ph-1101
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Antidepressant Agents Step Therapy and Quantity Limit Criteria

Policy Number: PH-1101

TARGET AGENTS

Aplenzin™ (bupropion)

Celexa® (citalopram)a

Cymbalta® (duloxetine)a

Desvenlafaxine (ER tablets, brand product)

Drizalma Sprinkle™ (delayed release sprinkle capsule)

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)

Khedezla™ (desvenlafaxine extended release)

Lexapro® (escitalopram)a

Maprotiline (tablets, brand product)

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

Remeron SolTab® (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

PRIOR AUTHORIZATION CRITERIA FOR APPROVAL

Brand Antidepressant Agents (except Cymbalta and Duloxetine [delayed release capsule, brand product] 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 in the past 365 days

OR

  1. There is information that the patient is currently being treated with the requested agent in the past 180 days

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 an intolerance, FDA labeled contraindication, or hypersensitivity to ALL generic antidepressant agents - SSRI, SNRI, bupropion, and mirtazapine

Cymbalta, Drizalma Sprinkle, and Duloxetine (delayed release capsule, brand product) 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 in the past 365 days

OR

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

OR

    1. The patient has an intolerance, FDA labeled contraindication, or hypersensitivity to ONE of the prerequisite agents listed above (i.e. amitriptyline, nortriptyline, desipramine, imipramine, or gabapentin)

OR

  1. For Cymbalta only, if the patient has a diagnosis of fibromyalgia, ONE of the following
    1. 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 an intolerance, FDA labeled contraindication, or hypersensitivity to ONE of the prerequisite agents listed above (i.e. amitriptyline, nortriptyline, desipramine, imipramine, cyclobenzaprine, gabapentin, or tramadol)

OR

  1. The patient has a diagnosis of chronic musculoskeletal pain, ONE of the following
    1. 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. The patient has an intolerance, FDA labeled contraindication, or hypersensitivity to ONE of the prerequisite agents listed above (i.e. acetaminophen, oral NSAID, topical NSAID, tramadol, amitriptyline, nortriptyline, desipramine, imipramine, cyclobenzaprine, or gabapentin)

OR

  1. If using for a diagnosis other than neuropathic pain, fibromyalgia for Cymbalta only, or musculoskeletal pain: The patient has an intolerance, FDA labeled contraindication, or hypersensitivity to ALL generic antidepressants -  SSRI, SNRI, bupropion, and mirtazapine

    OR

  1. There is information that the patient is currently being treated with the requested agent in the past 180 days

OR

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

Length of approval: 12 months

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

FDA APPROVED INDICATIONS AND DOSAGE1-31

Agent

MDD

OCD

PD

GAD

SAD

PDD

PTSD

Bulimia

Other Diagnoses

Dosage

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  Use of this product requires initial titration with another fluoxetine product

fluvoxamine ER

capsules

P

OCD: 100-300 mg/day

fluvoxamine

tablets

P

OCD: 50 mg at bedtime, with increases of 50 mg every 4 to 7 days as tolerated to maximum effect, not to exceed 300 mg/day.  Daily doses over 100 mg should be given in two divided doses

Pediatric: 25 mg at bedtime, with increases of 25 mg every 4 to 7 days, as tolerated to maximum effect, to the adult maximum dose of 300 mg/day.  A total daily dose of more than 50 mg should be given in two divided doses

Lexapro® (escitalopram)

tablets, oral solution

P

P

MDD: 10-20 mg/day

GAD: 10 mg/day

Adolescents, MDD: 10-20 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

Adult, MDD: Initial 20 mg/day, target 20 mg/day, max 80 mg/day OCD: Initial: 20 mg/day, target 20-60 ,g/day Bulimia: 60 mg/day, Panic Disorder: Initial 10 mg/day, target 20 mg/day, maximum 60 mg/day.

Pediatric, MDD: 10-20 mg/day OCD: Initial 10 mg/day, target 10 to 60 mg/day

Zoloft®

(sertraline)

tablets, oral concentrate

P

P

P

P

P

P

MDD, OCD: Initially 50 mg/day; Range 50-200 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

Pediatric; OCD: Initial 25 mg/day (ages 6-12 years) or 50 mg/day (13-17 years); Range: 50-200 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; 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 for one week; then 60 mg/day no evidence of added benefit and more adverse effects from doses >60 mg/day

Children and Adolescents (7 to 17 years of age): GAD: Initiate at 30 mg once daily for 2 weeks before considering an increase to 60 mg.  Recommended range: 30-60 mg/day.  If increasing past 60 mg/day, increase in increments of 30 mg, maximum dose 120 mg/day

Drizalma Sprinkle™

(duloxetine DR)

sprinkle capsules

P

P

P

DPNP,  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

DPNP: 60 mg/day; no evidence that doses > 60 mg/day confer additional significant benefit

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

Children and Adolescents (7 to 17 years of age): GAD: Initiate at 30 mg once daily for 2 weeks before considering an increase to 60 mg.  Recommended range: 30-60 mg/day.  If increasing past 60 mg/day, increase in increments of 30 mg, maximum dose 120 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®a

(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

Children and Adolescents (7 to 17 years of age): GAD: Initiate at 30 mg once daily for 2 weeks before considering an increase to 60 mg.  Recommended range: 30-60 mg/day.  If increasing past 60 mg/day, increase in increments of 30 mg, maximum dose 120 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

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

a-brand discontinued, only generics available

Agent

MDD

OCD

PD

GAD

SAD

PDD

PTSD

Bulimia

Other Diagnoses

Dosing

(adults)

Other Antidepressants

Aplenzin®

(bupropion ER)

tablets

P

P

SAFD

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)

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® (bupropion), 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; SAFD=Seasonal Affective Disorder; CR = controlled release; DR= delayed release; ER=extended release, ODT=orally disintegrating; SR= sustained release

CLINICAL RATIONALE

Depression

No antidepressant has been clearly shown to be superior to another.  All FDA-approved antidepressant medications should be considered potentially appropriate for first-line treatment.  Selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), bupropion, mirtazapine, and several newer agents are typically used as first-line medications because their safety and tolerability may be preferable to patients and clinicians compared to those of tricyclic antidepressants (TCAs) and monoamine oxidase (MAO) inhibitors32.  Many clinical features and medication characteristics influence the choice of a first-line antidepressant.  There are no absolutes, and relative differences between medications are small, hence, selecting an antidepressant involves an individualized needs assessment for each patient33.

Anxiety Disorders

Guidelines for treatment of anxiety include several anxiety-related conditions: generalized anxiety disorder (GAD), panic disorder (PD), obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and social anxiety disorder (SAD).  SSRIs are generally considered first-line therapy for GAD and PD.  In the treatment of PD, TCAs are as effective as SSRIs, but adverse effects may limit the use of TCAs in some patients.  Extended-release venlafaxine is effective and well tolerated for GAD and PD, whereas duloxetine has been adequately evaluated only for GAD.  Due to the typical delay in onset of action, medications should not be considered ineffective until they are titrated to the high end of the dose range and continued for at least four weeks.  Once symptoms have improved, medications should be used for 12 months before tapering to limit relapse.  Some patients will require longer treatment34.  OCD has a highly selective response to serotonergic medications.  SSRIs are preferred for initial therapy.  There is insufficient evidence to show that one SSRI is superior, and the choice should be individualized, taking into account potential drug interactions and tolerability.  Dosage should be increased over four to six weeks until maximum dose is achieved.  Trial of therapy should continue for eight to 12 weeks, with at least four to six weeks at the maximum tolerable dosage.  It usually takes at least four to six weeks for patients to note any significant improvement in symptoms; it may take 10 weeks or longer for some.  If successful, medication should be continued for at least one to two years, if not indefinitely35.  Among adult patients with PTSD, fluoxetine, paroxetine, sertraline, and venlafaxine are appropriate choices, with none showing improved efficacy over the others36.  For SAD, SSRIs and SNRIs venlafaxine are the clear first-line pharmacotherapy treatment based on demonstrated efficacy in randomized controlled trials and meta-analyses. Medications in these classes that have been FDA-approved in the U.S. are paroxetine (immediate-release and controlled release), sertraline, fluvoxamine controlled release, and venlafaxine extended release. Other medications in these classes with evidence of efficacy from randomized controlled trials include citalopram, escitalopram, and vilazodone. Fluoxetine has had mixed results in randomized controlled trials. SNRIs should be used with caution in patients at risk for suicide due to greater toxicity in overdose. No individual medication within this class has been consistently shown to be superior to another in this class37.

Neuropathic Pain

First-line treatment for neuropathic pain include TCAs, gabapentin, pregabalin, and SNRI antidepressants (duloxetine [most studied], venlafaxine) as first-line therapies.38 For patients with diabetic neuropathy, only two medications, pregabalin and duloxetine, have been approved by the FDA.  However, in addition to those two medications, gabapentin and amitriptyline are considered first-line therapy.  SNRIs such as venlafaxine and desvenlafaxine are considered second-line therapy.  SSRIs such as citalopram, paroxetine, and escitalopram are considered third-line therapy39.

Fibromyalgia

Pharmaceutical therapy recommendations depend on the source of the guideline.  Guidelines are available from the European League Against Rheumatism (EULAR-2016), the Canadian Pain Society (2012) and the Association of the Scientific Medical Societies in Germany (AWMF-2012).  Recommendations from these guidelines include amitriptyline, pregabalin, gabapentin, SNRIs (including duloxetine and milnacipran), and SSRIs.  Amitriptyline, pregabalin, and duloxetine are used most commonly40.

Chronic Musculoskeletal Pain

Antidepressants are options for the treatment of chronic pain.  Meta-analyses of randomized controlled trials indicate that TCAs and SNRIs provide effective pain relief for a variety of chronic pain etiologies41.  Duloxetine is FDA approved for chronic musculoskeletal pain13.

Adverse Effects

All of the above listed agents have had a black box warning issued by the FDA.  The warning concerns suicidal thoughts and behaviors.  Since there are small differences between the warnings, they are not listed here.  Please see the respective agent’s prescribing information for the warning.

REFERENCES

  1. Celexa prescribing information.  Allergan USA, Inc. January 2019. 
  2. Citalopram solution prescribing information.  Aurobindo Pharma Limited.  September 2019.
  3. Fluoxetine 60 mg tablet prescribing information.  Nivagen Pharmaceuticals, Inc.  May 2019.
  4. Fluvoxamine extended-release capsules prescribing information.  Actavis Pharma, Inc.  November 2017.
  5. Fluvoxamine tablet prescribing information. ANI Pharmaceuticals, Inc.  January 2017.
  6. Lexapro prescribing information.  Allergan USA, Inc.  January 2019.
  7. Paxil prescribing information.  GlaxoSmithKline.  October 2016.
  8. Paxil CR prescribing information.  Apotex Corp.  September 2019.
  9. Pexeva prescribing information.  Sebela Pharmaceuticals, Inc.  January 2017.
  10. Fluoxetine delayed release capsule prescribing information.  Dr. Reddy’s Laboratories Limited.  May 2017.
  11. Prozac prescribing information.  Eli Lilly and Company.  March 2017.
  12. Zoloft prescribing information.  Pfizer, Inc.  April 2019. 
  13. Cymbalta prescribing information.  Eli Lilly and Company.  October 2019.
  14. Drizalma Sprinkle prescribing information.  Sun Pharmaceutical Industries Limited.  July 2019.
  15. Venlafaxine tablets prescribing information.  Aurobindo Pharma Limited.  February 2019.
  16. Effexor XR prescribing information.  Pfizer, Inc.  December 2018. 
  17. Fetzima prescribing information.  Allergan USA, Inc.  October 2019.
  18. Khedezla prescribing information.  Pernix Therapeutics, LLC.  January 2019. 
  19. Irenka prescribing information.  Lupin Pharma.  June 2015.
  20. Pristiq prescribing information.  Pfizer, Inc.  November 2018. 
  21. Venlafaxine ER tablets prescribing information.  Nivagen Pharmaceuticals, Inc.  February 2019. 
  22. Aplenzin prescribing information.  Valeant Pharmaceuticals North America, LLC.  May 2017.
  23. Forfivo prescribing information.  Almatica Pharma, Inc.  May 2017.
  24. Maprotiline prescribing information.  Mylan Pharmaceuticals, Inc.  December 2014. 
  25. Remeron prescribing information.  Merck & Co, Inc.  September 2019. 
  26. Remeron SolTab prescribing information.  Merck & Co, Inc.  September 2019
  27. Trintellix prescribing information.  Takeda Pharmaceuticals America, Inc.  July 2019. 
  28. Viibryd prescribing information.  Allergan, Inc.  May 2018. 
  29. Bupropion prescribing information.  Cipla USA, Inc.  November 2017.
  30. Wellbutrin SR prescribing information.  GlaxoSmithKline, LLC.  November 2019. 
  31. Wellbutrin XL prescribing information.  Bausch Health Companies, Inc.  November 2019. 
  32. Halverson J, Beevers C, Kamholz B.  Clinical Practice Review for Major Depressive Disorder.  Anxiety and Depression Association of America, February 2, 2016.  Accessed 11/18/2019.  Available at: https://adaa.org/resources-professionals/practice-guidelines-mdd
  33. Kennedy SH, Lam RW, McIntyre RS, et. al.  Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder. Canadian Journal Psychiatry. 2016, Vol. 61(9) 540-560.  Accessed 11/18/2019.  Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994790/pdf/10.1177_0706743716659417.pdf
  34. Locke AB, Kirst N, Shuultz CG.  Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults.  Am Fam Physician. 2015 May 1;91(9):617-624.  Accessed 11/18/2019.  Available at: https://www.aafp.org/afp/2015/0501/p617.html
  35. Fenske JN, Petersen K.  Obsessive-Compulsive Disorder: Diagnosis and Management.  Am Fam Physician. 2015 Nov 15;92(10):896-903.  Accessed 11/18/2019.  Available at: https://www.aafp.org/afp/2015/1115/p896.html
  36. Courtois CA, Sonis J, Brown LS, et. al.  Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults.  American Psychological Association.  Accessed 11/18/2019.  Available at: https://www.apa.org/ptsd-guideline/ptsd.pdf
  37. van Amerigen M, Heimberg RG, Schneier F, et. al.  Clinical Practice Review for Social Anxiety Disorder.  Anxiety and Depression Association of America.  September 15, 2015.  Accessed 11/18/2019.  Available at: https://adaa.org/resources-professionals/clinical-practice-review-social-anxiety
  38. Gilron I, Baron R, Jensen T.  Neuropathic Pain: Principles of Diagnosis and Treatment.  Mayo Clinic Proceedings, April 2015.  Accessed: 11/18/2019.  Available at: https://www.mayoclinicproceedings.org/article/S0025-6196(15)00105-6/fulltext#sec6
  39. Snyder MJ, Gibbs LM, Lindsay TJ.  Treating Painful Diabetic Peripheral Neuropathy: An Update.  American Family Physician.  2016 Aug 1;94(3):227-234.  Accessed 11/18/2019.  Available at: https://www.aafp.org/afp/2016/0801/p227.html
  40. Kia S, Choy E.  Update on Treatment Guideline in Fibromyalgia Syndrome with Focus on Pharmacology.  Biomedicines.  2017 Jun; 5(2): 20.  Accessed 11/18/2019.  Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5489806/
  41. American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management. Anesthesiology. 2010;112:810-833.  Accessed 11/18/2019.  Available at:  https://anesthesiology.pubs.asahq.org/article.aspx?articleid=1932775.

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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