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

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 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); except Risperdal 4mg  OR 
• Member has had intolerance to drug administered as a single daily dose (Abilify 10mg, 15mg, 20mg tablets; Zyprexa/Zyprexa Zydis 5mg, 7.5mg, 10mg) OR 
• Member has failed the maximum labeled dose AND has a therapeutic response to a higher dose (Abilify 20mg, 30mg tablets; Clozaril 100mg; Fazaclo 100mg; Geodon 60mg, 80mg capsules; Risperdal 3mg, 4mg tablets; Serentil 100mg; Seroquel 200mg, 300mg, 400mg; Zyprexa, Zyprexa Zydis 15mg, 20mg)
• Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose (Abilify 20mg, 30mg tablets; Clozaril 100mg; Fazaclo 100mg; Geodon 60mg, 80mg; Risperdal 3mg, 4mg; Serentil 100mg; Seroquel 200mg, 300mg, 400mg;  Zyprexa, Zyprexa Zydis 15mg, 20mg).
  

Under some plans, including plans that use an open or closed formulary, Invega is subject to step-therapy.  Aetna considers Invega to be medically necessary for those members who meet the following step-therapy criteria:

A documented trial of one month of the preferred alternative Risperal.

If it is medically necessary for a member to be treated initially with a medication subject to step-therapy, the member's treating physician may contact the Aetna Pharmacy Management Precertification Unit to request coverage as a medical exception. (See criteria under section III below.)

Abilify, Equetro, Fazaclo, Geodon and Symbyax are currently listed on the Aetna Formulary Exclusions List.* Therefore, Abilify, Fazaclo, Geodon, Serentil and Symbyax 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 Abilify, Fazaclo, Geodon, Serentil and Symbyax to be medically necessary for those members who meet any of the following criteria:

Invega is currently listed on the Aetna Formulary Exclusions and Aetna Step-Therapy Lists.* Therefore, it is excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary or that  require step-therapy criteria, unless a medical exception is granted.  Aetna considers Invega  to be medically necessary for those members who meet the following criteria:

For Fazaclo
 
A documented:

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

For Abilify and Geodon

A.   A documented:

• Intolerance to two preferred atypical antipsychotics OR
• Contraindication to two preferred atypical antipsychotics OR
• Allergy to two preferred alternative agent indicated for the member's  condition OR
• Failure of an adequate trial of one month each of two preferred atypical antipsychotics

 OR

B.  Member is documented to have been successfully treated with requested   antipsychotic in the past - aripiprazole (Abilify) or ziprasidone (Geodon)

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 have been successfully treated with olanzapine/ fluoxetine (Symbyax) in the past.

For Equetro

A.   A documented:

• Intolerance to two preferred atypical antipsychotics OR
• Contraindication to two preferred atypical antipsychotics OR
• Allergy to two preferred alternative agent indicated for the member's  condition OR
• Failure of an adequate trial of one month each of two preferred atypical antipsychotics
  

For Invega

A.   A documented:

• Intolerance to preferred alternative agent Risperdal OR
• Contraindication to preferred alternative agent Risperdal OR
• Allergy to preferred alternative agent Risperdal indicated for the member's  condition OR
• Failure of an adequate trial of one month of the  preferred alternative agent Risperdal