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Pharmacy Clinical Policy Bulletins

Subject: Antidepressants

Class Edit Summary*
Status Drug PR PR-QL PR-AL ST M EX‡
Selective Serotonin Reuptake Inhibitors (SSRIs)
P citalopram   X      
P fluoxetine   X      
P fluvoxamine   X      
P paroxetine   X      
P sertraline   X      
P Paxil CR® (paroxetine SR)       X X
FE Celexa® (citalopram)   X   X X
FE Lexapro® (escitalopram)   X   X X
FE Paxil® (paroxetine)   X   X X
FE Pexeva® (paroxetine)   X   X X
FE Prozac® (fluoxetine)   X   X X
FE Prozac® Weekly (fluoxetine)   X   X X
FE Rapiflux® (fluoxetine)   X   X X
FE Zoloft® (sertraline)   X   X X
Selective Norepinephrine Reuptake Inhibitors (SNRIs)
P Effexor XR® (venlafaxine SR)   X   X X
FE Cymbalta® (duloxetine) X X   X X
FE Effexor® (venlafaxine)   X   X X
Tricyclic Antidepressants
P amitriptyline          
P amoxapine          
P clomipramine          
P desipramine          
P doxepin          
P imipramine          
P nortriptyline          
P protriptyline          
NP Anafranil® (clomipramaine)          
NP Asendin® (amoxapine)          
NP Aventil® (nortriptyline)          
NP Elavil® (amitriptyline)          
NP Norpramine® (desipramine)          
NP Pamelor® (nortriptyline)          
NP Sinequan® (doxepin)          
NP Surmontil® (trimipramine)          
NP Tofranil® (imipramine)          
NP Vivactil® (protriptyline)          
Tretracyclic Antidepressants
P maprotiline   X      
P mirtazapine          
NP Ludiomil® (maprotiline)          
NP Remeron® /Solutab (mirtazapine)       X X
Miscellaneous Antidepressants
P budeprion   X      
P bupropion, bupropion SR   X      
P trazodone          
P Wellbutrin XL® (bupropion SR)   X   X X
NP Desyrel® (trazodone)     X X
FE nefazodone       X X
FE Emsam® (selegiline td patch 24-Hr)         X
FE Serzone® (nefazodone)       X X
FE Trazamine Pak® (trazodone tab/nutritional supp cap pack)         X
FE Wellbutrin® (bupropion)   X   X X
FE Wellbutrin SR® (bupropion SR)   X   X X
Monoamine Oxidase Inhibitors
NP Marplan®(isocarboxazid)          
NP Nardil®(phenelzine)          
NP Parnate®(tranylcypromine)          

*P = Preferred; FE = Formulary Excluded; NP = Nonpreferred
PR = Precertification; QL = Quantity Limits; AL = Age Limits; ST = Step-Therapy
‡M EX = Medical Exception - This means the physician or health care professional must obtain a medical exception from Aetna, in order for the medication to be eligible for coverage. Medical Exception criteria apply to Formulary Excluded drugs for members enrolled in or covered by closed benefits plans, and also apply to Step-Therapy drugs in cases where a member's physician believes it is medically necessary for the member to use a step-therapy drug in the first instance without a trial of the prerequisite alternative drug(s).

Important Note

This Pharmacy Clinical Policy Bulletin expresses Aetna's determination of whether certain services or supplies are medically necessary. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefits plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their health care providers will need to consult the member's benefits plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members. CMS's Coverage Database can be found on the following website: http://www.cms.hhs.gov/center/coverage.asp.

Policy

  1. Precertification Criteria

    Under some plans, including plans that use an open or closed formulary, certain antidepressants are subject to precertification as specifically described below.

    • Cymbalta is subject to precertification. If precertification requirements apply, Aetna considers Cymbalta to be medically necessary for those members who meet the following precertification criteria:

      A documented diagnosis of one of the following:
         Cymbalta: major depressive disorder OR diabetic peripheral neuropathic pain

    • Bupropion, bupropion SR, citalopram, fluoxetine, fluvoxamine, maprotiline, paroxetine, sertraline, Celexa, Cymbalta, Effexor, Effexor XR, Lexapro, Paxil, Pexeva, Prozac, Prozac Weekly, Rapiflux, Wellbutrin, Wellbutrin SR, Wellbutrin XL and Zoloft may be subject to quantity limits.

      According to the manufacturers, these antidepressants can be dosed up to a maximum daily dose at the interval(s) as indicated in the table below. A quantity of each drug will be considered medically necessary as indicated in the table below; for Cymbalta, the member must also fulfill criteria A above.


    Drug Maximum DAILY Dose per Package Insert Doses per day Dosage Strengths Quantity Limits
    bupropion
    Wellbutrin    		 450 mg Three 75 mg, 100 mg Up to 180 tablets in 30 days
    bupropion SR
    Wellbutrin SR
    budeprion     		400 mg One or two 100, 150, 200 mg Up to 60 tablets in 30 days
    Wellbutrin XL 450 mg One 150 mg Up to 30 tablets in 30 days
    Wellbutrin XL 450 mg One 300 mg Up to 30 tablets in 30 days
    citalopram
    Celexa     		40 mg One 10, 20, 40 mg Up to 30 tablets in 30 days
    Cymbalta 60 mg One or two 20 mg, 30 mg Up to 60 capsules in 30 days
    Cymbalta 60 mg One or two 60 mg Up to 30 capsules in 30 days
    Effexor 375 mg Two or three 25mg, 100 mg Up to 90 tablets in 30 days
    Effexor 375 mg Two or three 37.5 mg Up to 120 tablets in 30 days
    Effexor 375 mg Two or three 50 mg Up to 180 tablets in 30 days
    Effexor 375 mg Two or three 75 mg Up to 150 tablets in 30 days
    Effexor XR 375 mg One 37.5 , 75 mg Up to 30 capsules in 30 days
    Effexor XR 375 mg Two 150 mg Up to 60 capsules in 30 days
    fluoxetine
    Prozac    		 80 mg One or two 10 mg Up to 30 tablets or capsules in 30 days
    fluoxetine
    Prozac    		 80 mg One or two 40 mg Up to 60 capsules in 30 days
    fluoxetine
    Prozac    		 80 mg One or two 20 mg capsules Up to 120 capsules in 30 days
    fluoxetine
    Rapiflux     		80 mg One or two 20 mg tablets Up to 30 tablets in 30 days
    fluoxetine
    Prozac    		 80 mg One or two Liquid 20 mg/5ml Up to 300 ml in 30 days (10ml/day)
    Prozac Weekly 90 mg One weekly 90 mg Up to 4 capsules in 28 days
    fluvoxamine 300 mg One or two 25 mg, 50 mg Up to 30 tablets in 30 days
    fluvoxamine 300 mg