CurrentArizona Complete HealthPolicy AZ.CP.PMN.11

Concomitant Antidepressant Treatment

Policy governing medical necessity and prior authorization criteria for concomitant use of more than one antidepressant for members of Arizona Complete Health - Arizona Medicaid (AzCH-CCP). Applies to providers seeking approval for combinations such as two SSRIs, an SSRI with an SNRI, or two SNRIs.

Policy Summary

PayerArizona Complete Health

PolicyConcomitant Antidepressant Treatment

Policy CodePolicy AZ.CP.PMN.11

Change Type1Q 2025 annual review — administrative updates (AHCCCS drug list reference added)

Effective Date07.16

Next Review Date

Key ActionSubmit prior authorization with supporting documentation for continued concomitant use beyond the automatic 60-day cross‑taper.

SourceLink

POLICY UPDATE CHANGES

Added instruction to refer to current AHCCCS Drug List for preferred products.

Removed reference to Care1st Health plan and logos.

Removed reference to retired policy AZ.CP.PMN.53 Off- Label Use policy

Converted to new template and added Dosage and Administration; Added Product availability; updated references; TCAs no longer reject as concomitant therapy.

60cross‑taper auto approval days

6initial approval (months)

12continued approval (months)

>=3required adequate trials

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4TCA products listed

Coverage Criteria for Concomitant Antidepressant Use

Initial Therapy - Treatment Resistant Depression

Covered when ALL of the following are met:

ALL of the following

Member has a diagnosis of treatment resistant depression (TRD).
Documentation of adequate trials of at least three (3) individual antidepressants listed on the AHCCCS Behavioral Health Drug Lists, from at least two (2) different therapeutic classes, each for 4-6 weeks at maximum tolerated doses.
Failure of previous single-agent antidepressant trials is due to one of the following: inadequate response at maximum tolerated dose; adverse reaction(s); or breakthrough symptoms.
Appropriate clinical monitoring has been completed, including monitoring of target symptoms, adverse reactions (including but not limited to signs and symptoms of serotonin syndrome), adherence to treatment, suicide risk, heart rate, blood pressure and weight.
Approval duration: 6 months.

Initial Therapy - Obsessive Compulsive Disorder

Covered when ALL of the following are met:

ALL of the following

Member has a diagnosis of obsessive compulsive disorder (OCD).
Documentation of adequate trials of at least three (3) individual antidepressants listed on the AHCCCS Behavioral Health Drug Lists, from at least two (2) different therapeutic classes, each for 4-6 weeks at maximum tolerated doses.
Failure of previous single-agent antidepressant trials is due to one of the following: inadequate response at maximum tolerated dose; adverse reaction(s); or breakthrough symptoms.
Appropriate clinical monitoring has been completed, including monitoring of target symptoms, adverse reactions (including but not limited to signs and symptoms of serotonin syndrome), adherence to treatment, suicide risk, heart rate, blood pressure and weight.

Continued Therapy

Continued therapy is authorized when ALL of the following are met:

ALL of the following

Member is currently receiving the medication via a health plan affiliated with Centene Corporation or the member previously met initial approval criteria.
Documentation of positive response to therapy (for example, reduction in signs/symptoms).
Approval duration: 12 months.

Coverage guidance

Coverage guidance (provider and policy guidance):

ALL of the following

Cross tapers will automatically be approved for 60 days; providers must submit a prior authorization request for continued concomitant use of any two (2) antidepressants beyond the 60-day cross-taper period.
Refer to the current AHCCCS Drug List for preferred products when selecting agents for therapy.
Excluded from this policy are tricyclic antidepressants (TCAs), trazodone, mirtazapine, and bupropion which are often used as adjunctive therapy with other agents including other antidepressants; these agents are addressed separately (see limitations/exclusions).
Members currently taking an MAOI are not covered for concomitant antidepressant therapy under this policy.

Coding, Durations, and Dosage

Codes presentmixed

N/A	No CPT/HCPCS/ICD codes provided in this document segment.

Adequate trial duration - inv-10

Required trial duration4-6 weeks at maximum tolerated doses

Context - Initial Approval (TRD)Evidence of adequate trials of >=3 individual antidepressants from >=2 therapeutic classes for 4-6 weeks at max tolerated doses is required

Context - Initial Approval (OCD)Same 4-6 week adequate trial requirement applies to obsessive compulsive disorder prior to concomitant therapy

Dosage strengths - inv-11

Imipramine (Tofranil)Tablets: 10 mg, 25 mg, 50 mg; Capsules: 75 mg, 100 mg, 150 mg

Nortriptyline (Pamelor)Capsules: 10 mg, 25 mg, 50 mg, 75 mg; Oral solution: 10 mg/5 mL

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Cross tapers will be automatically approved for up to 60 days. Continued concomitant use of two or more antidepressants beyond the 60‑day automatic cross‑taper period requires prior authorization. Providers must submit a PA request and supporting documentation for continued utilization.

Submit PA for concomitant use beyond 60 days
Include office notes, labs, and clinical rationale

Documentation Required

Documentation Requirements

Documentation Required: Providers must submit documentation (including office chart notes and lab results) demonstrating the member meets all approval criteria. Documentation must include evidence the member was adherent to prior treatment regimens and that non‑response was not due to nonadherence. Include monitoring for adverse effects and appropriate safety checks.

Office chart notes documenting diagnosis, symptom monitoring, and treatment history

Pharmacotherapy Options and Combinations

Pharmacotherapy - Concomitant antidepressants

Concomitant Antidepressants - Allowed Combinations: Concomitant use of more than one antidepressant (e.g., two SSRIs, an SSRI with an SNRI, or two SNRIs) is addressed for FDA‑approved indications such as Treatment Resistant Depression and Obsessive Compulsive Disorder; clinicians should consider agent-specific cardiac risks (QTc) and avoid combinations with MAOIs.

Refer to Appendix B for cardiac monitoring and TCA guidance.

Pharmacotherapy (antidepressant combinations/augmentation)

Pharmacotherapy - Combinations/Augmentation: Clinical guidance and referenced practice guidelines (e.g., APA, STAR*D, CO-MED) support consideration of antidepressant combinations or augmentation strategies when prior adequate single-agent trials have failed; decisions should align with published practice guidelines and include appropriate safety monitoring.

Definitions and Important Terms

Definition - Serotonin Syndrome (inv-21)

DefinitionSerotonin syndrome: condition that occurs when medications cause high levels of serotonin

Mild symptomsShivering, diarrhea

Severe symptomsMuscle rigidity, fever, seizures; can be fatal if not treated

Definition - MAOI (inv-22)

DefinitionMAOI: Monoamine Oxidase Inhibitors

ExamplesNardil, Parnate, Eldepryl, Marplan

NoteMembers taking MAOIs are excluded from concomitant antidepressant coverage per policy guidance

Background

This policy addresses concomitant antidepressant strategies including combinations of two selective serotonin reuptake inhibitors (two SSRIs), an SSRI with an SNRI, or two SNRIs. Its intent is to provide coverage guidance for carefully selected, monitored use of such combinations in treatment‑resistant cases—for example, treatment‑resistant depression and certain cases of obsessive‑compulsive disorder—after requirements such as adequate single‑agent trials, documented inadequate response or intolerance, and appropriate clinical monitoring have been met.

Revision History and Policy Changes

2025-01-01annual_reviewLatest

1Q 2025 annual review: added instruction to refer to the current AHCCCS Drug List for preferred products; removed references to Care1st Health plan and logos; removed reference to retired policy AZ.CP.PMN.53 and added AHCCCS FFS Prior Authorization Guideline for off-label non‑FDA indications.

2018-01-01format_and_content_update

Converted to new template and added Dosage and Administration, product availability, updated references, and changed handling of tricyclic antidepressants (no longer automatic rejection as concomitant therapy).

Policy Summary

PayerArizona Complete Health

PolicyConcomitant Antidepressant Treatment

Policy CodePolicy AZ.CP.PMN.11

Change Type1Q 2025 annual review — administrative updates (AHCCCS drug list reference added)

Effective Date07.16

Next Review Date

Key ActionSubmit prior authorization with supporting documentation for continued concomitant use beyond the automatic 60-day cross‑taper.

SourceLink

On This Page

Approval duration: 6 months.

Diagnoses/indications not FDA-approved are not authorized under this policy unless there is sufficient documentation of efficacy and safety per the AHCCCS FFS Prior Authorization Guideline - Coverage of Off-Label Non-FDA Approved Indications; refer to that guideline and other evidence of coverage documents as applicable.

Members on medication combinations, doses, or for identified indications that do not meet published practice guidelines or treatment protocols, or on regimens without adequate safeguards/monitoring, are not authorized under this policy.

When state Medicaid coverage provisions conflict with this clinical policy, state Medicaid provisions take precedence; refer to the state Medicaid manual for applicable coverage provisions.

Protriptyline (Vivactil)Tablets: 5 mg, 10 mg

TrimipramineCapsules: 25 mg, 50 mg, 100 mg

Laboratory results and monitoring relevant to safety

Documentation of adherence and rationale for combination therapy

Step Therapy

Required Prior Medication Trials

Required Prior Medication Trials: For initial approval, provide evidence of adequate trials of at least three (3) individual antidepressants from at least two (2) different therapeutic classes, each trial for 4–6 weeks at maximum tolerated doses, as listed on the AHCCCS Behavioral Health Drug Lists. For Obsessive Compulsive Disorder, the same requirement of ≥3 trials from ≥2 classes applies.

Document trials of ≥3 individual antidepressants from ≥2 classes
Each trial: 4–6 weeks at maximum tolerated dose
List drugs per current AHCCCS Behavioral Health Drug Lists

Denial Risk

Coverage Limitations / Denial Risk

Coverage Limitations and Denial Risks: Coverage is not authorized for non‑FDA approved indications unless there is sufficient documentation per the AHCCCS FFS Prior Authorization Guideline for Off‑Label Use. Coverage is not authorized for members currently taking an MAOI, for medication combinations or regimens that do not meet published practice guidelines, or where significant polypharmacy or comorbidities create safety concerns. Members on regimens lacking adequate monitoring or safeguards may be denied.

Non‑FDA indications require off‑label PA documentation per AHCCCS FFS guideline
MAOI coadministration is not authorized
Regimens without guideline support or monitoring may be denied

Note

Refer to AHCCCS Drug List

Refer to AHCCCS Drug List for Preferred Products: Providers must check the current AHCCCS Behavioral Health Drug List for preferred antidepressant products when documenting prior trials and selecting agents.

Verify preferred products on the current AHCCCS Drug List before submission

Note

Administrative Coverage Notes

Administrative and Coverage Notes: Coverage decisions are subject to all terms, conditions, exclusions and limitations of the member’s coverage documents and applicable state and federal requirements. For Medicaid members, state Medicaid coverage provisions take precedence when they conflict with this clinical policy.

Coverage subject to plan contract, exclusions, limitations, and applicable laws
State Medicaid provisions override this policy where conflicting

TCA product list and strengths - inv-23

Imipramine (Tofranil)Tablets: 10, 25, 50 mg; Capsules: 75, 100, 150 mg

Nortriptyline (Pamelor)Capsules: 10, 25, 50, 75 mg; Oral solution: 10 mg/5 mL

Protriptyline (Vivactil)Tablets: 5, 10 mg

TrimipramineCapsules: 25, 50, 100 mg

2025-01-01annual_reviewLatest

1Q 2025 annual review: policy updated to instruct providers to refer to the current AHCCCS Drug List for preferred products; removed plan-specific logos and references and removed citation to retired off‑label use policy AZ.CP.PMN.53.