CurrentAvMedPolicy N/A

Pharmacy prior authorization and coverage criteria for Nuplazid (pimavanserin)

Form and criteria for prior authorization/step-edit requests for Nuplazid (pimavanserin) for AvMed members; applies to prescribers requesting pharmacy coverage, including specialty pharmacy handling.

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization and coverage criteria for Nuplazid (pimavanserin)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must sign and complete the prior authorization/step-edit request form and supply supporting documentation verifying clinical criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Primary diagnosis required

>=1 moMin symptom duration

QTContraindicated history

PropriumRxSpecialty pharmacy

Coverage Criteria

Initial authorization criteria

Covered when ALL of the following are met:

Initial authorization for Nuplazid: Patient has a diagnosis of Parkinson's disease psychosis; Psychotic symptoms have been present for at least one month; Psychosis is not due to another cause; Patient does not have a history of cardiac arrhythmias or QT prolongation and is not using another medication that prolongs the QT interval.all

All criteria must be supported by documentation (labs, diagnostics, chart notes).

Coverage and benefit details for Nuplazid (pimavanserin) can vary by member plan. Not all drugs may be covered under every plan; when a medication is non‑formulary for a member’s plan, documentation of medical necessity is required to consider coverage. Specialty pharmacy requirements (e.g., PropriumRx) may also apply and should be confirmed with the plan prior to dispensing.

Requests will not be approved unless every listed clinical requirement is fully satisfied and supported by documentation. The form specifies that all criteria must be met for approval and that supporting evidence — including lab results, diagnostics, and chart notes — must be provided for each checked item. Requests are not approvable if key elements such as required symptom duration (≥ 1 month), exclusion of alternative causes, or absence of contraindicating cardiac history/concomitant QT‑prolonging medications are not documented. In addition, use of samples to start therapy does not satisfy step‑edit or preauthorization requirements.

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization and coverage criteria for Nuplazid (pimavanserin)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must sign and complete the prior authorization/step-edit request form and supply supporting documentation verifying clinical criteria.

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.

Coding and Diagnosis

Required diagnosis codeICD-10

ICD code (field)

ICD Code to be provided by prescriber for diagnosis

Duration of psychotic symptoms

Minimum required duration>= 1 month

How it's documentedMust be supported by documentation (lab results, diagnostics, and/or chart notes)

Approval conditionPsychotic symptoms must have been present for at least one month as part of meeting all clinical criteria

Provider Actions & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Nuplazid (pimavanserin). The prescribing physician must sign and clearly print their name on the prior authorization form (preprinted stamps are not valid). Fax completed forms to 1-305-671-0200. If the form or supporting documentation is incomplete, incorrect, or illegible, the authorization process may be delayed or denied.

Prescriber signature required (handwritten; preprinted stamps not valid)
Fax to: 1-305-671-0200
Incomplete/incorrect/illegible submissions may be delayed or denied

Step Therapy

Step-Edit Verification and Samples

Previous therapies will be verified through pharmacy paid claims or submitted chart notes. Use of manufacturer or office samples to initiate therapy does NOT satisfy step-therapy requirements or preauthorization criteria.

Step-edit verification via claims history or chart notes
Samples do not satisfy step-therapy or PA requirements

Documentation Required

Required Form Fields and Supporting Documentation

All clinical criteria listed on the form must be met for approval. To support each checked criterion, provide complete documentation (e.g., labs, diagnostics, and chart notes). Missing, incomplete, incorrect, or illegible documentation may result in delay or denial. The form must include member and prescriber details, drug form/strength, dosing schedule, length of therapy, diagnosis and ICD code (if applicable), weight, date, and the prescriber's handwritten signature.

Required form fields: member name, AvMed ID, DOB
Prescriber name, DEA or NPI, office contact, phone and fax
Drug form/strength, dosing schedule, length of therapy, diagnosis and ICD code (if applicable), weight, date
Prescriber handwritten signature (required)
Provide supporting documentation: lab results, diagnostics, chart notes to substantiate each checked clinical criterion
Incomplete/incorrect/illegible documentation may delay or deny authorization

Background

Pimavanserin (Nuplazid) is indicated for psychosis associated with Parkinson’s disease and is considered under this policy when used for that diagnosis. The prior authorization form requires documentation that psychotic symptoms have been present for at least one month, that the psychosis is not attributable to another cause, and that the patient has no history of cardiac arrhythmias or QT prolongation and is not taking other QT‑prolonging medications. All checked clinical criteria must be corroborated with supporting documentation to avoid delay or denial.

Definitions

Parkinson's disease psychosis — required diagnosis and duration

Required primary diagnosisParkinson's disease psychosis (must be checked on form and ICD code provided)

Symptom duration requirementPsychotic symptoms present for at least one month

Exclusion of alternate causesPsychosis must not be attributable to another cause

Cardiac safety requirementNo history of cardiac arrhythmias or QT prolongation and not using concomitant QT‑prolonging medications

Initial Therapy Criteria

Initial therapy criteria

Initial authorization requirements for starting pimavanserin (Nuplazid):

Initial therapy for pimavanserin: Patient has Parkinson's disease psychosis; Psychotic symptoms have been present for at least one month; Psychosis is not due to another cause; No history of cardiac arrhythmias or QT prolongation and no concomitant use of QT‑prolonging medications.all

Supporting documentation (diagnosis, duration of symptoms, ruling out alternative causes, and cardiac/medication history) is required.

Step Therapy / Prior Therapy Verification

Acceptable evidence of prior therapy	Source	Do samples satisfy requirement?
Pharmacy paid claims documenting prior dispenses	Verified via pharmacy paid claims	No — samples do not meet step-edit/preauthorization requirements
Submitted chart notes documenting prior therapy (prescriber or clinical records)	Verified via submitted chart notes	No — samples do not meet step-edit/preauthorization requirements

Site of Care / Specialty Pharmacy

Note

Specialty pharmacy dispensing (PropriumRx) — confirm coverage and processes

The medication may be dispensed through a specialty pharmacy (PropriumRx); confirm plan coverage and follow the specialty pharmacy's processing requirements when arranging fill and delivery.

Medication may be provided by PropriumRx (specialty pharmacy)
If drug is non‑formulary for the plan, documentation of medical necessity will be required