- Quantity Limit: limit maximum 2 EA PER 1 day(s)
- Step Therapy: Step Therapy Exists in PA
- Step Therapy Exists in PA
- Prior Authorization: Health Net Approved Indications and Usage Guidelines: 1. Fibromyalgia: a. Diagnosis of fibromyalgia. AND b. Failure or clinically significant adverse effects to duloxetine. 2. Depression: a. Failure or clinically significant adverse effects to TWO generic antidepressants: bupropion, bupropion SR, bupropion XL, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, paroxetine, paroxetine SR, sertraline, venlafaxine, venlafaxine XR. Coverage is Not Authorized For: 1. Pediatric patients. 2. Use of monoamine oxidase inhibitors (MAOI) concomitantly or in close temporal proximity. Authorization Limit: Length of benefit.
- Health Net Approved Indications and Usage Guidelines: 1. Fibromyalgia: a. Diagnosis of fibromyalgia. AND b. Failure or clinically significant adverse effects to duloxetine. 2. Depression: a. Failure or clinically significant adverse effects to TWO generic antidepressants: bupropion, bupropion SR, bupropion XL, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, paroxetine, paroxetine SR, sertraline, venlafaxine, venlafaxine XR. Coverage is Not Authorized For: 1. Pediatric patients. 2. Use of monoamine oxidase inhibitors (MAOI) concomitantly or in close temporal proximity. Authorization Limit: Length of benefit.
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