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Drug Category: Central Nervous System (CNS)

Medication Class/Individual Agents: Antidepressant

I. Prior-Authorization Requirements

 Antidepressants – Monoamine Oxidase Inhibitors (MAOI)

Clinical Notes
Drug Details

Drug Generic Name

Drug Brand Name

PA
Status
isocarboxazid Marplan PA  
phenelzine Nardil # PA   - < 6 years
selegiline transdermal patch Emsam PA  
tranylcypromine Parnate # PA   - < 6 years

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • In general, the elderly are more sensitive to side effects of medications, especially to sedation, orthostatic hypotension, and anticholinergic symptoms. Because of changes in drug metabolism, older patients need lower doses of antidepressants to reach therapeutic effect. Thus the maxim, “Start low and go slow.”
  • MassHealth does not encourage the use of combination products and recommends that the active medications be prescribed individually.
  • There is no evidence to support the use of two selective serotonin reuptake inhibitors (SSRIs) or a SSRI in combination with a serotonin/norepinephrine reuptake inhibitor (SNRI) or a serotonin modulator concurrently. These combinations may duplicate drug action, with increased side effects and minimal clinical benefit. PA is required when a patient has an overlap of 60 days or more in prescriptions of two SSRIs or a SSRI in combination with a SNRI or serotonin modulator.1
  • Due to bupropion’s dose-dependent risk of seizure (0.33-0.4% within recommended dosing limits) please dose accordingly. Bupropion immediate release (IR) should be dosed no greater than 150 mg per dose and 450 mg per day. Bupropion sustained release (SR) should be dosed no greater than 200 mg per dose and 400 mg per day. Bupropion extended-release (XL) requires PA for quantities > 30 units per month. It should be dosed no greater than 450 mg a day (300 mg tablet plus 150 mg tablet) as a single dose. Patients with seizure disorders, brain injuries, and eating disorders are at highest risk of seizures.
  • Brand-name Serzone is no longer available due to reports of life-threatening hepatic failure resulting in death or transplant. Generic nefazodone is still available from various manufacturers.
  • Blood pressure should be monitored during venlafaxine therapy because it may cause a dose-related increase in diastolic blood pressure (reported in 3-13% of patients). Sustained increases in diastolic blood pressure are reported with desvenlafaxine succinate as well (1.3-2.3% of patients).
  • Antidepressant discontinuation syndrome has been commonly reported with SSRIs and SNRIs. Among the SSRIs, this is most commonly reported with paroxetine (whose half-life is short and there is no active metabolite) and reported least with fluoxetine (with a long half-life and an active, long-acting metabolite). Symptoms include dizziness, nausea, fatigue, lethargy, flu-like symptoms, anxiety, irritability, and insomnia. This often occurs one-three days after abruptly stopping the medication. The agents in question should be slowly tapered to avoid this syndrome.

Monoamine Oxidase Inhibitors (MAOIs):

  • Hypertensive crisis may occur when MAOIs are coadministered with some prescription and over-the-counter products and foods, especially those high in tyramine.
  • Serotonin syndrome can occur when MAOIs are coadministered with other pro-serotonergic medications.
  • Patients should be counseled about dietary and medication restrictions and be given a list of food and drugs to be avoided.
 

 Antidepressants – NMDA Receptor Antagonist
Drug Details

Drug Generic Name

Drug Brand Name

PA
Status
esketamine Spravato PA  

 Antidepressants – Noradrenergic and Specific Serotonergic Antidepressants (NaSSA)
Drug Details

Drug Generic Name

Drug Brand Name

PA
Status
mirtazapine Remeron # PA   - < 6 years
mirtazapine orally disintegrating tablet Remeron Sol Tab PA  

 Antidepressants – Norepinephrine/Dopamine Reuptake Inhibitors (NDRI)
Drug Details

Drug Generic Name

Drug Brand Name

PA
Status
bupropion hydrobromide extended-release Aplenzin PA  
bupropion hydrochloride Wellbutrin # PA   - < 6 years
bupropion hydrochloride extended-release 150 mg, 300 mg tablets Wellbutrin XL # PA   - < 6 years and PA > 30 units/month
bupropion hydrochloride extended-release 450 mg tablet Forfivo XL BP PA  
bupropion hydrochloride sustained-release-Wellbutrin SR Wellbutrin SR # PA   - < 6 years

 Antidepressants – Second-Generation (Atypical) Antipsychotic and Selective Serotonin Reuptake Inhibitor
Drug Details

Drug Generic Name

Drug Brand Name

PA
Status
olanzapine / fluoxetine Symbyax PA  

 Antidepressants – Selective Serotonin Reuptake Inhibitors (SSRI)
Drug Details

Drug Generic Name

Drug Brand Name

PA
Status
citalopram Celexa # PA   - < 6 years
escitalopram Lexapro # PA   - < 6 years
fluoxetine 10 mg tablet for premenstrual dysphoric disorder Sarafem # PA   - < 6 years
fluoxetine 10 mg, 20 mg, 40 mg capsule, solution Prozac # PA   - < 6 years
fluoxetine 20 mg tablet for premenstrual dysphoric disorder Sarafem PA  
fluoxetine 60 mg tablet PA  
fluoxetine 90 mg delayed-release capsule Prozac Weekly PA  
fluvoxamine extended-release PA  
fluvoxamine immediate-release PA   - < 6 years
paroxetine controlled-release Paxil CR PA  
paroxetine hydrochloride Paxil # PA   - < 6 years
paroxetine mesylate Pexeva PA  
sertraline Zoloft # PA   - < 6 years

 Antidepressants – Serotonin Modulators
Drug Details

Drug Generic Name

Drug Brand Name

PA
Status
nefazodone PA   - < 6 years
trazodone 300 mg tablet PA  
trazodone 50 mg, 100 mg, 150 mg PA   - < 6 years
vilazodone Viibryd PA  
vortioxetine Trintellix PA  

 Antidepressants – Serotonin/Norepinephrine Reuptake Inhibitors (SNRI)
Drug Details

Drug Generic Name

Drug Brand Name

PA
Status
desvenlafaxine extended-release PA  
desvenlafaxine extended-release-Khedezla Khedezla PA  
desvenlafaxine succinate extended-release Pristiq PA  
duloxetine 20 mg, 30 mg, 60 mg Cymbalta # PA   - < 6 years
duloxetine 40 mg PA  
levomilnacipran Fetzima PA  
venlafaxine PA   - < 6 years
venlafaxine extended-release capsule Effexor XR # PA   - < 6 years
venlafaxine extended-release tablet PA  

 Antidepressants – Tricyclic Antidepressants (TCA)
Drug Details

Drug Generic Name

Drug Brand Name

PA
Status
amitriptyline powder PA  
amitriptyline tablet PA   - < 6 years
amoxapine PA   - < 6 years
clomipramine Anafranil PA  
desipramine Norpramin PA  
doxepin capsule, oral concentrate PA   - < 6 years
imipramine hydrochloride Tofranil # PA   - < 6 years
imipramine pamoate Tofranil-PM PA  
maprotiline PA   - < 6 years
nortriptyline Pamelor # PA   - < 6 years
protriptyline PA   - < 6 years
trimipramine Surmontil # PA   - < 6 years
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
 
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 

II. Therapeutic Uses

FDA-approved, for example:

  • Depressive disorders
  • Anxiety disorders

Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • All PA requests must include clinical diagnosis, drug name, dose and frequency.
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply depending upon diagnosis and/or requested medication (see below)

 

amitriptyline powder

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • clinical rationale why other commercially available alternatives cannot be used.

  

Aplenzin and bupropion hydrochloride extended-release 450 mg tablet

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years old; and
    • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to bupropion SR or bupropion XL; and
    • if the request is for Aplenzin, medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to bupropion hydrochloride extended-release 450 mg tablet.

 

bupropion hydrochloride extended-release 150 mg, 300 mg tablet > 30 units/month

  • Documentation of all of the following required:
    • appropriate diagnosis; and
    • medical records documenting medical necessity for quantities above 30 units/month.

Note: Quantities of 30 units per month of both the 300 mg and the 150 mg tablets are available without PA and can be used in combination for 450 mg total daily dose. 

 

clomipramine

  • Documentation of all of the following is required:            
    • appropriate diagnosis; and
    • an inadequate response (defined as at least four weeks of therapy) or adverse reaction to two SSRIs; or
    • contraindication to all SSRIs.

SmartPA: Claims for clomipramine will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for at least 90 days in the past 120 days of the respective medication, or if the member has a history of MassHealth medical claims for OCD and a history of paid MassHealth pharmacy claims for two SSRIs.†

 

desipramine and Marplan

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years old; and
    • one of the following:
      • an inadequate response (defined as at least four weeks of therapy) or adverse reaction to one SSRI and one other antidepressant that is not a SSRI; or
      • a contraindication to all SSRI and non-SSRI antidepressants.
SmartPA: Claims for desipramine and Marplan will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for at least 90 days in the past 120 days of the respective medication.† 

 

desvenlafaxine ER (Khedezla and generics) and desvenlafaxine succinate ER

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years old; and
    • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to venlafaxine (any formulation).

 

duloxetine 40 mg

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to duloxetine (two 20 mg capsules).

 

Emsam

  •  Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years old; and
    • one of the following:
      • medical necessity for a transdermal formulation; or 
      • an inadequate response (defined as at least four weeks of therapy) or adverse reaction to one SSRI and one other antidepressant that is not a SSRI; or
      • a contraindication to all SSRI and non-SSRI antidepressants; and
    • if the request is for a quantity > 1 patch and/or 12 mg daily, clinical rationale for dosing higher than the FDA approved limits.
SmartPA: Claims for Emsam will usually process at the pharmacy without a PA request for members ≥ 18 years of age if the member has a history of MassHealth medical claims for an appropriate diagnosis, a history of paid MassHealth pharmacy claims for at least 90 days in the past 120 days of the respective medication, and the request is for ≤ 1 patch per day or ≤ 12 mg/day.†

 

Fetzima

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years old; and
    • an inadequate response (defined as at least four weeks of therapy) or adverse reaction to one SNRI and one other antidepressant that is not a SNRI; and
    • request is within quantity limit of 30 units/30 days.

 

fluoxetine 20 mg tablet 

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to fluoxetine.

 

fluoxetine 60 mg tablet

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to fluoxetine (three 20 mg capsules).

 

fluoxetine 90 mg delayed-release capsule

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to fluoxetine daily.

 

fluoxetine/olanzapine

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical necessity for use of the combination product over the commercially available separate agents.

 

fluvoxamine extended-release

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to immediate-release fluvoxamine.

 

imipramine pamoate

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to imipramine hydrochloride.

 

mirtazapine orally disintegrating tablets

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • one of the following:
      • medical necessity for an orally disintegrating tablet formulation; or
      • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to mirtazapine tablets.

 

paroxetine controlled-release and Pexeva

  •  Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years old; and
    • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to immediate-release paroxetine; and
    • if the request is for Pexeva, medical records documenting an inadequate response (defined as at least 4 weeks of therapy) or adverse reaction to paroxetine controlled-release.

    

Spravato

  •  Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years old; and
    • prescriber is a specialist (e.g., psychiatrist) or consult is provided; and
    • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to one SSRI and one other antidepressant that is not a SSRI; and
    •  requested agent will be used in combination with an oral antidepressant; and
    • appropriate dosing; and
    • one of the following:
      • medical records documenting an inadequate response (defined as at least four weeks of therapy for antidepressants) or adverse reaction to one of the following antidepressant augmentation strategies:
        • second-generation antipsychotic; or
        • lithium; or
        • a second antidepressant from a different class; or
        • thyroid hormone; or
      • contraindication to all augmentation strategies.

   

trazodone 300 mg tablet

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to trazodone immediate-release (two 150 mg tablets).

 

Trintellix and Viibryd

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years old; and
    • one of the following:
      • an inadequate response (defined as at least four weeks of therapy) or adverse reaction to one SSRI and one other antidepressant that is not a SSRI; or
      • a contraindication to all SSRI and non-SSRI antidepressants; and
    • request is within quantity limit of 30 units/30 days.
SmartPA: Claims for Trintellix and Viibryd within polypharmacy requirements at a quantity ≤ 30 units per 30 days will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for at least 90 days in the past 120 days of the respective medication.†

 

venlafaxine extended-release tablet

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to venlafaxine extended-release capsules.
 

SSRI, SNRI, or Serotonin Modulator Polypharmacy (overlapping pharmacy claims for two or more agents for at least 60 days within a 90-day period) for members ≥ 18 years old

  • Documentation (including medical records) of the following is required:
    • a well-defined clinical rationale explaining medical necessity for two SSRIs, two SNRIs, two serotonin modulators or an SSRI, SNRI and/or serotonin modulator concurrently; and
    • the full medication regimen (including exact dosing of each therapy).
 
   

In addition to individual drug PA criteria where applicable, some behavioral health medications are subject to additional polypharmacy and age limit restrictions.

 

Behavioral Health Medication Polypharmacy (pharmacy claims for any combination of four or more behavioral health medications [i.e., alpha2 agonists, antidepressants, antipsychotics, atomoxetine, benzodiazepines, buspirone, cerebral stimulants, hypnotic agents, and mood stabilizers] within a 45-day period) for members < 18 years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • For regimens including ≤ 2 mood stabilizers (also includes regimens that do not include a mood stabilizer), documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnoses; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided.

 

  • For regimens including ≥ 3 mood stabilizers, documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnoses; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g., psychiatrist, neurologist) or consult is provided; and
      • one of the following:
        • member has a seizure diagnosis only; or
        • member has an appropriate psychiatric diagnosis and one of the following:
          • cross-titration/taper of mood stabilizer therapy; or
          • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate; or
        • member has a diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain) and documentation that other clinically appropriate therapies have been tried and failed; therefore, multiple mood stabilizers are needed; or
        • member has psychiatric and comorbid diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain) and documentation that other clinically relevant therapies have been tried and failed; therefore, multiple mood stabilizers are needed, and one of the following:
          • cross-titration/taper of mood stabilizer therapy; or
          • inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate.

SmartPA: Claims will usually process at the pharmacy without a PA request if the member is < 18 years of age, has a history of MassHealth medical claims for seizure, and has a history of paid MassHealth pharmacy claims for four or less behavioral health medications within the past 45 days and one mood stabilizer agent is identified as being used for seizure only.†

  

Antidepressant Polypharmacy (overlapping pharmacy claims for two or more antidepressants for at least 60 days within a 90-day period) for members < 18 years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate psychiatric diagnosis; and
      • treatment plan including names of current antidepressants and corresponding diagnoses; and
      • prescriber is a psychiatrist or consult is provided; and
      • one of the following:
        • cross-titration/taper of antidepressant therapy; or
        • inadequate response (defined as four weeks of therapy) or adverse reaction to two monotherapy trials as clinically appropriate; or
        • antidepressant polypharmacy regimen of ≤ two antidepressants includes one of the following: bupropion, mirtazapine or trazodone; or
        • one antidepressant in the regimen is indicated for a comorbid condition in which antidepressants may be clinically appropriate.

SmartPA: Claims will usually process at the pharmacy without a PA request if the member is < 18 years of age and has a history of paid MassHealth pharmacy claims for two antidepressants for at least 60 days of therapy out of the last 90 days and one or both agents are trazodone, mirtazapine, or bupropion.†

 

Antidepressant for members < six years old

  • For all requests, individual drug PA criteria must be met first where applicable.
  • Documentation of the following is required:
    • one of the following:
      • member had a recent psychiatric hospitalization (within the last three months); or
      • member has a history of severe risk of harm to self or others; or
    • all of the following:
      • appropriate diagnosis; and
      • treatment plan including names of current behavioral health medications and corresponding diagnoses; and
      • prescriber is a specialist (e.g. psychiatrist, neurologist) or consult is provided.

 

 

 
† Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans.

Original Effective Date: 04/2003

Last Revised Date: 08/2019

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Last updated 10/09/19