Pharmacy Prior Authorization Criteria

Nuplazid (pimavanserin)

Indications for Prior Authorization

Nuplazid (pimavanserin)

• For diagnosis of Parkinson's disease psychosis
  Indicated for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis.

Criteria

Nuplazid

Prior Authorization

Length of Approval: 12 Month(s)

• Both of the following:
• Diagnosis of Parkinson's disease
AND
• Patient has at least one of the following:
• Hallucinations
• Delusions
OR
• For continuation of prior therapy

P & T Revisions

1970-01-01, 2025-05-23, 2025-05-23, 2025-02-19, 2025-02-06, 2025-01-02, 2024-12-04, 2024-09-18, 2024-06-05, 2023-12-15, 2023-02-01, 2022-10-21, 2022-08-05, 2022-02-14, 2022-01-31, 2021-11-22, 2021-11-16, 2021-01-19, 2021-01-19, 2020-09-03, 2020-03-18, 2020-01-08

References

1. Nuplazid prescribing information. Acadia Pharmaceuticals Inc. San Diego, CA. May 2019.

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Revision History

• 2025-05-23: Standalone Nuplazid guideline
• 2025-05-23: Standalone Nuplazid guideline
• 2025-02-19: update guideline
• 2025-02-06: GPI cleanup
• 2025-01-02: update guideline
• 2024-12-04: Addition of new Erzofri as target drug
• 2024-09-18: Updated indication section, to include Fanapt's indication in bipolar I disorder. No change to criteria.
• 2024-06-05: Annual Review - No criteria changes
• 2023-12-15: Added Optum RX EHB formulary to guideline.
• 2023-02-01: Annual Review - no criteria changes
• 2022-10-21: update guideline
• 2022-08-05: Update Guideline
• 2022-02-14: Annual Review - Separation of Caplyta to address new indication of Bipolar Depression. Addition of diagnosis check within ST criteria.
• 2022-01-31: Annual Review - Separation of Caplyta to address new indication of Bipolar Depression. Addition of diagnosis check within ST criteria.
• 2021-11-22: Removal of Vraylar - ST retired
• 2021-11-16: Addition of Invega Hafyera and Lybalvi
• 2021-01-19: Program Update: Brand Saphris added as target to step therapy
• 2021-01-19: Program Update: added generic Saphris (asenapine) to list of prerequisite drugs
• 2020-09-03: Program Update: update prerequisite drug list to add clozapine, ziprasidone, paliperidone
• 2020-03-18: Annual Review, also added Caplyta as target to guideline
• 2020-01-08: Added Secuado as target to guideline

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