Under some plans, including plans that use an open or closed formulary, Abilify, Abilify Disc, clozapine, Clozaril, Fazaclo, Geodon, Invega, Mellaril, Risperdal, Risperdal M, Seroquel, Seroquel XR, Symbyax, thioridazine, Zyprexa and Zyprexa Zydis are subject to precertification.  If precertification requirements apply Aetna considers Abilify,  Abilify Disc, clozapine, Clozaril, Fazaclo, Geodon, Invega, Risperdal, Risperdal M, Seroquel, Seroquel XR, Symbyax, thioridazine, Zyprexa and Zyprexa Zydis to be medically necessary for those members who meet the following precertification criteria:

For Abilify, Abilify Disc, clozapine, Clozaril, Fazaclo, Geodon, Invega, Risperdal, Risperdal M, Seroquel, Seroquel XR, Symbyax,  Zyprexa and Zyprexa Zydis

A.  Quantity limits: 

According to the manufacturer, these antipsychotics can be dosed up to a maximum daily dose at the interval(s) as indicated in the table below.  A quantity of each drug will be considered medically necessary as indicated in the table below:

For coverage of additional quantities, a member's treating physician must request prior authorization through the Aetna Pharmacy Management Precertification Unit.  A prior authorization will be granted for coverage of additional quantities of these antipsychotics for those members who meet ANY of the following criteria:

• Member requires a dose including half tablets OR
• Member's dose is being titrated by physician (3-month limit) OR
• Member has had intolerance to drug administered as a single daily dose OR
• Member has failed the maximum labeled dose AND has a therapeutic response to a higher dose OR
• Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose

For thioridazine and Mellaril

A.  Age limit for members greater than or equal to 65 years of age:

• Member has tried and failed alternative drugs that are appropriate in the elderly to the treat the condition OR
• Member has been stabilized on the drug for an extended period and discontinuation or change in the drug might result in physical and/or mental impairment OR
• Member is in a critical or terminal state and disruption of therapy at this point would be inappropriate AND
  Member is being monitored AND
  Member has no known history of emergency department visits and/or hospital admissions from use of the drug in the member
  

Under some plans, including plans that use an open or closed formulary, Abilify, Abilify Disc, Geodon and Invega are subject to step-therapy.  Aetna considers Abilify, Abilify Disc, Geodon and Invega to be medically necessary for those members who are new starts on these medications not those who are currently stabilized on the medications and who meet the following step-therapy criterion:

For Abilify, Abilify Disc and Geodon

A documented trial of one month of one of the following alternatives on the Aetna Medicare Preferred Drug List: clozapine, Risperdal, Seroquel, Seroquel XR, Zyprexa Zydis or Zyprexa.

For Invega

A documented trial of one month of Risperdal- an alternative on the Aetna Medicare Preferred Drug List

If it is medically necessary for a member to be initially treated with a medication subject to Step-Therapy, or if the member meets transition of coverage (TOC) criteria for a medication subject to TOC, the member's treating physician may contact the Aetna Pharmacy Management Precertification Unit to request coverage as a medical exception at 1-800-414-2386. (See criteria under section III below.)

Abilify, Abilify Disc, Geodon and Invega are currently listed on the Aetna Step-Therapy List.*  If it is medically necessary for a member to be treated initially with one of these medications subject to step-therapy, Aetna considers these drugs to be medically necessary for those members who are new starts and who meet the criteria specified below:

For Abilify, Abilify Disc and Geodon

A.  A documented:

• Contraindication to one of the following preferred alternatives: clozapine, Risperdal, Seroquel, Seroquel XR, Zyprexa Zydis or Zyprexa OR
• Intolerance to one of the following preferred alternatives: clozapine, Risperdal, Seroquel, Seroquel XR, Zyprexa Zydis or Zyprexa OR
• Allergy to one of the following preferred alternatives: clozapine, Risperdal, Seroquel, Seroquel XR, Zyprexa Zydis or Zyprexa OR
• Failure of an adequate trial of one month of one of the following preferred alternatives: clozapine, Risperdal, Seroquel, Seroquel XR, Zyprexa Zydis or Zyprexa

OR

B.  Member is documented to be currently stabilized on one of these antipsychotics: Abilify, Abilify    Disc or Geodon.

OR

C. Transition of Coverage:

• Member is within 90 days of his or her effective date of enrollment
• Member is stable on Abilify, Abilify Disc or Geodon for 30 days or longer
  
  If applicable, quantity limits, age or gender edits will apply.  Approval is valid one year from the date of request.
  
  If the member has been a Medicare member for 91 days or longer standard precertification, step-therapy, or medical exception criteria will apply.

For Invega

A.   A documented:

• Contraindication to the preferred alternative Risperdal OR
• Intolerance to the preferred alternative Risperdal OR
• Allergy to the preferred alternative Risperdal OR
• Failure of an adequate trial of one month to the preferred alternative Risperdal
  
  OR

B.   Member is documented to be currently stabilized on Invega.


Clozaril, Haldol, Haldol inj, Loxitane, Mellaril, Navane, Symbyax and Thorazine tabs are currently Not Covered Part D drugs under the Aetna Medicare Prescription Drug Plan.*  Therefore, they are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary, unless a medical exception is granted.  Aetna considers Clozaril, Haldol, Haldol inj, Loxitane, Mellaril, Navane, Symbyax and Thorazine tabs to be medically necessary for those members who are new starts and who meet the criteria below:

For Clozaril, Haldol, Haldol inj, Mellaril, Loxitane, Navane and Thorazine tabs
 
A documented:

• Contraindication to the preferred generic equivalent OR
• Intolerance to the preferred generic equivalent OR
• Allergy to the preferred generic equivalent OR
• Failure of an adequate trial of one month of the preferred generic equivalent

For Symbyax

A.   A documented:

• Contraindication to one preferred antipsychotic, or other agent indicated for mania AND one preferred antidepressant OR
• Intolerance to one preferred antipsychotic, or other agent indicated for mania AND one preferred antidepressant OR
• Failure of an adequate trial of one month each of one preferred antipsychotic, or other agent indicated for mania AND one preferred antidepressant
  
  OR

B. Member is documented to be currently stabilized on Symbyax.

 OR

C. Transition of Coverage:

• Member is within 90 days of his or her effective date of enrollment
• Member is stable on Symbyax for 30 days or longer
  
  If applicable, quantity limits, age or gender edits will apply.  Approval is valid one year from the date of request.
  If the member has been a Medicare member for 91 days or longer standard precertification, step-therapy, or medical exception criteria will apply.