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Fetzima — Blue Cross Blue Shield of Illinois

chronic musculoskeletal pain

Preferred products

  • any generic antidepressant agent (i.e., SSRI, SNRI, bupropion, mirtazapine, vilazodone)
  • duloxetine delayed-release (for Cymbalta/Drizalma prerequisite use)
  • amitriptyline
  • nortriptyline
  • desipramine
  • imipramine
  • gabapentin
  • cyclobenzaprine
  • tramadol
  • acetaminophen
  • oral NSAID
  • topical NSAID

Initial criteria

  • Target Agent(s) will be approved when ONE of the following is met:
  • 1. BOTH of the following:
  • A. ONE of the following:
  • 1. Prescriber has stated patient has stage four advanced, metastatic cancer and requested agent is being used to treat the cancer OR
  • 2. Prescriber has submitted documentation patient diagnosed with stage four advanced, metastatic cancer and requested agent is being used to treat an associated condition related to stage four advanced metastatic cancer [chart notes required] AND
  • B. Use of requested agent is consistent with best practices for treatment of stage four advanced, metastatic cancer, or an associated condition; supported by peer-reviewed, evidence-based literature; and approved by the United States Food and Drug Administration
  • OR
  • 2. ONE of the following:
  • A. Patient has been treated with the requested agent within the past 180 days OR
  • B. Patient is currently being treated with the requested agent AND is currently stable on the requested agent [chart notes required] OR
  • C. Patient has tried and had an inadequate response to a generic antidepressant agent (i.e., SSRI, SNRI, bupropion, mirtazapine, or vilazodone) [chart notes required] OR
  • D. A generic antidepressant agent was discontinued due to lack of efficacy, effectiveness, diminished effect, or an adverse event [chart notes required] OR
  • E. Patient has an intolerance or hypersensitivity to a generic antidepressant agent [chart notes required] OR
  • F. Patient has an FDA labeled contraindication to ALL generic antidepressants [chart notes required] OR
  • G. A generic antidepressant agent is expected to be ineffective based on known clinical characteristics of patient and drug; OR cause a significant barrier to adherence; OR worsen comorbid condition; OR decrease ability to maintain reasonable functional ability; OR cause adverse reaction or physical/mental harm [chart notes required] OR
  • H. A generic antidepressant agent is not in the best interest of the patient based on medical necessity [chart notes required] OR
  • I. Patient has tried another prescription drug in the same pharmacologic class or mechanism of action as a generic antidepressant agent and discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required]

Approval duration

12 months