Download Coverage Guidelines: Selective Serotonin Reuptake Inhibitors

Coverage Guidelines: Selective Serotonin Reuptake Inhibitors
Policy
Network Health covers the preferred generic selective serotonin reuptake inhibitors (SSRIs)
citalopram, fluoxetine, fluvoxamine immediate-release, paroxetine immediate-release, and
sertraline for Network Health Together®, Network Health Forward®, and Network Health Extend
members without prior authorization.
Network Health covers the non-preferred SSRIs escitalopram (Lexapro), fluvoxamine
controlled-release (Luvox CR), paroxetine controlled-release (Paxil CR), and vilazodone
(Viibryd) for Network Health Together, Network Health Forward, and Network Health Extend
members with prior authorization.
When generic drugs are available, Network Health will not cover the brand-name drug without
prior authorization. Network Health will approve the brand-name drug if the member has tried
and failed treatment with the therapeutically equivalent generic in addition to one other
generic SSRI.
Covered conditions
Network Health covers the following non-preferred SSRIs with prior authorization when the
member meets these criteria:
Escitalopram (Lexapro)
Fluvoxamine controlled-release (Luvox CR)
Paroxetine controlled-release (Paxil CR)
Vilazodone (Viibryd)
 Member has been stable on the medication for a duration of at least two months, or
 Member recently started on the requested medication in an acute care setting,
residential setting, or partial hospital setting, or
 Member has tried and failed treatment with, or has a contraindication to, two
alternative SSRIs
Quantity Limit
 Network Health will approve a dose of one tablet/capsule per day
 Network Health will approve doses that exceed one tablet/capsule per day if it is not
feasible to consolidate doses, or if the provider documents the medical necessity for a
dose exceeding one tablet/capsule per day
Please note: Network Health will approve the above non-preferred SSRIs for lifetime use for
members according to the conditions described in the covered conditions section.
These guidelines apply to Network Health Together, Network Health Forward, and Network Health Extend plans. Coverage is based on member
benefits and eligibility; medical necessity review, where applicable; and the Network Health provider agreement. Adherence to these guidelines
by a provider does not guarantee coverage. Network Health reserves the right to amend these guidelines at its discretion.
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Network Health Coverage Guidelines – Selective Serotonin Reuptake Inhibitors
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References
Katon, W.J. (2006). “Panic disorder.” New England Journal of Medicine, 354, 2360-2367.
Mann, J.J. (2005). “The medical management of depression.” New England Journal of Medicine,
353, 1819-1834.
National Institute for Health and Clinical Excellence Clinical Guideline 22 (2011). Generalized
Anxiety Disorder and Panic Disorder (with or without Agoraphobia) in Adults.
Work Group on Major Depressive Disorder: Gelenberg, A.J., Freeman, M.P., Markowitz, J.C.,
Rosenbaum, J.F., Thase, M.E., Trivesi, M.H., VanRhoads, R.S. (May 2010). Practice Guideline
for the Treatment of Patients with Major Depressive Disorder, third edition. American
Psychiatric Association Practice Guidelines.
Work Group on Panic Disorder: Stein, M., Goin, M., Pollack, M., Roy-Byrne, P., Sareen, J.,
Simon, N., Campbell-Sills, L. (2009). Practice Guideline for the Treatment of Patients with
Panic Disorder, second edition. American Psychiatric Association.
These guidelines apply to Network Health Together, Network Health Forward, and Network Health Extend plans. Coverage is based on member
benefits and eligibility; medical necessity review, where applicable; and the Network Health provider agreement. Adherence to these guidelines
by a provider does not guarantee coverage. Network Health reserves the right to amend these guidelines at its discretion.
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Network Health Coverage Guidelines – Selective Serotonin Reuptake Inhibitors
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