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Wellbutrin SR — Blue Cross Blue Shield of Texas

neuropathic pain

Preferred products

  • any generic antidepressant (SSRI, SNRI, bupropion, mirtazapine, vilazodone)
  • duloxetine delayed-release
  • 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) 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 stable on the requested agent [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, effectiveness, diminished effect, or adverse event [chart notes required] OR
  • E. The patient has an intolerance or hypersensitivity to a generic antidepressant (SSRI, SNRI, bupropion, mirtazapine, or vilazodone) [chart notes required] OR
  • F. The patient has an FDA labeled contraindication to ALL generic antidepressants (SSRI, SNRI, bupropion, mirtazapine, or vilazodone) [chart notes required] OR
  • G. A generic antidepressant is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the drug; OR would cause adherence barriers, worsen a comorbid condition, decrease functional ability, 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 with the same mechanism as a generic antidepressant, discontinued for lack of efficacy or adverse event [chart notes required].
  • For Cymbalta/Drizalma (duloxetine delayed-release): Target Agent(s) will be approved when ONE of the following is met:
  • 1. BOTH of the following (stage four advanced, metastatic cancer use as above) OR 2. ONE of the following:
  • A. The patient has been treated with or is currently stable on the requested agent [chart notes required] OR
  • B. Inadequate response/intolerance/contraindication to a generic antidepressant [chart notes required] OR
  • C. For neuropathic pain – inadequate response/intolerance/contraindication to ONE prerequisite agent (duloxetine delayed-release, amitriptyline, nortriptyline, desipramine, imipramine, or gabapentin) [chart notes required] OR
  • D. For fibromyalgia – inadequate response/intolerance/contraindication to ONE prerequisite agent (duloxetine delayed-release, amitriptyline, nortriptyline, desipramine, imipramine, cyclobenzaprine, gabapentin, or tramadol) [chart notes required] OR
  • E. For chronic musculoskeletal pain – inadequate response/intolerance/contraindication to ONE prerequisite agent (duloxetine delayed-release, acetaminophen, oral NSAID, topical NSAID, tramadol, amitriptyline, nortriptyline, desipramine, imipramine, cyclobenzaprine, or gabapentin) [chart notes required] OR
  • F. A prerequisite agent was discontinued due to lack of efficacy/effectiveness, diminished effect, or adverse event [chart notes required] OR
  • G. A prerequisite agent expected ineffective, harmful, 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 pharmacologic class/mechanism discontinued for lack of efficacy or adverse event [chart notes required] OR
  • J. For diagnoses other than neuropathic pain, fibromyalgia, or musculoskeletal pain – intolerance or hypersensitivity, or contraindication to generic antidepressants.

Reauthorization criteria

  • Continuation of therapy allowed if patient currently stabilized on requested antidepressant; auto-continuation policy applies for another product with the same antidepressant.

Approval duration

12 months