Subject: GSTP SSRIs 384-D P07-2025

Drug

Selective Serotonin Reuptake Inhibitors (SSRIs)

TRINTELLIX

Policy:

Initial Step Therapy

If the patient has filled a prescription for at least a 30 day supply of at least one generic Selective Serotonin Reuptake Inhibitor (SSRI) or at least one generic Selective Serotonin Reuptake Inhibitor (SSRI) combination product within the past 730 days under a prescription benefit administered by CVS/Caremark, then the requested branded drug will be paid under that prescription benefit. If the patient does not meet the initial step therapy criteria, then the claim will reject with a message indicating that a prior authorization (PA) is required. The prior authorization criteria would then be applied to requests submitted for evaluation to the PA unit.

Coverage Criteria

Authorization may be granted for the requested drug when ONE of the following criteria are met:

• The patient has experienced an inadequate treatment response after at least a 30 day trial of at least ONE generic SSRI or at least ONE generic SSRI combination product.
• The patient has a documented contraindication or a potential drug interaction that would prohibit a trial of at least ONE generic SSRI or at least ONE generic SSRI combination product.
• The patient has experienced an intolerance to at least ONE generic SSRI or at least ONE generic SSRI combination product.

Duration of Approval (DOA)

• 384-D: DOA: 24 months

Place of Service:

Outpatient

The above policy is based on the following references:

N/A

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

December 13, 2025