Cobenfy (xanomeline and trospium chloride) — United Healthcare
schizophrenia
Preferred products
- aripiprazole
- olanzapine
- quetiapine IR or ER
- risperidone
- ziprasidone
Initial criteria
- Diagnosis of schizophrenia AND history of failure, contraindication, or intolerance to three of the following (document drug, date, and duration): aripiprazole (generic Abilify), olanzapine (generic Zyprexa), quetiapine IR or ER (generic Seroquel or Seroquel XR), risperidone (generic Risperdal), ziprasidone (generic Geodon)
- OR treatment with Cobenfy was initiated at a recent behavioral inpatient admission (discharge within past 3 months) AND member is currently stable on therapy (document date of discharge)
- OR member is new to the plan and currently stabilized on Cobenfy (coverage effective date ≤ 120 days)
Reauthorization criteria
- Documentation of a positive clinical response to therapy
Approval duration
12 months