CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Prior authorization request form for atypical antipsychotics

A prior authorization (PA) request form used by Blue Cross Blue Shield - South Carolina / OptumRx to collect provider, medication, and clinical information for atypical antipsychotic medications (listed brand names). It specifies required documentation and trial/failure questions needed to process PA requests.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyPrior authorization request form for atypical antipsychotics

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective Date

Next Review Date

Key ActionSubmit the completed prior authorization request form with all required provider, medication, and clinical information (including documentation of trials/failures and rating scales if applicable) to OptumRx via fax to 844-403-1029 or use goCoverMyMeds; incomplete information may result in denial.

POLICY UPDATE CHANGES

No material clinical/coverage changes — this document is an administrative prior authorization form used to collect required information.

1Form type

2Required trial failures

9Referenced medications (brands/generics)

Policy overview

This is an OptumRx prior authorization (PA) request form used by Blue Cross Blue Shield - South Carolina to collect standardized provider, medication, and clinical information for atypical antipsychotic medications. The form lists specific brand names and formulations including Clozaril, Fanapt, Fazaclo, Geodon, Invega, Latuda, Saphris, Versacloz, Zyprexa, and Zydis, and references generic examples (e.g., generic aripiprazole, generic clozapine, generic paliperidone, generic risperidone, generic olanzapine, generic quetiapine, generic ziprasidone).

Required clinical information for prior authorization

Prior authorization may be denied unless ALL required information is received. Provide answers to ALL of the following:

Adjunct for major depressive disorder: Is the requested drug being requested as an adjunct for major depressive disorder?
Yes/No required
Current medication improvement: Is the patient currently taking the prescribed medication with evidence of improvement?
Yes/No required
Prior trials/failures to two generics: Has the patient tried and failed a 30-day trial, is intolerant to or has had a confirmed adverse reaction to TWO of the following products: generic aripiprazole, generic clozapine (any dosage form), generic paliperidone, generic risperidone (any dosage form), generic olanzapine (any dosage form), generic quetiapine (any dosage form) or generic ziprasidone?
Yes/No required; requires documentation of trials/failures/intolerance/adverse reactions
Standardized rating scales submitted: Have standardized rating scales (e.g., SCID; Brief Psychiatric Rating Scale [BPRS]; Positive and Negative Syndrome Scale [PANSS]) as proof of treatment status been submitted?
Yes/No required; if yes, submit documentation
Medication information provided: Medication Information: Medication name, strength, dosage form, directions for use must be provided
Required fields on the form
Provider information provided: Provider information: Member name, provider name, insurance ID, NPI, specialty, DOB, contact and address details must be provided
Required fields on the form

Prior authorization may be denied unless ALL required information is received; provide answers to every required clinical question and attach supporting documentation where indicated (including documentation of prior trials/failures or intolerance, standardized rating scales such as SCID, BPRS, or PANSS, and prescriber signature and contact details).

Specifically, when applicable submit evidence of a 30-day trial and failure/intolerance/adverse reactions to two listed generic antipsychotics and include completed medication and provider fields on the form; incomplete submissions may result in denial.

Medications referenced on form

Medications referenced on form (brand and generic examples)mixed

Clozaril	brand atypical antipsychotic (clozapine)
Fanapt	brand atypical antipsychotic (iloperidone)
Fazaclo	brand/formulation
Geodon	brand atypical antipsychotic (ziprasidone)
Invega	brand atypical antipsychotic (paliperidone)
Latuda	brand atypical antipsychotic (lurasidone)
Saphris	brand atypical antipsychotic (asenapine)
Versacloz	brand/clozapine formulation
Zyprexa	brand atypical antipsychotic (olanzapine)
Zydis	formulation name (Zydis ODT formulations)

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What the provider must do

Prior Authorization

Submit completed PA form

Submit the completed prior authorization request form with all required provider, medication, and clinical information. Incomplete information may result in denial.

Fax to 844-403-1029
Or use goCoverMyMeds (Visit gocovermymeds.com/QtumRx to begin)

Documentation Required

Document prior trials/failures

Provide documentation that the patient tried and failed a 30-day trial, was intolerant to, or had confirmed adverse reactions to two listed generic antipsychotics when applicable.

Document 30-day trials (or intolerance/adverse reactions) to TWO of: generic aripiprazole; generic clozapine (any dosage form); generic paliperidone; generic risperidone (any dosage form); generic olanzapine (any dosage form); generic quetiapine (any dosage form); generic ziprasidone

Documentation Required

Submit standardized rating scales

If applicable, submit standardized rating scales as proof of treatment status.

Examples: Structured Clinical Interview for DSM Disorders (SCID)
Brief Psychiatric Rating Scale (BPRS)
Positive and Negative Syndrome Scale (PANSS)

Billing Rule

Form retention / signature

Ensure the form includes the prescriber's signature and date and that provider contact details and member identifiers are completed.

Prescriber's signature and date required
Include member name and insurance ID, provider name and NPI, office phone/address/fax