Fluoxetine Tablets (Prozac®, Sarafem®)

SELF ADMINISTRATION

FDA Approved Indications:
  • Prozac® (Fluoxetine)
    • Major Depressive Disorder (MDD)
    • Obsessive Compulsive Disorder (OCD)
    • Bulimia nervosa
    • Panic Disorder, with or without agoraphobia
  • Sarafem® (Fluoxetine PMDD)
    • Premenstrual dysphoric disorder (PMDD)
Prior authorization criteria:
  • Medically appropriate diagnosis for specific product, AND
  • Medically appropriate reason for use of the tablets and not the capsules is provided
  • Preferred agent is fluoxetine capsules (available as 10 mg, 20 mg and 40 mg)
Approval:
  • One year

Last review date: September 24, 2020

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