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Cymbalta — Blue Cross Blue Shield of Alabama

neuropathic pain

Preferred products

  • generic antidepressant agents – SSRI, SNRI, bupropion, mirtazapine, vilazodone

Initial criteria

  • Target Agent(s) will be approved when ONE of the following is met:
  • - The patient has been treated with the requested agent within the past 180 days OR
  • - The prescriber states the patient has been treated with the requested agent within the past 180 days AND is at risk if therapy is changed OR
  • - The patient has a medication history of use in the past 365 days that includes use of a generic antidepressant agent (SSRI, SNRI, bupropion, mirtazapine, or vilazodone) OR
  • - The patient has a diagnosis of neuropathic pain AND ONE of the following:
  • - Has a medication history of use in the past 90 days to ONE prerequisite agent (duloxetine delayed-release, amitriptyline, nortriptyline, desipramine, imipramine, or gabapentin) OR
  • - Has an intolerance or hypersensitivity to ONE prerequisite agent OR
  • - Has an FDA labeled contraindication to ALL prerequisite agents OR
  • - The patient has a diagnosis of fibromyalgia AND ONE of the following:
  • - Has a medication history of use in the past 90 days to ONE prerequisite agent (duloxetine delayed-release, amitriptyline, nortriptyline, desipramine, imipramine, cyclobenzaprine, gabapentin, or tramadol) OR
  • - Has an intolerance or hypersensitivity to ONE prerequisite agent OR
  • - Has an FDA labeled contraindication to ALL prerequisite agents OR
  • - The patient has a diagnosis of chronic musculoskeletal pain AND ONE of the following:
  • - Has a medication history of use in the past 90 days to ONE prerequisite agent (duloxetine delayed-release, acetaminophen, oral NSAID, topical NSAID, tramadol, amitriptyline, nortriptyline, desipramine, imipramine, cyclobenzaprine, or gabapentin) OR
  • - Has an intolerance or hypersensitivity to ONE prerequisite agent OR
  • - Has an FDA labeled contraindication to ALL prerequisite agents OR
  • - If using for a diagnosis other than neuropathic pain, fibromyalgia, or musculoskeletal pain, then ONE of the following:
  • - Has an intolerance or hypersensitivity to a generic antidepressant (SSRI, SNRI, bupropion, mirtazapine, vilazodone) OR
  • - Has an FDA labeled contraindication to ALL generic antidepressants (SSRI, SNRI, bupropion, mirtazapine, vilazodone)

Approval duration

12 months