pimavanserin tartrate tab 10 mg — Blue Cross Blue Shield of Alabama

Initial criteria

• ONE of the following: ▪ The patient has a diagnosis of hallucinations or delusions associated with Parkinson’s disease psychosis OR ▪ The patient has another FDA labeled indication for the requested agent and route of administration
• AND the prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, psychiatrist, or other mental health professional), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis for the requested indication
• AND the patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months