Criteria for Prior Authorization — Antipsychotic Medications
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Defines prior authorization requirements, dosing limits, provider-type restrictions, concurrent-use rules, and step-therapy conditions for antipsychotic medications covered under Kansas Medicaid.
Specific step-therapy requirements for branded products (e.g., Abilify MyCite, Secuado, Lybalvi, Opipza, Cobenfy, Caplyta, Fanapt, Rexulti, Vraylar) were defined.
Table 1 dosing limits updated for many agents including age-specific maximum daily doses.
Revised dates include May 20, 2026 and other recent revisions indicating updates to the document.
Coverage Criteria
inv-01: Initial prior authorization criteria
Covered with prior authorization when criteria below are met:
See Table 1 for dosing limits and product-specific step therapy.
Diagnostic list in policy.
Includes oral and long-acting injectables.
Two or more concurrent long-acting injectable antipsychotics for >60 days in patients >18 also require prior authorization and a written peer-to-peer consult with plan psychiatrist/medical director/pharmacy director (and verbal peer-to-peer if needed).
Table 1 contains agent- and age-specific maximum daily doses; drugs listed as 'Not Approved' for an age require appeal.
Examples: Abilify MyCite, Secuado, Lybalvi, Opipza, Cobenfy, Caplyta, Fanapt, Rexulti, Vraylar per policy details.
Prochlorperazine is excluded from management under this antipsychotic prior authorization policy because it is primarily used for nausea and vomiting rather than psychiatric indications; the policy notes that prochlorperazine is not being managed for this reason and was previously removed from coverage management at the May 18, 2018 MHMAC meeting.
Pediatric entries labeled "Not Approved" in Table 1 indicate that there is insufficient evidence or that pediatric dosing was reviewed but not recommended. Requests for use in those pediatric age groups are effectively excluded from routine approval because the table denotes these agents or doses as not approved for children.
Use of antipsychotic agents outside the age ranges specified in Table 1 (including agents listed as not approved for a given pediatric band) will not be granted by routine prior authorization and instead requires an appeal. In other words, requests for use outside the table's approved age ranges must be justified and pursued through the appeal process rather than through standard PA pathways.
Coding and Tables
| Aripiprazole | Aripiprazole (Abilify®, Abilify Asimtufii®, Abilify Discmelt®, Abilify Maintena®, Aristada®, Aristada Initio®, Abilify MyCite®, Opipza™) |
| Asenapine | Asenapine (Saphris®, Secuado®) |
| Brexpiprazole | Brexpiprazole (Rexulti®) |
| Cariprazine | Cariprazine (Vraylar®) |
| Chlorpromazine | Chlorpromazine |
| Clozapine | Clozapine (Clozaril®, Fazaclo®, Versacloz®) |
| Fluphenazine | Fluphenazine |
| Haloperidol | Haloperidol (Haldol®) |
| Iloperidone | Iloperidone (Fanapt®) |
| Lumateperone | Lumateperone (Caplyta®) |
| No codes listed |
Provider Actions and Requirements
Prior authorization required for all antipsychotics
Prior authorization is required for all current and future dose forms of antipsychotic medications; specific product criteria and step-therapy requirements are detailed in the policy and Table 1.
- All antipsychotic medications require PA regardless of formulation.
Reference Table 1 dosing limits for PA
Prior authorization decisions must reference the Table 1 antipsychotic medication dosing limits; agents or doses that exceed the age‑specific maximums listed in Table 1 require justification and will trigger PA and peer‑to‑peer review.
- Exceeding Table 1 dosing limits mandates prior authorization and written peer-to-peer consult for approval.
Step therapy / product-specific requirements
Step therapy and product-specific prerequisites apply to multiple branded antipsychotics; these agents require documented trials of specified generics, adherence to FDA label or other listed conditions before approval.
- Abilify MyCite: must meet FDA label, documented benefit, 12‑week approval period, not eligible for injections, and requires peer‑to‑peer review.
- Secuado: requires prior adequate trial of generic asenapine SL and medical rationale for alternate dosage form.
- Lybalvi: requires trial(s) of low-weight-gain generics, baseline/current weight reporting, opioid safety precautions, and initial 1‑year approval.
- Opipza, Cobenfy, Caplyta, Fanapt, Rexulti, Vraylar: require FDA label adherence and trials of or intolerance to specified generics per policy.
Concurrent-use PA triggers and specialist consults
For concurrent antipsychotic use, follow the policy triggers: concurrent use beyond specified durations requires prior authorization and specialist prescribing or consultation as described below.
- Patients <18 years using two or more antipsychotics concurrently for >60 days require PA and prescribing by or consultation with a psychiatrist, neurologist, or developmental/behavioral pediatrician.
- Patients ≥18 years using three or more antipsychotics concurrently for >60 days require PA and prescribing by or consultation with a psychiatrist; two or more concurrent LAIs >60 days require PA plus written peer‑to‑peer consult.
Required clinical monitoring and documentation
Prescribers should attempt to obtain fasting plasma glucose, lipid screening, weight, height, and an Abnormal Involuntary Movement Scale (AIMS) evaluation within the prior 12 months and document a developmentally‑appropriate comprehensive psychiatric assessment in the medical record.
- Include DSM‑5 (or latest) diagnosis, screening for parental psychopathology, family functioning evaluation, and collateral information (e.g., school).
- Document non‑pharmacologic interventions initiated or maintained when treating children.
Document agent, formulation, age band, and daily dose
Providers must document the prescribed antipsychotic agent, formulation, patient age category, and the daily dose to demonstrate the dose does not exceed the age‑specific maximums listed in Table 1.
- Record agent name, formulation (e.g., oral, LAI), patient age band, and calculated daily dose compared to Table 1 maxima.
Concurrent antipsychotic duration triggers for PA
Prior authorization is required when multiple antipsychotics are used concurrently beyond the policy's duration thresholds; failure to meet these rules may result in denial.
- Two or more antipsychotics for >60 days in patients <18 years triggers PA.
- Three or more antipsychotics for >60 days in patients ≥18 years triggers PA.
- Two or more concurrent long‑acting injectables for >60 days in adults triggers PA and requires written peer‑to‑peer consult.
Dose exceedance and 'Not Approved' age risk for denial
Requests for doses exceeding the Table 1 maximum daily doses or for pediatric ages labeled 'Not approved' are at risk for denial and may require appeal or peer‑to‑peer review per the dosing limits table.
- 'Not Approved' pediatric uses indicate insufficient evidence and are subject to denial or appeal.
- Exceeding age‑specific maxima requires PA and written peer‑to‑peer consult for approval.
Background
Antipsychotic medications are prescribed across the lifespan for a range of conditions (for example, schizophrenia, bipolar disorder, adjunctive treatment of major depressive disorder, irritability in autism, Tourette’s, and Huntington’s disease). The policy emphasizes age-appropriate prescribing and monitoring: clinicians should follow the age-stratified dosing limits in Table 1, obtain baseline and interval metabolic and movement monitoring where applicable, and prioritize nonpharmacologic interventions in children. These expectations support the policy's requirement that all antipsychotic dose forms obtain prior authorization and that dosing or age exceptions be documented and justified.
Definitions and Prescriber Requirements
Level of Care Criteria
Treatment Modalities
inv-22: Medication (antipsychotics)
Policy lists examples and specific requirements for Abilify MyCite, Secuado, Lybalvi, Opipza, Cobenfy, Caplyta, Fanapt, Rexulti, and Vraylar.
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