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Pharmacy Clinical Policy Bulletins Aetna Non-Medicare Prescription Drug Plan
Subject: Antidepressants
| Selective Serotonin Reuptake Inhibitors (SSRIs) |
| P |
citalopram
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|
X
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|
| P |
fluoxetine
|
|
X
|
|
|
|
| P |
fluvoxamine
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|
X
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|
|
|
| P |
paroxetine
|
|
X
|
|
|
|
| P |
sertraline
|
|
X
|
|
|
|
| NP |
Sarafem®
(fluoxetine)
|
|
X
|
|
|
|
| FE |
Celexa®
(citalopram)
|
|
X
|
|
X
|
X
|
| FE |
Lexapro®
(escitalopram)
|
|
X
|
|
X
|
X
|
| FE |
Paxil CR®
(paroxetine SR)
|
|
|
|
X
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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 |
venlafaxine
|
|
X
|
|
|
|
| P |
Cymbalta®
(duloxetine)
|
|
X
|
|
X
|
X
|
| P |
Effexor XR®
(velafaxine SR)
|
|
X
|
|
X
|
X
|
| FE |
Effexor®
(venlafaxine)
|
|
X
|
|
X
|
X
|
| Tricyclic Antidepressants |
| P |
amitriptyline
|
|
|
|
|
|
| P |
amoxapine
|
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|
|
| P |
clomipramine
|
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|
|
|
|
| P |
desipramine
|
|
|
|
|
|
| P |
doxepin
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|
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|
| P |
imipramine
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|
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|
|
| P |
nortriptyline
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|
|
|
|
|
| P |
protriptyline
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|
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|
|
| NP |
Anafranil®
(clomipramine)
|
|
|
|
|
|
| NP |
Asendin®
(amoxapine)
|
|
|
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|
|
| NP |
Aventil®
(nortriptyline)
|
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|
|
|
|
| NP |
Elavil®
(amitriptyline)
|
|
|
|
|
|
| NP |
Norpramine®
(desipramine)
|
|
|
|
|
|
| NP |
Pamelor®
(nortriptyline)
|
|
|
|
|
|
| NP |
Sinequan®
(doxepin)
|
|
|
|
|
|
| NP |
Surmontil®
(trimipramine)
|
|
|
|
|
|
| NP |
Tofranil®
(imipramine)
|
|
|
|
|
|
| NP |
Vivactil®
(protriptyline)
|
|
|
|
|
|
| Tetracyclic Antidepressants |
| P |
maprotiline
|
|
X
|
|
|
|
| P |
mirtazapine
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|
|
|
|
|
| NP |
Ludiomil®
(maprotiline)
|
|
|
|
|
|
| NP |
Remeron® / Solutab
(mirtazapine)
|
|
|
|
X
|
X
|
| Miscellaneous Antidepressants |
| P |
budeprion
|
|
X
|
|
|
|
| P |
bupropion, bupropion SR
|
|
X
|
|
|
|
| P |
buproprion, budeprion XL
|
|
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 |
| P |
tranylcypromine
|
|
|
|
|
|
| NP |
Marplan®
(isocarboxazid)
|
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|
|
|
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| NP |
Nardil®
(phenelzine)
|
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|
|
|
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| NP |
Parnate®
(tranylcypromine)
|
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Policy:
- Precertification Criteria
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;
| bupropion
Wellbutrin
|
450 mg/ Three times daily |
75 mg, 100 mg |
Up to 180 tablets in 30 days |
| bupropion SR
Wellbutrin SR
budeprion
|
400 mg/ Once or twice daily |
100, 150, 200 mg |
Up to 60 tablets in 30 days |
| bupropion XL
Wellbutrin XL
|
450 mg/ Once daily |
150 mg |
Up to 30 tablets in 30 days |
| budeprion
bupropion XL
Wellbutrin XL
|
450 mg/ Once daily |
300 mg |
Up to 30 tablets in 30 days |
| citalopram
Celexa
|
40 mg/ Once daily |
10, 20, 40 mg |
Up to 30 tablets in 30 days |
| Cymbalta |
60 mg/ Once or twice daily |
20, 30 mg |
Up to 60 capsules in 30 days |
| Cymbalta |
60 mg/ Once daily |
60 mg |
Up to 30 capsules in 30 days |
| venlafaxine
Effexor
|
375 mg/ Two or three times daily |
25, 100 mg |
Up to 90 tablets in 30 days |
| venlafaxine
Effexor |
375 mg/ Two or three times daily |
37.5 mg |
Up to 120 tablets in 30 days |
| venlafaxine
Effexor |
375 mg/ Two or three times daily |
50 mg |
Up to 180 tablets in 30 days |
| venlafaxine
Effexor |
375 mg/ Two or three times daily |
75 mg |
Up to 150 tablets in 30 days |
| Effexor XR |
375 mg/ Once daily |
37.5, 75 mg |
Up to 30 capsules in 30 days |
| Effexor XR |
375 mg/ Twice daily |
150 mg |
Up to 60 capsules in 30 days |
| fluoxetine
Prozac |
80 mg/ Once or twice daily |
10 mg |
Up to 30 tablets or capsules in 30 days |
| fluoxetine
Prozac |
80 mg/ Once or twice daily |
40 mg |
Up to 60 capsules in 30 days |
| fluoxetine
Prozac
Rapiflux |
80 mg/ Once or twice daily |
20 mg capsules/tablets |
Up to 120 in 30 days |
| fluoxetine
Prozac |
80 mg/ Once or twice daily |
Liquid 20 mg/5 ml |
Up to 300 ml in 30 days (10 ml/day) |
| Prozac Weekly |
90 mg/ One WEEKLY |
90 mg |
Up to 4 capsules in 28 days |
| fluvoxamine |
300 mg/ Once or twice daily |
25, 50 mg |
Up to 30 tablets in 30 days |
| fluvoxamine |
300 mg/ Once or twice daily |
100 mg |
Up to 90 days in 30 days |
| Lexapro |
20 mg/ Once daily |
5, 10, 20 mg |
Up to 30 tablets in 30 days |
| Lexapro |
20 mg/ Once daily |
Solution 5 mg/5 ml |
Up to 600 ml in 30 days |
| maprotiline |
225 mg/ Once daily, or can be divided |
25 mg |
Up to 30 tablets in 30 days |
| maprotiline |
225 mg/ Once daily, or can be divided |
50 mg |
Up to 60 tablets in 30 days |
| maprotiline |
225 mg/ Once daily, or can be divided |
75 mg |
Up to 90 tablets in 30 days |
| paroxetine
Paxil, Pexeva |
60 mg/ Once daily |
10, 20 mg |
Up to 30 tablets in 30 days |
| paroxetine
Paxil, Pexeva |
60 mg/ Once daily |
30, 40 mg |
Up to 60 tablets in 30 days |
| paroxetine
Paxil, Pexeva |
60 mg/ Once daily |
Suspension 10 mg/5 ml |
Up to 900 ml in 30 days |
| fluoxetine
Sarafem |
80 mg/ Once daily |
10 mg |
Up to 30 capsules in 30 days |
| fluoxetine
Sarafem |
80 mg/ Once daily |
20 mg |
Up to 120 capsules in 30 days |
| sertraline
Zoloft |
200 mg/ Once daily |
25 mg |
Up to 30 tablets in 30 days |
| sertraline
Zoloft |
200 mg/ Once daily |
50 mg |
Up to 45 tablets in 30 days |
| sertraline
Zoloft |
200 mg/ Once daily |
100 mg |
Up to 60 tablets in 30 days |
| sertraline
Zoloft |
200 mg/ Once daily |
Liquid 20mg/ml |
Up to 300 ml in 30 days |
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
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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
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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.
- Step Therapy Criteria
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).
- Medical Exception Criteria
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
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Allergy to one generic preferred alternative - budeprion ,bupropion, bupropion SR, citalopram, fluoxetine, fluvoxamine, paroxetine, mirtazapine sertraline trazodone, or venlafaxine OR
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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
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Allergy |