clomipramine (Anafranil) — CareFirst (Caremark)
Anxiety in patients age ≥ 65 years
Initial criteria
- Authorization may be granted when ALL of the following criteria are met:
- 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
Approval duration
12 months