Subject: Specialty Quantity Limit Nuplazid 4802-H P2025

Drug

NUPLAZID  (pimavanserin)

Policy:

Program Description

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended dosing parameters for the treatment of hallucinations and delusions associated with Parkinson’s disease psychosis fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.

Covered Quantities

Medication	Standard Limit
Nuplazid (pimavanserin) 34 mg capsules	30 per 30 days
Nuplazid (pimavanserin) 10 mg tablets	30 per 30 days

FDA-recommended Dosing

Standard dosing

34 mg once daily orally.

Coadministration with a strong CYP3A4 inhibitor

10 mg once daily orally.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Nuplazid [package insert]. San Diego, CA: Acadia Pharmaceuticals Inc.; January 2025.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

February 15, 2026