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DESCRIPTIONAripiprazole (Abilify) is an atypical antipsychotic available both as an oral and intramuscular medication. It is used to treat various psychiatric disorders, including schizophrenia, bipolar disorder, major depressive disorder, and autistic disorder.
Seroquel XR is an oral extended-release atypical antipsychotic that is indicated in adults for the treatment of the following: adjunctive therapy to antidepressants in major depressive disorder, acute depressive episodes in bipolar disorder, acute manic or mixed episodes in bipolar I disorder as either monotherapy or adjunct therapy to lithium or divalproex, maintenance treatment of bipolar I disorder as adjunct to lithium or divalproex, and schizophrenia.
The initial choice of antipsychotic medication or the decision to switch to a new antipsychotic should be made on an individual basis, considering prior treatment response, side effect experience; adherence history; relevant medical history, risk factors; individual medication side effect profile; and long-term treatment planning. Generally, antipsychotic medications other than clozapine and olanzapine, are recommended as first-line treatment for persons with schizophrenia experiencing their first acute positive symptom episode.
Atypical antipsychotics, except for clozapine, are not clearly more effective than typical antipsychotics, but they probably have a lower risk of tardive dyskinesia than typical antipsychotics. On the other hand, several atypicals, especially clozapine, olanzapine and, to a lesser extent, quetiapine, have been associated with marked weight gain, metabolic syndrome, and diabetes. Clozapine is the most effective antipsychotic, but it is usually reserved for refractory disease because of its potential for serious hematologic toxicity. Among other atypical drugs, olanzapine may have some slight advantages in terms of efficacy, but its adverse effects on weight and metabolism may be unacceptable for some patients. Ziprasidone and aripiprazole appear to cause the least weight gain. For patients with co-morbid depression, quetiapine may be preferred. Some patients who do not respond to one antipsychotic may respond to another. Long-acting injectable antipsychotics are useful for patients in whom adherence is a problem.
Lithium or quetiapine is preferred for treatment of depression in bipolar disorder. Lamotrigine in combination with lithium is an alternative for maintenance therapy of bipolar disorder, and it is a reasonable alternative to lithium alone or quetiapine for depressive episodes. Long-acting intramuscular risperidone can delay mood disorder relapse in patients with frequent episodes.
Atypical antipsychotics are less likely to produce extrapyramidal side effects than typical antipsychotics used at conventional doses, which is of particular significance in bipolar disorder because of an apparently greater risk of motor side effects, including tardive dyskinesia.
For symptoms of aggression, explosive outbursts, and self injury, the guideline lists the following medication options: atypical antipsychotics (risperidone, aripiprazole, olanzapine, quetiapine, ziprasidone), alpha agonists (clonidine, guanfacine), anticonvulsants (levetiracetam, topiramate, valproic acid), SSRIs (fluoxetine, fluvoxamine, citalopram, escitalopram, paroxetine, sertraline), beta-blockers (propranolol, nadolol, metoprolol, pindolol).
Dementia-Related Psychosis (off-label use)
The APA Practice Guideline for Treatment of Patients with Alzheimer’s disease and Other Dementias and the NICE guidelines on dementia currently recommend that nonpharmacologic interventions be attempted before a trial of antipsychotic drug therapy and that the interventions attempted be guided by the patient’s level of distress and the risk to the patients and caregiver. In addition, the FDA states that physicians who prescribe antipsychotics to elderly patients with dementia-related psychosis should discuss the risk of increased mortality with their patients, patients’ families, and caregivers.
Antipsychotic drug therapy generally is reserved for patients who have severe symptoms or when associated agitation, combativeness, or violent behavior puts the patient or others in danger. Current evidence indicates that the atypical antipsychotics can provide modest improvement in behavioral manifestations; some evidence suggests that efficacy may be better for psychosis than for other manifestations. Antipsychotic efficacy appears to be similar among available agents and therefore the choice of agent should be based on adverse effect profile and other patient considerations; to minimize adverse effects, the lowest possible effective dose should be used.
POLICYEffective 01/01/2013, step therapy is required for new start prescriptions for Abilify/Seroquel XR when purchased at a pharmacy. Sampling will not be acceptable for patient being on stable therapy.
Abilify Coverage Criteria
BCBSMS covers Abilify (aripiprazole) with prior authorization when the member meets all of the criteria for one of the following conditions:
Irritability Associated with Autistic Disorder
Depression with Psychotic Features
BCBSMS covers Seroquel XR (quetiapine ER) with prior authorization when the member meets all of the criteria for one of the following conditions:
Bipolar Disorder or Depressive Episodes Associated with Bipolar Disorder
POLICY EXCEPTIONSStep therapy for Abilify/Seroquel XR is not required for Federal Employee Program (FEP) and State Health Plan members.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
11/30/2012: New policy added. Effective 01/01/2013.
08/14/2015: Medical policy revised to add ICD-10 codes. Code Reference section updated to expand ICD-9 diagnosis codes 295.00 – 295.95 and 296.00 – 296.99 to the fifth digit.
02/02/2016: Approved by Pharmacy & Therapeutics (P&T) Committee. Investigative definition updated in policy guidelines section.
05/26/2016: Policy number added.
09/30/2016: Code Reference section updated to add new ICD-10 diagnosis codes F34.81 and F34.89.
SOURCE(S)Abilify Prescribing Information
Seroquel XR Prescribing Information
This 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.