Pharmacy Prior Authorization Criteria

Antidepressants

Indications for Prior Authorization

Trintellix (vortioxetine)

• For diagnosis of Major Depressive Disorder
  Indicated for the treatment of major depressive disorder (MDD) in adults.

Fetzima (levomilnacipran extended-release)

• For diagnosis of Major Depressive Disorder
  Indicated for the treatment of major depressive disorder (MDD) in adults.

  Limitation of Use: Fetzima is not approved for the management of fibromyalgia. The efficacy and safety of Fetzima for the management of fibromyalgia have not been established.

Criteria

Trintellix

Step Therapy

Length of Approval: 12 Month(s)

• Both of the following:
• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure (of a minimum 30-day supply), contraindication, or intolerance to any TWO of the following generics:
• bupropion
• citalopram
• desvenlafaxine extended-release (ER)
• duloxetine
• escitalopram
• fluoxetine
• mirtazapine
• paroxetine or paroxetine ER
• sertraline
• venlafaxine or venlafaxine ER
OR
• For continuation of prior therapy

Fetzima or Fetzima Pack

Step Therapy

Length of Approval: 12 Month(s)

• Both of the following:
• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure (of a minimum 30-day supply), contraindication, or intolerance to any TWO of the following generics:
• desvenlafaxine extended-release (ER)
• duloxetine
• venlafaxine or venlafaxine ER
OR
• For continuation of prior therapy

P & T Revisions

2024-03-04, 2023-02-28, 2022-08-02, 2022-03-03, 2021-09-27, 2021-05-18, 2021-03-04, 2020-03-05, 2019-12-10

References

1. Trintellix Prescribing Information. Takeda Pharmaceuticals America, Inc. Lexington, MA. September 2021.
2. Fetzima Prescribing Information. Allergan USA, Inc. Madison, NJ. September 2021.
3. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder, third edition. Oct. 2010. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Accessed January 21, 2022.
4. Soleimani L, Lapidus KA, Losifescu DV. Diagnosis and treatment of major depressive disorder. Neurol Clin. 2011;29(1):177-93.
5. American Geriatrics Society. American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63:2227-46.

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Revision History

• 2024-03-04: Annual Review
• 2023-02-28: Annual Review - removal of Aplenzin and Paxil oral solution. Addition of Emsam
• 2022-08-02: Formatting updates to criteria.
• 2022-03-03: Annual review: Updated criteria and background.
• 2021-09-27: EHB specific guideline, added to EHB formulary, removed from ORx standard formulary. no changes to criteria
• 2021-05-18: EHB specific guideline, added to EHB formulary, removed from ORx standard formulary. no changes to criteria
• 2021-03-04: Annual review: Background updates.
• 2020-03-05: Annual review: Background updates, GPI clean-up.
• 2019-12-10: Added brand Paxil suspension as a target.

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