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Coverage criteria policies

Atypical antipsychotic injections (Abilify Maintena™, Aristada™, and Zyprexa® Relprevv™) – Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Aripiprazole (Abilify Maintena), aripiprazole lauroxil (Aristada), and olanzapine (Zyprexa Relprevv) require prior authorization from HealthPartners Pharmacy Administration.

Coverage

All requests for doses exceeding the FDA-approved regimen will not be covered.

Abilify Maintena authorization criteria:
  1. Patient has a diagnosis of schizophrenia or bipolar I disorder; and,
  2. Patient is 18 years of age or older; and,
  3. Patient has shown a favorable response to oral aripiprazole (Abilify) in efficacy measures; and,
  4. One of the following:
    1. Patient has demonstrated poor compliance (> 30% missed doses) with oral aripiprazole (Abilify); or,
    2. Patient has been stabilized on Abilify Maintena (the drug is part of the patient’s current course of treatment) as covered on a previous health insurance plan, and patient is new to MHCP; or,
    3. Patient was started and stabilized on Abilify Maintena in an acute care setting, such as during a hospitalization, or within another place of care that offers acute care services.
Aristada authorization criteria:
  1. Patient has a diagnosis of schizophrenia; and,
  2. Patient is 18 years of age or older; and,
  3. Patient has shown a favorable response to oral aripiprazole (Abilify) in efficacy measures; and,
  4. One of the following:
    1. Patient has demonstrated poor compliance (> 30% missed doses) with oral aripiprazole (Abilify); or,
    2. Patient has been stabilized on Aristada (the drug is part of the patient’s current course of treatment) as covered on a previous health insurance plan, and patient is new to MHCP; or,
    3. Patient was started and stabilized on Aristada in an acute care setting, such as during a hospitalization, or within another place of care that offers acute care services.
Zyprexa Relprevv authorization criteria:
  1. Patient has a diagnosis of schizophrenia; and,
  2. Patient is 18 years of age or older; and,
  3. Patient has shown a favorable response to oral olanzapine (Zyprexa) in efficacy measures; and,
  4. One of the following:
    1. Patient has demonstrated poor compliance (> 30% missed doses) with oral aripiprazole (Abilify); or,
    2. Patient has been stabilized on Zyprexa Relprevv (the drug is part of the patient’s current course of treatment) as covered on a previous health insurance plan, and patient is new to MHCP; or,
    3. Patient was started and stabilized on Aristada in an acute care setting, such as during a hospitalization, or within another place of care that offers acute care services.

Definitions

Abilify Maintena is an atypical antipsychotic indicated for:

  • Treatment of schizophrenia in adults
  • Maintenance monotherapy treatment of bipolar I disorder in adults

Aristada is an atypical antipsychotic indicated for the treatment of schizophrenia.

Zyprexa® Relprevv™ is a long-acting atypical antipsychotic for intramuscular injection indicated for the treatment of schizophrenia.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The services associated with these codes require prior authorization:
HCPCS Codes

Codes

Description

C9399

Unclassified drugs or biologicals

J0401

Injection, aripiprazole, extended release, 1 mg

J1942

Injection, aripiprazole lauroxil, 1 mg

J2358

Injection, olanzapine, long-acting, 1 mg

J3490

Unclassified drugs

NDC Codes

Codes

Description

00002763511

Zyprexa Relprevv 210 MG SUSR

00002763611

Zyprexa Relprevv 300 MG SUSR

00002763711

Zyprexa Relprevv 405 MG SUSR

00002765801

Zyprexa Relprevv 210 MG SUSR

00002765901

Zyprexa Relprevv 300 MG SUSR

00002766001

Zyprexa Relprevv 405 MG SUSR

59148001870

Abilify Maintena 300 MG SRER

59148001871

Abilify Maintena 300 MG SRER

59148001970

Abilify Maintena 300 MG SRER

59148001971

Abilify Maintena 400 MG SRER

59148004580

Abilify Maintena 300 MG PRSY

59148007280

Abilify Maintena 400 MG PRSY

65757040101

Aristada 441 MG/1.6ML PRSY

65757040103

Aristada 441 MG/1.6ML PRSY

65757040201

Aristada 662 MG/2.4ML PRSY

65757040203

Aristada 662 MG/2.4ML PRSY

65757040301

Aristada 882 MG/3.2ML PRSY

65757040303

Aristada 882 MG/3.2ML PRSY

65757040401

Aristada 1064 MG/3.9ML PRSY

65757040403

Aristada 1064 MG/3.9ML PRSY

65757050003

Aristada Initio 675 MG/2.4ML PRSY

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. https://mn.gov/dhs/partners-and-providers/policies-procedures/minnesota-health-care-programs/provider/types/rx/pa-criteria/abilify-maintena.jsp

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Policy activity

  • 05/07/2018 - Date of origin
  • 10/01/2018 - Effective date

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