SSRI/SNRI Duplicate Therapy
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Policy governs coverage for concurrent use of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for Delaware First Health Medicaid members; it states therapeutic duplication is not medically necessary and requires provider documentation for exceptions. Applies to prescribers and prior authorization reviewers for the listed line of business.
No material clinical or coverage changes in this revision.
Coverage Criteria for Concurrent SSRI/SNRI Therapy
Duplicate SSRI/SNRI therapy - coverage restriction
Covered when ALL of the following are met
There are currently no controlled clinical studies to support the use of two SSRIs or the concomitant use of an SSRI and SNRI.
Prior authorization requests for concomitant SSRI/SNRI therapy are subject to denial if documentation does not justify concurrent use.
Therapeutic duplication — defined here as the concurrent use of two selective serotonin reuptake inhibitors (SSRIs) or an SSRI plus a serotonin‑norepinephrine reuptake inhibitor (SNRI) — is not medically necessary. The policy of Delaware First Health (Centene-affiliated plans) excludes such duplication from coverage.
Members are restricted to the use of only one SSRI or only one SNRI at a time. The policy states there are no controlled clinical studies supporting concurrent therapy with two SSRIs or an SSRI plus an SNRI, and therefore concomitant use will not be approved under this coverage rule.
Provider Actions, Prior Authorization, and Documentation
Prior authorization required for concurrent SSRI/SNRI
Therapeutic duplication of SSRIs and SNRIs is considered not medically necessary; prior authorization requests for concomitant SSRI/SNRI therapy must include supporting clinical documentation and are subject to denial upon review.
Therapeutic restriction — one SSRI or one SNRI only
Members are restricted to the use of only one SSRI or one SNRI at a time; concurrent use of two SSRIs or an SSRI plus an SNRI is not permitted under this policy.
Required supporting documentation
Provider must submit supporting clinical documentation (for example, office chart notes, laboratory results, or other clinical information) demonstrating that the member meets any approval criteria.
- Office chart notes
- Laboratory results
- Other relevant clinical information
Denial risk for duplicate SSRI/SNRI therapy
Requests for concurrent therapy with two SSRIs or an SSRI plus an SNRI will be considered not medically necessary and may be denied.
Clinical Background and Safety Considerations
Concurrent SSRI and SNRI use can increase the risk of additive adverse effects, most notably serotonin syndrome, a potentially serious condition associated with symptoms such as autonomic instability, altered mental status, hyperthermia, myoclonus, rigidity, and hypertension. Because there is no clinical evidence supporting combined SSRI/SNRI therapy, the policy restricts members to a single agent and requires providers to document any exceptional rationale when requesting coverage.
Definitions
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