pimavanserin tartrate — Blue Cross Blue Shield of Texas

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

Approval duration

12 months