clomipramine — CareFirst (Caremark)
Obsessive-Compulsive Disorder (OCD)
Preferred products
- Norpramin
- Pamelor
Initial criteria
- Patient is age ≥ 65 years
- Quantity limits apply only to patients age ≥ 65 years
- Authorization may be granted for the requested drug when ALL of the following criteria are met:
- The request is for the treatment of agitation, anxiety, or depression in patients age ≥ 65 years
- 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
- If the request is for amitriptyline, amoxapine, imipramine hydrochloride, imipramine pamoate, protriptyline, trimipramine, chlordiazepoxide/amitriptyline, doxepin, or perphenazine/amitriptyline, then the patient has experienced an inadequate treatment response or intolerance to a trial of desipramine (Norpramin) or nortriptyline (Pamelor)