CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Pimavanserin (Nuplazid) for Parkinson's disease psychosis - Coverage Criteria

This policy governs coverage and authorization criteria for pimavanserin (Nuplazid) to treat hallucinations and delusions associated with Parkinson's disease psychosis for Medicaid members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPimavanserin (Nuplazid) for Parkinson's disease psychosis - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateDec 1, 2017

Next Review DateMar 1, 2024

Key ActionObtain prior authorization with documentation of PD diagnosis, PD psychosis onset after PD diagnosis, symptom duration/frequency, prior trials of quetiapine and clozapine, cognitive assessment, and QT interval evaluation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moauthorization duration

one dailyquantity limit

quetiapine & clozapineprior treatment required

neurologistprescriber specialty

Coverage Criteria for Pimavanserin (Nuplazid)

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.

Initial Approval

Authorization of 12 months may be granted when ALL of the following are met:

Initial approval criteria: Documented diagnosis of Parkinson's disease

PD psychosis diagnosis: Documented diagnosis of Parkinson's disease (PD) psychosis

psychosis onset must be after PD diagnosis

Onset timing: Onset of psychosis after Parkinson's disease diagnosis (psychosis not present prior to PD diagnosis)

Symptom duration and frequency: Recent history of frequent moderate-to-severe hallucinations and delusions for at least one month in durationfrequency >= once weekly; duration >= 1 month

Frequent defined as psychotic events that occur at least once weekly

Cognitive status: Member has mild or no cognitive impairment as determined by physician clinical diagnosis and/or cognitive screening tests (e.g., MMSE, MOCA)

PD medication adjustment: Prescriber has attempted to decrease member's dose of prescribed Parkinson's disease medications to alleviate potential cause of psychotic events

QT interval and interacting medications: Member does not have evidence of a prolonged QT interval and is not taking medication that may prolong the QT interval

ECG or medication review recommended

Dementia-related psychosis exclusion: Member has been evaluated for, and does not have a diagnosis of, dementia-related psychosis

Prior antipsychotic trials: Member has experienced inadequate response, intolerance, or contraindication to quetiapine and clozapine

Step therapy requirement

Continuation of Therapy

Authorization of 12 months may be granted when ALL of the following are met:

Response requirement: Member has experienced improvement in psychotic symptoms (hallucinations and/or delusions) since starting therapy

Use of pimavanserin (Nuplazid) for any indication other than treatment of hallucinations and delusions associated with Parkinson's disease psychosis is considered experimental/investigational and is not a covered benefit.

Use of pimavanserin (Nuplazid) for non–FDA‑approved indications (other than compendial uses) is considered not covered/experimental.

Coding and Quantity Limits

Quantity-limited productsNDC|labelCovered

Nuplazid 10 mg tablet	Quantity limit: one tablet per day
Nuplazid 34 mg capsule	Quantity limit: one capsule per day

Quantity-limited productsNDC|labelCovered

Nuplazid 10mg tablet	Quantity limit: one tablet per day
Nuplazid 34mg capsules	Quantity limit: one capsule per day

Duration of psychotic symptoms — ≥ 1 month

Required durationPsychotic symptoms present for at least 1 month (≥ 1 month)

ContextApplies to recent history of moderate-to-severe hallucinations and delusions as part of PD psychosis

Documentation sourceMust be documented in clinical record as part of initial approval criteria

Frequency of psychotic events — ≥ once weekly

Required frequencyPsychotic events occur at least once weekly (≥ once weekly)

Applies toFrequent moderate-to-severe hallucinations and delusions in PD psychosis

Use in criteriaFrequency threshold used to define ‘recent history’ for initial approval

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required. Initial approval: up to 12 months when all clinical criteria are met. Continuation approval: up to 12 months when continuation criteria are met. Quantity limits: Nuplazid (pimavanserin) 10 mg — one tablet per day; Nuplazid 34 mg — one capsule per day.

Initial and continuation approvals limited to 12 months when criteria met
Quantity limit: 10 mg — 1 tablet/day; 34 mg — 1 capsule/day

Denial Risk

Indication Restrictions — Not Covered

Use of pimavanserin for any indication other than hallucinations and delusions associated with Parkinson's disease psychosis is considered experimental/investigational and is not covered.

All other indications are not a covered benefit

Documentation Required

Documentation Required — Provide Complete Clinical Records

Required documentation must be provided with the prior authorization request. Absence of required documentation may lead to denial.

Documented diagnosis of Parkinson's disease and documented diagnosis of Parkinson's disease psychosis with psychosis onset after the Parkinson's diagnosis
Description of duration and frequency of hallucinations/delusions (recent history of frequent moderate-to-severe events for ≥1 month; frequent = ≥ once weekly)
Evidence of mild or no cognitive impairment (clinical assessment or screening tests such as MMSE or MOCA)
Documentation that prescriber attempted to decrease PD medication dose to rule out medication-induced psychosis
Documentation of evaluation ruling out dementia-related psychosis
ECG or medication review showing no prolonged QT interval or interacting QT-prolonging medications
Prescriber statement that medication is prescribed by or in consultation with a board-certified neurologist
Documentation of prior inadequate response, intolerance, or contraindication to quetiapine and clozapine

Definitions

Frequent hallucinations and delusions

DefinitionPsychotic events that occur at least once weekly

Clinical contextUsed to define ‘frequent’ hallucinations and delusions for initial approval

Threshold linkageDirectly linked to duration requirement of ≥ 1 month for coverage consideration

Mild or no cognitive impairment

Assessment methodDetermined by physician clinical diagnosis and/or cognitive screening tests (e.g., MMSE, MOCA)

Required statusMember must have mild or no cognitive impairment to meet initial approval criteria

DocumentationCognitive status must be recorded in clinical documentation for prior authorization