perphenazine/amitriptyline — CareFirst (Caremark)
depression with anxiety and/or agitation
Preferred products
- desipramine (Norpramin)
- nortriptyline (Pamelor)
Initial criteria
- Patient age ≥ 65 years
- Request is for perphenazine/amitriptyline for depression with anxiety and/or agitation
- Patient has experienced an inadequate treatment response or intolerance to at least TWO of the following: a serotonin-norepinephrine reuptake inhibitor (SNRI), a selective serotonin reuptake inhibitor (SSRI), mirtazapine, bupropion, trazodone
- Patient has experienced an inadequate treatment response or intolerance to a trial of desipramine (Norpramin) or nortriptyline (Pamelor)