Asset Publisher

ph-1101

print Print Back Back

Antidepressant Agents Step Therapy and Quantity Limit Program Summary

Policy Number: PH-1101

 

This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.

 

POLICY REVIEW CYCLE                                                                                                                                                                           

Effective Date

Date of Origin 

7/1/2023

FDA APPROVED INDICATIONS AND DOSAGE

Agent(s)

FDA Indication(s)

Notes

Ref#

Aplenzin® 

(bupropion extended release)

Tablets

Treatment of:

- Major Depressive Disorder (MDD)

- Seasonal Affective Disorder (SAFD)

22

Auvelity®

(dextromethorphan hbr-bupropion hcl tab er)

Tablets

Treatment of:

- Major Depressive Disorder (MDD) in adults

44

Celexa®

(citalopram)

Tablets

Oral solution*

Treatment of:

- Depression

*generic available

1, 2

Cymbalta®

(duloxetine delayed release)

Capsules*

Treatment of:

- Major Depressive Disorder (MDD)

- Generalized Anxiety Disorder (GAD) in adults and pediatric patients 7 years of age and older

- Diabetic Peripheral Neuropathic Pain (DPNP) in adults

- Fibromyalgia (FM) in adults and pediatric patients 13 years of age and older

- Chronic Musculoskeletal Pain (CMP) in adults

*generic available

13

Desvenlafaxine ER

Tablets

Treatment of:

- Major Depressive Disorder (MDD)

 

 

18

Drizalma Sprinkle™

(duloxetine delayed release)

Sprinkle capsules

Treatment of:

- Major Depressive Disorder (MDD)

- Generalized Anxiety Disorder (GAD) in adults and pediatric patients ages 7 years to 17 years old

- Diabetic Peripheral Neuropathic Pain (DPNP) in adults

- Chronic Musculoskeletal Pain (CMP) in adults

- Fibromyalgia (FM) in adults

14

duloxetine delayed release

Capsules

Treatment of:

- Major Depressive Disorder (MDD)

- Panic Disorder

- Diabetic peripheral neuropathic pain (DPNP)

- Chronic musculoskeletal pain (CMP)

 

 

19

Effexor XR®

(venlafaxine extended release)

Capsules*

Treatment of:

- Major Depressive Disorder (MDD)

- Panic Disorder (MDD)

- Generalized Anxiety Disorder (GAD)

- Social Anxiety Disorder (SAD)

*generic available

16

Fetzima®

(levomilnacipran ER)

Capsules

Treatment of:

- Major Depressive Disorder (MDD)

17

Fluoxetine 60 mg

Tablets*

Treatment of:

- Major Depressive Disorder (MDD)

- Obsessive Compulsive Disorder (OCD)

- Bulimia Nervosa

- Panic Disorder (PD), with or without agoraphobia

*generic available

3

Fluoxetine Delayed Release

Capsules

Treatment of:

- Acute and maintenance treatment of Major Depressive Disorder (MDD)

 

 

10

Prozac®

(fluoxetine)

Tablets*

Capsules*

Oral solution*

Treatment of:

- Acute and maintenance treatment of Major Depressive Disorder (MDD)

- Acute and maintenance treatment of Obsessive Compulsive Disorder (OCD)

- Acute and maintenance treatment of Bulimia Nervosa

- Acute treatment of Panic Disorder (PD), with or without agoraphobia

*generic available

11

Forfivo XL®

(bupropion extended release)

Tablets

Treatment of:

- Major Depressive Disorder (MDD)

23

Lexapro®  

(escitalopram)

Tablets*

Oral Suspension*

Treatment of:

- Acute and maintenance treatment of Major Depressive Disorder (MDD) in adults and adolescents aged 12-17 years

- Acute Treatment of Generalized Anxiety Disorder (GAD) in adults

*generic available

6

Maprotiline

Tablets

Treatment of:

- Major Depressive Disorder (MDD)

24

Paxil® 

(paroxetine)

Tablets*

Oral Suspension*

Treatment of:

- Treatment of Major Depressive Disorder (MDD)

- Obsessive Compulsive Disorder

- Panic Disorder (PD)

- Generalized Anxiety Disorder

- Social Anxiety Disorder (SAD)

- Post-Traumatic Stress Disorder (PTSD)

*generic available

7

Paxil CR®

(paroxetine extended release)

Tablets*

Treatment of:

- Major Depressive Disorder (MDD)

- Panic Disorder (PD)

- Social Anxiety Disorder (SAD)

- Premenstrual Dysphoric Disorder (PMDD)

*generic available

8

Pexeva®

(paroxetine mesylate)

Tablets

Treatment of:

- Major Depressive Disorder (MDD)

- Obsessive Compulsive Disorder (OCD)

- Panic Disorder

- Generalized Anxiety Disorder (GAD)

 

 

9

Pristiq®

(desvenlafaxine succinate extended release)

Tablets*

Treatment of:

- Major Depressive Disorder (MDD)

*generic available

20

Remeron SolTab® 

(mirtazapine ODT)

Orally Disintegrating Tablets*

 

Treatment of:

- Major Depressive Disorder (MDD)

*generic available

25

Remeron® 

(mirtazapine)

Tablets*

Treatment of:

- Major Depressive Disorder (MDD)

*generic available

25

Sertraline

Capsules 

Treatment of:

- Major depressive disorder (MDD) in adults

- Obsessive-compulsive disorder (OCD) in adults  and pediatric patients 6 years and older

42

Trintellex®

(vortioxetine)

Tablets

Treatment of:

- Major Depressive Disorder (MDD)

27

Effexor®

(venlafaxine)

Tablets*

Treatment of:

- Major Depressive Disorder (MDD)

*generic available

15

venlafaxine ER

Tablets

Treatment of:

- Major Depressive Disorder

- Social Anxiety Disorder

21

Viibryd®

(vilazodone)

Tablets*

Treatment of:

- Major Depressive Disorder (MDD)

*generic available

28

Wellbutrin®

(bupropion)

Tablets*

Treatment of:

- Major Depressive Disorder (MDD)

*generic available

29

Wellbutrin SR® 

(bupropion sustained release)

Tablets*

Treatment of:

          - Major Depressive Disorder (MDD)

*generic available

30

Wellbutrin XL®

(bupropion extended release)

Tablets*

Treatment of:

- Major Depressive Disorder (MDD)

- Seasonal Affective Disorder (SAFD)

*generic available

31

Zoloft® 

(sertraline)

Tablets*

Oral concentrate*

Treatment of:

- Major Depressive Disorder (MDD)

- Obsessive Compulsive Disorder (OCD

- Panic disorder (PD)

- Post-traumatic stress disorder (PTSD)

- Social anxiety disorder (SAD)

- Premenstrual dysphoric disorder (PMDD)

*generic available

12

See package insert for FDA prescribing information:  https://dailymed.nlm.nih.gov/dailymed/index.cfm

CLINICAL RATIONALE

Depression

No antidepressant has been clearly shown to be superior to another. All FDA-approved antidepressant medications should be considered potentially appropriate for first-line treatment.  Selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), bupropion, mirtazapine, and several newer agents are typically used as first-line medications because their safety and tolerability may be preferable to patients and clinicians compared to those of tricyclic antidepressants (TCAs) and monoamine oxidase (MAO) inhibitors(32). Many clinical features and medication characteristics influence the choice of a first-line antidepressant. There are no absolutes, and relative differences between medications are small, hence, selecting an antidepressant involves an individualized needs assessment for each patient(33).

Anxiety Disorders

Guidelines for treatment of anxiety include several anxiety-related conditions: generalized anxiety disorder (GAD), panic disorder (PD), obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and social anxiety disorder (SAD). SSRIs are generally considered first-line therapy for GAD and PD. In the treatment of PD, TCAs are as effective as SSRIs, but adverse effects may limit the use of TCAs in some patients. Extended-release venlafaxine is effective and well tolerated for GAD and PD, whereas duloxetine has been adequately evaluated only for GAD. Due to the typical delay in onset of action, medications should not be considered ineffective until they are titrated to the high end of the dose range and continued for at least four weeks. Once symptoms have improved, medications should be used for 12 months before tapering to limit relapse. Some patients will require longer treatment(34). OCD has a highly selective response to serotonergic medications. SSRIs are preferred for initial therapy. There is insufficient evidence to show that one SSRI is superior, and the choice should be individualized, taking into account potential drug interactions and tolerability. Dosage should be increased over four to six weeks until maximum dose is achieved. Trial of therapy should continue for eight to 12 weeks, with at least four to six weeks at the maximum tolerable dosage. It usually takes at least four to six weeks for patients to note any significant improvement in symptoms; it may take 10 weeks or longer for some. If successful, medication should be continued for at least one to two years, if not indefinitely(35). Among adult patients with PTSD, fluoxetine, paroxetine, sertraline, and venlafaxine are appropriate choices, with none showing improved efficacy over the others(36). For SAD, SSRIs and SNRIs venlafaxine are the clear first-line pharmacotherapy treatment based on demonstrated efficacy in randomized controlled trials and meta-analyses. Medications in these classes that have been FDA-approved in the U.S. are paroxetine (immediate-release and controlled release), sertraline, fluvoxamine controlled release, and venlafaxine extended release. Other medications in these classes with evidence of efficacy from randomized controlled trials include citalopram, escitalopram, and vilazodone. Fluoxetine has had mixed results in randomized controlled trials. SNRIs should be used with caution in patients at risk for suicide due to greater toxicity in overdose. No individual medication within this class has been consistently shown to be superior to another in this class(37).

Neuropathic Pain

First-line treatment for neuropathic pain include TCAs, gabapentin, pregabalin, and SNRI antidepressants (duloxetine [most studied], venlafaxine) as first-line therapies.(38) For patients with diabetic neuropathy, only two medications, pregabalin and duloxetine, have been approved by the FDA. However, in addition to those two medications, gabapentin and amitriptyline are considered first-line therapy. SNRIs such as venlafaxine and desvenlafaxine are considered second-line therapy. SSRIs such as citalopram, paroxetine, and escitalopram are considered third-line therapy(39).

 Fibromyalgia

Pharmaceutical therapy recommendations depend on the source of the guideline. Guidelines are available from the European League Against Rheumatism (EULAR-2016), the Canadian Pain Society (2012) and the Association of the Scientific Medical Societies in Germany (AWMF-2012). Recommendations from these guidelines include amitriptyline, pregabalin, gabapentin, SNRIs (including duloxetine and milnacipran), and SSRIs. Amitriptyline, pregabalin, and duloxetine are used most commonly(40).

 Chronic Musculoskeletal Pain

Antidepressants are options for the treatment of chronic pain. Meta-analyses of randomized controlled trials indicate that TCAs and SNRIs provide effective pain relief for a variety of chronic pain etiologies(41). Duloxetine is FDA approved for chronic musculoskeletal pain(13).

Adverse Effects

All of the above listed agents have had a black box warning issued by the FDA. The warning concerns suicidal thoughts and behaviors. Since there are small differences between the warnings, they are not listed here. Please see the respective agent’s prescribing information for the warning.

REFERENCES                                                                                                                                                                           

Number

Reference

1

Celexa prescribing information.  Allergan USA, Inc. February 2022. 

2

Citalopram solution prescribing information. Aurobindo Pharma Limited. September 2021.

3

Fluoxetine 60 mg tablet prescribing information. Nivagen Pharmaceuticals, Inc. June 2021.

4

Fluvoxamine extended-release capsules prescribing information. Actavis Pharma, Inc. September 2021.

5

Fluvoxamine tablet prescribing information. ANI Pharmaceuticals, Inc.  September 2021.

6

Lexapro prescribing information. Allergan USA, Inc. September 2021.

7

Paxil prescribing information. GlaxoSmithKline. September 2021.

8

Paxil CR prescribing information. Apotex Corp. September 2021.

9

Pexeva prescribing information. Sebela Pharmaceuticals, Inc. September 2021.

10

Fluoxetine delayed release capsule prescribing information. Dr. Reddy’s Laboratories Limited. September 2021.

11

Prozac prescribing information. Eli Lilly and Company. October 2021.

12

Zoloft prescribing information. Pfizer, Inc. September 2021. 

13

Cymbalta prescribing information. Eli Lilly and Company. September 2021.

14

Drizalma Sprinkle prescribing information. Sun Pharmaceutical Industries Limited. July 2021.

15

Venlafaxine tablets prescribing information. Aurobindo Pharma Limited. September 2021.

16

Effexor XR prescribing information. Pfizer, Inc. August 2022. 

17

Fetzima prescribing information. Allergan USA, Inc. September 2021.

18

Desvenlafaxine ER prescribing information. Alembic Pharms LTC. September 2021.

19

Duloxetine 40mg prescribing information. BluePoint Laboratories. July 2021.

20

Pristiq prescribing information. Pfizer, Inc. November 2021.

21

Venlafaxine ER tablets prescribing information. Nivagen Pharmaceuticals, Inc. February 2019. 

22

Aplenzin prescribing information. Valeant Pharmaceuticals North America, LLC. March 2022.

23

Forfivo prescribing information. Almatica Pharma, Inc. December 2019.

24

Maprotiline prescribing information. Mylan Pharmaceuticals, Inc. December 2014.

25

Remeron prescribing information. Merck & Co, Inc. November 2021.

26

Remeron SolTab prescribing information. Merck & Co, Inc. November 2021.

27

Trintellix prescribing information. Takeda Pharmaceuticals America, Inc. September 2021. 

28

Viibryd prescribing information. Allergan, Inc. September 2021. 

29

Bupropion prescribing information. BluePoint Laboratories. December 2020.

30

Wellbutrin SR prescribing information. GlaxoSmithKline, LLC. December 2022.

31

Wellbutrin XL prescribing information. Bausch Health Companies, Inc. March 2022. 

32

Halverson J, Beevers C, Kamholz B. Clinical Practice Review for Major Depressive Disorder. Anxiety and Depression Association of America, February 2, 2016. Available at: https://adaa.org/resources-professionals/practice-guidelines-mdd

33

Kennedy SH, Lam RW, McIntyre RS, et. al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder. Canadian Journal Psychiatry. 2016, Vol. 61(9)540-560. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994790/pdf/10.1177_0706743716659417.pdf

34

Locke AB, Kirst N, Shuultz CG. Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults. Am Fam Physician. 2015 May 1;91(9):617-624. Available at: https://www.aafp.org/afp/2015/0501/p617.html

35

Fenske JN, Petersen K. Obsessive-Compulsive Disorder: Diagnosis and Management. Am Fam Physician. 2015 Nov 15;92(10):896-903. Available at: https://www.aafp.org/afp/2015/1115/p896.html

36

Courtois CA, Sonis J, Brown LS, et. al. Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults. American Psychological Association. Available at: https://www.apa.org/ptsd-guideline/ptsd.pdf

37

van Amerigen M, Heimberg RG, Schneier F, et. al. Clinical Practice Review for Social Anxiety Disorder. Anxiety and Depression Association of America. September 15, 2015. Available at: https://adaa.org/resources-professionals/clinical-practice-review-social-anxiety

38

Gilron I, Baron R, Jensen T.  Neuropathic Pain: Principles of Diagnosis and Treatment. Mayo Clinic Proceedings, April 2015. Available at: https://www.mayoclinicproceedings.org/article/S0025-6196(15)00105-6/fulltext#sec6

39

Snyder MJ, Gibbs LM, Lindsay TJ. Treating Painful Diabetic Peripheral Neuropathy: An Update. American Family Physician.  2016 Aug 1;94(3):227-234. Available at: https://www.aafp.org/afp/2016/0801/p227.html

40

Kia S, Choy E. Update on Treatment Guideline in Fibromyalgia Syndrome with Focus on Pharmacology. Biomedicines. 2017 Jun; 5(2): 20. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5489806/

41

American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management. Anesthesiology. 2010;112:810-833. Available at:  https://anesthesiology.pubs.asahq.org/article.aspx?articleid=1932775.

42

Sertraline prescribing information. Almatica Pharma LLC. October 2021.

43

Venlafaxine besylate ER tablets prescribing information. Almatica Pharma LLC.  June 2022.

44

Auvelity prescribing information. Axsome Therapeutics, Inc. December 2022.

 

POLICY AGENT SUMMARY STEP THERAPY

Agent Names

Strength

Targeted MSC

Available MSC

Final Age Limit

Preferred Status

MAPROTILINE*maprotiline hcl tab

25 MG ; 50 MG ; 75 MG

M ; N ; O

N

APLENZIN*bupropion hbr tab er  ; BUPROPION*bupropion hcl tab  ; BUPROPION*bupropion hcl tab er  ; FORFIVO*bupropion hcl tab er  ; WELLBUTRIN*bupropion hcl tab er

100 MG ; 150  ; 150 MG ; 174 MG ; 200 MG ; 300  ; 300 MG ; 348 MG ; 450 MG ; 522 MG ; 75 MG

M ; N ; O

M ; N ; O ; Y

AUVELITY*dextromethorphan hbr-bupropion hcl tab er

45-105 MG

M ; N ; O

N

CELEXA*citalopram hydrobromide tab  ; CITALOPRAM*citalopram hydrobromide cap  ; CITALOPRAM*citalopram hydrobromide oral soln  ; CITALOPRAM*citalopram hydrobromide tab

10 MG ; 10 MG/5ML ; 20  ; 20 MG ; 30 MG ; 40 MG

M ; N ; O

N ; O ; Y

CYMBALTA*duloxetine hcl enteric coated pellets cap  ; DULOXETINE*duloxetine hcl enteric coated pellets cap

20 MG ; 30 MG ; 40 MG ; 60 MG

M ; N ; O

O ; Y

DRIZALMA*duloxetine hcl cap delayed release sprinkle

20 MG ; 30 MG ; 40 MG ; 60 MG

M ; N ; O

N

EFFEXOR*venlafaxine hcl cap er  ; VENLAFAXINE*venlafaxine besylate tab er  ; VENLAFAXINE*venlafaxine hcl cap er  ; VENLAFAXINE*venlafaxine hcl tab  ; VENLAFAXINE*venlafaxine hcl tab er

100 MG ; 112.5 MG ; 150 MG ; 225 MG ; 25 MG ; 37.5 MG ; 50 MG ; 75 MG

M ; N ; O

M ; N ; O ; Y

FETZIMA*levomilnacipran hcl cap er

120 MG ; 20 & 40 MG ; 20 MG ; 40 MG ; 80 MG

M ; N ; O

N

ESCITALOPRAM*escitalopram oxalate soln  ; ESCITALOPRAM*escitalopram oxalate tab  ; LEXAPRO*escitalopram oxalate tab

10  ; 10 MG ; 20  ; 20 MG ; 5 MG ; 5 MG/5ML

M ; N ; O

O ; Y

PAROXETINE*paroxetine hcl oral susp  ; PAROXETINE*paroxetine hcl tab  ; PAROXETINE*paroxetine hcl tab er  ; PAXIL*paroxetine hcl oral susp  ; PAXIL*paroxetine hcl tab  ; PAXIL*paroxetine hcl tab er  ; PEXEVA*paroxetine mesylate tab

10 MG ; 10 MG/5ML ; 12.5 MG ; 20 MG ; 25 MG ; 30 MG ; 37.5 MG ; 40 MG

M ; N ; O

N ; O ; Y

DESVENLAFAXINE*desvenlafaxine succinate tab er  ; DESVENLAFAXINE*desvenlafaxine tab er  ; PRISTIQ*desvenlafaxine succinate tab er

100 MG ; 25 MG ; 50 MG

M ; N ; O

M ; N ; O ; Y

FLUOXETINE*fluoxetine hcl cap  ; FLUOXETINE*fluoxetine hcl cap delayed release  ; FLUOXETINE*fluoxetine hcl solution  ; FLUOXETINE*fluoxetine hcl tab  ; PROZAC*fluoxetine hcl cap

10 MG ; 20  ; 20 MG ; 20 MG/5ML ; 40 MG ; 60 MG ; 90 MG

M ; N ; O

N ; O ; Y

MIRTAZAPINE*mirtazapine orally disintegrating tab  ; MIRTAZAPINE*mirtazapine tab  ; REMERON*mirtazapine orally disintegrating tab  ; REMERON*mirtazapine tab

15 MG ; 30 MG ; 45 MG ; 7.5 MG

M ; N ; O

O ; Y

TRINTELLIX*vortioxetine hbr tab

10 MG ; 20 MG ; 5 MG

M ; N ; O

N

VIIBRYD*vilazodone hcl tab  ; VIIBRYD*vilazodone hcl tab starter kit  ; VILAZODONE*vilazodone hcl tab

10 & 20 MG ; 10 MG ; 20 MG ; 40 MG

M ; N ; O

N ; O ; Y

SERTRALINE*sertraline hcl cap  ; SERTRALINE*sertraline hcl oral concentrate for solution  ; SERTRALINE*sertraline hcl tab  ; ZOLOFT*sertraline hcl oral concentrate for solution  ; ZOLOFT*sertraline hcl tab

100  ; 100 MG ; 150 MG ; 20 MG/ML ; 200 MG ; 25  ; 25 MG ; 50  ; 50 MG

M ; N ; O

N ; O ; Y

POLICY AGENT SUMMARY QUANTITY LIMIT

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

QL Amount

Dose Form

Day Supply

Duration

Addtl QL Info

Allowed Exceptions

Targeted NDCs When Exclusions Exist

Bupropion HCl Tab 100 MG

100 MG

120

Tablets

30

DAYS

Bupropion HCl Tab 75 MG

75 MG

60

Tablets

30

DAYS

citalopram hydrobromide cap

30 MG

30

Capsules

30

DAYS

citalopram hydrobromide oral soln

10 MG/5ML

600

mLs

30

DAYS

desvenlafaxine tab er

100 MG ; 50 MG

30

Tablets

30

DAYS

Duloxetine HCl Enteric Coated Pellets Cap 40 MG (Base Eq)

40 MG

90

Capsules

30

DAYS

escitalopram oxalate soln

5 MG/5ML

600

mLs

30

DAYS

fluoxetine hcl cap delayed release

90 MG

4

Capsules

28

DAYS

Fluoxetine HCl Solution  ; fluoxetine hcl solution

20  ; 20 MG/5ML

600

mLs

30

DAYS

Fluoxetine HCl Tab 10 MG

10 MG

30

Tablets

30

DAYS

Fluoxetine HCl Tab 20 MG

20 MG

120

Tablets

30

DAYS

Fluoxetine HCl Tab 60 MG

60 MG

30

Tablets

30

DAYS

fluvoxamine maleate cap er

100 MG ; 150 MG

60

Capsules

30

DAYS

Fluvoxamine Maleate Tab 100 MG

100 MG

90

Tablets

30

DAYS

Fluvoxamine Maleate Tab 25 MG

25 MG

30

Tablets

30

DAYS

Fluvoxamine Maleate Tab 50 MG

50 MG

30

Tablets

30

DAYS

maprotiline hcl tab

25 MG ; 50 MG ; 75 MG

90

Tablets

30

DAYS

sertraline hcl cap

150 MG ; 200 MG

30

Capsules

30

DAYS

venlafaxine besylate tab er

112.5 MG

30

Tablets

30

DAYS

venlafaxine hcl tab

100 MG ; 25 MG ; 37.5 MG ; 50 MG ; 75 MG

90

Tablets

30

DAYS

Venlafaxine HCl Tab ER 24HR 150 MG (Base Equivalent)

150 MG

30

Tablets

30

DAYS

Venlafaxine HCl Tab ER 24HR 225 MG (Base Equivalent)

225 MG

30

Tablets

30

DAYS

Venlafaxine HCl Tab ER 24HR 37.5 MG (Base Equivalent)

37.5 MG

30

Tablets

30

DAYS

Venlafaxine HCl Tab ER 24HR 75 MG (Base Equivalent)

75 MG

90

Tablets

30

DAYS

Aplenzin

bupropion hbr tab er

174 MG ; 348 MG ; 522 MG

30

Tablets

30

DAYS

Auvelity

dextromethorphan hbr-bupropion hcl tab er

45-105 MG

60

Tablets

30

DAYS

Celexa

Citalopram Hydrobromide Tab  ; citalopram hydrobromide tab

10 MG ; 20  ; 20 MG ; 40 MG

30

Tablets

30

DAYS

Cymbalta

Duloxetine HCl Enteric Coated Pellets Cap 20 MG (Base Eq)

20 MG

60

Capsules

30

DAYS

Cymbalta

Duloxetine HCl Enteric Coated Pellets Cap 30 MG (Base Eq)

30 MG

60

Capsules

30

DAYS

Smart QL: 2 capsules daily for 60 days 3 capsules daily thereafter

Cymbalta

Duloxetine HCl Enteric Coated Pellets Cap 60 MG (Base Eq)

60 MG

60

Capsules

30

DAYS

Drizalma sprinkle

duloxetine hcl cap delayed release sprinkle

20 MG ; 30 MG ; 40 MG ; 60 MG

60

Capsules

30

DAYS

Effexor xr

Venlafaxine HCl Cap ER 24HR 150 MG (Base Equivalent)

150 MG

30

Capsules

30

DAYS

Smart QL: 1 capsule daily for 60 days 2 capsules daily thereafter

Effexor xr

Venlafaxine HCl Cap ER 24HR 37.5 MG (Base Equivalent)

37.5 MG

30

Capsules

30

DAYS

Effexor xr

Venlafaxine HCl Cap ER 24HR 75 MG (Base Equivalent)

75 MG

90

Capsules

30

DAYS

Fetzima

levomilnacipran hcl cap er

120 MG ; 20 MG ; 40 MG ; 80 MG

30

Capsules

30

DAYS

Fetzima titration pack

levomilnacipran hcl cap er

20 & 40 MG

28

Capsules

180

DAYS

Forfivo xl ; Wellbutrin xl

Bupropion HCl Tab ER  ; bupropion hcl tab er

150  ; 150 MG ; 300  ; 300 MG ; 450 MG

30

Tablets

30

DAYS

Lexapro

Escitalopram Oxalate Tab 10 MG (Base Equiv)

10  ; 10 MG

30

Tablets

30

DAYS

Lexapro

Escitalopram Oxalate Tab 20 MG (Base Equiv)

20  ; 20 MG

30

Tablets

30

DAYS

Smart QL: 1  tablet daily for 60 days 2 tablets daily thereafter

Lexapro

Escitalopram Oxalate Tab 5 MG (Base Equiv)

5 MG

30

Tablets

30

DAYS

Paxil

Paroxetine HCl Oral Susp 10 MG/5ML (Base Equiv)

10 MG/5ML

900

mLs

30

DAYS

Paxil

Paroxetine HCl Tab 10 MG

10 MG

30

Tablets

30

DAYS

Paxil

Paroxetine HCl Tab 20 MG

20 MG

30

Tablets

30

DAYS

Paxil

Paroxetine HCl Tab 30 MG

30 MG

60

Tablets

30

DAYS

Paxil

Paroxetine HCl Tab 40 MG

40 MG

30

Tablets

30

DAYS

Paxil cr

Paroxetine HCl Tab ER 24HR 12.5 MG

12.5 MG

30

Tablets

30

DAYS

Paxil cr

Paroxetine HCl Tab ER 24HR 25 MG

25 MG

60

Tablets

30

DAYS

Paxil cr

Paroxetine HCl Tab ER 24HR 37.5 MG

37.5 MG

60

Tablets

30

DAYS

Pexeva

Paroxetine Mesylate Tab 10 MG (Base Equiv)

10 MG

30

Tablets

30

DAYS

Pexeva

Paroxetine Mesylate Tab 20 MG (Base Equiv)

20 MG

30

Tablets

30

DAYS

Pexeva

Paroxetine Mesylate Tab 30 MG (Base Equiv)

30 MG

60

Tablets

30

DAYS

Pexeva

Paroxetine Mesylate Tab 40 MG (Base Equiv)

40 MG

30

Tablets

30

DAYS

Pristiq

desvenlafaxine succinate tab er

100 MG ; 25 MG ; 50 MG

30

Tablets

30

DAYS

Prozac

Fluoxetine HCl Cap 10 MG

10 MG

30

Capsules

30

DAYS

Prozac

Fluoxetine HCl Cap 20 MG

20 MG

120

Capsules

30

DAYS

Prozac

Fluoxetine HCl Cap 40 MG

40 MG

60

Capsules

30

DAYS

Remeron

mirtazapine tab

15 MG ; 30 MG ; 45 MG ; 7.5 MG

30

Tablets

30

DAYS

Remeron soltab

mirtazapine orally disintegrating tab

15 MG ; 30 MG ; 45 MG

30

Tablets

30

DAYS

Trintellix

vortioxetine hbr tab

10 MG ; 20 MG ; 5 MG

30

Tablets

30

DAYS

Viibryd

vilazodone hcl tab

10 MG ; 20 MG ; 40 MG

30

Tablets

30

DAYS

Viibryd starter pack

vilazodone hcl tab starter kit

10 & 20 MG

1

Tablets

180

DAYS

Wellbutrin sr

Bupropion HCl Tab ER  ; bupropion hcl tab er

100 MG ; 150 MG ; 200 MG

60

Tablets

30

DAYS

Zoloft

Sertraline HCl Oral Concentrate for Solution 20 MG/ML

20 MG/ML

300

mLs

30

DAYS

Zoloft

Sertraline HCl Tab 100 MG

100  ; 100 MG

60

Tablets

30

DAYS

Zoloft

Sertraline HCl Tab 25 MG

25  ; 25 MG

30

Tablets

30

DAYS

Zoloft

Sertraline HCl Tab 50 MG

50  ; 50 MG

30

Tablets

30

DAYS

CLIENT SUMMARY – STEP THERAPY

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Client Formulary

maprotiline hcl tab

25 MG ; 50 MG ; 75 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Aplenzin ; Forfivo xl ; Wellbutrin sr ; Wellbutrin xl

Bupropion HCl Tab ER  ; bupropion hbr tab er  ; bupropion hcl tab  ; bupropion hcl tab er

100 MG ; 150  ; 150 MG ; 174 MG ; 200 MG ; 300  ; 300 MG ; 348 MG ; 450 MG ; 522 MG ; 75 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Auvelity

dextromethorphan hbr-bupropion hcl tab er

45-105 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Celexa

Citalopram Hydrobromide Tab  ; citalopram hydrobromide cap  ; citalopram hydrobromide oral soln  ; citalopram hydrobromide tab

10 MG ; 10 MG/5ML ; 20  ; 20 MG ; 30 MG ; 40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Cymbalta

duloxetine hcl enteric coated pellets cap

20 MG ; 30 MG ; 40 MG ; 60 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Drizalma sprinkle

duloxetine hcl cap delayed release sprinkle

20 MG ; 30 MG ; 40 MG ; 60 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Effexor xr

venlafaxine besylate tab er  ; venlafaxine hcl cap er  ; venlafaxine hcl tab  ; venlafaxine hcl tab er

100 MG ; 112.5 MG ; 150 MG ; 225 MG ; 25 MG ; 37.5 MG ; 50 MG ; 75 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Fetzima ; Fetzima titration pack

levomilnacipran hcl cap er

120 MG ; 20 & 40 MG ; 20 MG ; 40 MG ; 80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lexapro

Escitalopram Oxalate Tab  ; escitalopram oxalate soln  ; escitalopram oxalate tab

10  ; 10 MG ; 20  ; 20 MG ; 5 MG ; 5 MG/5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Paxil ; Paxil cr ; Pexeva

paroxetine hcl oral susp  ; paroxetine hcl tab  ; paroxetine hcl tab er  ; paroxetine mesylate tab

10 MG ; 10 MG/5ML ; 12.5 MG ; 20 MG ; 25 MG ; 30 MG ; 37.5 MG ; 40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Pristiq

desvenlafaxine succinate tab er  ; desvenlafaxine tab er

100 MG ; 25 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Prozac

Fluoxetine HCl Solution  ; fluoxetine hcl cap  ; fluoxetine hcl cap delayed release  ; fluoxetine hcl solution  ; fluoxetine hcl tab

10 MG ; 20  ; 20 MG ; 20 MG/5ML ; 40 MG ; 60 MG ; 90 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Remeron ; Remeron soltab

mirtazapine orally disintegrating tab  ; mirtazapine tab

15 MG ; 30 MG ; 45 MG ; 7.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Trintellix

vortioxetine hbr tab

10 MG ; 20 MG ; 5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Viibryd ; Viibryd starter pack

vilazodone hcl tab  ; vilazodone hcl tab starter kit

10 & 20 MG ; 10 MG ; 20 MG ; 40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zoloft

Sertraline HCl Tab  ; sertraline hcl cap  ; sertraline hcl oral concentrate for solution  ; sertraline hcl tab

100  ; 100 MG ; 150 MG ; 20 MG/ML ; 200 MG ; 25  ; 25 MG ; 50  ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

CLIENT SUMMARY – QUANTITY LIMITS

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Client Formulary

Bupropion HCl Tab 100 MG

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Bupropion HCl Tab 75 MG

75 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

citalopram hydrobromide cap

30 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

citalopram hydrobromide oral soln

10 MG/5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

desvenlafaxine tab er

100 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Duloxetine HCl Enteric Coated Pellets Cap 40 MG (Base Eq)

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

escitalopram oxalate soln

5 MG/5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

fluoxetine hcl cap delayed release

90 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Fluoxetine HCl Solution  ; fluoxetine hcl solution

20  ; 20 MG/5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Fluoxetine HCl Tab 10 MG

10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Fluoxetine HCl Tab 20 MG

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Fluoxetine HCl Tab 60 MG

60 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

fluvoxamine maleate cap er

100 MG ; 150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Fluvoxamine Maleate Tab 100 MG

100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Fluvoxamine Maleate Tab 25 MG

25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Fluvoxamine Maleate Tab 50 MG

50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

maprotiline hcl tab

25 MG ; 50 MG ; 75 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

sertraline hcl cap

150 MG ; 200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

venlafaxine besylate tab er

112.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

venlafaxine hcl tab

100 MG ; 25 MG ; 37.5 MG ; 50 MG ; 75 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Venlafaxine HCl Tab ER 24HR 150 MG (Base Equivalent)

150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Venlafaxine HCl Tab ER 24HR 225 MG (Base Equivalent)

225 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Venlafaxine HCl Tab ER 24HR 37.5 MG (Base Equivalent)

37.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Venlafaxine HCl Tab ER 24HR 75 MG (Base Equivalent)

75 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Aplenzin

bupropion hbr tab er

174 MG ; 348 MG ; 522 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Auvelity

dextromethorphan hbr-bupropion hcl tab er

45-105 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Celexa

Citalopram Hydrobromide Tab  ; citalopram hydrobromide tab

10 MG ; 20  ; 20 MG ; 40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Cymbalta

Duloxetine HCl Enteric Coated Pellets Cap 20 MG (Base Eq)

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Cymbalta

Duloxetine HCl Enteric Coated Pellets Cap 30 MG (Base Eq)

30 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Cymbalta

Duloxetine HCl Enteric Coated Pellets Cap 60 MG (Base Eq)

60 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Drizalma sprinkle

duloxetine hcl cap delayed release sprinkle

20 MG ; 30 MG ; 40 MG ; 60 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Effexor xr

Venlafaxine HCl Cap ER 24HR 150 MG (Base Equivalent)

150 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Effexor xr

Venlafaxine HCl Cap ER 24HR 37.5 MG (Base Equivalent)

37.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Effexor xr

Venlafaxine HCl Cap ER 24HR 75 MG (Base Equivalent)

75 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Fetzima

levomilnacipran hcl cap er

120 MG ; 20 MG ; 40 MG ; 80 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Fetzima titration pack

levomilnacipran hcl cap er

20 & 40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Forfivo xl ; Wellbutrin xl

Bupropion HCl Tab ER  ; bupropion hcl tab er

150  ; 150 MG ; 300  ; 300 MG ; 450 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lexapro

Escitalopram Oxalate Tab 10 MG (Base Equiv)

10  ; 10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lexapro

Escitalopram Oxalate Tab 20 MG (Base Equiv)

20  ; 20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Lexapro

Escitalopram Oxalate Tab 5 MG (Base Equiv)

5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Paxil

Paroxetine HCl Oral Susp 10 MG/5ML (Base Equiv)

10 MG/5ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Paxil

Paroxetine HCl Tab 10 MG

10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Paxil

Paroxetine HCl Tab 20 MG

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Paxil

Paroxetine HCl Tab 30 MG

30 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Paxil

Paroxetine HCl Tab 40 MG

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Paxil cr

Paroxetine HCl Tab ER 24HR 12.5 MG

12.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Paxil cr

Paroxetine HCl Tab ER 24HR 25 MG

25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Paxil cr

Paroxetine HCl Tab ER 24HR 37.5 MG

37.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Pexeva

Paroxetine Mesylate Tab 10 MG (Base Equiv)

10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Pexeva

Paroxetine Mesylate Tab 20 MG (Base Equiv)

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Pexeva

Paroxetine Mesylate Tab 30 MG (Base Equiv)

30 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Pexeva

Paroxetine Mesylate Tab 40 MG (Base Equiv)

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Pristiq

desvenlafaxine succinate tab er

100 MG ; 25 MG ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Prozac

Fluoxetine HCl Cap 10 MG

10 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Prozac

Fluoxetine HCl Cap 20 MG

20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Prozac

Fluoxetine HCl Cap 40 MG

40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Remeron

mirtazapine tab

15 MG ; 30 MG ; 45 MG ; 7.5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Remeron soltab

mirtazapine orally disintegrating tab

15 MG ; 30 MG ; 45 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Trintellix

vortioxetine hbr tab

10 MG ; 20 MG ; 5 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Viibryd

vilazodone hcl tab

10 MG ; 20 MG ; 40 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Viibryd starter pack

vilazodone hcl tab starter kit

10 & 20 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Wellbutrin sr

Bupropion HCl Tab ER  ; bupropion hcl tab er

100 MG ; 150 MG ; 200 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zoloft

Sertraline HCl Oral Concentrate for Solution 20 MG/ML

20 MG/ML

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zoloft

Sertraline HCl Tab 100 MG

100  ; 100 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zoloft

Sertraline HCl Tab 25 MG

25  ; 25 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

Zoloft

Sertraline HCl Tab 50 MG

50  ; 50 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

STEP THERAPY CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

Brand Agents other than Cymbalta/Drizalma

TARGET AGENT(S)

Aplenzin (bupropion)

Celexa (citalopram)*

Citalopram (capsules)^

Desvenlafaxine ER (tablets)^  

Effexor (venlafaxine)*

Effexor XR (venlafaxine extended release)*

Fetzima (levomilnacipran extended release)

Fluoxetine 60 mg (tablets)*^     

Forfivo XL (bupropion extended release)

Lexapro (escitalopram)*

Maprotiline (tablets)^

Paxil (paroxetine hydrochloride)*

Paxil CR (paroxetine extended release)*

Pexeva (paroxetine mesylate)

Pristiq (desvenlafaxine succinate)*

Prozac (fluoxetine)* 

Fluoxetine delayed release (capsules)^ 

Remeron (mirtazapine)*

Remeron SolTab (mirtazapine)*

Sertraline (capsules)^

Trintellix (vortioxetine)

Viibryd (vilazodone)*

Wellbutrin (bupropion)*

Wellbutrin SR (bupropion extended release)*

Wellbutrin XL (bupropion extended release)*

Zoloft (sertraline)*

* - available as a generic; generic included as a prerequisite in step therapy program

^ – branded generic product(s) available; targeted in the step therapy program

 

Brand Antidepressant Agents (except Cymbalta and Drizalma) will be approved when ONE of the following are met:

  1. Information has been provided that indicates the patient has been treated with the requested agent within the past 180 days OR
  2. The prescriber states that the patient has been treated with the requested agent within the past 180 days AND is at risk if therapy is changed OR
  3. The patient has a medication history of use in the past 365 days, intolerance, or hypersensitivity to a generic antidepressant agent - SSRI, SNRI, bupropion, mirtazapine, or vilazodone OR
  4. The patient has an FDA labeled contraindication to ALL generic antidepressants - SSRI, SNRI, bupropion, mirtazapine or vilazodone

Length of Approval: 12 months

NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria.

Cymbalta/Drizalma

TARGET AGENT(S)

Cymbalta (duloxetine)*

Drizalma Sprinkle (duloxetine delayed release sprinkle capsule)

* - available as a generic; generic included as a prerequisite in step therapy program

 

Cymbalta and Drizalma Sprinkle will be approved when ONE of the following are met:

  1. Information has been provided that indicates the patient has been treated with the requested agent within the past 180 days OR
  2. The prescriber states the patient has been treated with the requested agent within the past 180 days AND is at risk if therapy is changed OR
  3. The patient’s medication history includes use of a generic antidepressant agent - SSRI, SNRI, bupropion, mirtazapine, or vilazodone in the past 365 days  OR
  4. The patient has a diagnosis of neuropathic pain and ONE of the following:
    1. The patient has a medication history of use in the past 90 days, intolerance, or hypersensitivity to ONE prerequisite agent (i.e., amitriptyline, nortriptyline, desipramine, imipramine, or gabapentin) OR
    2. The patient has an FDA labeled contraindication to ALL prerequisite agents (i.e., amitriptyline, nortriptyline, desipramine, imipramine, or gabapentin) OR
  5. The patient has a diagnosis of fibromyalgia and ONE of the following:
    1. The patient has a medication history of use in the past 90 days, intolerance, or hypersensitivity to ONE prerequisite agent (i.e., amitriptyline, nortriptyline, desipramine, imipramine, cyclobenzaprine, gabapentin, or tramadol) OR
    2. The patient has an FDA labeled contraindication to ALL prerequisite agents (i.e., amitriptyline, nortriptyline, desipramine, imipramine, cyclobenzaprine, gabapentin, or tramadol) OR
  6. The patient has a diagnosis of chronic musculoskeletal pain and ONE of the following:
    1. The patient has a medication history of use in the past 90 days, intolerance, or hypersensitivity to ONE prerequisite agent (i.e., acetaminophen, oral NSAID, topical NSAID, tramadol, amitriptyline, nortriptyline, desipramine, imipramine, cyclobenzaprine, or gabapentin)OR
    2. The patient has an FDA labeled contraindication to ALL prerequisite agents (i.e., acetaminophen, oral NSAID, topical NSAID, tramadol, amitriptyline, nortriptyline, desipramine, imipramine, cyclobenzaprine, or gabapentin OR
  7. If using for a diagnosis other than neuropathic pain, fibromyalgia, or musculoskeletal pain, ONE of the following:
    1. The patient has an intolerance or hypersensitivity to a generic antidepressant - SSRI, SNRI, bupropion, mirtazapine, or vilazodone OR
    2. The patient has an FDA labeled contraindication to ALL generic antidepressants - SSRI, SNRI, bupropion, mirtazapine, or vilazodone

Length of Approval: 12 months

NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria.

QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

Quantity Limit for the Target Agent(s) will be approved when ONE of the following is met:

  1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  2. The requested quantity (dose) is greater than the program quantity limit AND ONE of the following:
    1. BOTH of the following:
      1. The requested agent does not have a maximum FDA labeled dose for the requested indication AND
      2. Information has been provided to support therapy with a higher dose for the requested indication OR
    2. BOTH of the following:
      1. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
      2. Information has been provided to support why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit OR
    3. BOTH of the following:
      1. The requested quantity (dose) is greater than the maximum FDA labeled dose for the requested indication AND
      2. Information has been provided to support therapy with a higher dose for the requested indication

Length of Approval: up to 12 months

This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.

Commercial _ PS _ Antidepressant Agents Step Therapy with Quantity Limit _ProgSum_ 7/1/2023