WHA
 

Antidepressants

Indications for Prior Authorization

Trintellix (vortioxetine)
  • For diagnosis of Major Depressive Disorder
    Indicated for the treatment of major depressive disorder (MDD) in adults.

Fetzima (levomilnacipran extended-release)
  • For diagnosis of Major Depressive Disorder
    Indicated for the treatment of major depressive disorder (MDD) in adults.

    Limitation of Use: Fetzima is not approved for the management of fibromyalgia. The efficacy and safety of Fetzima for the management of fibromyalgia have not been established.

Criteria

Trintellix

Step Therapy

Length of Approval: 12 Month(s)

  • Both of the following:
    • Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
      • AND
    • Trial and failure (of a minimum 30-day supply), contraindication, or intolerance to any TWO of the following generics:
      • bupropion
      • citalopram
      • desvenlafaxine extended-release (ER)
      • duloxetine
      • escitalopram
      • fluoxetine
      • mirtazapine
      • paroxetine or paroxetine ER
      • sertraline
      • venlafaxine or venlafaxine ER
    OR
  • For continuation of prior therapy
Fetzima or Fetzima Pack

Step Therapy

Length of Approval: 12 Month(s)

  • Both of the following:
    • Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
      • AND
    • Trial and failure (of a minimum 30-day supply), contraindication, or intolerance to any TWO of the following generics:
      • desvenlafaxine extended-release (ER)
      • duloxetine
      • venlafaxine or venlafaxine ER
    OR
  • For continuation of prior therapy

  • Guideline ID
    GL-525253

  • Formulary
    EHB

  • Effective date
    May 1, 2026

  • P&T approval date

P & T Revisions

2026-03-05, 2025-12-18, 2025-03-04, 2024-03-04, 2023-02-28, 2022-08-02, 2022-03-03, 2021-09-27, 2021-05-18, 2021-03-04, 2020-03-05, 2019-12-10

  1. Trintellix Prescribing Information. Takeda Pharmaceuticals America, Inc. Lexington, MA. February 2025.
  2. Fetzima Prescribing Information. Allergan USA, Inc. Madison, NJ. April 2024.
  3. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder, third edition. Oct. 2010. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Accessed February 19, 2026.
  4. Soleimani L, Lapidus KA, Losifescu DV. Diagnosis and treatment of major depressive disorder. Neurol Clin. 2011;29(1):177-93.
  5. American Geriatrics Society. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023;71(7).
  • 2026-03-05: 2026 Annual Review - updated references
  • 2025-12-18: no criteria changes, added IL statute operational note
  • 2025-03-04: Annual review: No criteria changes. Updated references.
  • 2024-03-04: Annual Review
  • 2023-02-28: Annual Review - removal of Aplenzin and Paxil oral solution. Addition of Emsam
  • 2022-08-02: Formatting updates to criteria.
  • 2022-03-03: Annual review: Updated criteria and background.
  • 2021-09-27: EHB specific guideline, added to EHB formulary, removed from ORx standard formulary. no changes to criteria
  • 2021-05-18: EHB specific guideline, added to EHB formulary, removed from ORx standard formulary. no changes to criteria
  • 2021-03-04: Annual review: Background updates.
  • 2020-03-05: Annual review: Background updates, GPI clean-up.
  • 2019-12-10: Added brand Paxil suspension as a target.