All antidepressants other than those specifically listed as covered for pediatrics — Point32Health
Depression or other behavioral health conditions in pediatrics 12 years of age and younger
Preferred products
- fluoxetine
- venlafaxine
- fluvoxamine
- citalopram
- escitalopram
- clomipramine
- sertraline
- imipramine
- duloxetine
- Fluoxetine-olanzapine
Initial criteria
- Documentation that patient had a recent psychiatric hospitalization
- OR Documentation that patient has a history of severe risk of harm to self or others
- OR Documentation that patient is stable on the requested antidepressant for more than 2 months
- OR Documentation that the patient has tried and failed at least 1 preferred agent (listed on the table above), as appropriate for the patient’s diagnosis AND the requested antidepressant is prescribed by a specialist or in consultation with a specialist (psychiatrist, neurologist, or developmental pediatrician)