CurrentColorado Rocky Mountain Health PlansPolicy Program Number 2025 P 1424-3

Prior Authorization/Notification - Zurzuvae (zuranolone)

Defines prior authorization criteria for Zurzuvae (zuranolone) for treatment of postpartum depression in adults; applies to pharmacy prior authorization/notification program for the payer.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization/Notification - Zurzuvae (zuranolone)

Policy CodePolicy Program Number 2025 P 1424-3

Change TypeAnnual reviewno material changes

Effective DateMar 1, 2026

Next Review Date

Key ActionObtain prior authorization/notification and document that the patient has postpartum depression with onset during the third trimester or within 4 weeks postpartum to support approval; authorization is issued for 1 month.

SourceLink

POLICY UPDATE CHANGES

Program created for Prior Authorization/Notification of Zurzuvae (zuranolone) with initial P&T approval in 12/2023.

1authorization length (initial)

Adultsindicated population

3rd tri/4 wkstiming requirement for current depressive episode

Medical Necessity Criteria for Zurzuvae (zuranolone)

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What Providers Must Do

Prior Authorization

Prior authorization required

Prior authorization/notification is required. Approval will be granted only if the patient has a diagnosis of postpartum depression (PPD) and the onset of the current depressive episode was during the third trimester or within 4 weeks postpartum. Authorization will be issued for 1 month.

Documentation Required

Documentation of episode onset

Document the timing of the current depressive episode onset (occurred during the third trimester or within 4 weeks postpartum) and the diagnosis of postpartum depression (PPD) in the prior authorization request to support approval.

Denial Risk

Automated approval caveat

UnitedHealthcare may approve requests based solely on prior claim/medication history, diagnosis codes (ICD-10), and/or claim logic; conversely, if the required documentation (timing of onset and PPD diagnosis) is not present, the request may be denied.

Prior Authorization

Supply limits may apply

Supply limits may be enforced and quantity per day or total supply restrictions could affect approval of the authorization request.

Clinical and Administrative Background

Zurzuvae (zuranolone) is a neuroactive steroid GABA‑A receptor positive modulator indicated for the treatment of postpartum depression (PPD) in adults (source: manufacturer labeling). The payer program establishes prior authorization requirements to ensure use aligns with the labeled indication and the timing of onset of the depressive episode.

The program requires documentation that the patient has a diagnosis of PPD and that the onset of the current depressive episode occurred either during the third trimester or within 4 weeks postpartum. Prior authorization will be issued for 1 month. The program notes that state mandates, federal requirements, member benefit plan terms, and other utilization management programs may also affect coverage, and that supply limits or automated approval processes based on claims/medication history and diagnosis codes may apply.

Authorization Duration and Timing Requirements

Key Thresholds and Stats

Authorization duration1 month

Onset timing for current episodeduring third trimester OR within 4 weeks postpartum

Indicated populationAdults

Automated approval caveatUnitedHealthcare may approve initial and reauthorization requests based on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic

Supply limitsSupply limits may be enforced and could affect approval

1 monthauthorization length (initial)

Adultsindicated population

3rd trimester / 4 weekstiming requirement for current depressive episode

Policy Changes & Review Timeline

2023-12Policy creation

Program created for Prior Authorization/Notification of Zurzuvae (zuranolone) with initial P&T approval in 12/2023.

2024-12Annual review

Annual review completed with no changes to clinical criteria.

2025-12Annual reviewLatest