgment. Coverage decisions remain subject to the member's coverage documents, applicable state and federal requirements, and Health Plan administrative policies.
Provider Responsibilities and Authorization Requirements
POS cross-tapers: 60-day automatic approval, PA required thereafter
Cross-tapers are automatically approved at the Point of Sale (POS) for 60 days. Providers must submit a prior authorization request for continued concomitant use of any two atypical antipsychotics beyond the 60-day POS cross-taper period.
- Automatic POS approval = 60 days
- PA required for continued concomitant use beyond 60 days
Dual-policy review for LAI + oral antipsychotics
When a long‑acting injectable (LAI) second‑generation antipsychotic is used with an oral second‑generation antipsychotic, apply the AHCCCS FFS PA Criteria to the LAI and use AZ.CP.PMN.10 (this policy) to review the oral antipsychotic.
- Follow AHCCCS FFS PA Criteria for the LAI agent
- Use AZ.CP.PMN.10 to review the oral antipsychotic
Required medication trials before approval
Document adequate prior medication trials at maximum tolerated doses for the specified durations before requesting concomitant therapy: three (3) individual antipsychotic trials for refractory schizophrenia and at least four (4) evidence‑based treatment options (which may include combination therapy) for refractory bipolar disorder with psychosis/severe symptoms.
- Refractory schizophrenia: ≥3 individual antipsychotic trials, 4–6 weeks each at maximum tolerated doses
- Refractory bipolar with psychosis/severe symptoms: ≥4 evidence‑based treatment options (may include antipsychotic+mood stabilizer/anticonvulsant), 4–6 weeks each at maximum tolerated doses
Policy context and clinical judgment
(Reserved)
Required supporting documentation to accompany PA
Submit supporting clinical documentation with the prior authorization request to show approval criteria are met, including office chart notes, laboratory results, and evidence that nonadherence did not contribute to lack of response.
- Office chart notes and relevant labs
- Documentation that adherence was not a contributing factor to treatment failure
Continued therapy: required documentation of ongoing benefit
For continued therapy, provide documentation that the member is currently receiving the medication via the Centene benefit (or previously met initial approval criteria) and that there is a positive clinical response to therapy.
- Evidence member is currently receiving medication via Centene benefit or previously met initial approval criteria
- Documentation of positive response to therapy
Professional judgment and coverage context
Providers are expected to exercise professional medical judgment when applying these criteria. Coverage determinations remain subject to the terms, conditions, exclusions, and limitations of the member's coverage documents and applicable Health Plan administrative policies.
Unauthorized prescribers are excluded
Prescriptions written by non‑behavioral health professionals are excluded from coverage; prescribers must be contracted Behavioral Health Medical Professionals (BHMPs).
- Coverage excluded for prescriptions by non‑behavioral health professionals
- Prescriber requirement: contracted BHMP
Off‑label indications: off‑label guideline documentation required
Non‑FDA approved (off‑label) indications not addressed in this policy require sufficient documentation of efficacy and safety per the AHCCCS FFS Prior Authorization Guideline for Off‑Label Non‑FDA Approved Indications; otherwise coverage is not authorized.
- Refer to AHCCCS FFS Prior Authorization Guideline for Off‑Label Non‑FDA Approved Indications for nonlisted diagnoses
- Coverage not authorized without sufficient off‑label documentation
State Medicaid provisions take precedence
For Medicaid members, state Medicaid coverage provisions take precedence over this clinical policy when conflicts exist; providers should follow the applicable state Medicaid manual provisions.
- State Medicaid provisions override this policy in case of conflict
- Refer to state Medicaid manual for applicable coverage provisions
Antipsychotic Medications and Formulations
Antipsychotic medications (oral and long-acting injectable formulations)
Antipsychotic medications included (oral and long‑acting injectable formulations):
Antipsychotic medication (LAI and oral)
When a long‑acting injectable (LAI) second‑generation antipsychotic is used together with an oral second‑generation antipsychotic:
From policy guidance; follow AHCCCS criteria for LAI review
Clinical Background and Scope
Concomitant use of two second‑generation antipsychotics may be considered in members with refractory psychotic disorders (for example, schizophrenia spectrum disorders) or severe bipolar disorder with psychosis or severe symptoms when multiple adequate trials of monotherapy or other evidence‑based options have failed and adherence has been confirmed. The rationale is that, after documented failure of appropriate monotherapy trials (typically a minimum of three adequate antipsychotic trials for refractory schizophrenia and four evidence‑based trials or combinations for refractory bipolar presentations), carefully selected concomitant therapy can be medically necessary to manage persistent psychosis or severe mood‑related symptoms. Long‑acting injectable plus oral combinations are cross‑referenced to AHCCCS FFS LAI criteria and reviewed together using the LAI criteria for the injectable and this policy for the oral agent.
Terminology
Policy Revision History
Annual review: removed references to Care1st Health plan and logos; removed reference to retired policy AZ.CP.PMN.53 and added AHCCCS FFS Prior Authorization Guideline for Off‑Label Non‑FDA Approved Indications.
1Q 2024 annual review: no significant clinical changes; references reviewed and updated.
1Q 2023 annual review: added guidance for concomitant use of a long‑acting injectable (LAI) second‑generation antipsychotic and an oral second‑generation antipsychotic to apply AHCCCS FFS PA Criteria to the LAI and this policy to the oral agent.
Added Care1st logo and verbiage specifying criteria also applied to Care1st (later removed).
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