CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

GSTP SSRIs: Trintellix

Defines initial step therapy and prior authorization criteria for the branded antidepressant Trintellix under CVS/Caremark-administered prescription benefit for Neighborhood Health Plan of Rhode Island members; includes coverage criteria, duration of approval, and initial claim reject behavior when step therapy not met.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyGSTP SSRIs: Trintellix

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf the patient has not filled a 30-day supply of a generic SSRI or SSRI combination product within the past 730 days under CVS/Caremark, the claim will reject and a prior authorization request must be submitted for evaluation against the PA criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes.

1Minimum SSRI trial required

730Lookback period (days)

24Duration of Approval (months)

Coverage Summary

Coverage stance: covered_with_criteria. Scope: Defines initial step therapy and prior authorization criteria for the branded antidepressant Trintellix under a CVS/Caremark-administered prescription benefit for Neighborhood Health Plan of Rhode Island members; the CVS/Caremark-derived policy requires a generic-first step therapy (trial, intolerance, or contraindication to at least one generic SSRI or generic SSRI combination product) before branded Trintellix will be paid. Duration of Approval (DOA): 24 months. High-level claim behavior: if the step therapy requirement is not met, the claim will reject and a prior authorization (PA) is required.

Initial Step Therapy

If the patient has filled a prescription for at least a 30 day supply of at least one generic SSRI or generic SSRI combination product within the past 730 days under the CVS/Caremark prescription benefit, the requested branded drug will be paid; otherwise claim rejects and PA required.

Initial Step Therapy: Patient has filled a prescription for at least a 30 day supply of at least one generic SSRI or at least one generic SSRI combination product within the past 730 days under a prescription benefit administered by CVS/Caremark>= 30 day supply; 730 days

If not met, claim will reject indicating prior authorization is required

Key thresholds and duration

Minimum SSRI trial required1

Generic SSRI trial duration>= 30 day supply

Lookback period730 days

Duration of Approval24 months

Prior Authorization / Coverage Criteria

Coverage Criteria for Prior Authorization

Authorization may be granted when ONE of the following is met:

Coverage Criteria for Prior Authorization: Patient has experienced an inadequate treatment response after at least a 30 day trial of at least ONE generic SSRI or at least ONE generic SSRI combination product>= 30 day trial

Coverage Criteria for Prior Authorization: Patient has a documented contraindication or a potential drug interaction that would prohibit a trial of at least ONE generic SSRI or at least ONE generic SSRI combination product

Coverage Criteria for Prior Authorization: Patient has experienced an intolerance to at least ONE generic SSRI or at least ONE generic SSRI combination product

Prior Authorization

Prior Authorization required if step not met

If the patient has not filled a 30-day supply of a generic SSRI or SSRI combination product within the past 730 days under CVS/Caremark, the claim will reject and a prior authorization request must be submitted for evaluation against the PA criteria.

Claim will reject if no prior 30-day generic SSRI fill within 730 days under CVS/Caremark; submit PA for evaluation.

Documentation Required

Documentation of failure/contraindication/intolerance

For PA approval, document either inadequate response after a >=30-day trial of a generic SSRI or generic SSRI combination product, a documented contraindication or potential drug interaction preventing a trial of a generic SSRI or generic SSRI combination product, or intolerance to a generic SSRI or generic SSRI combination product.

Inadequate response after at least a 30-day trial of a generic SSRI or SSRI combination product
Documented contraindication or potential drug interaction that would prohibit an SSRI trial
Intolerance to at least one generic SSRI or SSRI combination product

Provider Actions & Operational Notes

Operational behavior (CVS/Caremark): claims for branded Trintellix will pay only when there is evidence the patient filled at least a 30 day supply of at least one generic SSRI or generic SSRI combination product within the past 730 days under the CVS/Caremark-administered benefit. If that initial step is not met, the claim will reject with a message indicating a prior authorization is required and the request will be routed to the PA unit for evaluation against the coverage criteria. Actionable checks for billing/clinical ops: verify a qualifying generic SSRI/generic SSRI combination fill of >= 30 days within the last 730 days before submitting a paid claim; if absent, prepare and submit a PA with documentation of a >= 30 day trial, documented contraindication/potential drug interaction preventing an SSRI trial, or documented intolerance.

Denial Risk

Step therapy not met — claim rejection and PA next steps

If the initial step therapy requirement is not met, the claim will reject and a prior authorization is required; document prior fills or any applicable contraindication or intolerance when submitting a PA.

Pharmacy fill history showing a 30-day (or longer) generic SSRI or SSRI combination fill within the past 730 days
Clinical notes documenting contraindication or potential drug interaction
Clinical notes documenting intolerance or inadequate response after a ≥30-day trial

Background & Definitions

Background: This is a CVS/Caremark-derived policy that imposes a generic-first step therapy requirement for branded Trintellix; approval requires prior trial, intolerance, or contraindication to at least one generic SSRI or generic SSRI combination product. The policy text does not enumerate specific generic SSRI combination products.

Definitions:

Generic SSRI combination product: A medication combining an SSRI with another agent marketed in generic form (policy does not enumerate specific products).

Revision History

statusLatest

CURRENT — Policy is in effect; no dated revisions or revision history provided. Defines a generic-first step therapy requirement for branded Trintellix: prior trial, intolerance, or contraindication to at least one generic SSRI or generic SSRI combination product (>=30-day supply within the past 730 days) required for coverage or prior authorization when step not met.