Tier 1 products available with no authorization necessary
Tier 2 Authorization Criteria:
- A documented, recent (within six months) trial of two Tier-1 medications at least four weeks in duration and titrated to recommended dosing, that did not provide an adequate response. Tier-1 selection must include at least one medication from the SSRI category; OR
- Prior stabilization on the Tier-2 medication documented within the last 100 days. A past history of success on the Tier-2 medication will also be considered with adequate documentation; OR
- A unique FDA-approved indication not covered by Tier-1 products or other products from a different therapeutic class; OR
- A petition may be submitted for consideration whenever a unique patient-specific situation exists.
Tier 3 Authorization Criteria
- A documented, recent (within six months) trial with two Tier-1 medications (Tier-1 selection must include at least one medication from the SSRI category) and a Tier-2 medication at least four weeks in duration and titrated to recommended dose, that did not provide an adequate response; OR
- Prior stabilization on the Tier-3 medication documented within the last 100 days. A past history of success on the Tier-3 medication will also be considered with adequate documentation; OR
- A unique FDA-approved indication not covered by a lowered tiered product or other products from a different therapeutic class; OR
- A petition may be submitted for consideration whenever a unique patient-specific situation exists.
Special Criteria:
- Use of any Special PA product will require a patient-specific, clinically significant reason why the member cannot use other available generic Tier-1 products; OR
- A petition may be submitted for consideration whenever a unique patient-specific situation exists.
- Tier structure rules still apply.
When Irenka™ (duloxetine 40mg) is being requested for non-depression related diagnoses, the criteria below will apply:
- An FDA approved diagnosis of diabetic peripheral neuropathy or chronic musculoskeletal pain; AND
- A patient-specific, clinically significant reason why the member cannot use two duloxetine 20mg capsules in place of Irenka™ 40mg capsules; AND
- A quantity limit of 30 capsules per 30 days will apply.
Marplan® (Isocarboxazid) Approval Criteria:
- A patient-specific, clinically significant reason why the member cannot use any of the Tier-3 monoamine oxidase inhibitors (MAOIs) or other cost-effective, lower tiered alternatives in place of Marplan®. Tier structure rules still apply.
Sertraline Capsule Approval Criteria:
- An FDA approved indication of major depressive disorder (MDD) in adults or obsessive-compulsive disorder (OCD) in adults and pediatric patients 6 years of age and older; and
- Member must have initiated treatment with sertraline tablets for dose titration up to the 150mg or 200mg dose; and
- A patient-specific, clinically significant reason why the member cannot use sertraline tablets, which are available without a prior authorization, in place of the capsule formulation must be provided; and
- A quantity limit of 30 capsules per 30 days will apply.
Desyrel® (Trazodone 300mg Tablets) Approval Criteria:
- A patient-specific, clinically significant reason why the member cannot use other available generic Tier-1 products including two trazodone 150mg tablets or three trazodone 100mg tablets to achieve a 300mg dose.
Fluoxetine capsules will be preferred over fluoxetine tablets.
- Fluoxetine capsules will be available without a prior authorization. The tablet formulation will require prior authorization and reasoning why the tablet formulation is required in place of the capsule formulation.
Citalopram 20mg/10mL, Escitalopram 10mg/10mL, and Fluoxetine 20mg/5mL Unit Dose Cups Approval Criteria:c
- An FDA approved indication; AND
- A patient-specific, clinically significant reason why the member cannot use the bulk medication must be provided.
Citalopram Capsule Approval Criteria:
- An FDA approved indication of major depressive disorder (MDD) in adults; and
- Member must have initiated treatment with citalopram tablets for dose titration up to the 30mg dose; and
- A patient-specific, clinically significant reason why the member cannot use citalopram tablets, which are available without prior authorization, in place of the capsule formulation must be provided; and
- Citalopram capsules will not be approved for members 60 years of age or older; and
- A quantity limit of 30 capsules per 30 days will apply.
Citalopram 20mg and 40mg Age Restriction:
- Doses of citalopram above 20mg are not covered for members older than 60 years of age due to an FDA issued a Drug Safety Communication (DSC) stating that citalopram should no longer be used at doses greater than 20mg/day for those older than 60 years of age because it could cause potentially dangerous abnormalities in the electrical activity of the heart. Prolongation of the QT interval of the electrocardiogram (ECG) can lead to a risk of an abnormal heart rhythm called Torsade de Pointes, which can be fatal
duloxetine Delayed-Release Capsule (Drizalma Sprinkle™) Approval Criteria [Diabetic Peripheral Neuropathy/Chronic Musculoskeletal Pain Diagnosis]:
- An FDA approved diagnosis of diabetic peripheral neuropathy or chronic musculoskeletal pain; AND
- A patient-specific, clinically significant reason why the member cannot use generic duloxetine 20mg, 30mg, or 60mg capsules, which are available without prior authorization, in place of Drizalma Sprinkle™ must be provided; AND
- A quantity limit of 30 capsules per 30 days will apply.
Spravato® (Esketamine Nasal Spray) Approval Criteria [Depressive Symptoms in Adults with Major Depressive Disorder (MDD) with Acute Suicidal Ideation or Behavior Diagnosis]:
- An FDA approved indication of depressive symptoms in adults with MDD with acute suicidal ideation or behavior; and
- Member must be 18 years of age or older; AND
- Spravato® must be used in conjunction with an oral antidepressant; AND
- Prescriber must agree that member will be monitored by a health care provider for at least 2 hours after each administration; AND
- Prescriber must agree that member’s blood pressure will be monitored prior to and after administration of Spravato® in accordance with the Spravato® prescribing information; AND
- Member must not have any contraindications to therapy [i.e., aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial, and peripheral arterial vessels) or arteriovenous malformation; intracerebral hemorrhage; hypersensitivity to esketamine, ketamine, or any of the excipients]; AND
- Member must not have severe hepatic impairment (Child Pugh C); AND
- Prescriber must verify that female members are not currently pregnant and will use effective contraception while receiving treatment with Spravato®; AND
- Prescriber must verify member is not breastfeeding; AND
- Pharmacy and health care setting must be certified in the Spravato® Risk Evaluation and Mitigation Strategy (REMS) program; AND
- Member must be enrolled in the Spravato® REMS program; AND
- Spravato® must be administered under the direct observation of a health care provider in a REMS certified health care setting; AND
- For initial approval, the number of doses the member received while hospitalized, if applicable, and the dates of these doses must be provided to allow authorization of the appropriate quantity for the initial 4 weeks of treatment; and
- For continued authorization, prescriber must verify member demonstrated an adequate response during the initial 4 weeks of treatment, verify member is using Spravato® in combination with an oral antidepressant, and provide patient-specific, clinically significant information to support continued use of Spravato®; and
- A quantity limit of 8 kits per 28 days will apply.
Spravato® (Esketamine Nasal Spray) Approval Criteria [Treatment-Resistant Depression Diagnosis]:
Approval Criteria for Atypical Antipsychotics as Adjunctive Treatment for Major Depression Disorder:
- An FDA approved indication of treatment-resistant depression in adult; and
- Member must be 18 year of age or older; and
- Spravato® must be used in conjunction with an oral antidepressant; and
- Member must have had an inadequate response to at least 2 different antidepressants from different classes at least 4 weeks in duration each and titrated to recommended dosing during the current depressive episode, unless contraindicated or clinically significant adverse effects; and
- Prescriber must agree that member will be monitored by a health care provider for at least 2 hours after each administration; and
- Prescriber must agree that member’s blood pressure will be monitored prior to and after administration of Spravato® in accordance with the Spravato® Prescribing Information; and
- Member must not have any contraindications to therapy [e.g., aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial, and peripheral arterial vessels) or arteriovenous malformation; intracerebral hemorrhage; hypersensitivity to esketamine, ketamine, or any of the excipients]; and
- Member must not have severe hepatic impairment (Child Pugh C); and
- Prescriber must verify that female members are not currently pregnant and will use effective contraception while receiving treatment with Spravato®; and
- Prescriber must verify female member is not breastfeeding; and
- Pharmacy and health care setting must be certified in the Spravato® Risk Evaluation and Mitigation Strategy (REMS) program; and
- Member must be enrolled in the Spravato® REMS program; and
- Spravato® must be administered under the direct observation of a health care provider in a REMS certified health care setting; and
- Initial approvals will be for the duration of the induction phase. For continued authorization, prescriber must verify member demonstrated an adequate response during the induction phase and verify member is using Spravato® in combination with an oral antidepressant; and
- A quantity limit of 4 kits per 28 days will apply for maintenance dosing.
Authorization of Rexulti® (brexipiprazole) or Symbyax® (olanzapine/fluoxetine) for a diagnosis of major depression disorder requires current use of an antidepressant, and previous trials with at least two other antidepressants from both categories (an SSRI and duloxetine) and a trial of aripiprazole tablets that did not yield adequate response. Tier structure rules still apply (the member would have needed to try the Tier-2 atypical antipsychotics indicated for adjunctive treatment of MDD before trying a Tier-3).
Prior Authorization form
**Irenka™ for musculoskeletal conditions will require a patient-specific, clinically significant reason why the member cannot use two duloxetine 20mg capsules in place of the 40mg capsules.
Tier 1
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Tier 2
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Tier 3
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Special PA
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Selective Serotonin Reuptake Inhibitors (SSRIs) |
- citalopram (Celexa®)
- escitalopram (Lexapro®)
- fluoxetine (Prozac®)
- fluvoxamine (Luvox®)
- paroxetine (Paxil®)
- sertraline (Zoloft®)
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- citalopram 20mg/10mL soln (UDC)
- citalopram capsules
- escitalopram 10mg/10mL soln (UDC)
- fluoxetine 20mg/5mL soln (UDC)
- fluvoxamine (Luvox CR®)
- fluoxetine 10mg, 20mg, & 60mg tablets
- fluoxetine DR (Prozac weekly®)
- paroxetine CR (Paxil CR®)
- paroxetine (Pexeva®)
- sertraline 150mg & 200mg caps
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Dual Acting Antidepressants
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- bupropion (Wellbutrin®, Wellbutrin SR®, Wellbutrin XL®)
- duloxetine HCI (Cymbalta ®)
- mirtazapine (Remeron®, Remeron SolTab®)
- trazodone (Desyrel®)
- venlafaxine (Effexor®, Effexor XR® capsules)
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- desvenlafaxine (Pristiq®)
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- desvenlafaxine (Khedezla®)
- levomilnacipran (Fetzima®)
- nefazodone (Serzone®)
- vilazodone (Viibryd®)
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- bupropion ER (Aplenzin®, Forfivo®)
- duloxetine (Irenka™)
- duloxetine (Drizalma Sprinkle™)
- trazodone 300mg tablet (Desyrel®)
- venlafaxine extended release tablets
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Monoamine Oxidase Inhibitors |
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- phenelzine (Nardil®)
- selegiline transderm (Emsam®)
- tranylcypromine(Parnate®)
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Unique Mechanisms of Action |
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- vortioxetine (Trintellix®)
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- esketamine nasal spray (Spravato™)
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PAROXETINE MESYLATE (BRISDELLE®) |
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PA Criteria:
- An FDA approved diagnosis of moderate to severe vasomotor symptoms associated with menopause; AND
- Approvals for Brisdelle® will not be granted for psychiatric indications; AND
- Member must not have any of the contraindications for use of Brisdelle®; AND
- Two previous trials with either a selective serotonin reuptake inhibitor (SSRI) or a selective serotonin norepinephrine reuptake inhibitor (SNRI) or both, or a patient-specific, clinically significant reasoning why a SSRI or SNRI is not appropriate for the member; AND
- Authorization requires a patient-specific, clinically significant reason why paroxetine 10mg is not appropriate for the member; AND
- A quantity limit of 30 capsules per 30 days will apply.
Prior Authorization form
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