Concomitant Antidepressant Treatment
Customize your policy alerts
Sign up for Arizona Complete Health Policy AZ.CP.PMN.11 alerts
Get alerted when Policy AZ.CP.PMN.11 changes without checking for updates manually.
Monitor payer policy activity
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.
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.
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.
- Approval duration: 6 months.
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.
- 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.
Coding, Durations, and Dosage
| N/A | No CPT/HCPCS/ICD codes provided in this document segment. |
Provider Requirements and 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 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
- Laboratory results and monitoring relevant to safety
- Documentation of adherence and rationale for combination 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
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
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
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
Pharmacotherapy Options and Combinations
Pharmacotherapy - Concomitant antidepressants
Refer to Appendix B for cardiac monitoring and TCA guidance.
Pharmacotherapy (antidepressant combinations/augmentation)
Definitions and Important Terms
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
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.
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).
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.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.