UnitedHealthcare Antipsychotics Prior Auth Coverage

Coverage and Medical Necessity Criteria

inv-01: General authorization criteria

Covered when ALL of the following are met:

General: Completed form with member and provider information; documentation submitted showing prior trials or intolerances to preferred formulary/PDL alternatives when requested; prior trials must sufficiently demonstrate that preferred alternatives are ineffective or inappropriate at the time of request; complete Section D and submit medical records when failures or intolerances are claimed.

Section D must document prior medication trials or intolerances; medical records must be submitted when indicated.

inv-02: Long-acting injectable (LAI) specific criteria

Product-specific tolerability and sequencing requirements:

Aripiprazole LAI: For Abilify Maintena, Aristada, and Aristada Initio the patient must have established tolerability with oral aripiprazole prior to initiating the long-acting injectable formulation.

Document oral aripiprazole tolerability on the form.

Paliperidone (Invega) products: Invega Sustenna requires established tolerability with oral paliperidone or oral risperidone; Invega Trinza requires the patient be established on Invega Sustenna for at least 4 consecutive months prior to initiating Trinza; Hafyera queries prior monthly or every-three-month paliperidone palmitate use as applicable.

Document prior oral or LAI paliperidone/risperidone use and durations as specified on the form.

inv-03: Abilify MyCite specific criteria

Covered when ALL of the following are met:

Current use and tolerability: Medical records must document the patient is currently prescribed aripiprazole and tolerates the medication.

Documentation required per form (ABILIFY MYCITE section).

Adherence history: Medical records must document the patient's adherence to aripiprazole is less than 80% within the past 6 months (medication adherence percentage defined on the form) unless other criteria apply; prescriber must attest that Abilify MyCite is medically necessary to maintain compliance and avoid life‑threatening worsening of symptoms.< 80%

Adherence percentage = (number of pills absent / number prescribed) x 100.

Adherence strategies attempted: Provider must confirm applicable adherence-improvement strategies have been tried without success (e.g., pill box, smartphone reminders, involving family/friends, coordinating dosing with another daily medication).

inv-04: Latuda (lurasidone) criteria

Covered when ALL of the following are met for schizophrenia/schizoaffective disorder:

Schizophrenia/schizoaffective: Patient has a diagnosis of schizophrenia or schizoaffective disorder AND has failure to three preferred alternatives, one of which is aripiprazole, or has intolerance/contraindication to three preferred alternatives (including aripiprazole).

If yes, complete Section D and submit medical records documenting failures or intolerances as indicated.

inv-05: Latuda (lurasidone) criteria

Latuda — coverage contingent on the following

Latuda initial criteria: Patient has diagnosis of schizophrenia or schizoaffective disorder AND either failure to three preferred alternatives (one being aripiprazole) with medical records submitted OR history of intolerance/contraindication to three preferred alternatives (including aripiprazole) with records submitted.

Form requests completion of Section D and submission of medical records when failures or intolerances are claimed.

inv-06: Vraylar (cariprazine) criteria

Vraylar — coverage contingent on the following

Vraylar indications: Patient has diagnosis of schizophrenia or schizoaffective disorder OR bipolar depression OR bipolar mania/mixed episodes; for schizophrenia and mania/mixed requires failure to three preferred alternatives, one being aripiprazole, OR history of intolerance/contraindication to three preferred alternatives including aripiprazole, with medical records submitted when indicated.

For bipolar depression the form lists fluoxetine plus olanzapine and quetiapine as alternatives to document trials against.

inv-07: Long-acting injectable risperidone criteria

Perseris / Risperdal Consta

LAI risperidone criteria: For Perseris and Risperdal Consta the form asks whether the patient has established tolerability with oral risperidone prior to LAI use.

Established oral risperidone tolerability is required per form.

inv-08: Risperidone oral solution criteria

Risperdal oral solution

Oral solution criteria: Patient is unable to swallow the oral solid preferred alternatives AND has failure to a majority of the oral solid preferred alternatives, or has a history of contraindication/intolerance to a majority of the oral solid preferred alternatives; medical records must be submitted when applicable.

Form requires specifying which preferred alternatives and documenting records in Section D.

inv-09: Caplyta (lumateperone) quantity limit

Caplyta quantity limit

Caplyta quantity exceedance: If requesting to exceed the quantity limit (one capsule at a maximum dose of 42 mg), provider must provide rationale and sign/date the form.one capsule at max dose of 42 mg

Provider signature and date required on the form when requesting exceedance.

The form implies that approval is contingent on submission of required documentation for prior medication trials or documented intolerances. Specifically, if the requester indicates the patient has demonstrated failure to a majority of preferred formulary/PDL alternatives or intolerance to those alternatives, the form instructs Section D must be completed and medical records must be submitted to show the trials, failures, or intolerances. Requests that do not include this documentation may be denied because prior trials must “sufficiently demonstrate that the formulary/PDL alternatives are either ineffective or inappropriate at the time of the request.”

Treatment Modalities and Special Products

inv-24: Long-acting injectable antipsychotics

LAI initiation: Document oral tolerability prior to many LAI antipsychotic initiations; sequencing requirements for paliperidone products apply (Invega Sustenna established oral tolerability; Invega Trinza requires >=4 months on Sustenna).

See product-specific sections on the form for required durations and tolerability statements.

inv-25: Digital adherence medication

Digital medicine (Abilify MyCite): Requires documentation of tolerability, adherence <80% in the past 6 months (unless other criteria apply), attempts at adherence interventions, and prescriber attestation of medical necessity; prescriber agreement to track adherence via manufacturer software is requested.< 80%

Continuation requires documentation that adherence has increased to >=80% and prescriber attestation of need for continued use.

Form Submission, Documentation, and Provider Requirements

Prior Authorization

Form submission — Providers must complete and fax the Antipsychotics Prior Authorization Request Form

Please complete and fax the Antipsychotics Prior Authorization Request Form with all required member, provider, medication, diagnosis, and prior trial information to 866-940-7328. If you have questions, call 800-310-6826. Allow at least 24 hours for review. Medical records must be submitted when the form indicates failure to preferred alternatives or when an intolerance/contraindication is claimed.

Fax: 866-940-7328
Phone: 800-310-6826
Allow ≥24 hours for review

Step Therapy

Complete product-specific prior trials — Document failures or intolerances to preferred alternatives

Prior authorization requires documentation of prior trials of preferred formulary/PDL alternatives (one of which is often aripiprazole). The form asks whether the patient has failed a majority of preferred oral/PDL alternatives or failed specific required alternatives for product-specific requests (e.g., Latuda, Vraylar require failure of three preferred alternatives including aripiprazole). If claiming intolerance/contraindication to preferred alternatives, complete Section D and submit supporting medical records.

Definitions and Operational Terms

Medication adherence percentage

CalculationMedication adherence percentage = (number of pills absent in a given time period ÷ number of pills prescribed during that same time) × 100.

Timeframe referencedAdherence documented for the past 6 months (used to determine <80% threshold).

Threshold used for MyCiteAdherence less than 80% within the past 6 months supports MyCite consideration.

Documentation requirementMedical records must be submitted to document current prescription, tolerability, and adherence history when requested.

Established tolerability

DefinitionEstablished tolerability = documentation that the patient tolerates oral risperidone prior to use of long-acting injectable risperidone products (Perseris, Risperdal Consta).

Background and Scope

This prior authorization form supports requests for a broad range of antipsychotic products, including oral agents, long‑acting injectables (LAIs), and product‑specific modalities such as digital adherence systems. The form includes product sections and checklist items that capture diagnosis, current treatment status, prior medication trials or intolerances, and product‑specific tolerability or sequencing requirements (for example, established tolerability with oral aripiprazole for Abilify Maintena/Aristada; documented oral paliperidone/risperidone tolerability and Sustenna-to‑Trinza sequencing for Invega products; and oral risperidone tolerability for Perseris/Risperdal Consta).

For digital adherence medication (Abilify MyCite) the form requests medical records documenting current prescription and tolerability, an adherence history showing adherence < 80% when applicable, and confirmation that adherence‑improvement strategies have been attempted; prescriber agreement to use manufacturer software is requested. The Caplyta section includes a quantity limit of one capsule at a maximum dose of 42 mg and requires provider rationale and signature when requesting an exceedance. The risperidone oral solution section requires documentation that the patient is unable to swallow oral solid preferred alternatives and evidence of failure or intolerance to a majority of oral solid preferred options.

OpenPayer

Antipsychotics Prior Authorization Request — Coverage Criteria

Coverage and Medical Necessity Criteria

Treatment Modalities and Special Products

Form Submission, Documentation, and Provider Requirements

Definitions and Operational Terms

Background and Scope