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Drizalma Sprinkle (duloxetine delayed-release) — Blue Cross Blue Shield of Kansas

chronic musculoskeletal pain

Preferred products

  • duloxetine delayed-release (generic)

Initial criteria

  • 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 (i.e., SSRI, SNRI, bupropion, mirtazapine, or vilazodone) OR
  • The patient has a diagnosis of neuropathic pain AND ONE of the following: (1) medication history of use in the past 90 days to ONE prerequisite agent (duloxetine delayed-release, amitriptyline, nortriptyline, desipramine, imipramine, or gabapentin) OR (2) intolerance or hypersensitivity to ONE prerequisite agent OR (3) FDA labeled contraindication to ALL prerequisite agents OR
  • The patient has a diagnosis of fibromyalgia AND ONE of the following: (1) 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 (2) intolerance or hypersensitivity to ONE prerequisite agent OR (3) FDA labeled contraindication to ALL prerequisite agents OR
  • The patient has a diagnosis of chronic musculoskeletal pain AND ONE of the following: (1) 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 (2) intolerance or hypersensitivity to ONE prerequisite agent OR (3) FDA labeled contraindication to ALL prerequisite agents OR
  • For diagnoses other than neuropathic pain, fibromyalgia, or musculoskeletal pain, ONE of the following: (1) intolerance or hypersensitivity to a generic antidepressant (SSRI, SNRI, bupropion, mirtazapine, or vilazodone) OR (2) FDA labeled contraindication to ALL generic antidepressants

Approval duration

12 months