determined that medication non-adherence is not the reason for the dose escalation. Supporting documentation indicates that use of the medication at a lower dose (or within the plan quantity limit) has been ineffective and a clinically significant was completed. The BHMP has ruled out a non-response due to an unrecognized or treated co-morbid disorder. The treatment plan must include ongoing safety monitoring. Brand Name FDA Approved Indication: Hospital Discharge: For adults, BHR has a diagnosis for which requested medication is an FDA approved treatment 60 days Behavioral Health indication. For individuals under the age of 18, the BHR must have a diagnosis for which the Medications requested medication meets the community standard of care. Initial Approval Indefinite Aplenzin Guidelines for Approval: Edluar 1. Documentation of intolerance, nonresponse or non-adherence to a formulary generic Emsam equivalent formulation of the requested medication at maximal tolerated for at least 4 Fanapt weeks. Gralise 2. Documentation of intolerance, nonresponse or non-adherence to a formulary generic Horizant pharmaceutical alternative formulation of the requested medication at maximal tolerated Intermezzo SL for at least 4 weeks. Intuniv Lamictal XR 3. Documentation of intolerance, non-adherence, or non-response to at least two generic Pexeva formulary medications in the same medication class at maximal tolerated doses for at least 4 Quillivant XR weeks. Saphris Seroquel XR Guidelines for Exceptions: Silenor 1. Documentation of intolerance/contraindication to other formulary medications (including documentation of the risk of metabolic syndrome, obesity, diabetes), and documentation for Suboxone Film the reason why the requested medication will ameliorate the risks Viibryd Zolpimist 2. Documentation that the individual has responded to a generic immediate release formulary medication, but requires the brand name extended release formulation to maintain adherence. Additional Requirements:
determined that medication non-adherence is not the reason for the dose escalation. Supporting documentation indicates that use of the medication at a lower dose (or within the plan quantity limit) has been ineffective and a clinically significant was completed. The BHMP has ruled out a non-response due to an unrecognized or co-morbid disorder. The treatment plan must include ongoing safety monitoring. Brand Name Behavioral Health Medications Aplenzin Edluar Emsam Fanapt Gralise Horizant Intermezzo SL Intuniv Lamictal XR Pexeva Quillivant XR Saphris Seroquel XR Silenor Suboxone Film Viibryd Zolpimist FDA Approved Indication: For adults, BHR has a diagnosis for which requested medication is an FDA approved treatment indication. For individuals under the age of 18, the BHR must have a diagnosis for which the requested medication meets the community standard of care. Guidelines for Approval: 1. Documentation of intolerance, nonresponse or non-adherence to a formulary generic equivalent formulation of the requested medication at maximal tolerated for at least 4 weeks. 2. Documentation of intolerance, nonresponse or non-adherence to a formulary generic pharmaceutical alternative formulation of the requested medication at maximal tolerated for at least 4 weeks. 3. Documentation of intolerance, non-adherence, or non-response to at least two generic formulary medications in the same medication class at maximal tolerated doses for at least 4 weeks. Guidelines for Exceptions: 1. Documentation of intolerance/contraindication to other formulary medications (including documentation of the risk of metabolic syndrome, obesity, diabetes), and documentation for the reason why the requested medication will ameliorate the risks 2. Documentation that the individual has responded to a generic immediate release formulary medication, but requires the brand name extended release formulation to maintain adherence. Additional Requirements: Hospital Discharge: 60 days Initial Approval Indefinite treated
Mercy-Maricopa-Integrated-Care-PA-Guidelines-SMI.docx