TCA with paroxetine TCA with paroxetine Guidelines for Approval: (strong 2D6 inhibitor) (strong 2D6 inhibitor) TCA Approval will be granted when a member is transitioning from one medication to another. TCA with bupropion with bupropion (moderate Evidence of adequate trials of at least three (3) individual formulary antidepressants, from (moderate 2D6 2D6 inhibitor) TCA with at least two (2) different therapeutic classes, for 4-6 weeks at maximum tolerated doses. inhibitor) TCA with duloxetine (moderate 2D6 Failure is due to: duloxetine (moderate inhibitor) a. Break through symptoms or an inadequate response at maximum tolerated doses, or 2D6 inhibitor) TCA with sertraline b. Adverse reaction(s) TCA with sertraline (moderate-weak 2D6 And (moderate-weak 2D6 inhibitor) Clomipramine inhibitor) Clomipramine with fluvoxamine (strong Documentation confirming that trials of at trial two (2) evidenced based with fluvoxamine 1A2 inhibitor) augmentation strategies have been tried for an adequate and failed, resulted in significant side effects, or arec ontraindicated. Examples of augmentation (strong 1A2 inhibitor) strategies include lithium, thyroid hormone, bupropion, mirtazapine, quetiapine, Bupropion, clomipramine, or aripiprazole. Bupropion, duloxetine, fluoxetine, Failure is due to: clomipramine, fluvoxamine, paroxetine, Inadequate response at maximum tolerated doses, duloxetine, fluoxetine, sertraline, tricyclic Adverse reaction(s), or fluvoxamine, antidepressants Break through symptoms paroxetine, sertraline, Initial TCA treatment should be initiated at the lowest possible dosage. tricyclic antidepressants Supporting clinical documentation must be provided with the initial prior authorization request. These parameters include the following: Assessment showing there is no evidence of cardiovascular conduction delays, Heart rate, Blood pressure and TCA levels. Additional Requirements: Provider must provide supporting documentation that: Adherence to the treatment regimen is not a contributing factor to the inadequate response to the medication trials,
TCA with paroxetine (strong 2D6 inhibitor) TCA with bupropion (moderate 2D6 inhibitor) TCA with duloxetine (moderate 2D6 inhibitor) TCA with sertraline (moderate-weak 2D6 inhibitor) Clomipramine with fluvoxamine (strong 1A2 inhibitor) Bupropion, clomipramine, duloxetine, fluoxetine, fluvoxamine, paroxetine, sertraline, tricyclic antidepressants Guidelines for Approval: Approval will be granted when a member is transitioning from one medication to another. Evidence of adequate trials of at least three (3) individual formulary antidepressants, from at least two (2) different therapeutic classes, for 4-6 weeks at maximum tolerated doses. Failure is due to: a. Break through symptoms or an inadequate response at maximum tolerated doses, or b. Adverse reaction(s) And Documentation confirming that trials of at two (2) evidenced based augmentation strategies have been tried for an adequate trial and failed, resulted in significant side effects, or arec ontraindicated. Examples of augmentation strategies include lithium, thyroid hormone, bupropion, mirtazapine, quetiapine, or aripiprazole. Failure is due to: Inadequate response at maximum tolerated doses, Adverse reaction(s), or Break through symptoms Initial TCA treatment should be initiated at the lowest possible dosage. Supporting clinical documentation must be provided with the initial prior authorization request. These parameters include the following: Assessment showing there is no evidence of cardiovascular conduction delays, Heart rate, Blood pressure and TCA levels. Additional Requirements: Provider must provide supporting documentation that: Adherence to the treatment regimen is not a contributing factor to the inadequate response to the medication trials, TCA with paroxetine (strong 2D6 inhibitor) TCA with bupropion (moderate 2D6 inhibitor) TCA with duloxetine (moderate 2D6 inhibitor) TCA with sertraline (moderate-weak 2D6 inhibitor) Clomipramine with fluvoxamine (strong 1A2 inhibitor) Bupropion, clomipramine, duloxetine, fluoxetine, fluvoxamine, paroxetine, sertraline, tricyclic antidepressants