pimavanserin tartrate — Blue Cross Blue Shield of Montana
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
- 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
- The patient does NOT have any FDA labeled contraindications to the requested agent
Reauthorization criteria
- The same criteria as initial approval apply for renewal
Approval duration
12 months