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nortriptyline — CareFirst (Caremark)

Agitation, Anxiety, Depression in patients age ≥ 65 years

Preferred products

  • desipramine (Norpramin)
  • nortriptyline (Pamelor)

Initial criteria

  • The request is for ONE of the following: amitriptyline, amoxapine, desipramine, imipramine hydrochloride, imipramine pamoate, nortriptyline, protriptyline, or trimipramine for depression; OR chlordiazepoxide/amitriptyline for depression associated with anxiety; OR doxepin for depression and/or anxiety; OR perphenazine/amitriptyline for depression with anxiety and/or agitation.
  • 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.
  • 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).