Viibryd (vilazodone) — Blue Cross Blue Shield of Montana

Neuropathic pain

Preferred products

Citalopram capsule
Desvenlafaxine Extended Release tablet
Escitalopram capsule
Fluoxetine 60 mg tablet
Fluoxetine Delayed-Release capsule
Venlafaxine Extended-Release tablet

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. The prescriber has stated that the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer OR
2. The prescriber has submitted documentation that the patient has been diagnosed with stage four advanced, metastatic cancer and the requested agent is being used to treat an associated condition related to stage four advanced metastatic cancer [chart notes required]
AND
B. The use of the requested agent is consistent with best practices for the treatment of stage four advanced, metastatic cancer or an associated condition; supported by evidence-based literature; and FDA-approved
OR
2. ONE of the following:
A. The patient has been treated with the requested agent within the past 180 days OR
B. The patient is currently being treated with the requested agent AND is currently stable [chart notes required] OR
C. The patient has tried and had an inadequate response to a generic antidepressant (SSRI, SNRI, bupropion, mirtazapine, or vilazodone) [chart notes required] OR
D. A generic antidepressant was discontinued due to lack of efficacy or adverse event [chart notes required] OR
E. The patient has intolerance or hypersensitivity to a generic antidepressant [chart notes required] OR
F. The patient has an FDA labeled contraindication to ALL generic antidepressants [chart notes required] OR
G. A generic antidepressant is expected to be ineffective or cause harm/adherence barrier/worsen comorbid condition [chart notes required] OR
H. Generic antidepressant not in patient’s best interest based on medical necessity [chart notes required] OR
I. The patient has tried another drug in same pharmacologic class with inadequate response or adverse event [chart notes required]
For Cymbalta/Drizalma specifically:
Target Agent(s) will be approved when ONE of the following is met:
1. BOTH of the following (stage four cancer criteria as above) OR
2. ONE of the following categories:
A. Current treatment or treatment within past 180 days OR stable on requested agent [chart notes required] OR
B. Inadequate response/intolerance/contraindication to generic antidepressants [chart notes required] OR
C. Diagnosis of neuropathic pain and inadequate response/intolerance/contraindication to ONE prerequisite (duloxetine delayed-release, amitriptyline, nortriptyline, desipramine, imipramine, or gabapentin) [chart notes required] OR
D. Diagnosis of fibromyalgia and inadequate response/intolerance/contraindication to ONE prerequisite (duloxetine delayed-release, amitriptyline, nortriptyline, desipramine, imipramine, cyclobenzaprine, gabapentin, or tramadol) [chart notes required] OR
E. Diagnosis of chronic musculoskeletal pain and inadequate response/intolerance/contraindication to ONE prerequisite (duloxetine delayed-release, acetaminophen, oral NSAID, topical NSAID, tramadol, amitriptyline, nortriptyline, desipramine, imipramine, cyclobenzaprine, or gabapentin) [chart notes required] OR
F. A prerequisite agent discontinued due to lack of efficacy or adverse event [chart notes required] OR
G. A prerequisite agent expected to be ineffective or cause harm or adherence barrier [chart notes required] OR
H. A prerequisite agent not in best interest based on medical necessity [chart notes required] OR
I. Tried another drug in same class as prerequisite with inadequate response/adverse event [chart notes required] OR
J. For diagnoses other than neuropathic pain, fibromyalgia, or musculoskeletal pain, intolerance or contraindication to generic antidepressants

Approval duration

12 months