CurrentNeighborhood Health Plan of Rhode IslandPolicy 657-D

Atypical Antipsychotics ST Post PA 657 D P10 2024 V2

CVS Caremark-managed step therapy and prior authorization policy for multiple atypical antipsychotic products (brand and generic forms) specifying initial step requirements, coverage criteria for authorization, continuation criteria, and duration of approval. Applies to prescriptions adjudicated under the CVS Caremark benefit referenced by code 657-D.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAtypical Antipsychotics ST Post PA 657 D P10 2024 V2

Policy CodePolicy 657-D

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf patient has not filled a 30-day supply of one of the listed generics within the past 180 days, submit a prior authorization and document either a 30-day trial with inadequate response, intolerance/contraindication to a generic, or that no generic alternative is appropriate per guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted in this brief.

>=9Generic agents listed for step

MultipleBrand & generic atypical antipsychotics referenced

36DOA (months)

Coverage Summary

Coverage stance: covered_with_criteria for atypical antipsychotics under the CVS Caremark benefit (policy reference 657-D). Scope: CVS Caremark-managed step therapy and prior authorization policy for multiple brand and generic atypical antipsychotic products adjudicated under the CVS Caremark benefit. The policy lists and manages both brand and generic agents and specifies initial step requirements, PA coverage criteria, continuation criteria, and a Duration of Approval (DOA) of 36 months. The policy identifies >=9 generic agents for step and references multiple brand and generic atypical antipsychotics.

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Initial Step Therapy

If the patient has filled a 30-day supply of any listed generic within the past 180 days under the CVS Caremark prescription benefit, the requested drug will be paid; otherwise claim rejects and PA required. Lookback: 180 days. Trial duration: ≥30 days.

ANY of the following

Generic aripiprazole fill: Patient has filled a prescription for at least a 30-day supply of generic aripiprazole within the past 180 days under a prescription benefit administered by CVS Caremark>= 30 days
lookback 180 days
Generic asenapine fill: Patient has filled a prescription for at least a 30-day supply of generic asenapine within the past 180 days under a prescription benefit administered by CVS Caremark>= 30 days
lookback 180 days
Generic lurasidone fill: Patient has filled a prescription for at least a 30-day supply of generic lurasidone within the past 180 days under a prescription benefit administered by CVS Caremark>= 30 days
lookback 180 days
Generic olanzapine fill: Patient has filled a prescription for at least a 30-day supply of generic olanzapine within the past 180 days under a prescription benefit administered by CVS Caremark>= 30 days
lookback 180 days
Generic paliperidone fill: Patient has filled a prescription for at least a 30-day supply of generic paliperidone within the past 180 days under a prescription benefit administered by CVS Caremark>= 30 days
lookback 180 days
Generic quetiapine fill: Patient has filled a prescription for at least a 30-day supply of generic quetiapine within the past 180 days under a prescription benefit administered by CVS Caremark>= 30 days
lookback 180 days
Generic quetiapine XR fill: Patient has filled a prescription for at least a 30-day supply of generic quetiapine extended-release within the past 180 days under a prescription benefit administered by CVS Caremark>= 30 days
lookback 180 days
Generic risperidone fill: Patient has filled a prescription for at least a 30-day supply of generic risperidone within the past 180 days under a prescription benefit administered by CVS Caremark>= 30 days
lookback 180 days
Generic ziprasidone fill: Patient has filled a prescription for at least a 30-day supply of generic ziprasidone within the past 180 days under a prescription benefit administered by CVS Caremark>= 30 days
lookback 180 days

Initial Therapy Criteria (Step Therapy / Prior Authorization)

Prior Authorization - Coverage Criteria (Authorization may be granted when ONE of the following is met)

Authorization for the requested (non-step) atypical antipsychotic may be granted when ONE of the following is met. Where applicable, trial duration threshold is ≥30 days.

ANY of the following

Inadequate response to generic: Patient has experienced an inadequate treatment response, after a trial of at least 30 days, to ONE of the following generic products: aripiprazole, asenapine, lurasidone, olanzapine, paliperidone, quetiapine, quetiapine extended-release, risperidone, ziprasidone>= 30 days
trial duration >=30 days
Intolerance or contraindication to trial: Patient has an intolerance or a contraindication that would prohibit a 30-day trial of ONE of the following generic products: aripiprazole, asenapine, lurasidone, olanzapine, paliperidone, quetiapine, quetiapine extended-release, risperidone, ziprasidone30 days prohibited
intolerance/contraindication prevents 30-day trial
No appropriate generic per guidelines: Patient has a clinical condition for which there is no generic alternative or the generic alternatives are not recommended based on published guidelines or clinical literature
use published guidelines/clinical literature to support

Continuation Therapy Criteria

Continuation of Therapy

Authorization may be granted for continuation when ALL of the following are met.

ALL of the following

Currently taking requested drug: Patient is currently taking the requested drug
document current use
Evidence of improvement: There is evidence of improvement
document clinical improvement

Provider Actions & Prior Authorization Requirements

Prior Authorization

Prior authorization required if initial step not met

If patient has not filled a 30-day supply of one of the listed generics within the past 180 days, the claim will reject and a prior authorization is required; PA criteria will be applied for review.

Claim will reject if no prior generic fill in past 180 days

Documentation Required

Document inadequate response or intolerance

To meet PA criteria, document either a trial of at least 30 days with inadequate treatment response to a listed generic, or evidence of intolerance/contraindication preventing a 30-day trial, or evidence that no generic alternative is appropriate per guidelines.

Trial duration 30 days or greater
Generics to trial: aripiprazole; asenapine; lurasidone; olanzapine; paliperidone; quetiapine (including XR); risperidone; ziprasidone

Documentation Required

Document clinical improvement for continuation

For continuation approvals, provide documentation that the patient is currently taking the requested drug and has evidence of improvement.

Duration of approval: 36 months

Background & Definitions

Background: This CVS Caremark-managed policy lists multiple atypical antipsychotic products (both brand and generic across dosage forms) and governs step therapy and prior authorization when less-costly generic alternatives are available. The policy specifies that if a patient has filled a 30‑day supply of a listed generic within the past 180 days the requested drug will be paid; otherwise the claim rejects and a PA is required. The document references product indications and package inserts to provide clinical context for listed agents and to inform PA determinations.

Requested drug: The atypical antipsychotic for which coverage/authorization is being requested when initial step criteria may not be met.

Generic alternatives listed: aripiprazole, asenapine, lurasidone, olanzapine, paliperidone, quetiapine (including XR), risperidone, ziprasidone.

Quick thresholds & facts

Generic trial duration>= 30 days

Lookback period for prior generic fill180 days

Duration of Approval (DOA)36 months

Generic agents listed for step>=9

Initial step ruleIf patient filled >=30-day supply of a listed generic within past 180 days, requested drug will be paid; otherwise claim rejects and PA required.