Medicare AdvantagePrior AuthHigh impact
Vraylar (cariprazine) (Revised)
Humana·Psychiatry, Internal Medicine, Pediatrics·Medicare Advantage
Effective date
Jan 1, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has issued a revised prior authorization policy for Vraylar (cariprazine) effective January 1, 2025, with updates as of January 28, 2026. The policy establishes specific prior authorization requirements for four indications: schizophrenia (age 13+, requires 2 prior antipsychotic failures), bipolar I manic/mixed episodes (age 10+, requires 2 prior antipsychotic failures), bipolar I depression (requires prior quetiapine or lurasidone failure), and major depressive disorder as adjunctive therapy (requires prior antidepressant and atypical antipsychotic adjunct trials). All approvals are granted for plan year duration with renewal options.
Action Required
By February 28, 2026 (before the January 21, 2026 review date passes): Billing team must implement prior authorization requirements for all Vraylar (cariprazine) prescriptions under Humana Medicare Advantage plans. Update billing software and encounter forms to capture and verify: (1) diagnosis-specific indication (schizophrenia, bipolar I manic/mixed, bipolar I depression, or MDD); (2) member age requirements (13+ for schizophrenia, 10+ for bipolar manic/mixed); (3) documentation of prior therapy, intolerance, or contraindication to specified antipsychotics (varies by indication); and (4) for MDD, verification that Vraylar is used as adjunctive therapy only, not monotherapy. Providers must submit prior authorization requests with clinical documentation supporting the required prior treatment history. Claims submitted without prior authorization or incomplete documentation will be denied. Front desk staff should flag Vraylar prescriptions during patient intake for prior auth screening. Ensure all staff understand the different criteria for each indication to avoid processing errors.