Pharmacy Prior Authorization Criteria

Savella

Indications for Prior Authorization

Savella (milnacipran)

• For diagnosis of Fibromyalgia
  Indicated for the management of fibromyalgia. Savella is not approved for use in pediatric patients.

Criteria

Savella, Savella Titration Pack

*Amitriptyline and cyclobenzaprine are considered to be potentially inappropriate medications for use in patients 65 years of age and older. [2, A]

Step Therapy

Length of Approval: 12 Month(s)

• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure, contraindication, or intolerance to one of the following generics: [A]
• amitriptyline*
• cyclobenzaprine*
• duloxetine
• gabapentin
• pregabalin

P & T Revisions

2024-03-04, 2023-02-01, 2022-01-10, 2021-10-06, 2021-09-27, 2021-05-20, 2021-03-26, 2021-03-03, 2020-02-19, 2019-12-05

References

1. Savella Prescribing Information. Allergan USA, Inc. Irvine, CA. September 2021.
2. American Geriatrics Society. American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019 Jan 29.
3. Clauw DJ. Fibromyalgia: a clinical review. JAMA. 2014 Apr 16;311(15):1547-55.

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End Notes

1. The 2019 Beers Criteria recommends avoiding the use of amitriptyline (independent of diagnosis or condition) and cyclobenzaprine in older adults due to their highly anticholinergic and sedating properties. [2] However, amitriptyline and cyclobenzaprine have strong evidence for efficacy in treating fibromyalgia. [3]

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Revision History

• 2024-03-04: Annual Review - No criteria changes
• 2023-02-01: Annual Review - no criteria changes
• 2022-01-10: Annual Review - addition of diagnosis verification
• 2021-10-06: EHB specific guideline, removed Gralise as a target.
• 2021-09-27: EHB specific guideline, added to EHB formulary, removed from ORx standard formulary. no changes to criteria
• 2021-05-20: EHB specific guideline, added to EHB formulary, removed from ORx standard formulary. no changes to criteria
• 2021-03-26: Added new Gralise Starter Pack GPI
• 2021-03-03: 2021 Annual Review. Removed Gralise Starter Pack as target (obsolete). No changes to clinical criteria.
• 2020-02-19: 2020 Annual review, no changes to criteria.
• 2019-12-05: Updated criteria for Savella: removed brand Lyrica and added pregabalin as a prerequisite option.

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