nortriptyline — CareFirst (Caremark)
Anxiety in patients 65 years of age or older
Initial criteria
- Patient is age ≥ 65 years
- Request is for ONE of the following conditions:
- 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