Health Net
Forfivo XL (bupropion HCl)
Drugs for the Nervous System : Drugs for Depression
  • Quantity Limit: limit maximum 1 EA PER 1 day(s)
  • 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: Major Depressive Disorder:
    Step Applies