PHARMACY PRE-AUTHORIZATION CRITERIA

DRUG

POLICY #
INDICATIONS

CRITERIA

AntidepressantStepTherapyProgram

SelectiveSerotoninReuptakeInhibitor(SSRI)
Fluoxetine60mg
LuvoxCR(fluvoxamine)
Pexeva(paroxetine)
ProzacWeekly(fluoxetine)
Sarafem(fluoxetine)
Viibryd(vilazodone)

SerotoninandNorepinephrineReuptakeInhibitors(SNRI)
DesvenlafaxineFumarate
Fetzima(levomilnacipran)
Irenka(duloxetine)
Khedezla(desvenlafaxine)
Pristiq(desvenlafaxine)
11126
IndicatedforthetreatmentofMajorDepressiveDisorder:All
IndicatedforthetreatmentofObsessiveCompulsiveDisorder:Pexeva
IndicatedforthetreatmentofPanicDisorder:ParoxetineCRandPexeva
IndicatedforthetreatmentofPremenstrualDysphoricDisorder:Sarafem

ThissteptherapyprogramhasbeendevelopedtoencouragetheuseofonegenericSSRIpriorto
theuseofabrandnameSSRIorSNRI,withoutinterruptingexistingtherapy.

Firstlineagents:escitalopram,citalopram,fluoxetine,fluvoxamine,paroxetineHClimmediate
releaseandextendedrelease,sertraline
Secondlineagents:LuvoxCR,Pexeva,ProzacWeekly,Sarafem,Viibryd
Thirdlineagents:DesvenlafaxineFumarate,Fetzima,Irenka,Khedezla,Pristiq

CoverageforSecondlineagentsForCommercialMembersOnly:(Fluoxetine60mg,LuvoxCR,
Pexeva,ProzacWeekly,Sarafem,Viibryd):

Fluoxetine60mg,LuvoxCR,Pexeva,ProzacWeekly,ViibrydandSarafemarecoveredfor
depressiononlyifthereis:

1) Failure or intolerance of at least one first line agent listed above. A physician chart note
documenting the trial and outcome is required if the claims can not be seen in the

PHARMACY PRE-AUTHORIZATION CRITERIA

DRUG

AntidepressantStepTherapyProgram

SelectiveSerotoninReuptakeInhibitor(SSRI)
Fluoxetine60mg
LuvoxCR(fluvoxamine)
Pexeva(paroxetine)
ProzacWeekly(fluoxetine)
Sarafem(fluoxetine)
Viibryd(vilazodone)

SerotoninandNorepinephrineReuptakeInhibitors(SNRI)
DesvenlafaxineFumarate
Fetzima(levomilnacipran)
Irenka(duloxetine)
Khedezla(desvenlafaxine)
Pristiq(desvenlafaxine)
prescriptionhistory.

OR
2) PrevioususeofbrandnameFluoxetine60mg,LuvoxCR,Pexeva,ProzacWeekly,Sarafem,at
anytimeinthepastwithsuccessanddiscontinueduse,mayreceiveauthorizationtorestart
the agent used in the past. For example, a patient who has used Paxil CR in the past for
depressionanddiscontinueditsusemayreceiveauthorizationforcoverageofPaxilCR.

CoverageforThirdlineagents:
DesvenlafaxineFumarate,Fetzima,Irenka,Khedezla,Pristiq
Diagnosis:MajorDepressiveDisorder/GeneralizedAnxietyDisorderandrelatedconditions:

Desvenlafaxine Fumarate, Fetzima, Khedezla, and Pristiq are covered for depression and related
conditionsonlyifthereis:
1. FailureorintolerancetoEffexorXR
OR
2. FailureorintolerancetoCymbalta
OR
3. Patient has taken the requested drug at any time in the past with success and
discontinueduse,mayreceiveauthorizationtorestarttheagentusedinthepast.For
example,apatientwhohasusedtherequesteddruginthepastfordepressionand
discontinueditsusemayreceiveauthorizationforcoverageofit.

PHARMACY PRE-AUTHORIZATION CRITERIA

DRUG

LIMITATIONS

AntidepressantStepTherapyProgram

SelectiveSerotoninReuptakeInhibitor(SSRI)
Fluoxetine60mg
LuvoxCR(fluvoxamine)
Pexeva(paroxetine)
ProzacWeekly(fluoxetine)
Sarafem(fluoxetine)
Viibryd(vilazodone)

SerotoninandNorepinephrineReuptakeInhibitors(SNRI)
DesvenlafaxineFumarate
Fetzima(levomilnacipran)
Irenka(duloxetine)
Khedezla(desvenlafaxine)
Pristiq(desvenlafaxine)
Some of the information in this Document DOES NOT APPLY to Freedom Drug List
Members
(Connecticut Exchange members and most ConnectiCare SOLO Plan members)

Basedonthemaximumdailydosethefollowingquantitieswillbelimitedto:
1. ProzacWeeklyquantitylimitedto4capsulespermonth
2. Pristiqquantitylimitedto1capsule/day

ConnectiCaredoesnotconsiderpoormetabolismofCYP2D6tobeaclinicalreasontouse
KhedezlaorPristiqovervenlafaxineandduloxetine.

In2007,theindependentEvaluationofGenomicApplicationsinPracticeandPrevention
(EGAPP)WorkingGroupdeterminedthattherewasnotenoughevidencetostatewhether
CYP450genotypingshouldorshouldnotbeusedtohelphealthcareprovidersmakedecisions
aboutbeginningSSRItreatmentinadultswithnonpsychoticdepression.Theydiscourageduseof
suchtestinguntilmorestudiesevaluatingpotentialharmsandbenefitsareconducted.

REFERENCES

1. Pristiqprescribinginformation,Pfizerpharmaceuticals
2. Viibrydprescribinginformation,MerckKGaA,Darmstadt,Germany
3. Hansen RA, Gartlehner G, Lohr KN, et al. Efficacy and safety of secondgeneration
antidepressants in the treatment of major depressive disorder. Ann Intern Med.
2005;143:415426.
4. Burke WJ. Selective versus multitransmitter antidepressants: are two mechanisms better
thanone?JClinPsychiatry.2004;65Suppl4:3745.
5. Dunn, Jeffrey D., Tierney, John G. A Step Therapy Algorithm for the Treatment and

PHARMACY PRE-AUTHORIZATION CRITERIA

DRUG

AntidepressantStepTherapyProgram

SelectiveSerotoninReuptakeInhibitor(SSRI)
Fluoxetine60mg
LuvoxCR(fluvoxamine)
Pexeva(paroxetine)
ProzacWeekly(fluoxetine)
Sarafem(fluoxetine)
Viibryd(vilazodone)

SerotoninandNorepinephrineReuptakeInhibitors(SNRI)
DesvenlafaxineFumarate
Fetzima(levomilnacipran)
Irenka(duloxetine)
Khedezla(desvenlafaxine)
Pristiq(desvenlafaxine)
Management of Chronic Depression. The American Journal of Managed Care. 2006;12 (12
supplement):335342.
6. Facts&ComparisonsOnline

P&T REVIEW
HISTORY
REVISION
RECORD

12/06,6/07,3/08,6/08,9/08,3/09,6/09,9/09,9/10,4/11,12/11,10/12,10/13,10/14,11/15,
5/16
6/07,3/08,8/08,3/09,6/09,12/09,12/10,4/11,12/11,6/12,11/13,12/13,4/14,5/14,12/14,
9/15,12/15,2/16(VenlafaxineandParoxetineCRremoved)