Antipsychotics - HID

Texas Prior Authorization Program Clinical Criteria

Drug/Drug Class

Antipsychotics

Clinical Criteria Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical criteria Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical criteria rules Logic diagram: a visual depiction of the clinical criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable References: clinical publications and sources relevant to this clinical criteria Note: Click the hyperlink to navigate directly to that section.

Revision Notes Annual review by staff Added GCNs for chlorpromazine ampule (14331), fluphenazine vial (14571), haloperidol lactate (15490 and 15500) and quetiapine ER (16193, 98522, 98523, 98524 and 98994) Updated Table 7 Updated references

February 17, 2021

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Texas Prior Authorization Program Clinical Criteria

Antipsychotics

Antipsychotics

Drugs Requiring Prior Authorization

The listed GCNS may not be an indication of TX Medicaid Formulary coverage. To learn the current formulary coverage, visit formulary/formulary-search.

Antipsychotics ? First Generation

Label Name

GCN

AMITRIPTYLINE/PERPHENAZINE 2-10 AMITRIPTYLINE/PERPHENAZINE 2-25 AMITRIPTYLINE/PERPHENAZINE 4-10 AMITRIPTYLINE/PERPHENAZINE 4-25 AMITRIPTYLINE/PERPHENAZINE 4-50 CHLORPROMAZINE 10 MG TABLET CHLORPROMAZINE 25MG/ML AMP CHLORPROMAZINE 25 MG TABLET CHLORPROMAZINE 50 MG TABLET CHLORPROMAZINE 100 MG TABLET CHLORPROMAZINE 200 MG TABLET CHLORPROMAZINE 30 MG/ML CONC CHLORPROMAZINE 100 MG/ML CONC FLUPHENAZINE 1 MG TABLET FLUPHENAZINE 2.5 MG TABLET FLUPHENAZINE 5 MG TABLET FLUPHENAZINE 10 MG TABLET FLUPHENAZINE 5 MG/ML CONC FLUPHENAZINE 2.5 MG/5 ML ELIX FLUPHENAZINE 2.5 MG/ML VIAL FLUPHENAZINE DEC 125 MG/5 ML

16674 16676 16675 16677 16678 14431 14331 14432 14433 14434 14435 14391 14390 14602 14604 14605 14603 14590 14580 14571 14540

HALOPERIDOL 0.5 MG TABLET HALOPERIDOL 1 MG TABLET HALOPERIDOL 2 MG TABLET HALOPERIDOL 5 MG TABLET HALOPERIDOL 10 MG TABLET HALOPERIDOL 20 MG TABLET HALOPERIDOL 1 MG/ML SOLUTION HALOPERIDOL DEC 100 MG/ML AMP HALOPERIDOL DECAN 50 MG/ML AMP

15530 15531 15533 15535 15532 15534 15522 14801 14800

HIC4 H2JB/H2GE H2JB/H2GE H2JB/H2GE H2JB/H2GE H2JB/H2GE H2GA H2GA H2GA H2GA H2GA H2GA H2GA H2GA H2GD H2GD H2GD H2GD H2GD H2GD H2GD H2GD H2LH H2LH H2LH H2LH H2LH H2LH H2LH H2LH H2LH

February 17, 2021

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Texas Prior Authorization Program Clinical Criteria

Antipsychotics

Antipsychotics ? First Generation

Label Name

GCN

HALOPERIDOL DEC 100 MG/ML VIAL HALOPERIDOL DEC 50 MG/ML VIAL HALOPERIDOL LAC 2 MG/ML CONC HALOPERIDOL LAC 5 MG/ML AMPULE HALOPERIDOL LAC 5 MG/ML VIAL LOXAPINE 5 MG CAPSULE LOXAPINE 10 MG CAPSULE LOXAPINE 25 MG CAPSULE LOXAPINE 50 MG CAPSULE MOLINDONE HCL 5 MG TABLET MOLINDONE HCL 10 MG TABLET MOLINDONE HCL 25 MG TABLET ORAP 1 MG TABLET ORAP 2 MG TABLET PERPHENAZINE 2 MG TABLET PERPHENAZINE 4 MG TABLET PERPHENAZINE 8 MG TABLET PERPHENAZINE 16 MG TABLET PIMOZIDE 1 MG TABLET PIMOZIDE 2 MG TABLET THIORIDAZINE 10 MG TABLET THIORIDAZINE 25 MG TABLET THIORIDAZINE 50 MG TABLET THIORIDAZINE 100 MG TABLET THIOTHIXENE 1 MG CAPSULE THIOTHIXENE 2 MG CAPSULE THIOTHIXENE 5 MG CAPSULE THIOTHIXENE 10 MG CAPSULE TRIFLUOPERAZINE 1 MG TABLET TRIFLUOPERAZINE 2 MG TABLET TRIFLUOPERAZINE 5 MG TABLET TRIFLUOPERAZINE 10 MG TABLET

14781 14780 15520 15490 15500 15562 15560 15561 15563 15653 15650 15652 11153 11150 14651 14652 14653 14650 11153 11150 14882 14880 14881 14883 15690 15692 15694 15691 14830 14832 14833 14831

HIC4 H2LH H2LH H2LH H2LH H2LH H7UA H7UA H7UA H7UA H7SA H7SA H7SA H2LG H2LG H2GE H2GE H2GE H2GE H7RB H7RB H2GH H2GH H2GH H2GH H2LT H2LT H2LT H2LT H2GG H2GG H2GG H2GG

The listed GCNS may not be an indication of TX Medicaid Formulary coverage. To learn the current formulary coverage, visit formulary/formulary-search.

February 17, 2021

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Texas Prior Authorization Program Clinical Criteria

Antipsychotics

Antipsychotics ? Second Generation (Oral/Regular Acting Injectables)

Label Name

GCN

HIC4

ABILIFY 1 MG/ML SOLUTION ABILIFY 2 MG TABLET ABILIFY 5 MG TABLET ABILIFY 10 MG TABLET ABILIFY 15 MG TABLET ABILIFY 20 MG TABLET ABILIFY 30 MG TABLET ABILIFY DISCMELT 10 MG TABLET ABILIFY DISCMELT 15 MG TABLET ABILIFY MYCITE 2 MG KIT ABILIFY MYCITE 5 MG KIT ABILIFY MYCITE 10 MG KIT ABILIFY MYCITE 15 MG KIT ABILIFY MYCITE 20 MG KIT ABILIFY MYCITE 30 MG KIT ARIPIPRAZOLE 1 MG/ML SOLUTION ARIPIPRAZOLE 2 MG TABLET ARIPIPRAZOLE 5 MG TABLET ARIPIPRAZOLE 10 MG TABLET ARIPIPRAZOLE 15 MG TABLET ARIPIPRAZOLE 20 MG TABLET ARIPIPRAZOLE 30 MG TABLET ARIPIPRAZOLE ODT 10 MG TABLET ARIPIPRAZOLE ODT 15 MG TABLET CAPLYTA 42 MG CAPSULE CLOZAPINE 12.5 MG TABLET CLOZAPINE 25 MG TABLET CLOZAPINE 50 MG TABLET CLOZAPINE 100 MG TABLET CLOZAPINE 200 MG TABLET CLOZAPINE ODT 12.5 MG TABLET CLOZAPINE ODT 25 MG TABLET CLOZAPINE ODT 100 MG TABLET CLOZAPINE ODT 150 MG TABLET CLOZAPINE ODT 200 MG TABLET CLOZARIL 25 MG TABLET CLOZARIL 100 MG TABLET

24062 26305 20173 18537 18538 18539 18541 26445 26448 44437 44438 44439 44441 44442 44443 24062 26305 20173 18537 18538 18539 18541 26445 26448 47492 20334 18141 18143 18142 31672 98791 21784 21785 28873 28874 18141 18142

H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7TM H2LS H2LS H2LS H2LS H2LS H2LS H2LS H2LS H2LS H2LS H2LS H2LS

February 17, 2021

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Texas Prior Authorization Program Clinical Criteria

Antipsychotics

Antipsychotics ? Second Generation (Oral/Regular Acting Injectables)

Label Name

GCN

HIC4

FANAPT 1 MG TABLET FANAPT 2 MG TABLET FANAPT 4 MG TABLET FANAPT 6 MG TABLET FANAPT 8 MG TABLET FANAPT 10 MG TABLET FANAPT 12 MG TABLET FANAPT TITRATION PACK FAZACLO 12.5 MG ODT FAZACLO 25 MG ODT FAZACLO 100 MG ODT FAZACLO 150 MG ODT FAZACLO 200 MG ODT GEODON 20 MG CAPSULE GEODON 40 MG CAPSULE GEODON 60 MG CAPSULE GEODON 80 MG CAPSULE GEODON 20 MG VIAL INVEGA ER 1.5 MG TABLET INVEGA ER 3 MG TABLET INVEGA ER 6 MG TABLET INVEGA ER 9 MG TABLET LATUDA 20 MG TABLET LATUDA 40 MG TABLET LATUDA 60 MG TABLET LATUDA 80 MG TABLET LATUDA 120 MG TABLET OLANZAPINE 2.5 MG TABLET OLANZAPINE 5 MG TABLET OLANZAPINE 7.5 MG TABLET OLANZAPINE 10 MG TABLET OLANZAPINE 10 MG VIAL OLANZAPINE 15 MG TABLET OLANZAPINE 20MG TABLET OLANZAPINE ODT 5MG TABLET OLANZAPINE ODT 10 MG TABLET OLANZAPINE ODT 15 MG TABLET

28025 28026 28027 28028 28029 28030 28033 28034 98791 21784 21785 28873 28874 13331 13332 13333 13334 17037 27685 97769 97770 97771 31226 29366 35192 29367 33147 15084 15083 15081 15082 11814 15085 15086 92007 92008 34022

H7TK H7TK H7TK H7TK H7TK H7TK H7TK H7TK H2LS H2LS H2LS H2LS H2LS H2GD H2GD H2GD H2GD H2GD H7TH H7TH H7TH H7TH H7TL H7TL H7TL H7TL H7TL H7TD H7TD H7TD H7TD H7TD H7TD H7TD H7TD H7TD H7TD

February 17, 2021

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Texas Prior Authorization Program Clinical Criteria

Antipsychotics

Antipsychotics ? Second Generation (Oral/Regular Acting Injectables)

Label Name

GCN

HIC4

OLANZAPINE ODT 20MG TABLET OLANZAPINE/FLUOXETINE 3-25 MG OLANZAPINE/FLUOXETINE 6-25 MG OLANZAPINE/FLUOXETINE 6-50 MG OLANZAPINE/FLUOXETINE 12-25 MG OLANZAPINE/FLUOXETINE 12-50 MG PALIPERIDONE ER 1.5 MG TABLET PALIPERIDONE ER 3 MG TABLET PALIPERIDONE ER 6 MG TABLET PALIPERIDONE ER 9 MG TABLET QUETIAPINE 25 MG TABLET QUETIAPINE 50 MG TABLET QUETIAPINE 100 MG TABLET QUETIAPINE 200 MG TABLET QUETIAPINE 300 MG TABLET QUETIAPINE 400 MG TABLET QUETIAPINE ER 150 MG TABLET QUETIAPINE ER 200 MG TABLET QUETIAPINE ER 300 MG TABLET QUETIAPINE ER 400 MG TABLET QUETIAPINE ER 50 MG TABLET REXULTI 0.25 MG TABLET REXULTI 0.5 MG TABLET REXULTI 1 MG TABLET REXULTI 2 MG TABLET REXULTI 3 MG TABLET REXULTI 4 MG TABLET RISPERDAL 1 MG/ML SOLUTION RISPERDAL 0.25 MG TABLET RISPERDAL 0.5 MG TABLET RISPERDAL 1 MG TABLET RISPERDAL 2 MG TABLET RISPERDAL 3 MG TABLET RISPERDAL 4 MG TABLET RISPERDAL M-TAB 0.5 MG ODT RISPERDAL M-TAB 1 MG ODT RISPERDAL M-TAB 2 MG ODT

34023 98648 20868 20869 20870 20872 27685 97769 97770 97771 67661 26409 67662 67663 67665 26411 16193 98522 98523 98524 98994 38278 38476 38589 38609 38618 38619 16135 92872 92892 16136 16137 16138 16139 19541 19178 19179

H7TD H7TD/H2JS H7TD/H2JS H7TD/H2JS H7TD/H2JS H7TD/H2JS H7TH H7TH H7TH H7TH H7TF H7TF H7TF H7TF H7TF H7TF H7TF H7TF H7TF H7TF H7TF H7XB H7XB H7XB H7XB H7XB H7XB H7TA H7TA H7TA H7TA H7TA H7TA H7TA H7TA H7TA H7TA

February 17, 2021

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Texas Prior Authorization Program Clinical Criteria

Antipsychotics

Antipsychotics ? Second Generation (Oral/Regular Acting Injectables)

Label Name

GCN

HIC4

RISPERDAL M-TAB 3 MG ODT RISPERDAL M-TAB 4 MG ODT RISPERIDONE 0.25 MG ODT RISPERIDONE 0.5 MG ODT RISPERIDONE 1 MG ODT RISPERIDONE 2 MG ODT RISPERIDONE 3 MG ODT RISPERIDONE 4 MG ODT RISPERIDONE 1 MG/ML SOLUTION RISPERIDONE 0.25 MG TABLET RISPERIDONE 0.5 MG TABLET RISPERIDONE 1 MG TABLET RISPERIDONE 2 MG TABLET RISPERIDONE 3 MG TABLET RISPERIDONE 4 MG TABLET SAPHRIS 2.5 MG TABLET SUBLINGUAL SAPHRIS 5 MG TABLET SUBLINGUAL SAPHRIS 10 MG TAB SUBLINGUAL SECUADO 3.8 MG/24 HR PATCH SECUADO 5.7 MG/24 HR PATCH SECUADO 7.6 MG/24 HR PATCH SEROQUEL 25 MG TABLET SEROQUEL 50 MG TABLET SEROQUEL 100 MG TABLET SEROQUEL 200 MG TABLET SEROQUEL 300 MG TABLET SEROQUEL 400 MG TABLET SEROQUEL XR 50 MG TABLET SEROQUEL XR 150 MG TABLET SEROQUEL XR 200 MG TABLET SEROQUEL XR 300 MG TABLET SEROQUEL XR 400 MG TABLET SYMBYAX 3-25 MG CAPSULE SYMBYAX 6-25 MG CAPSULE SYMBYAX 12-25 MG CAPSULE SYMBYAX 6-50 MG CAPSULE SYMBYAX 12-50 MG CAPSULE

25024 25025 24448 19541 19178 19179 25024 25025 16135 92872 92892 16136 16137 16138 16139 38479 21636 27528 47229 47232 47233 67661 26409 67662 67663 67665 26411 98994 16193 98522 98523 98524 98648 20868 20870 20869 20872

H7TA H7TA H7TA H7TA H7TA H7TA H7TA H7TA H7TA H7TA H7TA H7TA H7TA H7TA H7TA H7TI H7TI H7TI H7TI H7TI H7TI H7TF H7TF H7TF H7TF H7TF H7TF H7TF H7TF H7TF H7TF H7TF H7TD/H2JS H7TD/H2JS H7TD/H2JS H7TD/H2JS H7TD/H2JS

February 17, 2021

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Texas Prior Authorization Program Clinical Criteria

Antipsychotics

Antipsychotics ? Second Generation (Oral/Regular Acting Injectables)

Label Name

GCN

HIC4

VRAYLAR 1.5 MG CAPSULE

39579

H8WA

VRAYLAR 1.5 MG-3 MG PACK

40683

H8WA

VRAYLAR 3 MG CAPSULE VRAYLAR 4.5 MG CAPSULE VRAYLAR 6 MG CAPSULE VERSACLOZ 50MG/ML SUSPENSION ZIPRASIDONE 20 MG CAPSULE ZIPRASIDONE 40 MG CAPSULE ZIPRASIDONE 60 MG CAPSULE ZIPRASIDONE 80 MG CAPSULE ZYPREXA 2.5 MG TABLET ZYPREXA 5 MG TABLET ZYPREXA 7.5 MG TABLET ZYPREXA 10 MG TABLET ZYPREXA 10 MG VIAL ZYPREXA 15 MG TABLET ZYPREXA 20 MG TABLET ZYPREXA ZYDIS 5 MG TABLET ZYPREXA ZYDIS 10 MG TABLET ZYPREXA ZYDIS 15 MG TABLET ZYPREXA ZYDIS 20 MG TABLET

39582 39583 39584 14336 13331 13332 13333 13334 15084 15083 15081 15082 17407 15085 15086 92007 92008 34022 34023

H8WA H8WA H8WA H2LS H7TG H7TG H7TG H7TG H7TD H7TD H7TD H7TD H7TD H7TD H7TD H7TD H7TD H7TD H7TD

The listed GCNS may not be an indication of TX Medicaid Formulary coverage. To learn the current formulary coverage, visit formulary/formulary-search.

Antipsychotics ? Second Generation (Long-Acting Injectables)

Label Name

GCN

HIC4

ABILIFY MAINTENA ER 300 MG SYR ABILIFY MAINTENA ER 300 MG VL ABILIFY MAINTENA ER 400 MG SYR ABILIFY MAINTENA ER 400 MG VL ARISTADA ER 441 MG/1.6ML SYRINGE ARISTADA ER 662 MG/2.4ML SYRINGE ARISTADA ER 882 MG/3.2ML SYRINGE ARISTADA ER 1064 MG/3.9ML SYRINGE ARISTADA INITIO ER 675 MG/2.4ML INVEGA SUSTENNA 39 MG PREF SYR

37681 34284 37682 34285 39726 39727 39728 43488 44941 27414

H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7XA H7TH

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