CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Vraylar (cariprazine) prior authorization and coverage criteria

Criteria and utilization management for coverage of Vraylar (cariprazine) for members of Neighborhood Health Plan of Rhode Island, including initial approval, continuation of therapy, and quantity limits for schizophrenia, bipolar disorder, and adjunctive treatment of major depressive disorder.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVraylar (cariprazine) prior authorization and coverage criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective Date02/01/2021

Next Review DateN/A

Key ActionObtain prior authorization with documentation of required prior trials or a ≥30-day paid Vraylar claim for continuation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

≥3schizophrenia prior failures

3 agentsbipolar required agents

30-day claimcontinuation evidence

60 caps/30dmax supply (1.5/3mg)

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Coverage Criteria for Vraylar (cariprazine)

inv-01: Schizophrenia — Initial Approval

Covered when ALL of the following are met:

Schizophrenia initial criteria: Member is being treated for schizophrenia; AND member has experienced a failure, contraindication, or intolerance to at least three formulary atypical antipsychotics (aripiprazole, olanzapine, quetiapine IR or ER, risperidone, or ziprasidone)

inv-02: Bipolar disorder — Initial Approval

Covered when ALL of the following are met:

Bipolar disorder initial criteria: Member is being treated for bipolar disorder; AND member has experienced a failure, contraindication, or intolerance to all of the following: olanzapine, quetiapine IR or ER, and lurasidone

inv-03: Major Depressive Disorder (adjunctive) — Initial Approval

Covered when ALL of the following are met:

MDD adjunctive initial criteria: Member is being treated for adjunctive therapy for major depressive disorder (MDD); AND member has experienced a failure, contraindication, or intolerance to aripiprazole

inv-04: Continuation of Therapy

Continued coverage criteria:

Continuation criteria: At least one paid claim for a ≥30-day supply of Vraylar within the last 365 days OR documentation of a positive clinical response

inv-05: Quantity Limits

Quantity limits: Vraylar 1.5 mg or 3 mg: 60 capsules per 30 days; Vraylar 4.5 mg or 6 mg: 30 capsules per 30 days; Vraylar 1.5 mg–3.0 mg: 7 capsules every 5 days

Provider Requirements, Prior Authorization and Step Therapy

Prior Authorization

Prior Authorization Required

Prior authorization is required. Initial authorization may be granted for up to 12 months when indication‑specific prior trial requirements are met. Providers must document diagnosis and prior treatment history supporting failure, contraindication, or intolerance to required formulary agents per indication.

Initial authorization: up to 12 months when criteria met
Documentation: diagnosis and prior treatment history required

Denial Risk

Schizophrenia prior trials required

For schizophrenia, approval requires documentation that the member is being treated for schizophrenia and has experienced failure, contraindication, or intolerance to at least three formulary atypical antipsychotics.

Required agents (examples): aripiprazole, olanzapine, quetiapine IR or ER, risperidone, ziprasidone

Background and Drug Information

This policy addresses coverage and prior authorization for cariprazine (Vraylar), an atypical antipsychotic used for schizophrenia, bipolar disorder, and as adjunctive therapy for major depressive disorder. An initial authorization of up to 12 months may be granted when indication-specific prior trial requirements are met. For schizophrenia, the member must have failed or have a contraindication or intolerance to at least three formulary atypical antipsychotics (examples listed in the policy include aripiprazole, olanzapine, quetiapine IR/ER, risperidone, or ziprasidone). For bipolar disorder, the member must have failed or have a contraindication or intolerance to olanzapine, quetiapine (IR or ER), and lurasidone. For adjunctive treatment of major depressive disorder, the member must have failed or have a contraindication or intolerance to aripiprazole.

Continued coverage requires documentation of ongoing use or benefit: at least one paid claim for a ≥30-day supply of Vraylar within the prior 365 days or documentation of a positive clinical response. The policy also specifies quantity limits by strength (for example, Vraylar 1.5 mg or 3 mg: 60 capsules per 30 days; Vraylar 4.5 mg or 6 mg: 30 capsules per 30 days, with an additional refill pacing rule of 7 capsules every 5 days for the 1.5–3.0 mg dosing interval).

Definitions

Vraylar (definition)

Generic nameCariprazine

Brand nameVraylar

Drug classAtypical antipsychotic

Indications (policy notes)Schizophrenia, bipolar disorder, and adjunctive therapy for major depressive disorder

Medication and Treatment Modalities

inv-14: Medication (antipsychotic)

Cariprazine modality: Use of cariprazine governed by indication-specific prior trials and continuation criteria as stated in the policy