HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES

Transcription

1 Generic Brand HICL GCN Exception/Other BUPROPION HCL WELLBUTRIN, WELLBUTRIN SR, WELLBUTRIN XL BUPROPION HBR APLENZIN CITALOPRAM CELEXA GPID HYDROBROMIDE DESVENLAFAXINE KHEDEZLA BRAND = KHEDEZLA DESVENLAFAXINE FUMARATE DESVENLAFAXIN E FUMARATE DESVENLAFAXINE PRISTIQ ER SUCCINATE ESCITALOPRAM LEXAPRO OXALATE FLUOXETINE HCL PROZAC, GPID PROZAC WEEKLY, SARAFEM FLUVOXAMINE LUVOX CR MALEATE LEVOMILNACIPRAN FETZIMA HYDROCHLORIDE PAROXETINE HCL PAXIL, GPID PAXIL CR PAROXETINE PEXEVA, MESYLATE BRISDELLE SERTRALINE HCL ZOLOFT GPID VENLAFAXINE HCL EFFEXOR, EFFEXOR XR, VENLAFAXINE HCL EXTENDED RELEASE TAB VILAZODONE HYDROCHLORIDE VIIBRYD VORTIOXETINE HYDROBROMIDE TRINTELLIX Page 1

2 NOTE: Prescriptions that meet the initial step therapy requirements will adjudicate at the point of service. If the member does not meet the initial step therapy criteria, then the prescription will deny at point of service with a message indicating that prior authorization (PA) is required. Members who do not meet the step therapy criteria at point of service will need to submit a Medication Request Form (MRF) to MedImpact for clinical review. First level drug therapy required include the following: Generic bupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine; Lookback is 180 days, Lookback will also include brand name agents and look for itself. CUSTOMER SERVICE REPRESENTATIVE (CSR) PA COORDINATOR (PAC) This is a Rhode Island (RI) member or prescriber determination for behavioral health and substance abuse requests: 1. Does the member live in Rhode Island or is the prescribing physician's office located in Rhode Island? If yes, continue to #2. If no, continue to review by using the clinical determination criteria below. For Customer Service, all other requests require a Medication Request Form (MRF) be submitted for review. 2. Is the requested medication non-formulary? If yes, continue to review by using the clinical determination criteria below. For Customer Service, all other requests require a Medication Request Form (MRF) be submitted for review. If no, approve for 12 months by HICL. Page 2

3 CLINICAL DETERMINATION CRITERIA GUIDELINES FOR USE 1. Is the request for a multisource brand? If yes, continue to #2. If no, continue to #3. HARVARD PILGRIM HEALTH CARE 2. Has the patient tried and failed therapy with the generic product of the requested drug AND at least one additional product within the same therapeutic class? If yes, continue to #3. If no, do not approve. Please use status code #238 and the denial text provided. DENIAL TEXT: Per your health plan's Antidepressant guideline, a trial of therapy with the generic product of the requested drug and at least one additional product in the same therapeutic class is required prior to approving coverage for the requested medication. 3. Is the patient less than 18 years old? If yes, continue to #7. If no, continue to #4. 4. Is the request for Brisdelle and the medication is being used for the treatment of vasomotor symptoms associated with menopause? If yes, continue to #6. If no, continue to #5. 5. Does the physician state that the member is currently taking the requested medication (other than samples)? If yes, continue to #7. If no, continue to #6. Page 3

4 GUIDELINES FOR USE (CONTINUED) HARVARD PILGRIM HEALTH CARE 6. Has the patient tried and failed an alternative SSRI or SNRI antidepressant? If yes, continue to #7. If no, do not approve. Please use status code #238 and the denial text provided. DENIAL TEXT: Per your health plan's Antidepressant guideline, a trial with an alternative antidepressants, such as citalopram, venlafaxine or sertraline is required prior to approving coverage for the requested medication. Your physician did not indicate that you have been treated with an alternative antidepressant in the past and therefore your request was not approved. DENIAL TEXT (Brisdelle only): Per your health plan's Antidepressant guideline, a trial with an alternative medication used to treat vasomotor symptoms, such as generic paroxetine or venlafaxine, is required prior to approving coverage of Brisdelle. Your physician did not indicate that you have been treated with one of these alternative medications in the past and therefore your request was not approved. 7. Approve for 12 months by HICL. Please use status code #057. Requests for products on formulary with a restriction, please use the approval text provided. APPROVAL TEXT: Your request for [requested medication] has been approved for a 12-month period. Requests for products not on formulary, please use the approval text provided. APPROVAL TEXT: Your request for [requested medication] has been approved for a 12-month period at your highest cost-share tier. Refer to your Harvard Pilgrim ID card for the amount you pay for drugs on that tier. Page 4

5 RATIONALE To promote first line use of generic antidepressants due to availability of generic alternatives in the SSRI/SNRI class. FDA APPROVED INDICATIONS Celexa is indicated for the treatment of depression. Effexor is indicated for the treatment of major depressive disorder (MDD). Effexor XR is indicated for the treatment of MDD, GAD, social anxiety disorder (SAD), and panic disorder (PD) in adult patients. Wellbutrin and Wellbutrin SR are indicated for the treatment of MDD. Wellbutrin XL is indicated for the treatment of MDD and seasonal affective disorder. Aplenzin is indicated for the treatment of MDD. Paxil is indicated for the treatment of MDD, for the treatment of obsessions and compulsions in patients with obsessive compulsive disorder (OCD), for the treatment of panic disorder with or without agoraphobia, social anxiety disorder, generalized anxiety disorder, and posttraumatic stress disorder. Prozac is indicated for MDD, for the treatment of obsessions and compulsions in patients with OCD, for the treatment of binge eating and vomiting disorders in patients with moderate to severe bulimia nervosa, and panic disorder with or without agoraphobia. Zoloft is indicated for the treatment of MDD in adults, for the treatment of obsessions and compulsions in patients with OCD, panic disorder in adults with or without agoraphobia, posttraumatic stress disorder in adults, premenstrual dysphoric disorder (PMDD), and social anxiety disorder. Lexapro is indicated for the treatment of MDD and GAD. Pexeva is indicated for the treatment of GAD, MDD, the treatment of obsessions and compulsions in patients with OCD, and panic disorder. Luvox CR is indicated for the treatment of obsessions and compulsions in patients with OCD and social anxiety disorder. Paxil CR is indicated for the treatment of MDD, the treatment of panic disorder with or without agoraphobia, social anxiety disorder, and premenstrual dysphoric disorder. Pristiq is indicated for the treatment of MDD. Sarafem is indicated for the treatment of premenstrual dysphoric disorder (PMDD). Venlafaxine extended release tablets are indicated for the treatment of MDD and SAD. Viibryd is indicated for the treatment of major depressive disorder (MDD). Trintellix is indicated for the treatment of major depressive disorder (MDD). Fetzima is indicated for the treatment of major depressive disorder (MDD). Khedezla is indicated for the treatment of major depressive disorder (MDD) Brisdelle is indicated for the treatment of moderate to severe vasomotor symptoms associated with menopause (VMS). Limitation of Use: Brisdelle is not indicated for the treatment of any psychiatric condition. Page 5

6 REFERENCES Celexa product information available at Accessed June 11, Effexor product information available at Accessed June 11, Effexor XR product information available at Accessed June 11, Wellbutrin product information available at Accessed June 11, Wellbutrin XL product information available at Accessed June 11, Wellbutrin SR product information located at Accessed June 11, Paxil product information available at Accessed June 11, Zoloft product information available at Accessed June 11, Lexapro product information available at Accessed June 11, Pexeva product information available at Accessed 27 Nov Luvox CR product information available at Accessed 20 Mar Pristiq product information available at Accessed 26 March Paxil CR product information available at Accessed 22 May Sarafem product information available at Accessed 12 January Aplenzin product information available at Accessed 19 March Venlafaxine extended release tablets product information. Accessed 31 December Viibryd product information. Forest Pharmaceuticals, Inc. Revised March Trintellix product information available at Accessed 31 July 18, Fetzima product information available at Accessed 3 December Khedezla product information available at Accessed 25 February Bisdelle [prescribing information]. Noven Therapeutics, LLC. Miami, FL. December Created: 01/01/07 CK Effective: 06/01/18 Client Approval: 05/14/18 P&T Approval: 09/11/17 Page 6