ph-1101
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Antidepressant Agents Step Therapy and Quantity Limit Criteria

Policy Number: PH-1101

 

This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.

 

OBJECTIVE

The intent of the Antidepressant Agents Step Therapy program is to encourage the use of generic antidepressant agents - selective serotonin reuptake inhibiting agents (SSRIs), serotonin norepinephrine reuptake inhibiting agents (SNRIs), bupropion/bupropion extended-release, or mirtazapine [or generic trazodone extended-release if it becomes available] - prior to brand antidepressant agents and to accommodate for use of brand antidepressant agents when generic prerequisite agents cannot be used due to previous trial, documented intolerance, FDA labeled contraindication, or hypersensitivity. The criteria for Cymbalta also encourage its use for neuropathic pain after trial of amitriptyline, nortriptyline, imipramine, desipramine, or gabapentin; for fibromyalgia (FM) after a trial of amitriptyline, nortriptyline, imipramine, desipramine, cyclobenzaprine, tramadol, or gabapentin; and for chronic musculoskeletal pain (CMP; for example, osteoarthritis or chronic low back pain) after a trial of acetaminophen, oral NSAID, topical NSAID, or any other prerequisite for FM or neuropathic pain already listed. The criteria for duloxetine (delayed release capsule, brand product) and Irenka also encourage its use for neuropathic pain after trial of amitriptyline, nortriptyline, imipramine, desipramine, or gabapentin; and for chronic musculoskeletal pain (CMP; for example, osteoarthritis or chronic low back pain) after a trial of acetaminophen, oral NSAID, topical NSAID, amitriptyline, nortriptyline, imipramine, desipramine, cyclobenzaprine, tramadol, or gabapentin.  Requests for brand antidepressant agents will be reviewed when patient-specific documentation has been provided.

TARGET AGENTS

Aplenzin™ (bupropion)

Celexa® (citalopram)a

Cymbalta® (duloxetine)a

Desvenlafaxine (ER tablets, brand product)

Desvenlafaxine fumarate (ER tablets, brand product)

Duloxetine (delayed release capsule, brand product)

Effexor® (venlafaxine)a

Effexor XR® (venlafaxine extended release)a

Fetzima® (levomilnacipran extended release)

Fluvoxamine extended releasea

Fluoxetine 60 mg (tablets, brand product)a

Forfivo XL® (bupropion extended release)

Irenka™ (duloxetine delayed release)a

Khedezla™ (desvenlafaxine extended release)

Lexapro® (escitalopram)a

Maprotiline (tablets, brand product)

Oleptro™ (trazodone extended release)b

Paxil® (paroxetine hydrochloride)a

Paxil CR® (paroxetine extended release)a

Pexeva® (paroxetine mesylate)

Pristiq® (desvenlafaxine succinate)a

Prozac® (fluoxetine)a

Prozac® Weekly™ (fluoxetine delayed release)

Remeron® (mirtazapine)a

RemeronSolTab® (mirtazapine)a

Trintellix™ (vortioxetine)

Venlafaxine ER (tablets, brand product)a

Viibryd™ (vilazodone)

Wellbutrin® (bupropion)a

Wellbutrin SR® (bupropion extended release)a

Wellbutrin XL® (bupropion extended release)a

Zoloft® (sertraline)a

a - available as a generic; generic included as a prerequisite in step therapy program

b – generic product anticipated

PRIOR AUTHORIZATION CRITERIA FOR APPROVAL

Brand Antidepressant Agents (except Cymbalta, Duloxetine (delayed release capsule, brand product) and Irenka, see below) will be approved when BOTH of the following are met:

  1. The patient has not filled a prescription for a monoamine oxidase (MAO) inhibitor in the past 30 days

AND

  1. ONE of the following:
    1. The patient’s medication history includes use of a generic antidepressant agent - SSRI, SNRI, bupropion, or mirtazapine [or generic trazodone extended-release if it becomes available] in the past 365 days

OR

    1. There is documentation that the patient is currently being treated with the requested agent

OR

    1. The prescriber states that the patient is currently being treated with the requested agent AND is at risk if therapy is changed

OR

    1. The patient has a documented intolerance, FDA labeled contraindication, or hypersensitivity to ONE generic antidepressant agent - SSRI, SNRI, bupropion, or mirtazapine [or generic trazodone extended-release if it becomes available]

Cymbalta, Duloxetine (delayed release capsule, brand product), and Irenka will be approved when BOTH of the following are met:

  1. The patient has NOT filled a prescription for a monoamine oxidase (MAO) inhibitor in the past 30 days

AND

  1. ONE of the following:
    1. The patient’s medication history includes use of a generic antidepressant agent -  SSRI, SNRI, bupropion, or mirtazapine [or generic trazodone extended-release if it becomes available] in the past 365 days

OR

    1. The patient has a diagnosis of neuropathic pain and has a medication history that includes use of amitriptyline, nortriptyline, desipramine, imipramine, or gabapentin in the past 90 days

OR

    1. For Cymbalta only, the patient has a diagnosis of fibromyalgia and has a medication history that includes use of amitriptyline, nortriptyline, desipramine, imipramine, cyclobenzaprine, gabapentin, or tramadol in the past 90 days

OR

    1. The patient has a diagnosis of chronic musculoskeletal pain and has a medication history that includes use of acetaminophen, oral NSAID, topical NSAID, tramadol, amitriptyline, nortriptyline, desipramine, imipramine, cyclobenzaprine, or gabapentin in the past 90 days

OR

    1. There is documentation that the patient is currently being treated with the requested agent

OR

    1. The prescriber states that the patient is currently being treated with the requested agent AND is at risk if therapy is changed

OR

    1. The patient has a documented intolerance,  FDA labeled contraindication, or hypersensitivity to ONEprerequisite for the requested diagnosis

Length of approval: 12 months

NOTE: If Quantity Limit program also applies, please refer to Quantity Limit documents.

FDA APPROVED INDICATIONS AND DOSAGE1-20,26,27,30,32-35,36-38,39,40,42

Agent

MDD

OCD

PD

GAD

SAD

PDD

PTSD

Bulimia

Other Diagnoses

Dosing

(adults)

Selective Serotonin Reuptake Inhibitors (SSRIs)

Celexa

(citalopram)

tablets, oral solution

P

MDD: 20 mg/day up to 40 mg/day; doses above 40 mg/day are not recommended due to the risk of QT prolongation. 20 mg/day is maximum recommended dose for CYP2C19 poor metabolizers, patients taking cimetidine or another CYP2C19 inhibitor,  with hepatic impairment, or age >60

Fluoxetine 60 mg

tablets

P

P

P

P

MDD, OCD, PD, Bulimia: 60 mg/day

Fluvoxamine ER

capsules

P

P

OCD: 100-300 mg/day

Fluvoxamine

tablets

P

OCD: 50 mg/day as a single dose titrated up to 100-300 mg/day (divided twice daily)

Lexapro (escitalopram)

tablets, oral solution

P

P

MDD: 10-20 mg/day

GAD: 10 mg/day

Paxil

(paroxetine)

tablets, Oral suspension

P

P

P

P

P

P

MDD: 20-50 mg/day

OCD: 20-60 mg/day (target  40 mg/day)

PD: 10-60 mg/day (target 40 mg/day)

GAD: 20-50 mg/day (target  20 mg/day)

SAD: 20-60 mg/day (target 20 mg/day)

PTSD: 20-50 mg/day (target 20 mg/day)

Paxil CR

(paroxetine CR)

 tablets

P

P

P

P

MDD: 25-62.5 mg/day

PD: 12.5-75 mg/day

SAD: 12.5-37.5 mg/day

PDD: 12.5-25 mg/day (daily throughout cycle or limited to luteal phase)

Pexeva

(paroxetine mesylate)

tablets

P

P

P

P

MDD: 20-50 mg/day

OCD: 20-60 mg/day (target  40 mg/day)

PD: 10-60 mg/day (target 40 mg/day)

GAD: 20-50 mg/day (target  20 mg/day)

Prozac Weekly

(fluoxetine DR)

capsules

P

MDD: 90 mg once weekly

Prozac

(fluoxetine)

tablets, capsules, oral solution

P

P

P

P

MDD, OCD: 20-80 mg/day

Bulimia : 60 mg/day

PD: Initially 10 mg/day; titrated to 20 mg/day; up to 60 mg/day

Zoloft

(sertraline)

tablets, oral concentrate

P

P

P

P

P

P

MDD, OCD: Initially  50 mg/day

PD,PTSD, SAD: Initial titration 25 to 50 mg/day; Range: 50-200 mg/day

PDD: Initially 50 mg/day (daily throughout cycle or luteal phase only); Range: 50-100 mg/day for luteal phase only; up to 150 mg/day if taken throughout cycle

MDD=major depressive disorder; OCD= obsessive compulsive disorder; PD= panic disorder; GAD= generalized anxiety disorder; SAD= social anxiety disorder or social phobia; PDD= premenstrual dysphoric disorder; PTSD= post traumatic stress disorder; DPNP=diabetic peripheral neuropathic pain; FM=fibromyalgia;  CMP=chronic musculoskeletal pain; ER=extended release, ODT=orally disintegrating

Agent

MDD

OCD

PD

GAD

SAD

PDD

PTSD

Bulimia

Other Diagnoses

Dosing

(adults)

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

Cymbalta

(duloxetine DR)

capsules

P

P

P

DPNP, FM, CMP

MDD: 20 mg twice daily to 60 mg/day (once or divided twice daily); may titrate from 30 to 60 mg once daily

GAD: 60 mg/day (titrate from 30 mg/day)

MDD, GAD: 120 mg/day shown effective but no evidence of added benefit and more adverse effects from doses >60 mg/day

DPNP: 60 mg/day

FM, CMP: 30 mg/day x one week; then 60 mg/day no evidence of added benefit and more adverse effects from doses >60 mg/day

Desvenlafaxine ER

tablets

P

MDD: 50 mg/day (range 50-400 mg/day); no evidence of additional benefit and more adverse effects from doses >50 mg/day

Duloxetine DR

capsules

P

P

P

DPNP

CMP

MDD: 40 mg/day – 120 mg/day; no evidence of additional benefit for doses >60 mg/day

GAD: 30 mg/day – 120 mg /day; no evidence of additional benefit for doses >60 mg/day

DPNP: 60 mg/day; no evidence of additional benefit for doses >60 mg/day

CMP: 30 mg/day – 60 mg/day; no evidence of additional benefit for doses >60 mg/day

Effexor

(venlafaxine)

tablets

P

MDD: In 2-3 divided doses, 75-225 mg/day (moderately depressed outpatients);

     up to 350 mg/day (severely depressed inpatients) Maximum 375 mg/day in divided doses

Effexor XR

(venlafaxine ER)

capsules

P

P

P

P

MDD, GAD, PD: Initially 37.5 mg/day for 7 days; then range of 75-225 mg/day

SAD: 75 mg/day

Fetzima

(levomilnacipran ER)

capsules

P

MDD: initial 20 mg once daily, then 40 mg once daily. Based on efficacy/tolerability, increase in increments of 40 mg at intervals of >2 days. Range is 40 mg-120 mg once daily. Maximum recommended dose is 120 mg once daily.

Khedezla

(desvenlafaxine ER)

 tablets

P

MDD: 50 mg/day (range 50-400 mg/day); no evidence of additional benefit and more adverse effects from doses >50 mg/day

Irenka

(duloxetine DR)

capsules

  1. Capsules

P

P

P

DPNP

CMP

MDD: 40 mg/day – 120 mg/day; no evidence of additional benefit for doses >60 mg/day

GAD: 30 mg/day – 120 mg /day; no evidence of additional benefit for doses >60 mg/day

DPNP: 60 mg/day; no evidence of additional benefit for doses >60 mg/day

CMP: 30 mg/day – 60 mg/day; no evidence of additional benefit for doses >60 mg/day

Pristiq

(desvenlafaxine succinate)

tablets

P

MDD: 50 mg/day (range 50-400 mg/day); no evidence of additional benefit and more adverse effects from doses >50 mg/day

Venlafaxine ER

tablets

  1. ER Tablets
  1. P

P

MDD: Initially 37.5 to 75 mg/day; range of 75- 225 mg/day

SAD: 75 mg/day

MDD=major depressive disorder; OCD= obsessive compulsive disorder; PD= panic disorder; GAD= generalized anxiety disorder; SAD= social anxiety disorder or social phobia; PDD= premenstrual dysphoric disorder; PTSD= post traumatic stress disorder; DPNP=diabetic peripheral neuropathic pain; FM=fibromyalgia;  CMP=chronic musculoskeletal pain; CR= controlled release; DR=delayed release; ER=extended release; ODT=orally disintegrating

Agent

MDD

OCD

PD

GAD

SAD

PDD

PTSD

Bulimia

Other Diagnoses

Dosing

(adults)

Other Antidepressants

Aplenzin

(bupropion ER)

tablets

P

MDD: Initially, 174 mg/day; usual target dose is 348 mg/day; consider maximum dose 522 mg/day if no response to 348 mg

Forfivo XL

(bupropion ER)

tablets

P

MDD: Initially start with another formulation of bupropion until a patient has been on 300mg of bupropion per day for at least 2 weeks, and requires a dosage of 450mg per day

Maprotiline

tablets

P

MDD: 25 mg three times daily; may increase by 25-50 mg/day at weekly intervals depending on response. Usual dose: 75-150 mg/day (single dose at bedtime or divided). Maximum of 150-220 mg/day (1-3 doses)

Oleptro

(trazodone ER)

tablets

P

MDD: Initially 150 mg once daily; increase by 75 mg/day;  maximum 375 mg/day

Remeron, Remeron SolTab

(mirtazapine)

tablets, ODT tablets

P

MDD: initially 15 mg/day; range 15-45 mg/day

Trintellix

(vortioxetine)

tablets

P

MDD: Initially, 10 mg once daily; increase to 20 mg/day as tolerated. Efficacy and safety of doses above 20 mg/day have not been evaluated.

Viibryd (vilazodone)

tablets

P

MDD: Initially, 10 mg/day for 7 days; then 20 mg/day for 7 days; then 40 mg/day (recommended dose).

Wellbutrin (burpropion), Wellbutrin SR

(bupropion SR)

tablets

P

MDD - Wellbutrin: Initially 100 mg twice daily; may increase to 100 mg three times daily; Maximum of 450 mg/day (divided doses < 150 mg each)

MDD - Wellbutrin SR: Initially 150 mg once daily; then 150 mg twice daily as early as day 4; Maximum of 200 mg twice daily.

Wellbutrin XL

(bupropion ER)

tablets

P

P

SAFD

MDD: 150 mg/day titrated to 300 mg/day as early as day 4; Maximum 450 mg/day.

SAFD: 150 mg/day for one week; then 300 mg/day (target dose).

MDD=major depressive disorder; OCD= obsessive compulsive disorder; PD= panic disorder; GAD= generalized anxiety disorder; SAD= social anxiety disorder or social phobia; PDD= premenstrual dysphoric disorder; PTSD= post traumatic stress disorder; DPNP=diabetic peripheral neuropathic pain; FM=fibromyalgia;  CMP=chronic musculoskeletal pain; CR = controlled release; DR= delayed release; ER=extended release, ODT=orally disintegrating; SR= sustained release

CLINICAL RATIONALE

Depression

Selective serotonin reuptake inhibitors (SSRIs) along with serotonin norepinephrine reuptake inhibitors (SNRIs), bupropion, and mirtazapine are considered first line treatment options for adults with major depressive disorder (MDD). The choice of medication is based on side effect profiles, history of prior response, family history of response, type of depression, concurrent medical illnesses, concurrently prescribed medications, and cost of medication. Although all these drugs may have similar efficacy, they differ significantly in their side effect profiles. Patients who cannot tolerate one agent may do well with another.43-46 

Anxiety Disorders

Guidelines for treatment of anxiety include several anxiety-related conditions: obsessive compulsive disorder (OCD), panic disorder (PD), social anxiety disorder (SAD), post-traumatic stress disorder (PTSD), and generalized anxiety disorder (GAD). SSRIs or SNRIs (e.g. venlafaxine) are efficacidous for the treatment of GAD. Although all these drugs may have similar efficacy, they differ significantly in their side effect profiles. Treatment choice is typically based on several factors including patient preference and medical history, side effect profile, and drug interactions. If effective, antidepressant treatment for GAD should be continued for at least 12 months.47 

Neuropathic Pain

Treatment for neuropathic pain include TCAs, gabapentin, pregabalin, and SNRI antidepressants (duloxetine [most studied], venlafaxine) as first-line therapies. 21,22 For patients with diabetic neuropathy, an antidepressant (e.g., amitriptyline, duloxetine, venlafaxine) or anticonvulsant (e.g., pregabalin) is recommend as initial therapy. Available evidence suggests these agents have similar modest benefit, though few high-quality comparative trials have been done. Among these options, the preference is to start with amitriptyline, particularly in younger healthier patients. Patients who fail to improve with a reasonable trial of one of these agents can be switched to monotherapy with another agent. For patients who do not improve on one drug, suggest combination therapy employing two drugs from different medication classes as the next step in the treatment paradigm. For patients who are unable to tolerate any of these drugs, alternative treatments include capsaicin cream, lidocaine patch, alpha-lipoic acid, isosorbide dinitrate topical spray, and transcutaneous electrical nerve stimulation.48 Due to risk of addiction, abuse, sedation, and other complications associated with opioid use, opioids are not recommented for treatment of neuropathic pain.22,48

Fibromyalgia

Nonpharmacological therapy should be first-line therapy and then if there is a lack of effect,  therapy should be individualized according to patient need, which may include pharmacological therapy. Pharmacologic therapies include: duloxetine, milnacipran, tramadol, pregabalin, cyclobenzaprine. Strength of recommendation for all these options is weak.23,49 A review (2015) suggests  pharmaceuticals (e.g., pregabalin, duloxetine, milnacipran) will provide clinically meaningful improvement without any major adverse events for a relatively small subset of patients only. In many other patients, the benefits do not outweigh the adverse effects, while the remainder do not experience any symptom improvement or even get worse.23,50 

Pharmacological therapy should be guided by predominant symptoms that accompany pain. All patients should have a good therapeutic trial of a low-dose tricyclic compound (e.g., cyclobenzaprine, amitriptyline, or nortriptyline). Patients with comorbid depression or fatigue should next try a serotonin norepinephrine reuptake inhibitor (SNRI). Patients with comorbid anxiety or sleep issues should next try a gabapentinoid. It is often necessary to use several classes of drugs together. Use of opioids is discouraged. Nonsteroidal antiinflammatory drugs (NSAIDs) and acetaminophen can be used to treat comorbid peripheral pain generators. 25

Tramadol may be used in patients who require additional pain relief on a temporary basis for exacerbations or for patients who have inadequate pain control with other therapies.51

Chronic Musculoskeletal Pain

The American Psychiatric Association recommends the use of TCAs and SNRIs for treating chronic pain and comorbid depression.28, 41 SNRIs, which target both serotonin and norepinephrine, have a greater analgesic effect than antidepressants targeting either neurotransmitter alone. Duloxetine and venlafaxine have effectively reduced symptoms in patients with pain disorders and comorbid depression.57

Duloxetine is indicated for the management of chronic musculoskeletal pain, which was established in studies of patients with chronic low back pain and chronic pain due to osteoarthritis (OA).13 A guideline on treatment of chronic noncancer pain including neuropathic, somatic, myofascial and visceral types of pain (American Society of Anesthesiologists, 2010) includes anticonvulsants, antidepressants (TCAs and SNRIs), benzodiazepines, NMDA receptor antagonists, NSAIDs, opioids, skeletal muscle relaxants, and topical agents as part of a multimodal strategy for a variety of patients with chronic pain.31

Adverse Effects

SSRIs

SSRIs commonly cause nausea, vomiting, diarrhea, nervous activation (e.g., insomnia, restlessness, anxiety), and headaches and these may dissipate over time. Although sexual dysfunction (e.g., loss of libido, erectile/ejaculatory problems) can occur with any antidepressant, this appears to be more common with SSRIs, and may also disappear with time. Paroxetine is associated with a higher incidence of weight gain than other SSRIs. Serotonin syndrome is associated with simultaneous use of SSRIs plus other serotonergic agents (e.g., monoamine oxidase inhibitors [MAOIs]) and should be avoided. SSRIs should not be abruptly discontinued to avoid discontinuation syndrome; most likely with paroxetine, least likely with fluoxetine.28

Citalopram doses above 40 mg/day are not recommended due to the risk of QT prolongation; 20 mg/day is the maximum recommended dose for CYP2C19 poor metabolizers or those patients taking a CYP2C19 inhibitor.4 Citalopram should not be used in patients with QT syndrome, bradycardia, hypokalemia, hypomagnesemia, recent acute myocardial infarction, uncompensated heart failure, or with other drugs that prolong the QTc interval. Patients at risk for electrolyte disturbances should have baseline serum potassium and magnesium checked with periodic monitoring.4,24

SNRIs

SNRI side effects are similar with those of SSRIs (nausea, vomiting, nervous activation, sexual dysfunction) and may attenuate with continued use. SNRI effects are also more likely to reflect noradrenergic activity (increased pulse, dilated pupils, dry mouth, excess sweating, and constipation). All three SNRIs have a risk of increased blood pressure, especially at higher doses. As with SSRIs, serotonin syndrome is associated with simultaneous use of SNRIs plus other serotonergic agents (e.g., MAOIs) and should be avoided. Like SSRIs, SNRIs should not be abruptly discontinued to avoid discontinuation syndrome; more likely with venlafaxine and desvenlafaxine than duloxetine.28

Vortioxetine

Most common adverse reactions in patients on vortioxetine were nausea, constipation and vomiting. 38

Vilazodone

Most common adverse effects of vilazodone in clinical trials were diarrhea, nausea, vomiting, and insomnia. Vilazodone is an SSRI and partial serotonergic 5-HT1a agonist. Like SSRIs and SNRIs, the drug is associated with serotonin and discontinuation syndromes, and should not be given with other serotonergic agents or discontinued abruptly.30

Bupropion

Bupropion has fewer sexual side effects than other antidepressants. Neurologic adverse effects include headache, tremors, and seizures. Risk of seizures is minimized by avoiding high doses, avoiding rapid titration, using divided dosing schedules, avoiding use in patients at risk of seizures. Other side effects may include agitation/nervousness, mild cognitive dysfunction, insomnia, gastrointestinal upset.28

Mirtazapine

Most common side effects of mirtazapine include dry mouth, sedation, and weight gain (greater risk than other antidepressants). Mirtazapine is often given at bedtime and may be chosen for depressed patients with initial insomnia and weight loss. Mirtazapine increases serum cholesterol levels in some patients.28

Trazodone

The most common side effect with trazodone is sedation; this may be an advantage in patients with initial insomnias. Trazodone can also cause cardiovascular side effects, including orthostasis, particularly among elderly patients or those with preexisting heart disease. Use of trazodone has also been associated with life-threatening ventricular arrhythmias in several case reports. Trazodone also can cause sexual side effects, including erectile dysfunction in men; in rare instances, priapism occurs, which might require surgical correction.28

Maprotiline

Side effects with maprotiline may be similar to those seen with tricyclic antidepressants (TCAs), and can include cardiovascular effects including arrhythmias, anticholinergic effects, sedation, orthostatic hypotension, weight gain and seizures at therapeutic doses. Potentially dangerous interactions, including hypertensive crises and serotonin syndrome, can develop when TCAs are administered with MAOIs.28

Serotonin Syndrome

Serotonin syndrome is presumed to result from high levels of serotonin in the brain. Features of serotonin syndrome include abdominal pain, diarrhea, flushing, sweating,

hyperthermia, lethargy, mental status changes, tremor and myoclonus, rhabdomyolysis, renal failure, cardiovascular shock, and possibly death. Although it can occur with administration of one or more serotonergic medications, it is most severe when an MAOI is coadministered with another serotonergic medication (such as an antidepressant).28

Other antidepressants should not be used in patients concomitantly taking an MAOI.29

For additional clinical information see the Prime Therapeutics Formulary Chapters 9.2C Antidepressants: Selective Serotonin Reuptake Inhibitors (SSRI) and 9.2E Antidepressants:  Miscellaneous.

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This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

The purpose of pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.

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