Blog

Rexulti Prior Authorization: What You Need to Know?

If you’ve ever had to secure insurance approval for Rexulti, you know it’s no walk in the park. Whether you’re a healthcare provider juggling multiple PAs or a caregiver supporting a loved one’s treatment plan, the process can feel overwhelming. The good news? You’re not alone, and we’re here to help.

Rexulti, a specialty medication prescribed for conditions like major depressive disorder (MDD) and schizophrenia, often requires prior authorization (PA) because of its cost and specific prescribing guidelines. But don’t worry—this guide will walk you through everything you need to know to navigate the process smoothly. From understanding why insurers require PA to tackling the paperwork step by step, you’ll leave here ready to handle it all.

Understanding Insurance Company Requirements

Insurance companies have unique policies and approval requirements for Rexulti. Commercial insurance, such as Aetna, Blue Cross Blue Shield, and UnitedHealthcare, often require proof of prior treatments and a clear explanation of the prescription. Medicare Part D plans follow strict formularies, often requiring step therapy or trialing generic alternatives. Medicaid coverage varies by state but requires detailed documentation, including prescriber notes, diagnostic history, and proof of medical necessity. Reviewing the patient’s specific insurance plan details is crucial to avoid missed steps and save time.

Why Does Rexulti Require Prior Authorization?

Before we dive into the how, let’s talk about the why. Insurance companies require prior authorization for high-cost medications like Rexulti to ensure they’re being prescribed appropriately. Here are the main reasons:

1. High Cost: Rexulti is a branded medication, which makes it expensive. Insurers want to confirm it’s the best option for the patient.
2. Step Therapy: Many plans require patients to try lower-cost alternatives first (like generic antipsychotics or Abilify) to ensure Rexulti is necessary.
3. Indication Alignment: Approval is usually limited to FDA-approved uses, such as adjunctive therapy for major depressive disorder or treatment for schizophrenia.

Understanding these reasons helps you better prepare your prior authorization request, ensuring you include the right information to avoid unnecessary back-and-forth with insurers.

Step-by-Step Guide to Securing Prior Authorization for Rexulti

Now that we know the why and who, let’s talk about the how. Follow these steps to streamline the process and maximize your chances of success.

Step 1: Review the Patient’s Insurance Plan

• Access the formulary to confirm Rexulti is covered.
• Check for tier placement (specialty or non-preferred) and specific PA requirements.
• Look for step therapy guidelines. For example, some plans require the patient to try alternative medications before approving Rexulti.

Step 2: Gather All Necessary Documentation

Documentation is the backbone of a successful PA request. Insurers want detailed evidence to support the prescription. Here’s what you’ll need:

• Patient Diagnosis: Confirm the diagnosis aligns with Rexulti’s FDA-approved indications, such as severe MDD or schizophrenia. Use precise ICD-10 codes (more on that below).
• Treatment History: Include records of all previously prescribed medications, their dosages, durations, and outcomes. Clearly explain why alternative treatments were inadequate.
• Prescriber Notes: Provide a detailed justification for why Rexulti is the best option for the patient. Highlight expected benefits, such as improved symptom management or fewer side effects.

Step 3: Obtain the Correct PA Form

Each insurance company typically has a specific prior authorization form for Rexulti. These forms can usually be downloaded from the insurer’s website or requested by contacting their pharmacy benefits manager (PBM).

Pro Tip: Double-check that you’re using the latest version of the form, as insurers occasionally update their templates.

Step 4: Complete and Submit the PA Request

• Fill out the form completely, ensuring all sections are accurate and error-free.
• Attach all supporting documentation, including diagnostic codes, treatment history, and prescriber notes.
• Submit the form via the insurance company’s preferred method (fax, online portal, or mail).

Pro Tip: Make copies of everything before you submit, just in case you need to reference it later.

Step 5: Monitor the Status of Your Request

Once submitted, most insurance providers take 3–10 business days to process prior authorization requests. However, delays can happen, so it’s essential to stay proactive:

• Follow up after a few days to confirm receipt of the request.
• If the processing time exceeds the standard timeline, contact the insurer for an update.

Step 6: Handle Denials (If Necessary)

If your PA request is denied, don’t panic—this is more common than you might think, and many denials can be overturned with additional documentation. Here’s what to do:

• Review the denial letter carefully to understand the reason for denial.
• Submit an appeal with additional clinical justification addressing the insurer’s concerns.
• Escalate the issue to the insurance company’s medical review board if necessary.

ICD and CPT Codes Explained

Including the correct codes in your PA request ensures clarity and minimizes processing errors.

Relevant ICD-10 Codes:

• F32.2: Major depressive disorder, severe, without psychotic features.
• F32.3: Major depressive disorder, severe, with psychotic features.
• F20.9: Schizophrenia, unspecified.

CPT Code for Drug Administration:

• 96372: Therapeutic, prophylactic, or diagnostic injection (specify substance).

Frequently Asked Questions (FAQs)

Q: What if the PA request is denied?
A: Denials are common but can often be appealed successfully. Provide additional clinical documentation and address the reasons outlined in the denial letter.

Q: Does Rexulti have a patient assistance program?
A: Yes! The manufacturer offers financial assistance programs for eligible patients. Check their website or contact their support team for details.

Q: Is Rexulti covered by Medicare Part D?
A: It depends on the specific plan’s formulary. Many Medicare Part D plans require prior authorization or step therapy for Rexulti.

What Did We Learn?

Securing prior authorization for Rexulti may feel daunting at first, but with the right preparation and attention to detail, it’s entirely manageable. Here are the key takeaways:

• Always verify the patient’s insurance coverage and formulary guidelines before starting the PA process.
• Gather thorough documentation, including diagnosis, treatment history, and prescriber notes.
• Submit a detailed and accurate PA request to avoid delays.
• Stay proactive in monitoring the request and be prepared to appeal if needed.

With these steps in mind, you’ll be well-equipped to navigate the process confidently.

Staffingly, Inc. offers a solution to the time-consuming and distracting task of prior authorization requests. They handle insurance verification and other administrative tasks, allowing healthcare providers to focus on patient care. Partnering with Staffingly can save 70% on staffing costs, provide 24/7 support, and alleviate local staffing challenges, allowing healthcare providers to focus on patient care.

Disclaimer

The information in our posts is meant to inform and educate both healthcare providers and readers seeking a better understanding of the prior authorization process. However, it is not a substitute for professional advice. Insurance requirements, policies, and approval processes can vary widely and change over time. For accurate guidance, healthcare providers should consult directly with insurers or use professional resources, while patients should reach out to their insurance providers or healthcare professionals for advice specific to their situation.

This content does not establish any patient-caregiver or client-service relationship. Staffingly, Inc. assumes no liability for actions taken based on information provided in these posts.

For tailored support and professional services,

please contact Staffingly, Inc. at (800) 489-5877

Email : support@staffingly.com