Prior Authorization : Preferred Drug List

Antipsychotics

Note: The Preferred Drug List Quick Reference provides the most current list of preferred and non-preferred drugs in this drug class.

Abilify MyCite

Abilify MyCite requires clinical PA.

PA requests for Abilify MyCite must be completed, signed, and dated by the prescriber. PA requests for Abilify MyCite must be submitted using Section VI (Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form and the PA/RF.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

PA requests for Abilify MyCite may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Abilify MyCite

Clinical criteria that must be documented for approval of a PA request for Abilify MyCite are all of the following:

• The member has a mobile device with a data plan that is compatible with the MyCite monitoring application.
• The member has attempted standard measures to improve medication adherence. The prescriber must identify what adherence measures the member has previously attempted.
• The member has previously taken oral aripiprazole and had a measurable therapeutic response. The aripiprazole dose and approximate dates taken must be documented.
• The prescriber has agreed to track and document the member's adherence with Abilify MyCite using the MyCite software program.

Clinical documentation and medical records must be submitted with the PA request to support the need for Abilify MyCite. PA requests for Abilify MyCite may be approved for up to 90 days.

PA for Antipsychotic Drugs for Children 8 Years of Age and Younger

All antipsychotic drugs prescribed for oral use for all children 8 years of age and younger require PA.

PA requests must meet the criteria for children 8 years of age and younger to allow coverage of an antipsychotic drug.

PA requests for antipsychotic drugs for children 8 years of age and younger must be submitted on the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger form.

Claims submitted for an antipsychotic drug for children 8 years of age and younger without an approved Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger form on file will be denied.

Prescribers are encouraged to write prescriptions for preferred antipsychotic drugs.

Background

ForwardHealth monitors the use of antipsychotic drugs in young children. The PA process is intended to scrutinize the prescribing of antipsychotic drugs for mood disorders and the monitoring of metabolic effects of this class of drugs. ForwardHealth strongly encourages prescribers to earnestly engage in clarifying the differentiation between DMDD and bipolar disorder, NOS.

The increased use of antipsychotic drugs in young children over the past decade has been associated with the frequent use of the diagnosis of bipolar disorder, NOS (F31.9) per the DSM-5 in many of these children. A discussion and review of the issues in differentiating bipolar disorder, NOS from DMDD can be found in the Journal of the American Academy of Child and Adolescent Psychiatry, Volume 52, Issue 5, May 5, 2013, pp. 466-481 (Towbin, K. MD, Axelson, D. MD, Leibenluft, E. MD, Birmaher, B. MD, "Differentiating Bipolar Disorder-Not Otherwise Specified and Severe Mood Dysregulation").

In recent years, there has been some progress in the research of these clinical issues. Specifically, the DSM-5 addresses the inclusion of DMDD (F34.8). This evolved out of the observation that many children with a diagnosis of bipolar disorder do not progress to having bipolar disorder, NOS as adults, thus bringing into question the use of antipsychotic drugs for these children. Many of the children with DMDD (or severe mood dysregulation as referenced in several research studies) respond to stimulants and/or SSRI antidepressants. Although SSRIs may cause mild activation when first administered, this is not necessarily mania. These antidepressants can be very effective for irritability associated with anxiety and depression in young children, and they have far fewer side effects than antipsychotic drugs. Clinicians need to be vigilant about target symptoms and strive to clarify persistent irritability as seen in DMDD versus the more classic episodic irritability typical of bipolar spectrum disorders. Clinicians who prescribe antipsychotic drugs to children with bipolar disorder, NOS diagnoses will need to become familiar with the details of the current research on differentiating DMDD from bipolar disorder, NOS.

Prescriber Responsibilities for Antipsychotic Drugs for Children 8 Years of Age and Younger

If a child is 8 years of age or younger and requires an oral antipsychotic drug, the prescriber is required to complete the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger form. PA request forms must be faxed, mailed, or sent with the member to the pharmacy provider.

The pharmacy provider will use the completed form to submit a PA request to ForwardHealth. Prescribers should not submit the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger form directly to ForwardHealth. Prescribers are required to retain a completed and signed copy of the PA form.

PA requests for covered antipsychotic drugs for children 8 years of age and younger are approved at the active ingredient level. Therefore, an approved PA request allows any covered NDC with the same active ingredient of the prior authorized drug to be covered with the same PA. For example, if a member has an approved PA request for risperidone 1 mg tablets and the prescriber orders a new prescription for risperidone 2 mg tablets, an amended PA request or new PA request is not required.

Clinical Documentation

If the PA request for antipsychotic drugs for children 8 years of age and younger is for a member who is being treated for autism or tics, the only documentation required is the diagnosis information described in the following list. Pharmacy providers are encouraged to submit all PA requests for autism and tics using the STAT-PA system. The following clinical documentation is required on PA requests for members who are being treated for a condition other than autism or tics and must be submitted on the Portal, by fax, or by mail:

• Information about the child's diagnoses—There are appropriate indications for the use of antipsychotic drugs in young children with certain diagnoses, including autism spectrum disorders, psychotic disorders, and tic disorders. Antipsychotic drugs may also be helpful for severe symptoms of irritability, aggression, anger, or defiance that may accompany severe mood disorders, developmental disorders, or ADHD.
• BMI measurements—Antipsychotic drugs can have profoundly adverse effects on weight, glucose, and lipids. Because of these well-documented side effects, the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger form requires the submission of a BMI percentile measurement with each PA request. The BMI percentile measurement is required because it is the standard for stratifying individuals as obese or at-risk for obesity and, therefore, requiring closer monitoring and active intervention. Children who have a BMI percentile measurement greater than or equal to 85 percent are at risk for diabetes and the metabolic syndrome associated with many antipsychotic drugs. If the child's BMI percentile is 85 percent or greater, the PA request must include a triglyceride level and a fasting glucose or HBA1c drawn within the past six months for the PA request to be approved.
• Target symptoms—The prescriber is required to be very familiar with the criteria for DMDD and to clarify persistent versus episodic irritability/anxiety/anger/temper outbursts as well as to identify the presence, or absence, of comorbid conditions.
• Polypharmacy information—The Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger form requires documentation of the child's experience with any psychoactive drugs, concurrent drugs, as well as previous drug trials in the preceding 12 months.
• Specialty information—ForwardHealth is interested in tracking the prescriber's practice specialty information.
• Documentation for non-preferred antipsychotic drug requests—If the prescriber is requesting a non-preferred antipsychotic drug, clinical documentation must be provided to support the request and must include detailed reasons why preferred drugs were discontinued or not utilized.

Brand name antipsychotic drugs prescribed to children 8 years of age and younger that are BMN require that a Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger form be submitted on the Portal, by fax, or by mail with the PA/BMNA form and the PA/RF.

Two unique PA numbers will be assigned for a BMN antipsychotic drug. One PA number will be assigned to the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger form, and the other will be assigned to the PA/BMNA form.

PA Request Submission Methods

Pharmacy providers are encouraged to use the STAT-PA system to submit PA requests for antipsychotic drugs for children who have one of the following conditions:

• Autism
• Tics

If the prescriber indicates on the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger form that the child has autism or tics, no additional clinical information is required on the form, and the pharmacy may submit the request using the STAT-PA system.

PA requests cannot be submitted using the STAT-PA system if any of the following are true:

• The child has a condition other than autism or tics.
• The drug being requested is a non-preferred antipsychotic drug.
• The child is 2 years of age or younger.
• The PA request is for a BMN antipsychotic drug.

If the PA request is not approved through the STAT-PA system, pharmacy providers are required to submit the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 8 Years of Age and Younger form, a PA/RF, and any supporting documentation from the prescriber on the Portal, by fax, or by mail.

Approved PA Requests for Antipsychotic Drugs for Children 8 Years of Age and Younger

Neither a new PA request nor a PA amendment is needed if the antipsychotic drug the child is taking has changed and the new drug contains the same active ingredient as the original drug approved or if the child is taking multiple strengths of the same drug.

PA decision notice letters for antipsychotic drugs for children 8 years of age and younger will include a message stating: "The prior authorization for this drug has been approved at the active ingredient level instead of the drug strength and dosage form level. Additional PAs are not needed for a different strength of this same drug."

Expedited Emergency Supply for Antipsychotic Drugs for Children 8 Years of Age and Younger

ForwardHealth strongly encourages pharmacy providers to utilize the expedited emergency supply process for antipsychotic drugs for children 8 years of age and younger when it is determined that the member should begin taking the medication immediately, but the PA request submission and adjudication process would delay dispensing the medication to the member. This may occur if a child 8 years of age or younger receives a prescription for an antipsychotic covered drug and the prescriber has not completed the necessary PA form or the PA request is still in process.

Expedited emergency supply requests for antipsychotic drugs will be approved for up to a 14-day supply. Members will be limited to receiving two 14-day expedited emergency supply approvals of the same drug from one pharmacy provider within a six-month time period. A PA is not required to be in process when the first expedited emergency supply request is submitted.

If a second expedited emergency supply is necessary for a member, there must be a PA request for the drug submitted to ForwardHealth, and it must be in the process of being adjudicated. The second expedited emergency supply request may be approved if a PA request is in process for the same drug and strength and the PA is submitted by the pharmacy that submitted the first expedited emergency supply request.

If a PA request for the drug has been approved, the second expedited emergency supply request will not be approved.

Requests for a second expedited emergency supply request may be submitted seven to 21 days after the initial request was submitted. Second expedited emergency supply requests will not be approved if they are submitted before day seven or after day 21.

For example, if an initial expedited emergency supply request was submitted on March 4 and a PA request for the drug was submitted on March 7 and a second expedited emergency supply is necessary for the member because the PA request had not yet been adjudicated, the second expedited emergency request may be submitted on March 10 or as late as March 24.