trimipramine — CareFirst (Caremark)

Initial criteria

• Coverage applies only to patients age ≥ 65 years
• Quantity limits apply as follows: 25 mg or 50 mg – maximum 60 capsules per 25 days (180 capsules per 75 days); 100 mg – maximum 30 capsules per 25 days (90 capsules per 75 days)
• For any strength with 0 listed as limit, prior authorization is required before coverage if quantity exceeds the specified limit