Prozac — Blue Cross Blue Shield of Alabama

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 that the patient has been treated with the requested agent within the past 180 days AND is at risk if therapy is changed OR
• - The request is for Auvelity AND ONE of the following:
• - The patient has a medication history of use in the past 365 days to TWO prerequisite agents OR
• - Has a medication history of use in the past 365 days to ONE prerequisite agent and an intolerance or hypersensitivity to ONE prerequisite agent OR
• - Has an intolerance or hypersensitivity to TWO prerequisite agents OR
• - Has an FDA labeled contraindication to ALL prerequisite agents OR
• - The request is for a medication other than Auvelity AND ONE of the following:
• - Has a medication history of use in the past 365 days to ONE prerequisite agent OR
• - Has an intolerance or hypersensitivity to ONE prerequisite agent OR
• - Has an FDA labeled contraindication to ALL prerequisite agents

Approval duration

12 months