Antidepressants
PDL Reference Documents
- Esketamine - Feb 01, 2024
- Antidepressants - Dec 07, 2023
- Antidepressants - Feb 02, 2023
- Antidepressants - Feb 04, 2021
- Antidepressants - Jul 25, 2019
- Fibromyalgia Indication Review - Jan 24, 2019
- Neuropathic Pain - Jul 26, 2018
- Antidepressants - Nov 30, 2017
- Nonanalgesics for Pain Class Update - Mar 23, 2017
- Antidepressants - Jul 28, 2016
- First-generation Antidepressants - Sep 23, 2014
- Antidepressant Class Update and New Drug Evaluations - May 29, 2014
- DERP Drug Class Review Executive Summary: Neuropathic Pain - Feb 23, 2012
Drug Use Review Documents
- Duplicate Therapy Drug Evaluation - Dec 01, 2022
- Combination Use of Antipsychotics and Other Psychotropic Drugs - Apr 01, 2021
- Tricyclic Antidepressants in Children - Nov 21, 2019
- Fibromyalgia Review and Drug Use Evaluation - Mar 26, 2015
- Pediatric SSRI High Dose Initiation DUE - Nov 20, 2014
- Retrospective Drug Use Review for the Use of Psychotropic Medications in Children - Sep 26, 2013
Newsletters
- May 2022 - Population Trends in the Use of Migraine Preventative Treatments
- February 2021 - Anitdepressant Review
- December 2017 - Current Landscape of the Antidepressant Class: First Line Agents, Newer Agents, and Safety Risks
- March 2017 - Non-Analgesics for Pain Management
- February 2015 - Evaluation of High Dose SSRI Initiation in Pediatrics and Young Adults
- June 2014 - Update on New Therapies for Major Depressive Disorder
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | New Drug Evaluation |
---|---|---|---|---|---|
amitriptyline HCl | ELAVIL | TABLET | Y | Age Restriction | |
amitriptyline HCl | AMITRIPTYLINE HCL | TABLET | Y | Age Restriction | |
bupropion HCl | BUPROPION XL | TAB ER 24H | Y | ||
bupropion HCl | WELLBUTRIN XL | TAB ER 24H | Y | ||
bupropion HCl | BUPROPION HCL SR | TAB SR 12H | Y | ||
bupropion HCl | WELLBUTRIN SR | TAB SR 12H | Y | ||
bupropion HCl | BUPROPION HCL | TABLET | Y | ||
citalopram hydrobromide | CITALOPRAM HBR | SOLUTION | Y | ||
citalopram hydrobromide | CITALOPRAM HBR | TABLET | Y | ||
citalopram hydrobromide | CELEXA | TABLET | Y | ||
desipramine HCl | NORPRAMIN | TABLET | Y | Age Restriction | |
desipramine HCl | DESIPRAMINE HCL | TABLET | Y | Age Restriction | |
desvenlafaxine succinate | DESVENLAFAXINE SUCCINATE ER | TAB ER 24H | Y | ||
desvenlafaxine succinate | PRISTIQ | TAB ER 24H | Y | ||
doxepin HCl | DOXEPIN HCL | CAPSULE | Y | Age Restriction | |
doxepin HCl | DOXEPIN HCL | ORAL CONC | Y | Age Restriction | |
duloxetine HCl | CYMBALTA | CAPSULE DR | Y | ||
duloxetine HCl | DULOXETINE HCL | CAPSULE DR | Y | ||
escitalopram oxalate | LEXAPRO | TABLET | Y | ||
escitalopram oxalate | ESCITALOPRAM OXALATE | TABLET | Y | ||
fluoxetine HCl | PROZAC | CAPSULE | Y | ||
fluoxetine HCl | FLUOXETINE HCL | CAPSULE | Y | ||
fluoxetine HCl | FLUOXETINE HCL | SOLUTION | Y | ||
fluoxetine HCl | FLUOXETINE HCL | TABLET | Y | ||
fluvoxamine maleate | FLUVOXAMINE MALEATE | TABLET | Y | ||
imipramine HCl | IMIPRAMINE HCL | TABLET | Y | Age Restriction | |
mirtazapine | REMERON | TAB RAPDIS | Y | ||
mirtazapine | MIRTAZAPINE | TAB RAPDIS | Y | ||
mirtazapine | REMERON | TABLET | Y | ||
mirtazapine | MIRTAZAPINE | TABLET | Y | ||
nefazodone HCl | NEFAZODONE HCL | TABLET | Y | ||
nortriptyline HCl | PAMELOR | CAPSULE | Y | Age Restriction | |
nortriptyline HCl | NORTRIPTYLINE HCL | CAPSULE | Y | Age Restriction | |
nortriptyline HCl | NORTRIPTYLINE HCL | SOLUTION | Y | Age Restriction | |
paroxetine HCl | PAXIL | TABLET | Y | ||
paroxetine HCl | PAROXETINE HCL | TABLET | Y | ||
sertraline HCl | ZOLOFT | ORAL CONC | Y | ||
sertraline HCl | SERTRALINE HCL | ORAL CONC | Y | ||
sertraline HCl | ZOLOFT | TABLET | Y | ||
sertraline HCl | SERTRALINE HCL | TABLET | Y | ||
venlafaxine HCl | EFFEXOR XR | CAP ER 24H | Y | ||
venlafaxine HCl | VENLAFAXINE HCL ER | CAP ER 24H | Y | ||
venlafaxine HCl | VENLAFAXINE HCL | TABLET | Y | ||
amoxapine | AMOXAPINE | TABLET | V | Age Restriction | |
bupropion HBr | APLENZIN | TAB ER 24H | V | ||
bupropion HCl | FORFIVO XL | TAB ER 24H | V | ||
bupropion HCl | BUPROPION XL | TAB ER 24H | V | ||
citalopram hydrobromide | CITALOPRAM HBR | CAPSULE | V | ||
clomipramine HCl | CLOMIPRAMINE HCL | CAPSULE | V | Age Restriction | |
clomipramine HCl | ANAFRANIL | CAPSULE | V | Age Restriction | |
desvenlafaxine | DESVENLAFAXINE ER | TAB ER 24H | V | ||
dextromethorphan HBr/bupropion | AUVELITY | TAB IR ER | V | ||
duloxetine HCl | DRIZALMA SPRINKLE | CAP DR SPR | V | ||
escitalopram oxalate | ESCITALOPRAM OXALATE | SOLUTION | V | ||
esketamine HCl | SPRAVATO | SPRAY | V | PA Document | |
fluoxetine HCl | FLUOXETINE DR | CAPSULE DR | V | ||
fluvoxamine maleate | FLUVOXAMINE MALEATE ER | CAP ER 24H | V | ||
imipramine pamoate | IMIPRAMINE PAMOATE | CAPSULE | V | Age Restriction | |
isocarboxazid | MARPLAN | TABLET | V | ||
levomilnacipran HCl | FETZIMA | CAP SA 24H | V | ||
levomilnacipran HCl | FETZIMA | CAP24HDSPK | V | ||
paroxetine HCl | PAROXETINE HCL | ORAL SUSP | V | ||
paroxetine HCl | PAXIL | ORAL SUSP | V | ||
paroxetine HCl | PAXIL CR | TAB ER 24H | V | ||
paroxetine HCl | PAROXETINE ER | TAB ER 24H | V | ||
paroxetine HCl | PAROXETINE CR | TAB ER 24H | V | ||
paroxetine mesylate | PEXEVA | TABLET | V | ||
phenelzine sulfate | NARDIL | TABLET | V | ||
phenelzine sulfate | PHENELZINE SULFATE | TABLET | V | ||
protriptyline HCl | PROTRIPTYLINE HCL | TABLET | V | Age Restriction | |
selegiline | EMSAM | PATCH TD24 | V | ||
sertraline HCl | SERTRALINE HCL | CAPSULE | V | ||
tranylcypromine sulfate | TRANYLCYPROMINE SULFATE | TABLET | V | ||
trimipramine maleate | TRIMIPRAMINE MALEATE | CAPSULE | V | Age Restriction | |
venlafaxine besylate | VENLAFAXINE BESYLATE ER | TAB ER 24 | V | ||
venlafaxine HCl | VENLAFAXINE HCL ER | TAB ER 24 | V | ||
vilazodone HCl | VIIBRYD | TABLET | V | ||
vilazodone HCl | VILAZODONE HCL | TABLET | V | ||
vortioxetine hydrobromide | TRINTELLIX | TABLET | V | ||
zuranolone | ZURZUVAE | CAPSULE | V | PA Document | |
brexanolone | ZULRESSO | VIAL | PA Document | ||
bupropion HCl | BUPROPION HCL | TABLET | |||
escitalopram oxalate | ESCITALOPRAM OXALATE | TABLET | |||
olanzapine/fluoxetine HCl | SYMBYAX | CAPSULE | |||
olanzapine/fluoxetine HCl | OLANZAPINE-FLUOXETINE HCL | CAPSULE | |||
trazodone HCl | TRAZODONE HCL | TABLET |