CurrentCignaPolicy N/A

Antidepressants - Selective Serotonin Reuptake Inhibitors Drug Quantity Management Policy - Per Rx

Defines Cigna's drug quantity limits, dosing/availability, and exception criteria for multiple SSRIs (brand and generic) on a per-prescription basis; approvals generally for 1 year unless noted and exceptions to quantity limits are permitted when specified criteria are met.

Policy Summary

PayerCigna

PolicyAntidepressants - Selective Serotonin Reuptake Inhibitors Drug Quantity Management Policy - Per Rx

Policy CodePolicy N/A

Change TypeClarified/obsolescence

Effective Date

Next Review DateDec 8, 2025

Key ActionFor requests exceeding standard quantity limits due to divided dosing or non-commercial strengths, document the dosing schedule and rationale so the requested quantity (up to 30-day retail / 90-day home delivery) can be approved.

SourceLink

POLICY UPDATE CHANGES

Pexeva (paroxetine mesylate tablets) marked obsolete 5/2023 in product list.

17Products listed

1 yearStandard approval duration

30/90Common retail/home delivery max (days)

Coverage Summary

Defines Cigna's drug quantity limits, dosing/availability, and exception criteria for multiple SSRIs (brand and generic) on a per-prescription basis; approvals are generally provided for 1 year unless noted. The policy lists per-Rx retail and home delivery maximum quantities (commonly 30 tablets/capsules retail and 90 for home delivery) and specific dosing/availability details for each product. If the Drug Quantity Management rule is not met at the point of service, coverage will be determined by the product-specific criteria and documented exceptions described in the policy.

Exceptions to Quantity Limits (Per Product Criteria)

Exceptions to the quantity limits listed are covered as medically necessary when the following criteria are met. Any other exception is considered not medically necessary.

ALL of the following

Citalopram 10 mg tablets (Celexa, generic)
- If the patient requires the dose to be divided two times daily, approve a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
- If the patient is taking a dose that does not correspond to a commercially-available dosage form (requires multiple same strength tablets OR two or more strengths), approve the requested quantity, not to exceed a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
Citalopram 20 mg tablets (Celexa, generic)
- If the patient requires the dose to be divided two times daily, approve a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
- If the patient is receiving a 30 mg daily dose, approve 45 tablets per dispensing at retail or 135 tablets per dispensing at home delivery.
- If the patient is taking a dose that does not correspond to a commercially-available dosage form (requires multiple same strength tablets OR two or more strengths), approve the requested quantity, not to exceed a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
Citalopram 30 mg capsules: No overrides recommended.
Citalopram capsules should not be used to initiate treatment as the only strength available is 30 mg; another citalopram product should be used for initial dosing, titration, and any dose other than 30 mg once daily.
Citalopram 40 mg tablets (Celexa, generic)
- If the patient is receiving a 60 mg daily dose, approve up to 45 tablets per dispensing at retail or 135 tablets per dispensing at home delivery.
- If the patient has been receiving 60 mg per day and the dose is now being increased to > 60 mg per day, approve a quantity sufficient to allow for a 30-day supply per dispensing.
Escitalopram 5 mg tablets (Lexapro, generic)
- If the patient requires the dose to be divided two times daily, approve a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
- If the patient is taking a dose that does not correspond to a commercially-available dosage form (requires multiple same strength tablets OR two or more strengths), approve the requested quantity, not to exceed a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
Escitalopram 10 mg tablets (Lexapro, generic)
- If the patient requires the dose to be divided two times daily, approve a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
- If the patient is taking a dose that does not correspond to a commercially-available dosage form (requires multiple same strength tablets OR two or more strengths), approve the requested quantity, not to exceed a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
Escitalopram 20 mg tablets (Lexapro, generic)
- If the patient has already been started and stabilized on a dose > 20 mg per day, approve the requested quantity, not to exceed a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
- If the patient has been receiving 20 mg per day and the dose is now being increased to > 20 mg per day, approve the requested quantity, not to exceed a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
Fluoxetine 10 mg tablets and capsules (Prozac generics; generics to discontinued Sarafem)
- If the patient requires the dose to be divided two or three times daily, approve the requested quantity, not to exceed a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
- If the patient is taking a dose that does not correspond to a commercially-available dosage form (requires multiple same strength tablets OR two or more strengths), approve the requested quantity, not to exceed a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
Fluoxetine 40 mg capsules (Prozac, generic)
- If the patient has already been started and stabilized on a dose > 80 mg per day, approve the requested quantity, not to exceed a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
- If the patient has been receiving 80 mg per day and the dose is now being increased to > 80 mg per day, approve the requested quantity, not to exceed a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
Fluoxetine 20 mg capsules and 60 mg tablets: No overrides recommended.
Fluoxetine 90 mg delayed-release capsules (Prozac Weekly, generic)
- If the patient has already been receiving 90 mg twice weekly, approve the requested quantity, not to exceed a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
- If the patient has been receiving 90 mg once weekly and the dose is now being increased to 90 mg twice weekly, approve the requested quantity, not to exceed a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
Fluvoxamine 25 mg tablets: No overrides recommended.
Patients receiving doses of 100 mg, 150 mg, or 200 mg should use the 100 mg tablets.
Fluvoxamine 50 mg tablets: If the patient is taking a dose that does not correspond to a commercially-available dosage form (requires multiple same strength tablets OR two or more strengths), approve the requested quantity, not to exceed a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
Fluvoxamine 100 mg tablets
- If the patient has already been started and stabilized on a dose > 300 mg per day, approve the requested quantity, not to exceed a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
- If the patient has been receiving 300 mg per day and the dose is now being increased to > 300 mg per day, approve the requested quantity, not to exceed a 30-day supply per dispensing at retail or a 90-day supply per dispensing at home delivery.
Fluvoxamine 100 mg extended-release capsules: No overrides recommended.
Fluvoxamine 150 mg extended-release capsules: Criteria section continues in part 2 of the document (no overrides recommended text may apply or further criteria may be listed).

Listed Products (per-Rx quantity limits & dosing)

Listed Products (per-rx quantity limits & dosing)mixed

Brisdelle (paroxetine mesylate capsules, generic)	7.5 mg QHS; Retail max 30 caps; Home delivery max 90 caps
Celexa (citalopram tablets, generic)	10, 20, 40 mg tablets; Retail max 30; Home delivery max 90 (doses >40 mg sometimes used; 60 mg described in exceptions)
citalopram capsules (Almatica)	30 mg capsules; Retail max 30; Home delivery max 90; should not be used to initiate treatment (not for initiation)
fluoxetine tablets (generic)	various strengths (10,20,40,60, etc.); some strengths have no quantity limit; retail/home limits vary by strength with examples of no quantity limit for certain formulations
fluvoxamine tablets (generic)	25, 50, 100 mg; Retail max ranges 30–90 depending on strength; Home delivery max ranges 90–270 depending on strength
fluvoxamine extended-release capsules (generic)	100,150 mg; Retail max 60; Home delivery max 180
Lexapro (escitalopram tablets, generic)	5,10,20 mg; Retail max 30; Home delivery max 90 (exceptions for stabilizing doses >20 mg)
Paxil (paroxetine HCl tablets, generic)	10–40 mg strengths (and 20,30,40 listed); Retail max 30–60 depending on strength; Home delivery max 90–180 depending on strength
Paxil CR (paroxetine HCl CR tablets, generic)	12.5–37.5 mg CR formulations; Retail max 60; Home delivery max 180
Pexeva (paroxetine mesylate tablets) [obsolete 5/2023]	10–40 mg; Retail max 30–60; Home delivery max 90–180; product noted obsolete 5/2023

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Term	Definition
{"text":"MDD","status":""},{"text":"Major Depressive Disorder","status":""}
{"text":"OCD","status":""},{"text":"Obsessive Compulsive Disorder","status":""}
{"text":"PTSD","status":""},{"text":"Posttraumatic Stress Disorder","status":""}
{"text":"SAD","status":""},{"text":"Social Anxiety Disorder","status":""}
{"text":"GAD","status":""},{"text":"Generalized Anxiety Disorder","status":""}
{"text":"PMDD","status":""},{"text":"Premenstrual Dysphoric Disorder","status":""}
{"text":"VMS","status":""},{"text":"Vasomotor Symptoms","status":""}

OpenPayer

Antidepressants - Selective Serotonin Reuptake Inhibitors Drug Quantity Management Policy - Per Rx

Coverage Summary

General Approval Duration

Exceptions to Quantity Limits (Per Product Criteria)

Listed Products (per-Rx quantity limits & dosing)

Provider Actions

Background

Definitions

Revision History