Obtain prior authorization; approvals up to 12 months

Prior authorization is required for brand second‑generation antipsychotics. When criteria are met, approvals may be issued for up to 12 months.

Document required trials of generic SGAs (1–3 trials depending on product)

Most brand SGAs require documented prior trials of generic second‑generation antipsychotics; the number of required trials varies by product (typically 1, and for some products 2 or 3).

• General requirement: 1 generic SGA trial with inadequate response or intolerance for individuals not previously treated with the requested therapy ([[see citations]]).
• Bysanti (milsaperidone): requires trial of 2 generic SGAs and age ≥18; dose limit 24 mg/day.
• Cobenfy (xanomeline and trospium chloride): requires trial of 3 generic SGAs and age ≥18; additional product‑specific requirements apply.

Provide complete medical record documentation with request

Submit office visit notes that document the diagnosis, relevant history, physical evaluation, and medication history to demonstrate that medical necessity criteria are met.

• Include documentation of inadequate response or intolerance to required generic SGA trials as applicable per product‑specific criteria.
• For product‑specific approvals, include supporting documentation required by the drug entry (e.g., DSM diagnosis for Cobenfy; clinical necessity for Opipza formulation).

Denial risk if required prior trials are not documented

Requests may be denied if records do not document the required number of prior generic SGA trials and inadequate response or intolerance as specified in the product‑specific criteria.

• Failure to document the required trials (e.g., 1 general trial, 2 for Bysanti, 3 for Cobenfy) and associated outcomes risks denial of the request.

Manage oral SGAs through the pharmacy benefit

These oral antipsychotic drugs are managed through the pharmacy benefit; submit requests and prescriptions via pharmacy channels per benefit rules.