- Prior Authorization: Bipolar:
Documented Diagnosis: Yes
Age Requirement: >= 10
Duration: 1 plan year
Reauthorization Required: Yes
Psychiatry: Schizophrenia:
Documented Diagnosis: Yes
Age Requirement: >= 13
Duration: 1 plan year
Reauthorization Required: Yes
- Bipolar:
Age Requirement: >= 10
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Major Depressive Disorder:
Age Requirement: >= 18
Duration: 12 Month(s)
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Documented Diagnosis: Yes
Psychiatry: Schizophrenia:
Age Requirement: >= 13
Duration: 1 plan year
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Policy Requires Documentation of Patient Noncompliance to Oral Therapy: No
Established tolerability to oral formulation: No
Documented Diagnosis: Yes
- Step Therapy: Psychiatry: Schizophrenia:
ST Single Generic
- I. Health Net Approved Indications and Usage Guidelines: 1. Diagnosis of schizophrenia, schizoaffective disorder, bipolar depression, bipolar manic or mixed episodes, or major depressive disorder; AND 2. Failure or clinically significant adverse effects to generic quetiapine AND one of the following atypical antipsychotics: aripiprazole, ziprasidone, olanzapine, risperidone. Requests for continuation of therapy will be approved. II. Coverage is Not Authorized For: Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature. III. Authorization Limit: Length of Benefit.
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