CurrentAvMedPolicy N/A

Emsam (selegiline) transdermal system prior authorization and step-edit

Form and criteria governing prior authorization and step therapy for Emsam (selegiline) transdermal system for AvMed members; applies to prescribers requesting pharmacy coverage for this drug.

Policy Summary

PayerAvMed

PolicyEmsam (selegiline) transdermal system prior authorization and step-edit

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete and sign prior authorization form and provide chart notes documenting at least two failed oral antidepressant trials (>=6 weeks each).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30maximum approval per 30 days

>=12minimum member age

2failed antidepressant trials required

>=6wminimum trial duration

Coverage Criteria

Initial Authorization Criteria

Covered when ALL of the following are met

Initial Authorization for Emsam: Member must be 12 years of age or older; medication prescribed by or in consultation with a psychiatrist; diagnosis of major depressive disorder (MDD) and does NOT have a diagnosis of Parkinson's disease; unsuccessful trial of at least 2 oral antidepressants from 2 different drug classes with each trial >= 6 weeks documented; member will not take listed contraindicated medications concurrently; member will follow a tyramine-restricted diet if using selegiline doses > 6 mg/24 hours.

All documentation including chart notes, lab results, and diagnostics must be provided to support each checked criterion; maximum approval is 30 patches per 30 days.

The form explicitly excludes members with a diagnosis of Parkinson's disease from approval when the requested indication is Major Depressive Disorder (MDD). This exclusion is part of the required clinical criteria that must all be met for authorization; failure to meet it will render the request ineligible for approval.

Coding and Limits

Minimum antidepressant trial duration — 6 weeks per medication

Policy Summary

PayerAvMed

PolicyEmsam (selegiline) transdermal system prior authorization and step-edit

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete and sign prior authorization form and provide chart notes documenting at least two failed oral antidepressant trials (>=6 weeks each).

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Minimum antidepressant trial duration6 weeks per medication (each oral antidepressant trial must be a minimum of 6 weeks with chart note documentation)

Documentation requiredChart notes or pharmacy paid claims must be submitted to document therapy failures

Number of classesTrials must be from 2 different oral antidepressant drug classes

Maximum quantity — 30 patches per 30 days

Maximum quantity30 patches per 30 days

Approval unitPatches per month

VerificationLimit stated as 'Maximum Approval of #30 patches/30 days' on the form

Minimum age — 12 years

Minimum age for approval12 years

Age criterion source'Member must be 12 years of age or older' listed among required clinical criteria

DocumentationAge must be documented on the request form to support approval

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. The prescribing physician must sign and clearly print their name on the request (preprinted stamps are not valid). Fax completed form to 1-305-671-0200. Incomplete, incorrect, or illegible information (including missing phone/fax numbers) can delay or lead to denial of the authorization.

Fax number: 1-305-671-0200
Prescriber signature required (handwritten; preprinted stamps not valid)

Step Therapy

Step Therapy Requirement

Member must have had unsuccessful trials of at least two oral antidepressants from two different drug classes. Each trial must be a minimum of 6 weeks and chart notes or pharmacy claims must be provided to document therapy failures. Use of samples to initiate therapy does not satisfy step edit/ prior authorization requirements.

Required: >= 2 oral antidepressant trials from different classes
Each trial duration: >= 6 weeks
Documentation: chart notes or pharmacy paid claims

Documentation Required

Required Documentation

Prescriber and clinical documentation must be complete and submitted with the request. Required information includes member and prescriber details, prescriber signature, drug form/strength, dosing schedule, length of therapy, diagnosis and supporting clinical documentation (labs, diagnostics, chart notes). Maximum approval is 30 patches per 30 days.

Member name, AvMed ID, DOB
Prescriber name, DEA or NPI, office contact, phone and fax
Prescriber signature and date
Drug form/strength, dosing schedule, length of therapy, weight, diagnosis and ICD code
Supporting clinical documentation (labs, diagnostics, chart notes)
Maximum approval: 30 patches per 30 days

Denial Risk

Form Completeness

If the form is incomplete, incorrect, or illegible authorization processing may be delayed or denied. Ensure all fields are completed and legible before submission.

Incomplete/illegible information can delay or cause denial of authorization
Ensure phone and fax numbers are included and accurate

Denial Risk

Clinical Criteria Unmet

All clinical criteria must be met for approval. Criteria include age (>=12 years), prescriber specialty (psychiatrist or consultation with psychiatrist), diagnosis of major depressive disorder (MDD) with no Parkinson's disease diagnosis, required prior therapy trials, and avoidance of contraindicated concomitant medications. Failure to meet any listed clinical criterion may result in denial.

Age requirement: 12 years or older
Prescribed by or in consultation with a psychiatrist
Diagnosis: MDD and NOT Parkinson's disease
Concomitant contraindicated drugs must not be used with selegiline patches (list provided on form)
Tyramine-restricted diet required if using selegiline > 6 mg/24 hours

Background

Selegiline transdermal system (Emsam) is presented on the request form as a treatment for Major Depressive Disorder (MDD). The form emphasizes safety and appropriate use by requiring that all listed clinical criteria be met and documented before coverage is approved, and notes a maximum approval of 30 patches per 30 days.

Definitions

Major Depressive Disorder (MDD) — diagnosis required for approval

Required diagnosisMajor Depressive Disorder (MDD) — diagnosis required for approval

ExclusionMember must NOT have a diagnosis of Parkinson's disease for MDD indication

Prescriber requirementMedication must be prescribed by or in consultation with a psychiatrist

Initial Therapy Criteria

Initial therapy

Initial therapy requirements

Initial therapy: At least 2 unsuccessful trials of oral antidepressants from 2 different drug classes, each trial >= 6 weeks with chart notes documenting failures; prescriber must be a psychiatrist or the medication is prescribed in consultation with a psychiatrist; member must be >= 12 years of age; member must not have a diagnosis of Parkinson's disease; member will not take contraindicated agents concurrently (includes SSRIs, SNRIs, other MAOIs, tricyclic antidepressants, bupropion, buspirone, mirtazapine, sympathomimetic amines, cyclobenzaprine, oral selegiline, meperidine, tramadol, methadone, dextromethorphan, St. John's wort, carbamazepine, oxcarbazepine); member will follow a tyramine-restricted diet if using selegiline doses > 6 mg/24 hours.>= 6 weeks per oral antidepressant trial

Use of samples to initiate therapy does not meet step edit/preauthorization criteria. Previous therapies may be verified through pharmacy paid claims or submitted chart notes.

Step Therapy and Trial Documentation

Requirement	Documentation / Verification
Member must have had unsuccessful trials of at least 2 oral antidepressant medications from 2 different drug classes (each trial must have been for a minimum of 6 weeks)	Chart notes documenting therapy failures for each trial; previous therapies may be verified through pharmacy paid claims or submitted chart notes
Trials must be documented with chart notes	Chart note submission required to document noted therapy failures; pharmacy paid claims may be used to verify prior therapies

Quantity Limits

Emsam (selegiline) transdermal system — maximum 30 per 30 days

ProductEmsam (selegiline) transdermal system

Maximum monthly quantity30 patches per 30 days

Form statementListed as 'Maximum Approval of #30 patches/30 days' on the prior authorization form