Antidepressants

← Back to Class List

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 but eligible patients will encounter a co-pay at the pharmacy.
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 AMITRIPTYLINE HCL TABLET Y    
BUPROPION HCL BUPROPION HCL SR TAB ER 12H Y    
BUPROPION HCL WELLBUTRIN SR TAB ER 12H Y    
BUPROPION HCL BUPROPION HCL TABLET Y    
CITALOPRAM HYDROBROMIDE CITALOPRAM HBR SOLUTION Y Age Restriction  
CITALOPRAM HYDROBROMIDE CELEXA TABLET Y Age Restriction  
CITALOPRAM HYDROBROMIDE CITALOPRAM HBR TABLET Y Age Restriction  
CLOMIPRAMINE HCL ANAFRANIL CAPSULE Y    
DESIPRAMINE HCL NORPRAMIN TABLET Y    
DESIPRAMINE HCL DESIPRAMINE HCL TABLET Y    
DOXEPIN HCL DOXEPIN HCL CAPSULE Y    
DOXEPIN HCL DOXEPIN HCL ORAL CONC Y    
ESCITALOPRAM OXALATE LEXAPRO TABLET Y Age Restriction  
ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE TABLET Y Age Restriction  
FLUOXETINE HCL FLUOXETINE HCL CAPSULE Y Age Restriction  
FLUOXETINE HCL PROZAC CAPSULE Y Age Restriction  
FLUOXETINE HCL FLUOXETINE HCL SOLUTION Y Age Restriction  
FLUOXETINE HCL SARAFEM TABLET Y Age Restriction  
FLUOXETINE HCL FLUOXETINE HCL TABLET Y Age Restriction  
FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE TABLET Y Age Restriction  
IMIPRAMINE HCL TOFRANIL TABLET Y    
IMIPRAMINE HCL IMIPRAMINE HCL TABLET Y    
MAPROTILINE HCL MAPROTILINE HCL TABLET Y    
MIRTAZAPINE REMERON TAB RAPDIS Y    
MIRTAZAPINE MIRTAZAPINE TAB RAPDIS Y    
MIRTAZAPINE REMERON TABLET Y    
MIRTAZAPINE MIRTAZAPINE TABLET Y    
NORTRIPTYLINE HCL PAMELOR CAPSULE Y    
NORTRIPTYLINE HCL NORTRIPTYLINE HCL CAPSULE Y    
NORTRIPTYLINE HCL NORTRIPTYLINE HCL SOLUTION Y    
PAROXETINE HCL PAROXETINE HCL TABLET Y Age Restriction  
PAROXETINE HCL PAXIL TABLET Y Age Restriction  
PROTRIPTYLINE HCL PROTRIPTYLINE HCL TABLET Y    
SERTRALINE HCL SERTRALINE HCL ORAL CONC Y Age Restriction  
SERTRALINE HCL ZOLOFT ORAL CONC Y Age Restriction  
SERTRALINE HCL SERTRALINE HCL TABLET Y Age Restriction  
SERTRALINE HCL ZOLOFT TABLET Y Age Restriction  
TRIMIPRAMINE MALEATE SURMONTIL CAPSULE Y    
TRIMIPRAMINE MALEATE TRIMIPRAMINE MALEATE CAPSULE Y    
VENLAFAXINE HCL EFFEXOR XR CAP ER 24H Y    
VENLAFAXINE HCL VENLAFAXINE HCL ER CAP ER 24H Y    
VENLAFAXINE HCL VENLAFAXINE HCL TABLET Y    
BUPROPION HBR APLENZIN TAB ER 24H V    
BUPROPION HCL BUPROPION XL TAB ER 24H V    
BUPROPION HCL FORFIVO XL TAB ER 24H V    
BUPROPION HCL WELLBUTRIN XL TAB ER 24H V    
CLOMIPRAMINE HCL CLOMIPRAMINE HCL CAPSULE V    
DESVENLAFAXINE KHEDEZLA TAB ER 24 V    
DESVENLAFAXINE DESVENLAFAXINE ER TAB ER 24 V    
DESVENLAFAXINE DESVENLAFAXINE ER TAB ER 24H V    
DESVENLAFAXINE FUMARATE DESVENLAFAXINE FUMARATE ER TAB ER 24 V    
DESVENLAFAXINE SUCCINATE DESVENLAFAXINE SUCCINATE ER TAB ER 24H V    
DESVENLAFAXINE SUCCINATE PRISTIQ TAB ER 24H V    
DULOXETINE HCL DULOXETINE HCL CAPSULE DR V    
DULOXETINE HCL CYMBALTA CAPSULE DR V    
ESCITALOPRAM OXALATE ESCITALOPRAM OXALATE SOLUTION V Age Restriction  
FLUOXETINE HCL FLUOXETINE DR CAPSULE DR V Age Restriction  
FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE ER CAP ER 24H V Age Restriction  
IMIPRAMINE PAMOATE IMIPRAMINE PAMOATE CAPSULE V    
ISOCARBOXAZID MARPLAN TABLET V    
LEVOMILNACIPRAN HCL FETZIMA CAP SA 24H V    
LEVOMILNACIPRAN HCL FETZIMA CAP24HDSPK V    
NEFAZODONE HCL NEFAZODONE HCL TABLET V    
PAROXETINE HCL PAXIL ORAL SUSP V Age Restriction  
PAROXETINE HCL PAROXETINE CR TAB ER 24H V Age Restriction  
PAROXETINE HCL PAROXETINE ER TAB ER 24H V Age Restriction  
PAROXETINE HCL PAXIL CR TAB ER 24H V Age Restriction  
PAROXETINE MESYLATE BRISDELLE CAPSULE V Age Restriction  
PAROXETINE MESYLATE PEXEVA TABLET V Age Restriction  
PHENELZINE SULFATE PHENELZINE SULFATE TABLET V    
PHENELZINE SULFATE NARDIL TABLET V    
SELEGILINE EMSAM PATCH TD24 V    
TRANYLCYPROMINE SULFATE TRANYLCYPROMINE SULFATE TABLET V    
TRANYLCYPROMINE SULFATE PARNATE TABLET V    
VENLAFAXINE HCL VENLAFAXINE HCL ER TAB ER 24 V    
VILAZODONE HCL VIIBRYD TAB DS PK V    
VILAZODONE HCL VIIBRYD TABLET V    
VORTIOXETINE HYDROBROMIDE TRINTELLIX TABLET V    
AMOXAPINE AMOXAPINE TABLET    
MILNACIPRAN HCL SAVELLA TAB DS PK PA Document  
MILNACIPRAN HCL SAVELLA TABLET PA Document  
TRAZODONE HCL TRAZODONE HCL TABLET