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Wellbutrin SR — Blue Cross Blue Shield of Oklahoma

major depressive disorder or other labeled uses of antidepressants

Preferred products

  • generic antidepressant agent (i.e., SSRI, SNRI, bupropion, mirtazapine, vilazodone)

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 peer-reviewed, evidence-based literature, and approved by the FDA 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 and is currently stable on the requested agent [chart notes required] OR
  • C. The patient has tried and had an inadequate response to a generic antidepressant agent (SSRI, SNRI, bupropion, mirtazapine, or vilazodone) [chart notes required] OR
  • D. A generic antidepressant was discontinued due to lack of efficacy, diminished effect, or an adverse event [chart notes required] OR
  • E. The patient has an intolerance or hypersensitivity to a generic antidepressant agent [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, cause adherence barriers, worsen a comorbid condition, decrease ability to perform daily activities, or cause an adverse reaction or harm [chart notes required] OR
  • H. A generic antidepressant is not in the best interest of the patient based on medical necessity [chart notes required] OR
  • I. The patient has tried another prescription drug in the same pharmacologic class or mechanism as a generic antidepressant and discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required]

Approval duration

12 months