Table 17: Antidepressants
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Drug Category: Central Nervous System (CNS)
Medication Class/Individual Agents: Antidepressant
I. Prior-Authorization Requirements
Antidepressants – Gamma-Aminobutyric (GABA)-A Receptor Positive Modulator |
Clinical Notes |
|||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
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.
Monoamine Oxidase Inhibitors (MAOIs):
|
|||||||||||||||||||||||||||||||||||||||||||||||||||
Antidepressants – Monoamine Oxidase Inhibitors (MAOI) |
||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||
Antidepressants – NMDA Receptor Antagonist |
||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||
Antidepressants – Noradrenergic and Specific Serotonergic Antidepressants (NaSSA) |
||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||
Antidepressants – Norepinephrine/Dopamine Reuptake Inhibitors (NDRI) |
||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||
Antidepressants – Second-Generation (Atypical) Antipsychotic and Selective Serotonin Reuptake Inhibitor |
||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||
Antidepressants – Selective Serotonin Reuptake Inhibitors (SSRI) |
||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||
Antidepressants – Serotonin Modulators |
||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||
Antidepressants – Serotonin/Norepinephrine Reuptake Inhibitors (SNRI) |
||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||
Antidepressants – Tricyclic Antidepressants (TCA) |
||||||||||||||||||||||||||||||||||||||||||||||||||||
|
| # | 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. |
| ^ | This drug is available through the health care professional who administers the drug. MassHealth does not pay for this drug to be dispensed through a retail pharmacy. |
II. Therapeutic Uses
FDA-approved, for example:
- Depressive disorders
- Anxiety disorders
- Postpartum depression
Note: The above list may not include all FDA-approved indications.
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, bupropion hydrochloride extended-release 150 mg, 300 mg tablet, desvenlafaxine succinate ER, and Fetzima > one unit/day
- Documentation of all of the following required:
- appropriate diagnosis; and
- clinical rationale why the dose cannot be consolidated; or
- clinical rationale why the member requires dosing at intervals exceeding what is recommended by the FDA.
Note: Bupropion hydrochloride extended-release quantities of one unit per day 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.
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.
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)
- 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 desvenlafaxine succinate ER.
Drizalma
- Documentation of all of the following is required:
- appropriate diagnosis; and
- clinical rationale for the requested formulation over solid oral formulation (e.g., swallowing disorder, dysphagia).
duloxetine 40 mg capsule
- 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 > one 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 ≤ one patch per day or ≤ 12 mg/day.†
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 or tablets).
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 for a diagnosis of treatment-resistant depression:
- 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
- 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; and
- 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:
- appropriate dosing.
- Documentation of all of the following is required for treatment of depressive symptoms in adults with major depressive disorder with acute suicidal ideation or behavior:
- appropriate diagnosis; and
- member is ≥ 18 years old; and
- prescriber is a specialist (e.g., psychiatrist) or consult is provided; and
- one of the following:
- medical records documenting current acute suicidal ideation or behavior related to depressive symptoms of major depressive disorder; or
- member was stabilized on esketamine during a psychiatric hospitalization; and
- requested agent will be used in combination with an oral antidepressant; and
- appropriate dosing.
- For recertification, documentation that the member meets criteria above for treatment-resistant depression is required.
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 one unit/day.
SmartPA: Claims for Trintellix and Viibryd within polypharmacy requirements at a quantity ≤ one unit per day 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.
Zulresso
- Documentation of all of the following is required:
- appropriate diagnosis; and
- member is ≥18 years of age; and
- prescriber is a specialist (e.g., obstetrician-gynecologist or psychiatrist) or consult was provided; and
- member is ≤ six months postpartum at screening with onset of a major depressive episode no earlier than the third trimester and no later than four weeks after delivery; and
- member is not currently pregnant; and
- appropriate dosing.
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, armodafinil, atomoxetine, benzodiazepines, buspirone, cerebral stimulants, donepezil, hypnotic agents, memantine, modafinil, mood stabilizers, and naltrexone] 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.
- one of the following:
- 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.
- one of the following:
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.
- one of the following:
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.
- one of the following:
† 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: 11/2020
Clinical Criteria Main Page | Back to top | Previous | Next
Last updated 01/26/21