imipramine hydrochloride — 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)