CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Rexulti (brexpiprazole) prior authorization form and coverage criteria

Form and prior authorization requirements for coverage of Rexulti (brexpiprazole) for members under the payer; describes information providers must submit to request authorization.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyRexulti (brexpiprazole) prior authorization form and coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with documentation of at least two classes of prior antidepressant trials (≥4 weeks each) and objective rating scale results.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CoverMyMedselectronic portal

844-403-1029fax submissions

2+classes required

4wminimum trial

Coverage Criteria

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Adjunctive use for MDD: Rexulti is being used as adjunctive treatment for major depressive disorder (must be indicated on form).

From question 1 on form.

Prior medication trials: Patient has tried agents from at least two of the following classes for at least four weeks each: selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), buspirone, bupropion, or mirtazapine.>= 4 weeks per agent

From question 2 on form.

Augmentation trial: Documentation that patient has tried augmentation with an SSRI or SNRI plus either buspirone, bupropion, or mirtazapine for at least four weeks.>= 4 weeks

From question 3 on form.

Monitoring documentation: Submission of objective, quantitative rating scale documentation to monitor clinical status (examples: AIMS, SCID, BPRS, PANSS).

From question 4 on form.

Coverage for Rexulti (brexpiprazole) as an adjunctive agent for major depressive disorder is considered when the prior authorization form documents the required clinical elements. Specifically, the form queries whether Rexulti is being used as adjunctive treatment for major depressive disorder, whether the member has tried agents from at least two specified classes for at least 4 weeks each, whether an augmentation trial has been attempted for at least 4 weeks, and whether objective, quantitative rating scale documentation has been submitted. These items together constitute the initial authorization criteria used to evaluate medical necessity.

The form explicitly states that this request may be denied unless all required information is received. While the form does not enumerate specific not-medically-necessary conditions, failure to provide the completed clinical information — including documentation of prior medication trials and any requested rating-scale records — can result in denial of the prior authorization request.

Initial Therapy Criteria

Initial therapy requirements

Initial authorization supports use as adjunctive therapy when prior medication trials and monitoring documentation are provided.

Adjunctive MDD indication: Rexulti is being used as adjunctive treatment for MDD.

Question 1.

Prior agent trials: At least two classes among SSRIs, SNRIs, buspirone, bupropion, or mirtazapine have been tried for >=4 weeks each.>=4 weeks

Question 2.

Augmentation attempt: Augmentation with an SSRI or SNRI plus buspirone, bupropion, or mirtazapine for >=4 weeks has been tried (if applicable).>=4 weeks

Question 3.

Rating scale documentation: Objective rating scale documentation submitted (examples: AIMS, SCID, BPRS, PANSS).

Question 4.

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Requests can be submitted electronically via CoverMyMeds (go.covermymeds.com/OptumRx) or by fax using the Rexulti Prior Authorization Request Form. The form may be faxed to 844-403-1029. For assistance with the prior authorization process call 855-811-2218 (Mon–Fri 8 a.m.–1 a.m. ET; Sat 9 a.m.–6 p.m. ET).

Electronic submission: CoverMyMeds (go.covermymeds.com/OptumRx)
Fax submission: Completed Rexulti Prior Authorization Request Form to 844-403-1029
Phone support: 855-811-2218 (Mon–Fri 8 a.m.–1 a.m. ET; Sat 9 a.m.–6 p.m. ET)

Step Therapy

Prior Medication Trials Required

Patient must have tried agents from at least two of the following classes for a minimum of four weeks each: selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), buspirone, bupropion, or mirtazapine. Additionally, documentation is requested regarding whether augmented therapy with an SSRI or SNRI plus either buspirone, bupropion, or mirtazapine was tried for at least four weeks.

Required prior medication trials: ≥2 classes (SSRIs, SNRIs, buspirone, bupropion, mirtazapine) for ≥4 weeks each
Augmentation trial: SSRI or SNRI + (buspirone, bupropion, or mirtazapine) for ≥4 weeks (if applicable)

Documentation Required

Required Documentation

A completed prior authorization form must be submitted and include member and provider details, medication requested (including dosing and start date), documentation of prior medication trials (agents, durations, and outcomes), and evidence of use of objective rating scales where applicable. Provider contact information and prescriber signature/date are required.

Include member and provider identifiers (Name, Insurance ID#, NPI, contact info)
Document medication details: drug name, dose, start date, and indication
Provide prior trial documentation: agents tried, class, duration (≥4 weeks each), and response
Submit any objective rating scale documentation (e.g., AIMS, SCID, BPRS, PANSS) if used
Prescriber's signature and date

Denial Risk

Incomplete Information May Cause Denial

This request may be denied unless all required information is received. Incomplete submissions lacking documentation of prior medication trials or objective rating scales may result in denial or delay.

Incomplete information (missing prior trial details or rating scale documentation) may lead to denial
Ensure the completed form includes prescriber signature and all requested clinical details to avoid processing delays

Coding & Trial Duration

Minimum trial duration

Minimum trial duration>= 4 weeks per prior antidepressant trial

ContextEach required prior agent (from specified classes) must be tried for at least four weeks as documented on the form.

Step therapy implicationTry agents from at least two listed classes for >=4 weeks each prior to approval (form queries trial duration in questions 2 and 3).

Step Therapy Requirements

Requirement	Details
{"text":"Try agents from at least two of the following classes","status":""},{"text":"Selective serotonin reuptake inhibitors (SSRIs); serotonin–norepinephrine reuptake inhibitors (SNRIs); buspirone; bupropion; or mirtazapine — each tried for at least 4 weeks","status":""}
{"text":"Augmentation trial (if applicable)","status":""},{"text":"Documentation queried whether patient tried augmentation with an SSRI or SNRI plus either buspirone, bupropion, or mirtazapine for at least 4 weeks","status":""}
{"text":"Minimum trial duration","status":""},{"text":">= 4 weeks per agent","status":""}

Definitions & Rating Scales

Objective, quantitative rating scales

Examples listed on formAbnormal Involuntary Movement Scale (AIMS), Structured Clinical Interview for DSM-IV Axis I Disorders (SCID), Brief Psychiatric Rating Scale (BPRS), Positive and Negative Syndrome Scale (PANSS)

PurposeObjective, quantitative rating scales requested/submitted to monitor clinical status for prior authorization review.

Documentation instructionIf yes, submit documentation of the rating scale results on the form as indicated.

Background

Rexulti (brexpiprazole) is requested and reviewed as an adjunctive treatment for major depressive disorder. The prior authorization form collects clinical details necessary to assess prior treatments and monitoring, including: confirmation that Rexulti is being used as adjunctive therapy; documentation that the patient has tried agents from at least two classes (SSRIs, SNRIs, buspirone, bupropion, or mirtazapine) for at least 4 weeks each; whether an augmentation regimen (SSRI or SNRI plus buspirone, bupropion, or mirtazapine) was tried for at least 4 weeks; and submission of objective quantitative rating scale documentation (examples listed on the form include AIMS, SCID, BPRS, and PANSS).