- Prior Authorization Required
- Major Depressive Disorder:
Duration: 1 plan year
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Documented Diagnosis: Yes
- 1. Health Net Approved Indications and Usage Guidelines: A. Diagnosis of depression; AND i. Failure or clinically significant adverse effects to TWO of the following generic antidepressants: Budeprion SR, bupropion, bupropion SR, bupropion XL, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, paroxetine, sertraline, venlafaxine, venlafaxine XR; OR ii. The patient or a first degree relative of the patient has been successfully treated in the past with the requested agent. 2. Coverage is Not Authorized For: Use of monamine oxidase inhibitor. 3. Recommended Authorization Limit: Length of Benefit.
- Step Therapy: Anxiety:
ST Multiple Generics
- Quantity Limit: limit maximum 2 EA PER 1 day(s)
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