Clinical Pharmacy Program Guidelines for Antipsychotics- ARIZONA Program Prior Authorization Medication Antipsychotics Markets in Scope Arizona 1. Background: Preferred Typical Antipsychotics/ Non-Preferred Typical Antipsychotics Antimanic Agents Haldol® (haloperidol) concentrate/tablets* Triavil® (perphenazine-amitriptyline) tablet* Haldol decanoate® (haloperidol decanoate Moban (molindone) tablet solution)* Loxitane® (loxapine) capsules* Trilafon (perphenazine) tablets* Mellaril® (thioridazine) tablets* Navane® (thiothixene) capsules* Orap® (pimozide) tablets* Prolixin® (fluphenazine hydrochloride) concentrate/elixir/tablets* Prolixin® (fluphenazine decanoate) solution Stelazine® (trifluoperazine) tablets* Thorazine® (chlorpromazine) tablets /solution* Lithium carbonate capsules/tablets Lithium carbonate CR tablet (Lithobid)* Lithium solution Preferred Atypical Antipsychotics Non-Preferred Atypical Antipsychotics Abilify® (aripiprazole) tablets* Abilify Discmelt® (aripiprazole) orally Clozaril® (clozapine) tablets/orally disintegrating tablet dispersible tablet * Abilify MyCite (aripiprazole tablet with Geodon® (ziprasidone) capsules* sensor) Fazaclo (clozapine orally disintergrating Abilify Oral Solution® (aripiprazole) tablet) Caplyta (lumateperone) capsule Latuda (lurasidone) tablets Invega® (paliperidone) tablet Risperdal® (risperidone) oral solution/tablets* Fanapt® (iloperidone) tablets Risperdal M-Tab® (risperidone) orally Seroquel XR® (quetiapine extended release) disintegrating tablet* tablet Seroquel® (quetiapine) tablets* Perseris (risperidone) SubQ injection ® Zyprexa (olanzapine) tablets* Rexulti (brexpiprazole) tablet ® Zyprexa Zydis (olanzapine) orally Saphris (asenapine) sublingual tablet dispersible tablet* Secuado (asenapine) Symbyax (fluoxetine/ olanzapine) capsule Abilify Maintena ® (aripiprazole) IM Versacloz (clozapine) suspension injection Vraylar (cariprazine) capsule Aristada (aripiprazole lauroxil) IM injection Zyprexa Relprevv (olanzapine) IM injection Confidential and Proprietary, © 2020 UnitedHealthcare Services Inc. 1 Aristada (aripirazole lauroxil) Initio IM Injection Invega Sustenna ® (paliperidone) IM injection Invega Trinza ® (paliperidone) IM injection Risperdal Consta ® (risperidone) IM injection *Only generic versions are covered UHC C&S Plan Minimum Age Edits: Prior authorization is required for atypical antipsychotic claims for members less than the following ages: Generic Name Brand Name Age Edit PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral ARIPIPRAZOLE TABLETS ABILIFY health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral ASENAPINE MALEATE SUBLINGUAL SAPHRIS health provider PA Required for Ages < 18 years and patients ≥ 18 years when prescribed by a non-behavioral CLOZAPINE ORALLY DISPERSABLE TABLET FAZACLO health provider PA Required for Ages < 18 years and patients ≥ 18 years when prescribed by a non-behavioral CLOZAPINE TABLETS CLOZARIL health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral LURASIDONE HCL TABS LATUDA health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral OLANZAPINE ORALLY DISPERSABLE TABLET ZYPREXA ZYDIS health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral OLANZAPINE TABLETS ZYPREXA health provider PA Required for Ages < 6 years and patients ≥ 6 years when QUETIAPINE FUMARATE TABLETS SEROQUEL prescribed by a non-behavioral Confidential and Proprietary, © 2020 UnitedHealthcare Services Inc. 2 health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral RISPERIDONE ORALLY DISPERSABLE TABLET RISPERIDONE ODT health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral RISPERIDONE ORAL SOLUTION RISPERDAL health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral RISPERIDONE TABLETS RISPERDAL health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral ZIPRASIDONE HCL CAPSULES GEODON health provider PA Required for Ages < 18 years and patients 18 years and older when prescribed by a non- ARIPIPRAZOLE LAUROXIL ARISTADA and Aristada Initio Behavioral Health provider PA Required for Ages < 18 years and patients 18 years and older when prescribed by a non- ARIPIPRAZOLE SUSPENSION ABILIFY MAINTENA Behavioral Health provider PA Required for Ages < 18 years and patients 18 years and older when prescribed by a non- PALIPERIDONE PALMITATE SUSPENSION INVEGA SUSTENNA Behavioral Health provider PA Required for Ages < 18 years and patients 18 years and older when prescribed by a non- PALIPERIDONE PALMITATE SUSPENSION INVEGA TRINZA Behavioral Health provider PA Required for Ages < 18 years and patients 18 years and older when prescribed by a non- RISPERIDONE MICROSPHERES SUSPENSION RISPERDAL CONSTA Behavioral Health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral CHLORPROMAZINE HCL SOLUTION VARIOUS health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral CHLORPROMAZINE HCL TABLETS VARIOUS health provider Confidential and Proprietary, © 2020 UnitedHealthcare Services Inc. 3 PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral FLUPHENAZINE HCL CONCENTRATE VARIOUS health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral FLUPHENAZINE HCL ELIXIR VARIOUS health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral FLUPHENAZINE HCL TABLETS VARIOUS health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral HALOPERIDOL LACTATE CONCENTRATE VARIOUS health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral HALOPERIDOL TABLETS VARIOUS health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral LOXAPINE SUCCINATE CAPSULES LOXITANE health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral PERPHENAZINE TABLETS VARIOUS health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral PIMOZIDE ORAP health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral THIORIDAZINE HCL TABLETS VARIOUS health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral THIOTHIXENE CAPSULES VARIOUS health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral TRIFLUOPERAZINE HCL TABLETS VARIOUS health provider PA Required for Ages < 18 years FLUPHENAZINE DECANOATE SOLUTION FLUPHENAZINE DECANOATE and patients ≥ 18 years when Confidential and Proprietary, © 2020 UnitedHealthcare Services Inc. 4 prescribed by a non-behavioral health provider PA Required for Ages < 18 years and patients ≥ 18 years when prescribed by a non-behavioral HALOPERIDOL DECANOATE SOLUTION HALDOL DECANOATE health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral Lithium capsules/ tablets Lithium health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral Lithium CR tablets Lithobid health provider PA Required for Ages < 6 years and patients ≥ 6 years when prescribed by a non-behavioral Lithium solution Lithium health provider Off-labeled Use: Drug therapies must be utilized in accordance with FDA approved indications OR the uses found within the compendia of literature† AND the drug is being prescribed for a medically accepted indication that is recognized as a covered benefit by the applicable health plans’ program. Authorization for off-labeled use of medication will be evaluated on an individual basis. Review of an off-labeled request by the UnitedHealthcare Community & State Medical Staff will be predicated on the appropriateness of treatment, scientific evidence and full consideration of medical necessity. †-compendia of current literature: a. Food and Drug Administration (FDA) approved indications and limits, b. Published practice guidelines and treatment protocols, c. Comparative data evaluating the efficacy, type and frequency of side effects and potential drug interactions among alternative products as well as the risks, benefits and potential member outcomes, d. Drug Facts and Comparisons, e. American Hospital Formulary Service Drug Information, f. United States Pharmacopeia – Drug Information, g. DRUGDEX Information System, h. UpToDate, i. MicroMedex, j. Peer-reviewed medical literature, including randomized clinical trials, outcomes, research data and pharmacoeconomic studies, and k. Other drug reference resources Indications Confidential and Proprietary, © 2020 UnitedHealthcare Services Inc. 5 The intent of the criteria is to ensure the appropriate utilization of antipsychotic agents for the appropriate FDA labeled indications and consistent with current evidence in the literature. 2. Coverage Criteria: A. Preferred Antipsychotics: Antipsychotic Medications in Children Under 6 Years Old All of the following: 1. The patient has been diagnosed per current DSM criteria with one of the following disorders: a. Bipolar Spectrum Disorder