Prior authorization required for listed antipsychotics and concurrent-use rules

Prior authorization is required for all current and future dose forms of the antipsychotics listed in Table 1. PA is specifically required for concurrent antipsychotic use beyond the durations in the policy (patients <18: two or more agents >60 days; adults: three or more agents >60 days; two or more concurrent long-acting injectables >60 days) and for use that exceeds the age- or dose-specific limits in Table 1.

• PA applies to all named agents and their dose forms in Table 1.
• PA required when dosing exceeds Table 1 limits or when agents are used in age bands listed as 'Not approved'.
• PA required for multiple concurrent antipsychotics per durations defined (see concurrent use rules).

Written peer-to-peer consult required for certain PA approvals

Approval for certain prior authorization requests (for example, approvals that exceed dosing limits or involve multiple long-acting injectables) will require a written peer-to-peer consult with a health plan psychiatrist, medical director, or pharmacy director; if a written consult cannot secure approval, a verbal peer-to-peer will follow.

• Written peer-to-peer with health plan psychiatrist, medical director, or pharmacy director is required for approval.
• A verbal peer-to-peer will be conducted if unable to approve based on the written request.

PA decisions follow Table 1 medication- and age-specific dosing limits

Prior authorization determinations reference the maximum daily and any specified multi-day dosing limits shown in Table 1 for each medication and age band; prescriptions that exceed those Table 1 limits require PA.

• Table 1 provides medication- and age-specific maximum doses (daily unless otherwise specified) including multi-day maximums where noted.
• Exceeding a Table 1 limit triggers requirement for prior authorization.

Step therapy and product-specific requirements (Abilify MyCite, Secuado, Lybalvi, etc.)

Product-specific step therapy requirements apply as listed in the policy: e.g., Abilify MyCite requires FDA-label indication, documented benefit/no contraindication to aripiprazole tablets, 12-week approval period, inability to receive injections, and peer-to-peer review; Secuado requires treatment of schizophrenia in adults, a positive response to an adequate trial (≥2 weeks at max tolerated dose) of generic asenapine sublingual tablets, and a valid medical reason for the alternate dosage form; Lybalvi and other agents have their stated step requirements.

• Abilify MyCite: must meet FDA labeling, documented benefit/no contraindication to aripiprazole tablets, 12-week approval, not able to receive injections, requires peer-to-peer.
• Secuado: adult schizophrenia indication, ≥2-week adequate trial of generic asenapine sublingual at max tolerated dose, and valid medical reason for alternate form.
• Lybalvi and others: follow the product-specific trials and baseline requirements stated in Table/step sections.

Provide additional clinical rationale and be prepared for peer-to-peer on exceptional requests

When PA is requested for cases that meet exceptional criteria (e.g., requests beyond dosing/age limits or complex concurrent therapy), providers must include the additional clinical information described in the policy and be prepared for peer-to-peer review as required.

• Include rationale for use beyond Table 1 limits or in age bands listed as 'Not approved'.
• Be prepared to complete a written peer-to-peer and provide supporting clinical documentation if requested.

Required clinical documentation: metabolic labs, weight/height, and AIMS within 12 months

Document baseline and recent monitoring: prescribers should attempt to gather fasting plasma glucose, lipid screening, weight, height, and an Abnormal Involuntary Movement Scale (AIMS) evaluation within the previous 12 months; for children, include a developmentally-appropriate comprehensive psychiatric assessment (DSM diagnosis, collateral information).

• Fasting plasma glucose and lipid screening within the previous 12 months, if available.
• Weight and height documented.
• AIMS evaluation within the previous 12 months.
• For children: DSM-5 diagnosis, screening for parental psychopathology, family functioning, and collateral information (e.g., school).

When requesting beyond Table 1 limits or for 'Not approved' ages, submit justification

If requesting authorization for use in age bands or doses listed as 'Not approved' in Table 1, providers must submit justification explaining why the agent/dose is clinically necessary despite the 'Not Approved' designation.

• 'Not Approved' indicates insufficient evidence or pediatric dosing was reviewed but not recommended.
• Documentation should explicitly justify clinical necessity when requesting beyond table limits or for 'Not approved' ages.

Denial risk when concurrent antipsychotics exceed duration thresholds or dosing limits

Requests may be denied when multiple antipsychotics are used concurrently beyond the policy durations (patients <18: two or more agents >60 days; adults: three or more agents >60 days; two or more long-acting injectables >60 days) or when dosing exceeds Table 1 limits.

• Concurrent use triggers: <18 years — ≥2 antipsychotics >60 days; >18 years — ≥3 antipsychotics >60 days; ≥2 concurrent long-acting injectables >60 days.
• Dosing exceedance of Table 1 may also result in denial without PA and appropriate justification.

Dose- and age-mismatch denials: exceeding Table 1 limits or using in 'Not approved' ages may be denied

Requests that exceed the dosing limits in Table 1 (including specified multi-day maximums) or that seek use in ages listed as 'Not approved' may be denied; these exceedances specifically trigger the need for prior authorization and are unlikely to be approved without compelling documentation.

• Table 1 establishes maximum daily doses (unless otherwise noted) and multi-day maximums where specified.
• 'Not Approved' entries denote insufficient evidence and are unlikely to be approved without strong justification.