Nuplazid — Blue Cross Blue Shield of Illinois

other FDA labeled indication for the requested agent and route of administration

Initial criteria

ONE of the following:
A. The patient has a diagnosis of hallucinations or delusions associated with Parkinson’s disease psychosis OR
B. 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

12 months