milnacipran — Highmark
fibromyalgia
Preferred products
- duloxetine
- pregabalin
- amitriptyline
- cyclobenzaprine
- gabapentin
- tramadol
Initial criteria
- age ≥ 18 years
- clinical documentation of fibromyalgia diagnosis (ICD-10: M79.7) supported by ALL of the following criteria: widespread bilateral pain above and below the waist; pain duration of at least 3 months; at least ONE of the following fibromyalgia-related symptoms: cognitive impairment OR fatigue OR sleep disturbance OR neurologic symptoms OR exercise intolerance
- therapeutic failure, contraindication, or intolerance to ALL of the following: duloxetine AND pregabalin
- therapeutic failure or intolerance to ONE of the following, or all are contraindicated: amitriptyline OR cyclobenzaprine OR gabapentin OR tramadol
Reauthorization criteria
- prescriber attests that the member has experienced positive clinical response to therapy
Approval duration
12 months