Anafranil (clomipramine) — CareFirst (Caremark)
Anxiety in patients age ≥ 65 years
Preferred products
- Norpramin (desipramine)
- Pamelor (nortriptyline)
Initial criteria
- The request is for ONE of the following:
- • Amitriptyline, amoxapine, desipramine, imipramine hydrochloride, imipramine pamoate, nortriptyline, protriptyline, or trimipramine for depression
- • Chlordiazepoxide/amitriptyline for depression associated with anxiety
- • Doxepin for depression and/or anxiety
- • Perphenazine/amitriptyline for depression with anxiety and/or agitation
- AND the patient has experienced an inadequate treatment response or intolerance to at least TWO of the following agents: a serotonin-norepinephrine reuptake inhibitor (SNRI), a selective serotonin reuptake inhibitor (SSRI), mirtazapine, bupropion, trazodone
- AND if the request is for amitriptyline, amoxapine, imipramine hydrochloride, imipramine pamoate, protriptyline, trimipramine, chlordiazepoxide/amitriptyline, doxepin or perphenazine/amitriptyline, the patient has also experienced an inadequate treatment response or intolerance to a trial of desipramine (Norpramin) or nortriptyline (Pamelor)