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chlordiazepoxide/amitriptyline — CareFirst (Caremark)

Anxiety in patients age ≥ 65 years

Preferred products

  • Norpramin
  • Pamelor

Initial criteria

  • Authorization may be granted when ALL of the following criteria are met:
  • 1. 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
  • 2. 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, or trazodone
  • 3. If the request is for amitriptyline, amoxapine, imipramine hydrochloride, imipramine pamoate, protriptyline, trimipramine, chlordiazepoxide/amitriptyline, doxepin, or perphenazine/amitriptyline, the patient has experienced an inadequate treatment response or intolerance to a trial of desipramine (Norpramin) or nortriptyline (Pamelor)