than 8 years old Organic Psychiatric Conditions Last reviewed: 10/31/14 Schizophrenic Disorders Affective Psychoses (bipolar disorders) Risperidone Quetiapine Psychoses Seroquel XR Autism Spectrum Disorders Clozapine Tourette’s Olanzapine Reactive Adjustment Disorders Saphris Other applicable behavioral diagnoses Latuda AND, Fanapt 3) Written, informed consent for the medication must be obtained from the parent or guardian Ziprasidone AND, Paliperidone 4) Formulary atypical antipsychotics must be tried prior to authorization of non-formulary agents. Aripiprazole Risperidone ODT requires ST therapy with risperidone tablets first. Ziprasidone requires ST therapy with both risperidone and quetiapine. Atypical Initial An appropriate indication/diagnosis for the medication based on FDA approval, nationally established/recognized guidelines, Antipsychotics 8-17 peer-reviewed medical literature or clinical studies AND, years old Age of member is within FDA-approved age limits for medication prescribed or based on nationally established/recognized Last reviewed: 10/31/14 guidelines, peer-reviewed medical literature or clinical studies, AND, Risperidone Dose is appropriate for age and indication based on FDA approval, nationally established/recognized guidelines, peer-reviewed Quetiapine medical literature or clinical studies AND, Seroquel XR Written, informed consent for the medication must be obtained from the parent or guardian AND, Clozapine Formulary antipsychotics must be tried prior to authorization of non-formulary agents. Olanzapine Covered for psychiatrists and neurologists Saphris Latuda Risperidone ODT requires ST therapy with risperidone tablets first. Fanapt Ziprasidone requires ST therapy with both risperidone and quetiapine. Ziprasidone Paliperidone Aripiprazole
than 8 years old Last reviewed: 10/31/14 Risperidone Quetiapine Seroquel XR Clozapine Olanzapine Saphris Latuda Fanapt Ziprasidone Paliperidone Aripiprazole Organic Psychiatric Conditions Schizophrenic Disorders Affective Psychoses (bipolar disorders) Psychoses Autism Spectrum Disorders Tourette’s Reactive Adjustment Disorders Other applicable behavioral diagnoses AND, 3) Written, informed consent for the medication must be obtained from the parent or guardian AND, 4) Formulary atypical antipsychotics must be tried prior to authorization of non-formulary agents. Risperidone ODT requires ST therapy with risperidone tablets first. Ziprasidone requires ST therapy with both risperidone and quetiapine. Atypical Antipsychotics 8-17 years old Last reviewed: 10/31/14 Risperidone Quetiapine Seroquel XR Clozapine Olanzapine Saphris Latuda Fanapt Ziprasidone Paliperidone Aripiprazole An appropriate indication/diagnosis for the medication based on FDA approval, nationally established/recognized guidelines, peer-reviewed medical literature or clinical studies AND, Age of member is within FDA-approved age limits for medication prescribed or based on nationally established/recognized guidelines, peer-reviewed medical literature or clinical studies, AND, Dose is appropriate for age and indication based on FDA approval, nationally established/recognized guidelines, peer-reviewed medical literature or clinical studies AND, Written, informed consent for the medication must be obtained from the parent or guardian AND, Formulary antipsychotics must be tried prior to authorization of non-formulary agents. Covered for psychiatrists and neurologists Risperidone ODT requires ST therapy with risperidone tablets first. Ziprasidone requires ST therapy with both risperidone and quetiapine. Initial