AUVELITY (dextromethorphan hydrobromide, bupropion hydrochloride)

AUVELITY (dextromethorphan hydrobromide, bupropion hydrochloride)

Self-Administration – oral

Diagnosis considered for coverage:

• Indicated for the treatment of major depressive disorder (MDD) in adults

Coverage Criteria:

For diagnosis of MDD:

• Dose does not exceed one tablet twice daily; AND
• Patient is 18 years of age or older; AND
• Diagnosis of major depressive disorder (MDD); AND
• Paid claims or submission of medical records (e.g., chart notes) confirming trial and failure to a minimum 30-day supply, contraindication, or intolerance to any TWO of the following generics:
  • bupropion 
  • citalopram 
  • desvenlafaxine succinate extended-release (ER) 
  • duloxetine 
  • escitalopram 
  • fluoxetine 
  • mirtazapine 
  • paroxetine 
  • paroxetine ER 
  • sertraline 
  • venlafaxine 
  • venlafaxine ER 

Reauthorization Criteria:

For diagnosis of MDD:

• Dose does not exceed one tablet twice daily; AND
• Documentation of a positive clinical response to therapy

Coverage Duration: 

• Initial: 1 year
• Reauthorization: 1 year

Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information: 

• Starting dose: one tablet (45 mg dextromethorphan hydrobromide-105 mg bupropion hydrochloride) once daily in the morning
• Maximum recommended dose: one tablet twice daily
• The safety and effectiveness of Auvelity have not been established in pediatric patients
• Contraindications:
  • With a seizure disorder
  • With a current or prior diagnosis of bulimia or anorexia nervosa as a higher incidence of seizures was observed in such patients treated with the immediate-release formulation of bupropion
  • Undergoing abrupt discontinuation of alcohol, benzodiazepines, barbiturates, and antiepileptic drugs
  • Taking, or within 14 days of stopping, MAOIs due to the risk of serious and possibly fatal drug interactions, including hypertensive crisis and serotonin syndrome
  • Starting Auvelity in a patient treated with reversible MAOIs such as linezolid or intravenous methylene blue is contraindicated
  • With known hypersensitivity to bupropion, dextromethorphan, or other components of Auvelity. Anaphylactoid/anaphylactic reactions and Stevens-Johnson syndrome have been reported with bupropion. Arthralgia, myalgia, fever with rash, and other serum sickness-like symptoms suggestive of delayed hypersensitivity have also been reported with bupropion 

Policy Updates:

• 3/1/2023 – New policy approved by P&T

References:

• Auvelity prescribing information. New York, NY. Axsome Therapeutics, Inc. October 2022.