CurrentUnitedHealthcarePolicy N/A

Antipsychotics prior authorization form (Arizona)

A prior authorization request form and criteria checklist for antipsychotic medications (including oral, long-acting injectables, concomitant therapy, and Abilify MyCite) used for UnitedHealthcare members in Arizona; used by prescribers to request new or continuation therapy and document clinical justification.

Policy Summary

PayerUnitedHealthcare

PolicyAntipsychotics prior authorization form (Arizona)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete the prior authorization form with required member, provider, diagnosis, prior medication trials, and supporting documentation and fax it for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24+distinct form questions/fields across sections A–E and specialty sections

Under 6pediatric section (<6)

Abilify MyCitedetailed adherence pathway

Invega TrinzaInvega Trinza prerequisite

Coverage Criteria for Antipsychotic Therapies

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General antipsychotic approval criteria

Covered when ALL of the following are met

Indication and documentation: Request documents that the patient has one of the listed indications (schizophrenic spectrum disorder, bipolar disorder, autism spectrum disorder, Tourette's/tic disorder) and provides specific diagnosis and ICD-10 code

Form includes checkboxes for indications and diagnosis field

Preferred agent trial: Has the patient demonstrated failure or intolerance to a majority (not more than 3) of the preferred alternatives listed on the PDL?

Section D to document prior trials

Hospital continuation: If patient is currently receiving requested non-preferred behavioral health medication in the hospital and must continue upon discharge, provide start and discharge dates and documentation

Hospital continuation checkbox and dates

LAI (long-acting injectable) criteria

Long-acting injectable (LAI) specific criteria — Covered when ALL of the following are met

Oral alternative intolerance or inability: Patient is unable to take oral solid alternatives; reason must be provided

Form asks to document reason

Established tolerability for LAI family: Evidence of tolerability with the requested LAI family or prior specific LAI use when required (e.g., Invega Trinza requests require prior Invega Sustenna treatment for at least 4 months)>= 4 months for Sustenna before Trinza

Checkboxes for aripiprazole, paliperidone, risperidone; Trinza prerequisite

Non-compliance: Documented non-compliance with oral atypical antipsychotic dosage forms may support LAI approval

Form queries non-compliance and requests prior trial documentation

Concomitant / refractory treatment criteria

Concomitant antipsychotic treatment (cross-taper or combination) — Covered when ALL of the following are met

Cross taper documentation: If request is for a cross taper, provide start date of cross taper and supporting plan

Form includes cross-taper checkbox and start date field

Refractory schizophrenia criteria: For refractory schizophrenic spectrum disorder: evidence of adequate trials of at least three individual antipsychotics listed on the AHCCCS Behavioral Health Drug Lists for 4–6 weeks at maximum tolerated doses (document in Section D)4-6 weeks each

Form requests documentation in Section D

Refractory bipolar criteria: For refractory bipolar disorder with psychosis/severe symptoms: evidence of at least four evidence-based treatment options tried for 4–6 weeks at maximum tolerated doses (document in Section D)4-6 weeks each

Abilify MyCite criteria

Abilify MyCite specific coverage — Covered when ALL of the following are met

Current aripiprazole use and tolerability: Submission of medical records documenting the patient is currently prescribed aripiprazole and tolerates the medication

Required documentation for MyCite consideration

Adherence below threshold: Medical records document adherence to aripiprazole is less than 80% within the past 6 months (adherence defined as number of pills absent divided by number prescribed times 100); provide percentage and date< 80%

Form specifies adherence calculation and requests percentage and date

Failed adherence strategies: All applicable adherence strategies (pill box, smartphone reminders, involving family/friends, coordinating dosing with another daily medication) have been tried without success

Form lists adherence strategies to document

Pediatric (<6) criteria

Members under 6 years old — Covered when ALL of the following are met

Psychosocial evaluation: Documentation that psychosocial issues have been evaluated before the request for antipsychotic medications

Form asks yes/no

Non-medication alternatives attempted: Documentation that non-medication alternatives were attempted before antipsychotic use (if yes, complete Section D)

Form asks to complete Section D if applicable

Expected outcomes and adverse event evaluation: Documentation including expected outcomes and an evaluation of potential adverse events

Form asks yes/no

Behavioral health prescriber and FDA awareness: Medication prescribed by a behavioral health provider and prescriber attests awareness of FDA labeling for antipsychotic use in this age group and provides rationale

The form requires documentation that the member has demonstrated failure or intolerance to a majority (but no more than three) of the preferred alternatives listed on the PDL before a non‑preferred antipsychotic will be approved. When the prior‑trial fields on the form (Section D) are not completed to show these preferred‑agent trials and reasons for discontinuation, the request implies lack of trials and will not meet coverage criteria for non‑preferred agents.

If the prior‑trial, intolerance, or clinical‑justification fields required on the form are left blank or lack sufficient detail, the submission is considered non‑supportive of medical necessity. The prescriber must document indications, dates, medications tried, and reasons for failure/intolerance; absence of this documentation risks denial under the policy.

Coding and Measurement Fields

Requested diagnosis code fieldICD-10

ICD-10 CODE

Field to specify the member's ICD-10 diagnosis code on the form

inv-09: Adherence percentage — <80% adherence threshold for Abilify MyCite consideration

Adherence thresholdMedical records must document aripiprazole adherence is less than 80% within the past 6 months (adherence defined as number of pills absent divided by number prescribed × 100).

Documentation requiredSubmit medical records showing current aripiprazole prescription and tolerability, plus the calculated adherence percentage and date.

Adherence-improvement strategiesDocument attempted adherence strategies (pill box, smartphone reminders, family assistance, coordinating dosing) and that they were unsuccessful.

Severe outcome evidenceIf applicable, include records of life‑threatening symptoms or hospitalization attributed to lack of adherence.

inv-10: Invega Sustenna prior duration — At least 4 months required before Invega Trinza

Minimum prior Sustenna durationIf requesting Invega Trinza, patient must have been treated with Invega Sustenna for at least 4 months (document dates).

Section D documentationIf yes, complete Section D with prior trial dates, reasons for discontinuation, and tolerability information.

Established tolerabilityDocument tolerability with relevant agents (aripiprazole, paliperidone, risperidone) as applicable.

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Standard prior authorization is required for non-preferred antipsychotics and certain long-acting injectables (LAIs). Prescribers must complete the prior authorization form in full and provide supporting documentation to avoid processing delays. Allow at least 24 hours for review.

Fax completed form to 866-940-7328; questions: 800-310-6826
Complete all pages of the form to avoid delays
All requests: ensure diagnosis and relevant clinical information are provided

Step Therapy

Preferred-Agent Trial Requirement

A trial and documentation of failure or intolerance to preferred alternatives is required before a non-preferred agent will be approved. Document attempts and reasons for failure/intolerance (e.g., lack of efficacy, adverse effects) in Section D (Previous Medication Trials) and reference the patient's PDL review.

Has the patient demonstrated failure or intolerance to a majority (not more than 3) of preferred agents? — document in Section D
Section E: review and document PDL alternatives considered

Denial Risk

Incomplete Prior Trial Documentation May Lead to Denial

If prior trials are not documented or intolerance to preferred agents is not clearly recorded, the request may be denied. Ensure Section D is fully completed with medication names, strengths, directions, dates of therapy, and reasons for discontinuation.

Failure to document prior trials or reasons for discontinuation may lead to denial
List specific dates and rationale for each prior medication trial in Section D

Documentation Required

Required Form Fields and Prior Trial Documentation

Required form fields include complete Member information (Section A), Provider information (Section B), Medication details and Diagnosis with ICD-10 code (Section C), and Previous Medication Trials (Section D). For non-preferred agents and LAIs, include documentation of tried preferred alternatives and reasons for failure/intolerance.

Section A: member name, ID, DOB, contact, current hospitalization/discharge info
Section B: provider name, NPI, phone, fax, specialty
Section C: medication, strength, directions, quantity, diagnosis with ICD-10
Section D: medication name, strength, directions, dates of therapy, reason for discontinuation
Section E: document review of PDL preferred alternatives

Documentation Required

Abilify MyCite Supporting Records

For Abilify MyCite requests, submit medical records showing the patient is currently prescribed and tolerates aripiprazole, plus documentation that adherence to aripiprazole was <80% in the past 6 months and attempts to improve adherence have been tried without success. Also include any records of life‑threatening symptoms or hospitalization attributed to nonadherence when applicable.

Medical records confirming current aripiprazole prescription and tolerability
Adherence documentation: % adherence (<80%) and date (calculation method as defined)
Evidence of adherence interventions tried (pill box, smartphone reminders, family support, dose coordination)
Documentation of life‑threatening worsening or hospitalizations due to nonadherence, if applicable
Prescriber attestation that Abilify MyCite is medically necessary and agreement to track adherence via manufacturer software

Background

The form is structured to capture clinical justification for antipsychotic prescribing across the listed indications (schizophrenic spectrum disorder, bipolar disorder, autism spectrum disorder, and Tourette's/tic disorders). It asks whether the patient is currently on the requested medication, start dates, hospital continuation details, and explicit prior‑trial information to support medical necessity.

Definitions and Clinical Terms

inv-19: Refractory disorder — definition requiring evidence of multiple adequate trials for refractory schizophrenic or bipolar disorders

Schizophrenia refractory definitionRefractory schizophrenic spectrum disorder requires evidence of adequate trials of at least three individual antipsychotics listed on the AHCCCS Behavioral Health Drug Lists for 4–6 weeks at maximum tolerated doses.

Bipolar refractory definitionRefractory bipolar disorder with psychosis or severe symptoms requires evidence of at least four evidence‑based treatment options tried for 4–6 weeks at maximum tolerated doses.

Adherence verificationProvide supporting documentation that nonadherence was not a contributing factor to lack of response in the medication trials.

Level-of-Care and Continuation Criteria

Outpatient / Post-discharge medication continuation

Continuation of outpatient or post-discharge antipsychotic therapy is covered when the applicable conditions below are met

Current therapy documented: If the patient is currently receiving the requested drug, provide start date and documentation of clinical response/tolerability

Form requests current drug start date and related information

Hospital discharge continuation: If patient is receiving the requested non-preferred behavioral health medication in the hospital and must continue upon discharge, provide start and discharge dates and documentation

Hospital continuation checkbox and dates

Treatment Modalities (LAI, Abilify MyCite, Concomitant Therapy)

LAI, Abilify MyCite

Modality-specific criteria for long-acting injectables and Abilify MyCite

LAI-specific requirements: Document inability to use oral alternatives, evidence of tolerability with the LAI family or prior specific LAI use where required (e.g., >=4 months Sustenna before Trinza), and documentation of non-compliance if applicable>= 4 months for Sustenna before Trinza

Section dedicated to long-acting injectables

Abilify MyCite-specific requirements: Document current aripiprazole prescription and tolerability, adherence <80% in past 6 months with percentage/date, failed adherence-improvement strategies, and prescriber attestation to track adherence via manufacturer software< 80%

Detailed MyCite checklist and continuation pathway

Revision History

policy_effective_or_reviewLatest

No dated revision entries were provided in the document or brief; the form header indicates contact/fax information and review turnaround but contains no explicit policy effective, last review, or next review dates.

Policy Summary

PayerUnitedHealthcare

PolicyAntipsychotics prior authorization form (Arizona)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete the prior authorization form with required member, provider, diagnosis, prior medication trials, and supporting documentation and fax it for review.

SourceLink

On This Page

Form requests documentation in Section D

Adherence verified: Documentation that nonadherence is not the contributing factor to lack of response in prior medication trials

Form includes a question regarding adherence documentation

Severe consequence of nonadherence: Medical records document life‑threatening or potentially life‑threatening symptoms, or severe worsening leading to hospitalization attributed to lack of adherence

Form asks for rationale and documentation

Prior LAI or alternatives failed: History of failure, contraindication, intolerance, or special circumstance preventing use of listed LAIs (Abilify Maintena, Invega Sustenna, Risperdal Consta, Aristada)

If yes, complete Section D

Prescriber attestation: Prescriber acknowledges MyCite has not been shown to improve adherence, attests MyCite is medically necessary to maintain compliance and avoid life‑threatening worsening, and agrees to track/document adherence via manufacturer software

Form includes prescriber attestations and agreement to track adherence

Form includes attestations and rationale field