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Drug Category: Central Nervous System (CNS)

Medication Class/Individual Agents: Antipsychotics

I. Prior-Authorization Requirements

 Antipsychotics – First-Generation (Typical)

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

amitriptyline / perphenazine PA   - < 6 years
chlorpromazine PA   - < 6 years
fluphenazine PA   - < 6 years
haloperidol Haldol # PA   - < 6 years
loxapine capsule Loxitane # PA   - < 6 years
molindone PA   - < 6 years
perphenazine PA   - < 6 years
pimozide Orap # PA   - < 6 years
thioridazine PA   - < 6 years
thiothixene Navane # PA   - < 6 years
trifluoperazine PA   - < 6 years

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • Limited scientific data supports the concomitant use of two or more antipsychotics. It is recommended that monotherapy trials be attempted before polypharmacy is used.
  • Dissolvable tablets do not have a faster onset of action compared to their conventional oral dosage forms. They possess the same side effects and have similar pharmacokinetic profiles as the oral tablet. Since dissolvable tablets offer no therapeutic advantage, and they are more costly than other oral formulations, all dissolvable tablets will require PA. Asenapine has minimal to no absorption if swallowed and must be dissolved in the mouth to be absorbed via buccal/sublingual sites.
  • All second-generation (atypical) antipsychotics have a black box warning for increased mortality in elderly patients with dementia-related psychosis.
  • Second-generation (atypical) antipsychotics have been associated with substantial weight gain. This risk is statistically greater with some products compared to others.
  • In November 2003, the FDA mandated that the following information be added to the WARNINGS section of all second-generation (atypical) antipsychotic drug labeling. "Hyperglycemia in extreme progressing to ketoacidosis, hyperosmolar coma and/or death has been reported for this class of drugs. Fasting glucose should be obtained at the beginning of treatment and periodically. Patients with established diagnosis of diabetes mellitus should be monitored for worsening of glycemic control (for complete details see package insert)."
  • A consensus statement issued by the APA, ADA and others suggested a scheduled monitoring of the following patients on these drugs: weight/BMI, waist circumference, blood pressure, fasting glucose, and fasting lipid profile.1
  • Antipsychotic induced metabolic complications such as weight increases, glucose increases, and triglyceride increases are more pronounced in children and adolescents compared to the adult population.

1American Diabetes Association; American Psychiatric Association; American Association of Clinical Endocrinologists; North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. J Clin Psych 2004;65(2):267-72.

Please see the following link to find out more information regarding Second-Generation (Atypical) Antipsychotics. https://www.mass.gov/lists/second-generation-antipsychotics-also-known-as-atypical-antipsychotics

 

 Antipsychotics – Second-Generation (Atypical)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

aripiprazole extended-release injection Abilify Maintena PA  
aripiprazole lauroxil 1,064 mg Aristada PD PA   - < 6 years and PA > 1 injection/2 months
aripiprazole lauroxil 441 mg, 662 mg, 882 mg Aristada PD PA   - < 6 years and PA > 1 injection/month
aripiprazole lauroxil 675 mg Aristada Initio PD PA   - < 6 years and PA > 1 injection/month
aripiprazole orally disintegrating tablet Abilify Discmelt PA  
aripiprazole solution Abilify # PA   - < 6 years or ≥ 18 years and PA > 750 mL/month
aripiprazole tablet Abilify # PA   - < 6 years and PA > 30 units/month
asenapine Saphris PA  
brexpiprazole Rexulti PA  
cariprazine Vraylar PA  
clozapine orally disintegrating tablet Fazaclo PA  
clozapine suspension Versacloz PA  
clozapine tablet Clozaril # PA   - < 6 years
iloperidone Fanapt PA  
lurasidone Latuda PA  
olanzapine 15 mg orally disintegrating tablet Zyprexa Zydis # PA   - < 6 years and PA > 60 units/month
olanzapine 15 mg tablet Zyprexa # PA   - < 6 years and PA > 60 units/month
olanzapine 2.5 mg, 5 mg, 7.5 mg, 10 mg, 20 mg tablets Zyprexa # PA   - < 6 years and PA > 30 units/month
olanzapine 210 mg, 300 mg extended-release injection Zyprexa Relprevv PA   - < 6 years and PA > 2 injections/month
olanzapine 405 mg extended-release injection Zyprexa Relprevv PA   - < 6 years and PA > 1 injection/month
olanzapine 5 mg, 10 mg, 20 mg orally disintegrating tablet Zyprexa Zydis # PA   - < 6 years and PA > 30 units/month
olanzapine injection Zyprexa # test  
paliperidone extended-release 1-month injection Invega Sustenna PA   - < 6 years, PA > 2 units/month within the first 30 days of therapy and PA > 1 unit/month after 30 days of therapy
paliperidone extended-release 3-month injection Invega Trinza PA   - < 6 years and PA > 1 unit/3 months
paliperidone tablet Invega PA  
quetiapine Seroquel # PA   - < 6 years and PA > 90 units/month
quetiapine extended-release 150 mg, 200 mg Seroquel XR # PA   - < 6 years and PA > 30 units/month
quetiapine extended-release 50 mg, 300 mg and 400 mg Seroquel XR # PA   - < 6 years and PA > 60 units/month
risperidone 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg tablets Risperdal # PA   - < 6 years and PA > 60 units/month
risperidone 0.25 mg, 4 mg orally disintegrating tablet Risperdal M-Tab PA  
risperidone 0.5 mg, 1 mg, 3 mg orally disintegrating tablet Risperdal M-Tab # PA   - < 6 years and PA > 60 units/month
risperidone 2 mg orally disintegrating tablet Risperdal M-Tab # PA   - < 6 years and PA > 240 units/month
risperidone 4 mg tablet Risperdal # PA   - < 6 years and PA > 120 units/month
risperidone extended-release intramuscular injection Risperdal Consta PA   - < 6 years and PA > 2 units (2 syringes)/month
risperidone extended-release subcutaneous injection Perseris PA  
risperidone solution Risperdal # PA   - < 6 years and PA > 480 mL/month
ziprasidone capsule Geodon # PA   - < 6 years and PA > 60 units/month
ziprasidone injection Geodon test  

 Antipsychotics – Second-Generation (Atypical) Antipsychotic and Selective Serotonin Reuptake Inhibitor

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

olanzapine / fluoxetine Symbyax PA  
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
 
PD Preferred Drug. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Bipolar disorder
  • Irritability associated with autistic disorder
  • Major depressive disorder
  • Schizoaffective disorder
  • Schizophrenia

Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • All PA requests must include clinical diagnosis, drug name, dose, and frequency.
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply depending upon diagnosis and/or requested medication (see below).

  

Monotherapy

Abilify Maintena

  • Documentation of all of the following is required:
    • clinical rationale for use of the requested agent instead of Aristada; and
    • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within quantity limits and polypharmacy requirements for Abilify Maintena will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested agent for 90 days in the past 120 days.

aripiprazole ODT for members < 18 years

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • medical necessity for an orally disintegrating dosage form; and
    • requested quantity does not exceed established quantity limits of 30 units/month.

aripiprazole ODT and solution for members ≥ 18 years with the diagnosis of autism spectrum disorder

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response, adverse reaction, or contraindication to risperidone; and
    • medical necessity for dosage form; and
    • requested quantity does not exceed established quantity limits (please refer to the reference table below).

aripiprazole ODT and solution for members ≥ 18 years with the diagnosis of major depressive disorder or treatment-resistant depression

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to two antidepressants (either alone or in combination). Note: unless a contraindication to all antidepressants exists, two of them must be tried; and
    • requested agent will be used as adjunctive antidepressant therapy; and
    • medical necessity for dosage form; and
    • requested quantity does not exceed established quantity limits (please refer to the reference table below).

aripiprazole ODT and solution for members ≥ 18 years with a psychiatric diagnosis not listed above

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to two second-generation (atypical) antipsychotics (generic or brand). Note: unless a contraindication to all second-generation (atypical) antipsychotics exists, two of them must be tried; and
    • medical necessity for dosage form; and
    • requested quantity does not exceed established quantity limits (please refer to the reference table below).

clozapine ODT and risperidone ODT 0.25 mg and 4 mg for all members

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • medical necessity for an orally disintegrating dosage form; and
    • requested quantity does not exceed established quantity limits (please refer to the reference table below).

Fanapt and Vraylar for members < 18 years of age

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to one of the following generic second-generation (atypical) antipsychotics: aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone. Note: unless a contraindication to all second-generation (atypical) antipsychotics exists, one of them must be tried; and
    • one of the following:
      • inadequate response or adverse reaction to two other different atypical or typical antipsychotics; or
      • contraindication to all other antipsychotics; and
    • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within quantity limits and polypharmacy requirements for Fanapt or Vraylar for members < 18 years of age will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of one of the following generic second-generation (atypical) antipsychotics: aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone, and any two other atypical or typical antipsychotics, or of the requested agent for 90 days in the past 120 days.

Fanapt and Vraylar for members ≥ 18 years of age

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to two second-generation (atypical) antipsychotics (generic or brand). Note: unless a contraindication to all second-generation (atypical) antipsychotics exists, two of them must be tried; and
    • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within quantity limits and polypharmacy requirements for Fanapt or Vraylar for members ≥ 18 years of age will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for two second-generation (atypical) antipsychotics or of the requested agent for 90 days in the past 120 days.

Latuda, paliperidone tablet, and Saphris for all members

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to two second-generation (atypical) antipsychotics (generic or brand). Note: unless a contraindication to all second-generation (atypical) antipsychotics exists, two of them must be tried; and
    • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within quantity limits and polypharmacy requirements for Latuda, paliperidone tablet, or Saphris will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for two second-generation (atypical) antipsychotics or of the requested agent for 90 days in the past 120 days.

olanzapine/fluoxetine for all members

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical necessity for use of the combination product over the commercially available separate agents.

Perseris

  • Documentation of all of the following is required:
    • one of the following:
      • inadequate response or adverse reaction to Risperdal Consta or Invega Sustenna; or
      • clinical rationale for use of the requested agent instead of Risperdal Consta or Invega Sustenna; and
    • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within quantity limits and polypharmacy requirements for Perseris will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested agent for 90 days in the past 120 days.

Rexulti for members with the diagnosis of major depressive disorder or treatment-resistant depression

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to two antidepressants (either alone or in combination). Note: unless a contraindication to all antidepressants exists, two of them must be tried; and
    • Rexulti will be used as adjunctive antidepressant therapy; and
    • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within quantity limits and polypharmacy requirements for Rexulti will usually process at the pharmacy without a PA request if the member has a diagnosis of major depressive disorder, a history of paid MassHealth pharmacy claims for any two antidepressants, and a history of paid MassHealth pharmacy claims for an antidepressant in the past 30 days.†  

Rexulti for members < 18 years of age with an appropriate psychiatric diagnosis (excluding major depressive disorder or treatment-resistant depression)

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to one of the following generic second-generation (atypical) antipsychotics: aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone. Note: unless a contraindication to all second-generation (atypical) antipsychotics exists, one of them must be tried; and
    • one of the following:
      • inadequate response or adverse reaction to two other different atypical or typical antipsychotics; or
      • contraindication to all other antipsychotics; and
    • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within quantity limits and polypharmacy requirements for Rexulti for members < 18 years of age will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of one of the following generic second-generation (atypical) antipsychotics: aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone, and any two other antipsychotics or of the requested agent for 90 days in the past 120 days.

Rexulti for members ≥ 18 years of age with an appropriate psychiatric diagnosis (excluding major depressive disorder or treatment-resistant depression)

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to two second-generation (atypical) antipsychotics (generic or brand). Note: unless a contraindication to all second-generation (atypical) antipsychotics exists, two of them must be tried; and
    • requested quantity does not exceed established quantity limits (please refer to the reference table below).

SmartPA: Claims within quantity limits and polypharmacy requirements for Rexulti for members ≥ 18 years of age will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for two second-generation (atypical) antipsychotics or of the requested agent for 90 days in the past 120 days.

Versacloz for all members

  • Documentation of all of the following is required:  
    • appropriate diagnosis; and
    • medical necessity for an oral suspension dosage form. 

  

Exceeding quantity limits for all members

  • Documentation of one of the following is required:
    • clinical rationale why the dose cannot be consolidated; or
    • clinical rationale why the member requires dosing at intervals exceeding what is recommended by the FDA. 

   

Polypharmacy (overlapping pharmacy claims for two or more antipsychotics [includes first-generation and/or second-generation antipsychotics, except clozapine and injectable formulations] for at least 60 days within a 90-day period) for members ≥ 18 years old

  • Documentation of all of the following is required:
    • psychiatric diagnosis including treatment-resistant conditions; and
    • treatment plan including names of current antipsychotics and corresponding diagnoses; and
    • prescriber is a psychiatrist or a psychiatry consult is provided; and
    • one of the following:
      • inadequate response or adverse reaction to two monotherapy trials as clinically appropriate; or
      • member had a recent psychiatric hospitalization and was discharged on the current regimen; or
      • cross-titration/taper of antipsychotic therapy.

  

In addition to individual drug PA criteria where applicable, some behavioral health medications are subject to additional polypharmacy and age limit restrictions.

 

Behavioral Health Medication Polypharmacy (pharmacy claims for any combination of four or more behavioral health medications [i.e., alpha2 agonists, antidepressants, antipsychotics, atomoxetine, benzodiazepines, buspirone, cerebral stimulants, hypnotic agents, and mood stabilizers] within a 45-day period) for members < 18 years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • For regimens including ≤ 2 mood stabilizers (also includes regimens that do not include a mood stabilizer), documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnoses and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g.,  psychiatrist, neurologist) or consult is provided.

 

  • For regimens including ≥ 3 mood stabilizers, documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnoses; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided; and
      • one of the following:
        • member has a seizure diagnosis only; or
        • member has an appropriate psychiatric diagnosis and one of the following:
          • cross-titration/taper of mood stabilizer therapy; or
          • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate; or
        • member has a diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain)  and documentation that other clinically appropriate therapies have been tried and failed; therefore, multiple mood stabilizers are needed ; or
        • member has psychiatric and comorbid diagnosis in which mood stabilizers may be clinically appropriate  (e.g., migraine, neuropathic pain) and documentation that other clinically relevant  therapies have been tried and failed; therefore, multiple mood stabilizers are needed, and one of the following:
          • cross-titration/taper of mood stabilizer therapy; or
          • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate.

SmartPA: Claims will usually process at the pharmacy without a PA request if the member is < 18 years of age, has a history of MassHealth medical claims for seizure, and has a history of paid MassHealth pharmacy claims for four or less behavioral health medications within the past 45 days and one mood stabilizer agent is identified as being used for seizure only.

  

Antipsychotic Polypharmacy (overlapping pharmacy claims for 2 or more antipsychotics [includes first-generation and/or second-generation antipsychotics, except short-acting injectable formulations] for at least 60 days within a 90-day period) for members < 18 years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required:
    • one of the following:
      • member  had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • treatment plan including name, dose, and frequency of all current behavioral health medications, associated target symptom(s), and behavioral health diagnoses; and
      • a comprehensive behavioral health plan (i.e., non-pharmacologic interventions) is in place; and
      • prescriber is a  psychiatrist or consult is provided; and
      • stage of treatment is acute, maintenance, or discontinuation; and
      • one of the following:
        • for acute stage (initiation of antipsychotic treatment likely with subsequent dose adjustments to maximize response and minimize side effects), one of the following:
          • cross-titration/taper of antipsychotic therapy; or
          • inadequate response or adverse reaction to two monotherapy trials as clinically appropriate; or
        • for maintenance stage (response to antipsychotic treatment with goal of remission or recovery), all of the following:
          • regimen is effective, therapy benefits outweigh risks, and appropriate monitoring is in place; and
          • if member has been on the antipsychotic regimen for the past 12 months, clinical rationale for extended therapy including at least one of the following: previous efforts to reduce/simplify the antipsychotic regimen in the past 24 months resulted in symptom exacerbation; or family/caregiver does not support the antipsychotic regimen change at this time due to risk of exacerbation; or other significant barrier for antipsychotic therapy discontinuation; or
        • for discontinuation stage (clinically indicated that the antipsychotic regimen can likely be successfully tapered), cross-titration/taper of antipsychotic therapy.

    

Antipsychotic for members < six years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required:
    • one of the following:
      • member  had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • complete medication treatment plan including name, dose, and frequency of all current behavioral health medications, associated target symptom(s), and behavioral health diagnoses; and
      • a comprehensive behavioral health treatment plan (i.e., non-pharmacological interventions) is in place; and
      • prescriber is a specialist (e.g., child psychiatry, pediatric neurology, or developmental/behavioral pediatrics) or consult is provided; and
      • one of the following:
        • member is in acute stage of treatment (initiation of antipsychotic treatment likely with subsequent dose adjustments to maximize response and minimize side effects); or
        • all of the following:
          • member is in maintenance stage of treatment (response to antipsychotic treatment with goal of remission or recovery); and
          • regimen is effective, therapy benefits outweigh risks, and appropriate monitoring is in place; and
          • if member has been on the antipsychotic regimen for the past 12 months, clinical rationale for extended therapy including at least one of the following: previous efforts to reduce/simplify the antipsychotic regimen in the past 12 months resulted in symptom exacerbation; or family/caregiver does not support the antipsychotic regimen change at this time due to risk of exacerbation; or other significant barrier for antipsychotic therapy discontinuation; or
        • all of the following:
          • member is in discontinuation stage of treatment (clinically indicated that the antipsychotic regimen can likely be successfully tapered); and
          • cross-titration/taper of antipsychotic therapy.

 

    

Reference Table:

Drug

Quantity Limits

Abilify (aripiprazole tablet)

30 units/month

Abilify (aripiprazole solution)

750 ml/month

Abilify Discmelt (aripiprazole orally disintegrating tablet)

30 units/month

Abilify Maintena (aripiprazole extended-release injectable suspension)

1 injection/month

Aristada (aripiprazole lauroxil 441 mg, 662 mg, 882 mg)

1 injection/month

Aristada (aripiprazole lauroxil 1,064 mg)

1 injection/2 months

Aristada Initio (aripiprazole lauroxil 675 mg)

1 injection/month

Fanapt (iloperidone)

60 units/month

Geodon (ziprasidone)

60 units/month

Invega (paliperidone tablet) 1.5 mg, 3 mg, 9 mg

30 units/month

Invega (paliperidone tablet) 6 mg

60 units/month

Invega Sustenna (paliperidone IM)

2 syringes month 1, 1 syringe/month thereafter

Invega Trinza (paliperidone IM)

1 syringe/3 months

Latuda (lurasidone) 20 mg, 40 mg, 60 mg, 120 mg

30 units/month              

Latuda (lurasidone) 80 mg

60 units/month

Perseris (risperidone subcutaneous injection)

1 injection/month

Rexulti (brexpiprazole)

30 units/month

Risperdal (risperidone tablet) 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg

60 units/month

Risperdal (risperidone tablet) 4 mg

120 units/month

Risperdal (risperidone solution)

480 ml/month

Risperdal Consta (risperidone intramuscular injection)

2 syringes/month

Risperdal M-Tab (risperidone orally disintegrating tablet) 0.25 mg, 0.5 mg, 1 mg, 3 mg

60 units/month

Risperdal M-Tab (risperidone orally disintegrating tablet) 2 mg

240 units/month

Risperdal M-Tab (risperidone orally disintegrating tablet) 4 mg

120 units/month

Saphris (asenapine)

60 units/month

Seroquel (quetiapine)

90 units/month

Seroquel XR (quetiapine extended-release) 150 mg, 200 mg

30 units/month

Seroquel XR (quetiapine extended-release) 50 mg, 300 mg, 400 mg

60 units/month

Vraylar (cariprazine)

30 units/month

Zyprexa (olanzapine tablet) 2.5 mg, 5 mg, 7.5 mg, 10 mg, 20 mg

30 units/month

Zyprexa (olanzapine tablet) 15 mg

60 units/month

Zyprexa Relprevv (olanzapine pamoate long-acting injection) 210 mg, 300 mg

2 vials/month

Zyprexa Relprevv (olanzapine pamoate long-acting injection) 405 mg

1 vial/month

Zyprexa Zydis (olanzapine orally disintegrating tablet) 5 mg, 10 mg, 20 mg

30 units/month                

Zyprexa Zydis (olanzapine orally disintegrating tablet) 15 mg

60 units/month

Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans.

Please see the following link to find out more information regarding Second-Generation (Atypical) Antipsychotics: https://www.mass.gov/lists/second-generation-antipsychotics-also-known-as-atypical-antipsychotics


Original Effective Date: 03/2010

Last Revised Date: 08/2019


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Last updated 08/29/19