- 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
- 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
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