Pamelor — CareFirst (Caremark)
Insomnia characterized by difficulty with sleep maintenance (Silenor)
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
- Quantity limits apply only to patients age ≥ 65 years
Approval duration
12 months