| Document Date: 2014-05-06 13:41:32
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Facility Pharmacy Services Subject / / Person Fluvoxamine (Luvox) Paroxetine / Mirtazapine (Remeron) Bupropion / Escitalopram (Lexapro) Fluoxetine / Bupropion (Wellbutrin) Trazodone / Tranylcypromine (Parnate) Others Mirtazapine / Isocarboxazid (Marplan) Phenelzine / Paroxetine (Paxil) Sertraline / Citalopram (Celexa) Escitalopram / Clomipramine (Anafranil) Doxepin / Trazodone (Desyrel) Vilazodone / Protriptyline (Vivactil) Clomipramine / Desipramine (Norpramin) Amoxapine Maprotiline / Fluoxetine (Prozac) Fluvoxamine / Doxepin (Sinequan) Imipramine / Vilazodone (Viibryd) Nefazodone / Duloxetine (Cymbalta) Tricyclics Amitriptyline / Phenelzine (Nardil) Tranylcypromine / Imipramine (Tofranil) Nortriptyline / Amitriptyline (Elavil) Protriptyline / Nortriptyline (Pamelor) Desipramine / / Product Venlafaxine / Wellbutrin / Effexor / Parnate / Mirtazapine / Fluoxetine / Luvox / Marplan / Celexa / Escitalopram / Serzone / Lexapro / Amoxapine / Desyrel / Anafranil / Pristiq / 20mg / Vivactil / Tofranil / Sinequan / Norpramin / Pamelor / Cymbalta / Remeron / Zoloft / Prozac / Paxil / Elavil / Nardil / Ludiomil / /
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Division: Pharmacy Services Subject: Prior Authorization Criteria Original Development Date: Original Effective Date: