Antidepressants - Essential Formulary

Brand name products/single manufacturer products 

• Emsam® (selegiline td patch 24 hr) 
• Fetzima® (levomilnacipran hcl cap sr 24 hr) 
• Fluoxetine delayed release 90 mg tab 
• Nortriptyline hcl solution

• 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 TWO unrestricted alternatives; OR 
   1. The patient has a documented intolerance, hypersensitivity, or FDA labeled contraindication to ALL unrestricted alternatives; AND 
3. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies.

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).

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.

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

January 2023: Criteria update: Viibryd Starter Kit and Maprotiline removed from policy.

November 2022: Criteria change: Sertraline and Escitalopram QL changes.

October 2022: Criteria update: Viibryd 10, 20, 40 mg 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). Removed the following from restricted products Celexa, Citalopram 30 mg, Cymbalta, desvenlafazine ER, Drisalma, duloxetine 40 mg cap, Effexor XR, Khedelza, Lexapro tabs, Marplan, Paxil, Paxil CR, Pexeva, Pristiq, Prozac, Remeron, Sertraline 150 / 200 mg caps, Wellbutrin SR, Zoloft.

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

January 2022: Criteria update: Removed Amoxapine from restriction. Created Essential only policy.

October 2021: Criteria update: Added new to market Sertraline 150 mg & 200 mg capsules.

September 2021: Criteria update: Duration of approval changed to 365 days. Requests for Brand products with unrestricted generic equivalents required to trial generic. Venlafaxine ER removed from policy.

January 2021: Criteria update: Removed Aplenzin and Forfivo to separate policy. Added Wellbutrin SR to policy.

January 2020: Criteria update: Removed unrestricted / suggested alternatives.

October 2019: Criteria update: Added new to market Drizalma Sprinkle to the criteria. 

May 2019: Criteria update: Removed Fluoxetine 60 mg tablets from policy due to MSC change.

January 2019: Removed Trintellix from the Antidepressant policy and moved to the Trintellix UM Es & NR policy; Separated Enhanced from the Essential and Net Results policies.

October 2018: Added new to market generic Bupropion ER 24 HR tab (Forfivo XL) to restricted products.

September 2018: Added Nortriptyline solution to restriction as it became a single manufacturer product.

June 2018: Duloxetine 40 mg (Irenka®) removed from restriction as it is no longer a single source product.

May 2018: Nortriptyline solution removed from restriction due to more generics entering the market.

March 2018: Removed reference to Basic Open formulary.

October 2017: Criteria reformatted; Combined Net Results and other formulary criteria; the following were removed from criteria: Citalopram Solution (multiple manufacturers); fluoxetine 10 mg and 20 mg tablets (multiple manufacturers); Fluvoxamine no longer (multiple manufacturers); Brand Irenka (off the market); Brand Luvox (off the market); Oleptro (off the market); Venlafaxine tabs (multiple manufacturers); Wellbutrin (off the market).

April 2017: Added Fluoxetine DR 90 to restriction as it became a single manufacturer product.

November 2016: Reviewed for Essential formulary; added escitalopram to generic alternatives; removed fluoxetine solution from restriction.

October 2016: Original utilization management criteria issued.