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Please perform a formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.
DESCRIPTIONAtypical antipsychotics, as a group, have diverse pharmacodynamic profiles differing considerably from the typical antipsychotics, but in general have an increased affinity for serotonin 5-HT2 receptors compared with D2 receptors. They act on several neurotransmitter systems, including antagonism at 1 or more types of dopamine receptors (eg, D1, D2, D4, D5); selectivity for limbic dopamine receptors; antagonism at 1 or more types of serotonin receptors (eg, 5-HT1, 5-HT2) ; antagonism at alpha-1 adrenergic receptors; and activity at muscarinic or histamine H1 receptors.
Fanapt (iloperidone) is indicated for the treatment of schizophrenia in adults.
Invega (paliperidone) is indicated for the treatment of schizophrenia in adults and adolescents (12 -17 years of age), and for the treatment of schizoaffective disorder as monotherapy and as an adjunct to mood stabilizers and/or antidepressant therapy in adults.
Saphris (asenapine) is indicated for the treatment of manic or mixed episodes associated with bipolar 1 disorder in adults.
Latuda (lurasidone) is indicated for the treatment of schizophrenia, depressive episodes associated with Bipolar 1 disorder as monotherapy or as adjunctive therapy with lithium or valproate.
POLICYFanapt, Invega, Saphris, and Latuda are considered medically necessary for patients who meet the following criteria:
POLICY EXCEPTIONSAtypical antipsychotic prior authorization is not required for Federal Employee Program (FEP) and State Health Plan members.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
01/01/2014: New policy added.
07/06/2015: Code Reference section updated for ICD-10.
SOURCE(S)Fanapt® Prescribing Information
Invega® Prescribing Information
Latuda® Prescribing Information
Saphris® Prescribing Information
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.