CurrentNeighborhood Health Plan of Rhode IslandPolicy 1888-E 03-2023

Desvenlafaxine and Fetzima step therapy and prior authorization

Defines step therapy, initial quantity limits, and prior authorization coverage criteria for desvenlafaxine (including Khedezla/Pristiq) and Fetzima for treatment of major depressive disorder in adults under the payer's prescription benefit.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDesvenlafaxine and Fetzima step therapy and prior authorization

Policy CodePolicy 1888-E 03-2023

Change TypeNo material change

Effective DateMar 1, 2023

Next Review Date

Key ActionObtain prior authorization when step therapy criteria are unmet or the requested quantity exceeds the initial limit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

301-month quantity limit

903-month quantity limit

Adults with MDDFDA indication

Coverage Criteria

Prior Authorization Coverage Criteria

Covered with prior authorization when ALL of the following are met

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Population and indication: Patient is an adult and the requested drug is being prescribed for treatment of major depressive disorder (MDD)

Prior exposure or reason: Patient has experienced an inadequate treatment response, intolerance, OR has a contraindication to ANY of the following: (A) a serotonin and norepinephrine reuptake inhibitor (SNRI), (B) a selective serotonin reuptake inhibitor (SSRI), (C) mirtazapine, (D) bupropion

This condition is required in addition to the population/indication criterion

Quantity limits apply per drug and strength: Desvenlafaxine (all brand/generic products): 30 tablets per 25 days (or 90 per 75 days for a 90-day fill); Fetzima: 30 capsules per 25 days (or 90 per 75 days for a 90-day fill)30 per 25 days; 90 per 75 days

The duration of 25 days is used for a 30-day fill period and 75 days is used for a 90-day fill period to allow time for refill processing; limits apply when initial step therapy criteria are met; requests exceeding limits require PA

Prescription and Billing Codes / Limits

Prescription/Billing Codes Affectedmixed

affected codes

Prescription benefit claims codes affected by step therapy/PA (document references 'affected codes' placeholder)

Initial quantity limit — inv-04: Coding thresholds (initial)

1-month initial quantity limit30 tablets/capsules per 25 days (30-day fill)

3-month initial quantity limit90 tablets/capsules per 75 days (90-day fill)

Applies toDesvenlafaxine (all brand/generic products) and Fetzima

Reason for 25/75 day durations25 days used for a 30-day fill and 75 days used for a 90-day fill to allow time for refill processing.

Provider Actions, Prior Authorization & Step Therapy

Prior Authorization

Prior Authorization Required

Prior authorization required when initial step therapy criteria are not met or when quantity requested exceeds the initial quantity limit. If the patient does not meet the initial step therapy criteria the claim will reject with a message indicating that a prior authorization (PA) is required; the PA criteria will then be applied to requests submitted for evaluation to the PA unit.

Desvenlafaxine, Fetzima ST with Limit, Post PA Policy 1888-E 03-2023

Step Therapy

Initial Step Therapy Requirement

Initial step therapy applies when the patient has NOT filled at least a 30‑day supply of an SNRI, mirtazapine, bupropion (except generic Zyban), or an SSRI within the past 180 days under a prescription benefit administered by CVS Caremark. If the patient has filled at least a 30‑day supply of any of these agents within the past 180 days the requested drug will be paid under that prescription benefit. If the patient meets initial step therapy, initial quantity limits apply; if the patient requests more than the initial quantity limit the claim will reject with a message indicating a PA is required.

Includes Rx and OTC products unless otherwise stated
If filled within past 180 days under CVS Caremark benefit = covered under that benefit
Initial quantity limits: Desvenlafaxine (all brand/generic): 30 tablets / 25 days; Fetzima: 30 capsules / 25 days — 25 days used for a 30‑day fill period (75 days for 90‑day)

Documentation Required

Required Clinical Justification

Documentation must demonstrate the patient is an adult with major depressive disorder (MDD) and has experienced an inadequate treatment response, intolerance, or has a contraindication to an SNRI, an SSRI, mirtazapine, or bupropion. Quantity limits apply per policy.

Coverage criteria: Treatment of an adult with MDD AND inadequate response, intolerance, or contraindication to any of: A) SNRI, B) SSRI, C) mirtazapine, D) bupropion
Quantity limits: Desvenlafaxine (all brand/generic): 30 tablets / 25 days; Fetzima: 30 capsules / 25 days