Savella (milnacipran) — Point32Health
management of fibromyalgia
Preferred products
- gabapentin
- duloxetine
- pregabalin
- amitriptyline
- cyclobenzaprine
Initial criteria
- The patient has had a trial of one Step-1 or Step-2 medication within the previous 180 days as evidenced by a previous paid claim under the prescription benefit administered by the plan
- OR
- The patient has had a trial of a Step-1 or Step-2 medication as evidenced by physician’s documented use, excluding the use of samples
- OR
- The patient has a physician documented trial and failure with one, or contraindication or intolerance to all of the following Step-1 medications: gabapentin, duloxetine, pregabalin, amitriptyline, or cyclobenzaprine