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Table 17: Antidepressants


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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

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

brexanolone Zulresso PA   ^

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.

  • In general, the elderly are more sensitive to side effects of medications, especially to sedation, orthostatic hypotension, and anticholinergic symptoms. Because of changes in drug metabolism, older members need lower doses of antidepressants to reach therapeutic effect. Thus the maxim, “Start low and go slow.”
  • MassHealth does not encourage the use of combination products and recommends that the active medications be prescribed individually.
  • There is no evidence to support the use of two selective serotonin reuptake inhibitors (SSRIs) or a SSRI in combination with a serotonin/norepinephrine reuptake inhibitor (SNRI) or a serotonin modulator concurrently. These combinations may duplicate drug action, with increased side effects and minimal clinical benefit. PA is required when a member has an overlap of 60 days or more in prescriptions of two SSRIs or a SSRI in combination with a SNRI or serotonin modulator.1
  • Due to bupropion’s dose-dependent risk of seizure (0.33-0.4% within recommended dosing limits), please dose accordingly. Bupropion immediate release (IR) should be dosed no greater than 150 mg per dose and 450 mg per day. Bupropion sustained release (SR) should be dosed no greater than 200 mg per dose and 400 mg per day. Bupropion extended-release (XL) requires PA for quantities > one unit per day. It should be dosed no greater than 450 mg a day (300 mg tablet plus 150 mg tablet) as a single dose. Members with seizure disorders, brain injuries, and eating disorders are at highest risk of seizures.
  • Brand-name Serzone is no longer available due to reports of life-threatening hepatic failure resulting in death or transplant. Nefazodone is still available from various manufacturers.
  • Blood pressure should be monitored during venlafaxine therapy because it may cause a dose-related increase in diastolic blood pressure (reported in 3-13% of members). Sustained increases in diastolic blood pressure are reported with desvenlafaxine succinate as well (1.3-2.3% of members).
  • Antidepressant discontinuation syndrome has been commonly reported with SSRIs and SNRIs. Among the SSRIs, this is most commonly reported with paroxetine (whose half-life is short and there is no active metabolite) and reported least with fluoxetine (with a long half-life and an active, long-acting metabolite). Symptoms include dizziness, nausea, fatigue, lethargy, flu-like symptoms, anxiety, irritability, and insomnia. This often occurs one-three days after abruptly stopping the medication. The agents in question should be slowly tapered to avoid this syndrome.

Monoamine Oxidase Inhibitors (MAOIs):

  • Hypertensive crisis may occur when MAOIs are coadministered with some prescription and over-the-counter products and foods, especially those high in tyramine.
  • Serotonin syndrome can occur when MAOIs are coadministered with other pro-serotonergic medications.
  • Members should be counseled about dietary and medication restrictions and be given a list of food and drugs to be avoided.
 

 Antidepressants – Monoamine Oxidase Inhibitors (MAOI)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

isocarboxazid Marplan PA  
phenelzine Nardil PA   - < 6 years # , A90
selegiline transdermal patch Emsam PA  
tranylcypromine PA   - < 6 years A90

 Antidepressants – NMDA Receptor Antagonist

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

esketamine Spravato PA  

 Antidepressants – Noradrenergic and Specific Serotonergic Antidepressants (NaSSA)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

mirtazapine Remeron PA   - < 6 years # , A90
mirtazapine orally disintegrating tablet Remeron Sol Tab PA   A90

 Antidepressants – Norepinephrine/Dopamine Reuptake Inhibitors (NDRI)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

bupropion hydrobromide extended-release Aplenzin PA   - < 6 years and PA > 1 unit/day
bupropion hydrochloride PA   - < 6 years A90
bupropion hydrochloride extended-release 150 mg, 300 mg tablet Wellbutrin XL PA   - < 6 years and PA > 1 unit/day # , A90
bupropion hydrochloride extended-release 450 mg tablet Forfivo XL PA   BP, A90
bupropion hydrochloride sustained-release-Wellbutrin SR Wellbutrin SR PA   - < 6 years # , A90

 Antidepressants – Second-Generation (Atypical) Antipsychotic and Selective Serotonin Reuptake Inhibitor

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

olanzapine / fluoxetine Symbyax PA   A90

 Antidepressants – Selective Serotonin Reuptake Inhibitors (SSRI)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

citalopram capsule PA   A90
citalopram solution, tablet Celexa PA   - < 6 years # , A90
escitalopram Lexapro PA   - < 6 years # , A90
fluoxetine 10 mg, 20 mg tablet for premenstrual dysphoric disorder PA   - < 6 years A90
fluoxetine 10 mg, 20 mg, 40 mg capsule, solution Prozac PA   - < 6 years # , A90
fluoxetine 60 mg tablet PA   A90
fluoxetine 90 mg delayed-release capsule PA   A90
fluvoxamine extended-release PA   A90
fluvoxamine immediate-release PA   - < 6 years A90
paroxetine controlled-release Paxil CR PA   A90
paroxetine hydrochloride Paxil PA   - < 6 years # , A90
paroxetine mesylate tablet Pexeva PA  
sertraline capsule PA   A90
sertraline oral concentrate, tablet Zoloft PA   - < 6 years # , A90

 Antidepressants – Serotonin Modulators

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

nefazodone PA   - < 6 years A90
trazodone 300 mg tablet PA   A90
trazodone 50 mg, 100 mg, 150 mg PA   - < 6 years A90
vilazodone Viibryd PA   BP, A90
vortioxetine Trintellix PA  

 Antidepressants – Serotonin/Norepinephrine Reuptake Inhibitors (SNRI)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

desvenlafaxine extended-release PA   A90
desvenlafaxine succinate extended-release Pristiq PA   - < 6 years and PA > 1 unit/day BP, A90
duloxetine 20 mg, 30 mg, 60 mg capsule Cymbalta PA   - < 6 years # , A90
duloxetine 40 mg capsule PA   A90
duloxetine sprinkle capsule Drizalma PA  
levomilnacipran Fetzima PA   - < 6 years and PA > 1 unit/day
venlafaxine PA   - < 6 years A90
venlafaxine besylate extended-release tablet PA  
venlafaxine extended-release capsule Effexor XR PA   - < 6 years # , A90
venlafaxine hydrochloride extended-release tablet PA   A90

 Antidepressants – Tricyclic Antidepressant (TCA) and Benzodiazepine

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

amitriptyline / chlordiazepoxide PA  

 Antidepressants – Tricyclic Antidepressant (TCA) and First-Generation (Typical) Antipsychotic

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

amitriptyline / perphenazine PA   A90

 Antidepressants – Tricyclic Antidepressants (TCA)

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

amitriptyline powder PA  
amitriptyline tablet PA   - < 6 years A90
amoxapine PA   - < 6 years A90
clomipramine Anafranil PA   A90
desipramine Norpramin PA   A90
doxepin capsule, oral concentrate PA   - < 6 years A90
imipramine hydrochloride PA   - < 6 years A90
imipramine pamoate PA   A90
maprotiline PA   A90
nortriptyline Pamelor PA   - < 6 years # , A90
protriptyline PA   A90
trimipramine PA   A90
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization 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.
 
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 
^ This drug is available through the health care professional who administers the drug. MassHealth does not pay for this drug to be dispensed through a retail pharmacy.
 
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:

  • Depressive disorders
  • Anxiety disorders
  • Postpartum depression

Note: The above list may not include all FDA-approved indications.

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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)

 

amitriptyline powder

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • clinical rationale why other commercially available alternatives cannot be used.

    

 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 iout of the last 120 days.

 

Aplenzin, bupropion hydrochloride extended-release 150 mg, 300 mg tablet, desvenlafaxine succinate ER, and Fetzima > 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. 

  

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 at least four weeks of therapy) or adverse reaction to bupropion SR or bupropion XL.

 

citalopram capsule

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • appropriate dosing; and
    • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to citalopram tablets (three 10 mg tablets or one 10mg and one 20 mg tablet).

   

clomipramine

  • Documentation of all of the following is required:            
    • appropriate diagnosis; and
    • inadequate response (defined as at least four weeks of therapy) or adverse reaction to two SSRIs; or
    • contraindication to all SSRIs.

SmartPA: Claims for 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.

 

desipramine, maprotiline, 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 at least four weeks of therapy) or adverse reaction to one of the following or contraindication to both of the following: SSRI, SNRI; and
    • inadequate response (defined at least four weeks of therapy) or adverse reaction to one tricyclic antidepressant available without PA. 
SmartPA: Claims for desipramine, maprotiline, 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. 

 

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 at least four weeks of therapy) or adverse reaction to desvenlafaxine succinate ER.

 

Drizalma

  • Documentation of all of the following is required:            
    • appropriate diagnosis; and
    • clinical rationale 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 at least four weeks of therapy) or adverse reaction to duloxetine (two 20 mg capsules).

 

Emsam

  •  Documentation of all of the following is required:
    • 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 at least four weeks of therapy) or adverse reaction to one SSRI and one other antidepressant that is not a SSRI; or
      • contraindication to all SSRI and non-SSRI antidepressants; and
    • if the requested quantity is > one patch and/or 12 mg daily, clinical rationale for dosing higher than the FDA approved limits.
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 an appropriate 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.

 

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 at least four weeks of therapy) or adverse reaction to fluoxetine (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 at least four weeks of therapy) or adverse reaction to fluoxetine daily.

 

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 at least four weeks of therapy) or adverse reaction to immediate-release fluvoxamine.

 

imipramine pamoate

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • appropriate dosing; and 
    • medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to imipramine hydrochloride.

 

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 at least four weeks of therapy) or adverse reaction to mirtazapine tablets.

 

paroxetine controlled-release and Pexeva

  •  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 at least four weeks of therapy) or adverse reaction to immediate-release paroxetine; and
    • for Pexeva, medical records documenting an inadequate response (defined as at least four weeks of therapy) or adverse reaction to paroxetine controlled-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 at least four weeks of therapy) or adverse reaction to sertraline tablets (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 at least 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 at least four weeks of therapy for antidepressants) or adverse reaction to one or contraindication to all of the following antidepressant 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 at least four weeks of therapy) or adverse reaction to trazodone immediate-release (two 150 mg tablets).

 

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 at least 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.
SmartPA: Claims for Trintellix and vilazodone within polypharmacy requirements at a quantity ≤ one unit 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.

 

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 at least four weeks of therapy) or adverse reaction to venlafaxine extended-release capsules.

 

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.
 

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 old

  • Documentation (including medical records) of the following is required:
    • a well-defined clinical rationale explaining medical necessity for two SSRIs, two SNRIs, two serotonin modulators, or an SSRI, SNRI and/or serotonin modulator concurrently; and
    • the full medication regimen (including exact dosing of each therapy).
 
   

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, modafinil, mood stabilizers (agents considered to be used only for seizure diagnoses are not included), naltrexone, and viloxazine] within a 45-day period) for members < 18 years old

  • 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, neurologist) or consult is provided.

 

  • For regimens including ≥ three 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, neurologist) or consult is provided; 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.

 

Antidepressant Polypharmacy (overlapping pharmacy claims for two or more antidepressants for at least 60 days within a 90-day period) for members < 18 years old

  • 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 psychiatrist or consult is provided; 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 or trazodone; or
        • one antidepressant in the regimen is indicated for a comorbid condition in which antidepressants may be clinically appropriate.

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 for at least 60 days of therapy out of the last 90 days and one or both agents are trazodone, mirtazapine, or bupropion.

 

Antidepressant for members < six years old

  • 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, neurologist) or consult is provided.

 

 

 
 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: 10/2022


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Last updated 10/31/22

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