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

A. Bupropion, bupropion SR, budeprion XL citalopram, fluoxetine, fluvoxamine, maprotiline, paroxetine, sertraline, venlafaxine, Celexa, Cymbalta, Effexor, Lexapro, Paxil, Pexeva, Prozac, Prozac Weekly, Rapiflux, Wellbutrin, Wellbutrin SR 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 coverage of additional quantities, a member's treating physician must request prior authorization through the Pharmacy Management Precertification Unit. A prior authorization will be granted for coverage of additional quantities of these antidepressants for those members who meet ANY of the following criteria:

• Member requires a dose including half tablets OR
• Member's dose is being titrated by physician (3-month limit) OR
• Member has had intolerance to drug administered as a single daily dose OR
• Member's dose cannot be achieved with proposed qty limits for a given strength  (ex. Mm needs 375mg per day and would require 5 capsules of Effexor XR 75mg to achieve dose ) OR
• Member has a diagnosis of Diabetic Peripheral Neuropathy -For Cymbalta (60mg; 60 capsules in 30 days are allowed)
• Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose.
  

Under some plans, including plans that use an open or closed formulary, Celexa, Cymbalta, Desyrel, Effexor, Effexor XR, Lexapro, nefazodone, Paxil, Paxil CR, Pexeva, Prozac, Prozac Weekly, Rapiflux, Remeron, Remeron Solutab, Serzone, Wellbutrin, Wellbutrin SR, Wellbutrin XL and Zoloft are subject to step-therapy.  Aetna considers these drugs to be medically necessary for those members who meet the following step-therapy criterion:

For Celexa, Cymbalta, Desyrel, Effexor, Effexor XR, Lexapro, nefazodone, Paxil, Paxil CR, Pexeva, Prozac, Prozac Weekly, Rapiflux, Remeron, Remeron Solutab, Serzone, Wellbutrin, Wellbutrin SR, Wellbutrin XL:

A documented trial of one month of one of budeprion, bupropion, bupropion SR, citalopram, fluoxetine, fluvoxamine, paroxetine, mirtazapine, sertraline, trazodone or venlafaxine -alternatives on the Preferred Drug List.

For Zoloft
A documented trial of one month of the preferred generic equivalent sertraline.

If it is medically necessary for a member to be treated initially with a medication subject to step-therapy, the member's treating physician may contact the Aetna Pharmacy Management Precertification Unit to request coverage as a medical exception at 1-800-414-2386. (See criteria under section III below).

Cymbalta, Desyrel, Effexor XR, Remeron, Remeron Solutab and Wellbutrin XL are currently listed on the Aetna Step-Therapy List.* If it is medically necessary for a member to be treated initially with one of these medications subject to step-therapy, Aetna considers these drugs to be medically necessary for those members who meet the criteria specified below.  

Celexa,  Effexor, Lexapro, nefazodone, Paxil, Paxil CR, Pexeva, Prozac, Prozac Weekly, Rapiflux, Serzone, Wellbutrin, Wellbutrin SR and Zoloft are currently listed on the Aetna Formulary Exclusions and Step-Therapy lists.* Therefore, they are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary or that require step-therapy criteria, unless a medical exception is granted.  Aetna considers these drugs to be medically necessary for those members who meet the criteria specified below:

Emsam,  and Trazamine Pak are currently listed on the Aetna Formulary Exclusions list.* Therefore, they are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary, unless a medical exception is granted.  Aetna considers  Emsam,  and Trazamine Pak to be medically necessary for those members who meet the criteria specified below:

For Celexa, Desyrel, Effexor, Emsam, nefazodone, Paxil, Pexeva, Prozac, Prozac Weekly, Rapiflux, Remeron, Remeron Solutab, Serzone, Wellbutrin and Wellbutrin SR:
A.  A documented:

• Intolerance to one generic preferred alternative - budeprion,bupropion, bupropion SR, citalopram, fluoxetine, fluvoxamine, paroxetine, mirtazapine sertraline  trazodone, or venlafaxine OR
• Contraindication to one generic preferred alternative - budeprion, bupropion, bupropion SR, citalopram, fluoxetine, fluvoxamine, paroxetine, mirtazapine sertraline  trazodone, or venlafaxine OR 
• Allergy to one generic preferred alternative - budeprion ,bupropion, bupropion SR, citalopram, fluoxetine, fluvoxamine, paroxetine, mirtazapine sertraline  trazodone, or venlafaxine OR 
• Failure of an adequate trial of one month of one generic preferred alternative - budeprion, bupropion, bupropion SR, citalopram, fluoxetine, fluvoxamine, paroxetine, mirtazapine sertraline  trazodone, or venlafaxine.

For Lexapro, Paxil CR,  Wellbutrin XL- A OR B

  A. A documented:

• Intolerance to one generic preferred alternative - budeprion ,bupropion, bupropion SR, citalopram, fluoxetine, fluvoxamine, paroxetine, mirtazapine sertraline  trazodone, or venlafaxine OR 
• Contraindication to one generic preferred alternative - budeprion, bupropion, bupropion SR, citalopram, fluoxetine, fluvoxamine, paroxetine, mirtazapine sertraline  trazodone, or venlafaxine OR 
• Allergy