Antidepressants - Enhanced Formulary

 Brand name products/single manufacturer products.

• Auvelity (dextromethorphan / bupropion hcl ER tab)
• Citalopram 30 mg capsule
• Desvenlafaxine ER (Khedezla)
• Drizalma Sprinkle (duloxetine dr capsule)
• Emsam (selegiline td patch 24hr)
• Fetzima (levomilnacipran hcl cap sr 24hr)
• Fluoxetine delayed release 90 mg tab
• Marplan (isocarboxazid tab)
• Pexeva (paroxetine mesylate tab)
• Sertraline 150mg & 200mg caps
• Venlafaxine ER 112.5mg tab
• Viibryd (vilazodone hcl tab) Starter Kit

• Treatment of multiple depression and anxiety disorders

1. The patient is currently on one of the restricted antidepressants and cannot be safely transitioned to an unrestricted alternative; OR 
2. The patient has experienced a therapeutic failure or inadequate response to ONE unrestricted alternative; OR
3. The patient has a documented intolerance, hypersensitivity, or FDA labeled contraindication to ALL unrestricted alternatives.

Duration of Approval: 365 days (1 year)

Quantity limitations apply to brand and associated generic products. 

1. The quantity (dose) requested is for documented titration purposes at the initiation of therapy (authorization for a 90 day titration period); AND
2. The prescribed dose cannot be achieved using a lesser quantity of a higher strength; AND
3. The quantity (dose) requested does not exceed the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert; OR
4. If the quantity (dose) requested exceeds the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert, then the prescriber must submit documentation in support of therapy with a higher dose for the intended diagnosis (submitted documentation may include medical records OR fax form which reflects medical record documentation that shows the length of time the requested dose has been used, and what other medications and doses have been tried and failed).

Duration of Approval: 365 days (1 year)

All information referenced is from FDA package insert unless otherwise noted below.

Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q4 annually.

April 2025: Criteria change: Added Auvelity to policy. Removed obsolete Khedezla and Maprotiline. Removed nortriptyline solution due to MSC flip to Y. Removed Trintellix from policy.

November 2023: Criteria update: Increased QL for Cymbalta 30mg and Drizalma Sprinkle 30mg capsules.

October 2023: Criteria update: Removed Amoxapine from restricted products.

October 2022: Criteria update: Sertraline and Escitalopram QL increase.

October 2022: Criteria update: Viibryd 10, 20, 40mg tablets removed from restricted products.

August 2022: Criteria update: Added new to market Venlafaxine ER 112.5 mg tablets to policy.

July 2022: Criteria change: Added quantity limits. Removed Brand Surmontil and Brand Lexapro solution from policy (obsolete). Termed the following medications from restricted products: Celexa, Cymbalta, Effexor XR, Lexapro, Paxil, Paxil CR, Pristiq, Prozac, Remeron, Wellbutrin SR, Zoloft.

March 2022:  Criteria update:  Added new to market Citalopram 30mg capsules.

Additional historical revisions available upon request from Corporate Pharmacy