PriorAuthorizationGuidelines
ExceedingFDA-RecommendedMaximumDailyDosages
MedicationClass:Antidepressants-Oral
MedicationName:ApprovedMaximumDose:
Bupropion HCl
BupropionHydrobromide
450mg/day(IR),400mg/day(SR),450mg/day(XL)
348mg/day
Citalopram40mg/day
**Desvenlafaxine50mg/day
Duloxetine120mg/day
**Escitalopram20mg/day
Fluoxetine 80mg/day Fluvoxamine 300mg/day Mirtazapine 45mg/day Paroxetine 60mg/day Sertraline 200mg/day
Trazodone600mg(IR),375mg/day(ER) Venlafaxine375mg(IR), 225mg/day(XR)
**Vilazodone40mg/day
MedicationClass:SecondGenerationAntipsychotics-Oral
MedicationName:ApprovedMaximumDose:
Aripiprazole30mg/day
**Asenapine20mg/day
Clozapine900mg/day Iloperidone24mg/day Lurasidone 160mg/day Olanzapine 20mg/day Quetiapine 800mg/day for bothIRSR Risperidone 16mg/day* Ziprasidone 160mg/day
*Use of Risperidone6mg/dayis associatedwithincreasedrisk ofEPS.
**Thereisnowell-established maximumdosefortheapproved indicationaccordingtotheprescribinginformation.
FDAApprovedIndication:
TheBehavioralHealthRecipientmusthavea diagnosisforwhichtherequestedmedicationis FDAapprovedforor therequestedmedicationis includedontreatment guidelines.
Guidelinesfor Approval:
1.TheBehavioralHealthMedicalProvide(BHMP)hasevaluatedand determinedthatmedicationnon- adherenceisnotthereasonforthe doseescalation.
2.Supportingdocumentationindicatesthatuseof themedicationatspecified dosage(s)has been ineffective
andaclinicallysignificanttrialwascompleted.
3.TheBHMPhasruledoutanon-responsedueto an unrecognizedorunder-treatedco-morbiddisorder.
AdditionalRequirements:
Initialapprovalforahigher-dosetrial shallbe grantedfor no longerthan120days.Continuedauthorization approvalwill be basedonadditionalsupportingdocumentationof symptomimprovement.
References:
1.ADHS/DBHS: ProviderManualSection3.15:PsychotropicMedication:PrescribingandMonitoring
2.ManufacturerProductInformation
3.MillerAL,MooreTA,CrimsonML,ArgoTR,BendeleSD,SuehsB.TIMA(TexasImplementationof
MedicationAlgorithms)ProcedureManual:SchizophreniaModule.Version:April2008.
4.CaseyDE,DanielDG, WassefAA,etal.Effectofdivalproexcombinedwitholanzapineor risperidonein patientswith acute exacerbationofschizophrenia.Neuropsychopharmacology2003;28:182-192.
5.MarderSR,EssockSM,MillerAL,etal.Physicalhealthmonitoringofpatientswith schizophrenia.American
JournalofPsychiatry2004;161:1334-1349.
6.LehmanAF, etal.Practice guidelineforthe treatment ofpatientswith schizophrenia.AmericanPsychiatric
Association.Feb2004.
7.Stahl,SM.Essentialpsychopharmacology.SecondEdition,pg283-285.
8.TrivediMH,etal.Medicationaugmentationafter thefailure ofSSRIsfor depression.NewEnglandJournal ofMedicine.2006;354:1243-1253.