Table 17: Antidepressants
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Drug Category: Central Nervous System (CNS)
Medication Class/Individual Agents: Antidepressant
I. Prior-Authorization Requirements
Antidepressants – Gamma-Aminobutyric (GABA)-A Receptor Positive Modulator |
Clinical Notes |
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Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.
Monoamine Oxidase Inhibitors (MAOIs):
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Antidepressants – Monoamine Oxidase Inhibitors (MAOI) |
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Antidepressants – NMDA Receptor Antagonist |
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Antidepressants – Noradrenergic and Specific Serotonergic Antidepressants (NaSSA) |
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Antidepressants – Norepinephrine/Dopamine Reuptake Inhibitors (NDRI) |
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Antidepressants – Second-Generation (Atypical) Antipsychotic and Selective Serotonin Reuptake Inhibitor |
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Antidepressants – Selective Serotonin Reuptake Inhibitors (SSRI) |
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Antidepressants – Serotonin Modulators |
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Antidepressants – Serotonin/Norepinephrine Reuptake Inhibitors (SNRI) |
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Antidepressants – Tricyclic Antidepressant (TCA) and Benzodiazepine |
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Antidepressants – Tricyclic Antidepressant (TCA) and First-Generation (Typical) Antipsychotic |
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Antidepressants – Tricyclic Antidepressants (TCA) |
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| # | This designates a brand-name drug with FDA “A”-rated generic equivalents. PA is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent. |
| PD | Preferred Drug. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. |
| MB | This drug is available through the health care professional who administers the drug or in an outpatient or inpatient hospital setting. MassHealth does not pay for this drug to be dispensed through the retail pharmacy. If listed, PA does not apply through the hospital outpatient and inpatient settings. Please refer to 130 CMR 433.408 for PA requirements for other health care professionals. Notwithstanding the above, this drug may be an exception to the unified pharmacy policy; please refer to respective MassHealth Accountable Care Partnership Plans (ACPPs) and Managed Care Organizations (MCOs) for PA status and criteria, if applicable. |
| A90 | Allowable 90-day supply. Dispensing in up to a 90-day supply is allowed. May not include all strengths or formulations. Quantity limits and other restrictions may apply. |
II. Therapeutic Uses
FDA-approved, for example:
- Anxiety disorders
- Bipolar disorder
- Chronic musculoskeletal pain
- Depressive disorders
- Diabetic peripheral neuropathy
- Obsessive-compulsive disorder
- Panic disorders
- Postpartum depression
non-FDA-approved, for example:
- Diabetic neuropathy
- Fibromyalgia
- Neuropathic pain
- Other psychiatric or neurologic condition requiring treatment with an antidepressant (i.e., psychotic disorder, neuropathic pain)
- Parkinson's Disease
- Postherpetic neuralgia
- Post-traumatic stress disorder
Note: The above lists may not include all FDA-approved and non-FDA-approved indications.
III. Evaluation Criteria for Approval
Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.
- All PA requests must include clinical diagnosis, drug name, dose, and frequency.
- Dispensing in a 90-day supply of medication may be mandated or allowable for agents in this therapeutic class (designated by M90 or A90, respectively, in the Drug Notes section above). Applicable quantity limits are described below as units per day, per month, per 28 days, or as clinically appropriate, and may be extrapolated for fills of longer day supply.
- A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
- For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
- Additional criteria may apply depending upon diagnosis and/or requested medication (see below). Other factors, including rebate and FDA-approval status, may change independently of scheduled MassHealth updates, which may result in additional restrictions.
amitriptyline/chlordiazepoxide, amitriptyline/perphenazine, and fluoxetine/olanzapine
- Documentation of all of the following is required:
- appropriate diagnosis; and
- medical necessity for use of the combination product instead of the commercially available separate agents.
SmartPA: Claims for amitriptyline/chlordiazepoxide and amitriptyline/perphenazine will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested agent for at least 90 days out of the last 120 days.†
amoxapine and clomipramine
- Documentation of all of the following is required:
- appropriate diagnosis; and
- inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to two or contraindication to all SSRIs.
SmartPA: Claims for amoxapine or clomipramine will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested medication for at least 90 days out of the last 120 days, or if the member has a history of MassHealth medical claims for an appropriate diagnosis and a history of paid MassHealth pharmacy claims for at least four weeks of therapy with two SSRIs.†
Aplenzin and bupropion hydrochloride extended-release 450 mg tablet
- Documentation of all of the following is required:
- appropriate diagnosis; and
- member is ≥ 18 years of age; and
- medical records documenting an inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to bupropion XL at an equivalent dose to the requested product; and
- requested quantity is ≤ one unit/day.
Aplenzin, bupropion hydrochloride extended-release 150 mg, 300 mg tablet, and desvenlafaxine succinate ER > one unit/day
- Documentation of all of the following required:
- appropriate diagnosis; and
- clinical rationale why the dose cannot be consolidated; or
- clinical rationale why the member requires dosing at intervals exceeding what is recommended by the FDA.
Note: Bupropion hydrochloride extended-release quantities of one unit per day of both the 300 mg and the 150 mg tablets are available without PA and can be used in combination for 450 mg total daily dose.
SmartPA: Claims for Aplenzin with a quantity limit of one unit/day will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested agent for at least 90 days out of the last 120 days.†
Auvelity
- Documentation of all of the following is required:
- appropriate diagnosis; and
- member is ≥ 18 years of age; and
- inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to one SSRI and one other non-SSRI antidepressant or contraindication to all SSRI and non-SSRI antidepressants; and
- requested quantity is ≤ two units/day.
SmartPA: Claims for Auvelity within polypharmacy requirements at a quantity ≤ two units per day will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested agent for at least 90 days out of the last 120 days, or if the member is ≥ 18 years of age, has a history of MassHealth medical claims for an appropriate diagnosis, and has a history of paid MassHealth pharmacy claims of at least four weeks of therapy with one SSRI and one non-SSRI.†
citalopram capsule
- Documentation of all of the following is required:
- appropriate diagnosis; and
- appropriate dosing; and
- medical records documenting an inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to citalopram tablets at an equivalent dose (three 10 mg tablets or one 10mg and one 20 mg tablet).
desipramine
- Documentation of all of the following is required for anxiety disorder, bipolar disorder, depressive disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, or other psychiatric or neurologic condition requiring treatment with an antidepressant (i.e., psychotic disorder):
- appropriate diagnosis; and
- inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to one or contraindication to both of the following: SSRI, SNRI; and
- inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to one tricyclic antidepressant available without PA.
- Documentation of all of the following is required for diabetic neuropathy, fibromyalgia, or postherpetic neuralgia:
- appropriate diagnosis; and
- inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to one other tricyclic antidepressant or contraindication to all other tricyclic antidepressants; and
- appropriate dosing.
SmartPA: Claims for desipramine will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested agent for at least 90 days out of the last 120 days.†
desvenlafaxine ER
- Documentation of all of the following is required:
- appropriate diagnosis; and
- member is ≥ 18 years of age; and
- medical records documenting an inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to desvenlafaxine succinate ER.
Drizalma
- Documentation of all of the following is required:
- appropriate diagnosis; and
- medical necessity for the requested formulation instead of a solid oral formulation (e.g., swallowing disorder, dysphagia).
duloxetine 40 mg capsule
- Documentation of all of the following is required:
- appropriate diagnosis; and
- appropriate dosing; and
- medical records documenting an inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to duloxetine at an equivalent dose (two 20 mg capsules).
Emsam
- Documentation of all of the following is required for major depressive disorder:
- appropriate diagnosis; and
- member is ≥ 18 years of age; and
- one of the following:
- medical necessity for the use of a transdermal formulation; or
- inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to both of the following: SSRI, one other antidepressant that is not a SSRI; or
- contraindication to all SSRI and non-SSRI antidepressants; and
- one of the following:
- both of the following:
- requested quantity is ≤ one patch/day; and
- requested dose is ≤ 12 mg/day; or
- clinical rationale for dosing higher than the FDA approved limits.
- both of the following:
- Documentation of all of the following is required for Parkinson's disease:
- appropriate diagnosis; and
- member is ≥ 18 years of age; and
- medical necessity for use of a transdermal formulation; and
- requested quantity is ≤ 9 mg/day.
SmartPA: Claims for Emsam will usually process at the pharmacy without a PA request for members ≥ 18 years of age if the member has a history of MassHealth medical claims for a psychiatric diagnosis, a history of paid MassHealth pharmacy claims of the requested medication for at least 90 days out of the last 120 days, and the request is for ≤ one patch per day or ≤ 12 mg/day.†
Fetzima, Trintellix, and vilazodone
- Documentation of all of the following is required:
- appropriate diagnosis; and
- member is ≥ 18 years of age; and
- inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to one SSRI and one other non-SSRI antidepressant or contraindication to all SSRI and non-SSRI antidepressants; and
- requested quantity is ≤ one unit/day.
fluoxetine 60 mg tablet
- Documentation of all of the following is required:
- appropriate diagnosis; and
- appropriate dosing; and
- medical records documenting an inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to fluoxetine at an equivalent dose (three 20 mg capsules or tablets).
fluoxetine 90 mg delayed-release capsule
- Documentation of all the following is required:
- appropriate diagnosis; and
- appropriate dosing; and
- medical records documenting an inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to fluoxetine daily at an equivalent dose.
fluvoxamine extended-release
- Documentation of all of the following is required:
- appropriate diagnosis; and
- appropriate dosing; and
- medical records documenting an inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to fluvoxamine immediate-release at an equivalent dose.
imipramine pamoate
- Documentation of all of the following is required:
- appropriate diagnosis; and
- appropriate dosing; and
- medical records documenting an inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to imipramine hydrochloride at an equivalent dose.
Ketalar
- Documentation of all of the following is required for a diagnosis of treatment-resistant depression:
- appropriate diagnosis; and
- member is ≥ 18 years of age; and
- prescriber is a specialist (e.g., psychiatrist) or consult notes from a specialist are provided; and
- medical records documenting an inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to one SSRI and one other non-SSRI antidepressant; and
- requested agent will be used in combination with an oral antidepressant; and
- medical records documenting an inadequate response (defined as concomitant use of an augmenting agent plus antidepressant therapy combined ≥ four weeks of therapy) or adverse reaction to one or contraindication to all of the following augmentation strategies: second-generation antipsychotic, lithium, a second antidepressant from a different class, or thyroid hormone; and
- appropriate dosing.
Marplan, protriptyline, and trimipramine
- Documentation of all of the following is required:
- appropriate diagnosis; and
- member is ≥ 18 years of age; and
- inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to one or contraindication to both of the following: SSRI, SNRI; and
- inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to one tricyclic antidepressant available without PA.
SmartPA: Claims for Marplan, protriptyline, and trimipramine will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims of the requested agent for at least 90 days out of the last 120 days.†
mirtazapine orally disintegrating tablets
- Documentation of all of the following is required:
- appropriate diagnosis; and
- one of the following:
- medical necessity for the orally disintegrating tablet formulation; or
- medical records documenting an inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to mirtazapine tablets.
paroxetine controlled-release
- Documentation of all of the following is required:
- appropriate diagnosis; and
- member is ≥ 18 years of age; and
- medical records documenting an inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to paroxetine immediate-release.
sertraline capsule
- Documentation of all of the following is required:
- appropriate diagnosis; and
- appropriate dosing; and
- medical records documenting an inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to sertraline tablets at an equivalent dose (one 50 mg and one 100 mg tablet [150 mg capsule] or two 100 mg tablets [200 mg capsule]).
Spravato
- Documentation of all of the following is required for a diagnosis of treatment-resistant depression:
- appropriate diagnosis; and
- member is ≥ 18 years of age; and
- prescriber is a specialist (e.g., psychiatrist) or consult notes from a specialist are provided; and
- medical records documenting an inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to one SSRI and one other non-SSRI antidepressant; and
- requested agent will be used in combination with an oral antidepressant; and
- medical records documenting an inadequate response (defined as concomitant use of an augmenting agent plus antidepressant therapy combined ≥ four weeks of therapy) or adverse reaction to one or contraindication to all of the following augmentation strategies: second-generation antipsychotic, lithium, a second antidepressant from a different class, or thyroid hormone; and
- appropriate dosing.
- Documentation of all of the following is required for treatment of depressive symptoms in adults with major depressive disorder with acute suicidal ideation or behavior:
- appropriate diagnosis; and
- member is ≥ 18 years of age; and
- prescriber is a specialist (e.g., psychiatrist) or consult notes from a specialist are provided; and
- one of the following:
- medical records documenting current acute suicidal ideation or behavior related to depressive symptoms of major depressive disorder; or
- member was stabilized on esketamine during a psychiatric hospitalization; and
- requested agent will be used in combination with an oral antidepressant; and
- appropriate dosing.
- For recertification, documentation that the member meets criteria above for treatment-resistant depression is required.
trazodone 300 mg tablet
- Documentation of all of the following is required:
- appropriate diagnosis; and
- appropriate dosing; and
- medical records documenting an inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to trazodone immediate-release at an equivalent dose (two 150 mg tablets).
venlafaxine besylate extended-release tablet and venlafaxine hydrochloride extended-release tablet
- Documentation of all of the following is required:
- appropriate diagnosis; and
- appropriate dosing; and
- medical records documenting an inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to venlafaxine extended-release capsules at an equivalent dose.
Zulresso
- Documentation of all of the following is required:
- appropriate diagnosis; and
- member is ≥ 18 years of age; and
- prescriber is a specialist (e.g., obstetrician-gynecologist or psychiatrist) or consult notes from a specialist are provided; and
- member is ≤ six months postpartum at screening with onset of a major depressive episode no earlier than the third trimester and no later than four weeks after delivery; and
- member is not currently pregnant; and
- appropriate dosing.
Zurzuvae
- Documentation of all of the following is required:
- appropriate diagnosis; and
- member is ≥ 18 years of age; and
- prescriber is a specialist (e.g., obstetrician-gynecologist/family medicine or psychiatrist) or consult notes from a specialist are provided; and
- member is ≤ 12 months postpartum; and
- member is not currently pregnant; and
- one of the following:
- requirement for rapid symptom reduction; or
- inadequate response (defined as ≥ four weeks of therapy) or adverse reaction to one or contraindication to all of the following: bupropion, citalopram, duloxetine, escitalopram, fluoxetine, mirtazapine, sertraline, venlafaxine; and
- one of the following:
- for 30 mg capsule, requested quantity is ≤ one unit/day for 14 days total (start date required); or
- for 20 mg and 25 mg capsule, requested quantity is ≤ two units/day for 14 days total (start date required); and
- for 30 mg capsule, one of the following:
- severe hepatic impairment (Child-Pugh Class C); or
- moderate to severe renal impairment.
SSRI, SNRI, or Serotonin Modulator Polypharmacy (overlapping pharmacy claims for two or more agents for at least 60 days within a 90-day period) for members ≥ 18 years of age
- For all requests, individual drug PA criteria must be met first where applicable.
- Documentation of all of the following is required:
- psychiatric diagnosis included severe or treatment-resistant conditions; and
- clear treatment plan including names and doses of current antidepressants and corresponding diagnoses; and
- prescriber is a psychiatrist or consult notes from a psychiatrist are provided; and
- one of the following:
- cross-titration/taper of antidepressant therapy; or
- inadequate response or adverse reaction to two monotherapy trials as clinically appropriate; or
- member had a recent psychiatric hospitalization and was discharged on the current regimen.
In addition to individual drug PA criteria where applicable, some behavioral health medications are subject to additional polypharmacy and age limit restrictions.
Behavioral Health Medication Polypharmacy (pharmacy claims for any combination of four or more behavioral health medications [i.e., alpha2 agonists, antidepressants, antipsychotics, armodafinil, atomoxetine, benzodiazepines, buspirone, cerebral stimulants, donepezil, hypnotic agents, memantine, meprobamate, modafinil, mood stabilizers (agents considered to be used only for seizure diagnoses are not included), naltrexone, prazosin, and viloxazine] within a 45-day period if one of the following is included: an antipsychotic, a benzodiazepine, divalproex/valproate, lithium, or a tricyclic antidepressant; or, pharmacy claims for any combination of five or more behavioral health medications [as defined above] within a 45-day period) for members < 18 years of age
- For all requests, individual drug PA criteria must be met first where applicable.
- For regimens including < two mood stabilizers (also includes regimens that do not include a mood stabilizer), documentation of the following is required:
- one of the following:
- member had a recent psychiatric hospitalization (within the last three months); or
- member has a history of severe risk of harm to self or others; or
- all of the following:
- appropriate diagnoses; and
- treatment plan including names of current behavioral health medications and corresponding diagnoses; and
- prescriber is a specialist (e.g., psychiatrist, child adolescent psychiatrist [including psychiatric nurse practitioners], neurologist, pediatric neurologist, developmental and behavioral pediatrics) or consult is provided; and
- if member has been on the requested polypharmacy regimen for the past 12 months with no adjustments (i.e., dose decrease, attempted discontinuation), at least one of the following:
- previous efforts to reduce/simplify the regimen in the past 24 months resulted in symptom exacerbation; or
- family/caregiver does not support the regimen change at this time due to risk of exacerbation; or
- other significant barrier for therapy discontinuation.
- one of the following:
- For regimens including ≥ two mood stabilizers, documentation of the following is required:
- one of the following:
- member had a recent psychiatric hospitalization (within the last three months); or
- member has a history of severe risk of harm to self or others; or
- all of the following:
- appropriate diagnoses; and
- treatment plan including names of current behavioral health medications and corresponding diagnoses; and
- prescriber is a specialist (e.g., psychiatrist, child adolescent psychiatrist [including psychiatric nurse practitioners], neurologist, pediatric neurologist, developmental and behavioral pediatrics) or consult is provided; and
- if member has been on the requested polypharmacy regimen for the past 12 months with no adjustments (i.e., dose decrease, attempted discontinuation), at least one of the following:
- previous efforts to reduce/simplify the regimen in the past 24 months resulted in symptom exacerbation; or
- family/caregiver does not support the regimen change at this time due to risk of exacerbation; or
- other significant barrier for therapy discontinuation; and
- one of the following:
- member has a seizure diagnosis only; or
- member has an appropriate psychiatric diagnosis, with or without seizure diagnosis, and one of the following:
- cross-titration/taper of mood stabilizer therapy; or
- inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate; or
- member has a diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain), with or without seizure diagnosis, and that other clinically appropriate therapies have been tried and failed; therefore, multiple mood stabilizers are needed; or
- member has psychiatric and comorbid diagnosis in which mood stabilizers may be clinically appropriate (e.g., migraine, neuropathic pain), with or without seizure diagnosis, and that other clinically relevant therapies have been tried and failed; therefore, multiple mood stabilizers are needed, and one of the following:
- cross-titration/taper of mood stabilizer therapy; or
- inadequate response or adverse reaction to two monotherapy trials and/or multiple combination therapy trials as clinically appropriate.
- one of the following:
Antidepressant Polypharmacy (overlapping pharmacy claims for two or more antidepressants for at least 60 days within a 90-day period, except esketamine) for members < 18 years of age
- For all requests, individual drug PA criteria must be met first where applicable.
- Documentation of the following is required:
- one of the following:
- member had a recent psychiatric hospitalization (within the last three months); or
- member has a history of severe risk of harm to self or others; or
- all of the following:
- appropriate psychiatric diagnosis; and
- treatment plan including names of current antidepressants and corresponding diagnoses; and
- prescriber is a is a specialist (e.g., psychiatrist, child adolescent psychiatrist [including psychiatric nurse practitioners], neurologist, pediatric neurologist, developmental and behavioral pediatrics) or consult is provided; and
- if member has been on the requested polypharmacy regimen for the past 12 months with no adjustments (i.e., dose decrease, attempted discontinuation), at least one of the following:
- previous efforts to reduce/simplify the regimen in the past 24 months resulted in symptom exacerbation; or
- family/caregiver does not support the regimen change at this time due to risk of exacerbation; or
- other significant barrier for therapy discontinuation; and
- one of the following:
- cross-titration/taper of antidepressant therapy; or
- inadequate response (defined as four weeks of therapy) or adverse reaction to two monotherapy trials as clinically appropriate; or
- antidepressant polypharmacy regimen of ≤ two antidepressants includes one of the following: bupropion, mirtazapine, trazodone, zuranolone; or
- one antidepressant in the regimen is indicated for a comorbid condition in which antidepressants may be clinically appropriate.
- one of the following:
SmartPA: Claims will usually process at the pharmacy without a PA request if the member is < 18 years of age and has a history of paid MassHealth pharmacy claims for two antidepressants (except esketamine) for at least 60 days of therapy out of the last 90 days and one or both agents are bupropion, trazodone, mirtazapine, or zuranolone.†
Antidepressant for members < six years of age
- For all requests, individual drug PA criteria must be met first where applicable.
- Documentation of the following is required:
- one of the following:
- member had a recent psychiatric hospitalization (within the last three months); or
- member has a history of severe risk of harm to self or others; or
- all of the following:
- appropriate diagnosis; and
- treatment plan including names of current behavioral health medications and corresponding diagnoses; and
- prescriber is a specialist (e.g., psychiatrist, child adolescent psychiatrist [including psychiatric nurse practitioners], neurologist, pediatric neurologist, developmental and behavioral pediatrics) or consult is provided; and
- if member has been on the requested agent for the past 12 months with no adjustments (i.e., dose decrease, attempted discontinuation), at least one of the following:
- previous efforts to reduce/simplify the regimen in the past 24 months resulted in symptom exacerbation; or
- family/caregiver does not support the regimen change at this time due to risk of exacerbation; or
- other significant barrier for therapy discontinuation.
- one of the following:
† Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans.
Original Effective Date: 04/2003
Last Revised Date: 01/2025
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Last updated 01/06/25