Antidepressants

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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    
citalopram hydrobromide CELEXA TABLET Y    
citalopram hydrobromide CITALOPRAM HBR TABLET 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 ESCITALOPRAM OXALATE TABLET Y    
escitalopram oxalate LEXAPRO TABLET Y    
fluoxetine HCl PROZAC CAPSULE Y    
fluoxetine HCl FLUOXETINE HCL CAPSULE Y    
fluoxetine HCl FLUOXETINE HCL SOLUTION Y    
fluoxetine HCl SARAFEM TABLET Y    
fluoxetine HCl FLUOXETINE HCL TABLET Y    
fluvoxamine maleate FLUVOXAMINE MALEATE TABLET Y    
imipramine HCl IMIPRAMINE HCL TABLET Y    
imipramine HCl TOFRANIL TABLET Y    
maprotiline HCl MAPROTILINE HCL TABLET Y    
mirtazapine MIRTAZAPINE TAB RAPDIS Y    
mirtazapine REMERON TAB RAPDIS Y    
mirtazapine MIRTAZAPINE TABLET Y    
mirtazapine REMERON 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    
paroxetine HCl PAXIL TABLET Y    
protriptyline HCl PROTRIPTYLINE HCL TABLET Y    
sertraline HCl SERTRALINE HCL ORAL CONC Y    
sertraline HCl ZOLOFT ORAL CONC Y    
sertraline HCl SERTRALINE HCL TABLET Y    
sertraline HCl ZOLOFT TABLET Y    
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 ANAFRANIL CAPSULE V    
clomipramine HCl CLOMIPRAMINE HCL CAPSULE V    
desvenlafaxine DESVENLAFAXINE ER TAB ER 24 V    
desvenlafaxine KHEDEZLA TAB ER 24 V    
desvenlafaxine DESVENLAFAXINE ER TAB ER 24H V    
desvenlafaxine fumarate DESVENLAFAXINE FUMARATE ER TAB ER 24 V    
desvenlafaxine succinate PRISTIQ TAB ER 24H V    
desvenlafaxine succinate DESVENLAFAXINE SUCCINATE ER TAB ER 24H V    
duloxetine HCl DULOXETINE HCL CAPSULE DR V    
duloxetine HCl CYMBALTA CAPSULE DR V    
escitalopram oxalate ESCITALOPRAM OXALATE SOLUTION V    
fluoxetine HCl FLUOXETINE DR CAPSULE DR V    
fluvoxamine maleate FLUVOXAMINE MALEATE ER CAP ER 24H V    
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 PAROXETINE HCL ORAL SUSP V    
paroxetine HCl PAXIL ORAL SUSP V    
paroxetine HCl PAROXETINE ER TAB ER 24H V    
paroxetine HCl PAROXETINE CR TAB ER 24H V    
paroxetine HCl PAXIL CR TAB ER 24H V    
paroxetine mesylate PEXEVA TABLET V    
phenelzine sulfate PHENELZINE SULFATE TABLET V    
phenelzine sulfate NARDIL TABLET V    
selegiline EMSAM PATCH TD24 V    
tranylcypromine sulfate PARNATE TABLET V    
tranylcypromine sulfate TRANYLCYPROMINE SULFATE 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    
trazodone HCl OLEPTRO ER TAB ER 24H    
trazodone HCl TRAZODONE HCL TABLET