Nuplazid — Blue Cross Blue Shield of Oklahoma

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

Reauthorization criteria

• The member resides in Ohio AND the plan is Fully Insured or HIM Shop (SG) AND BOTH of the following: (A) The patient does NOT have any FDA labeled contraindications to the requested agent AND (B) ONE of the following: (1) The patient has another FDA labeled indication for the requested agent and route of administration OR (2) The patient has another indication that is supported in compendia for the requested agent and route of administration OR (3) The prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use(s) as generally safe and effective

Approval duration

12 months