CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Emsam (selegiline transdermal system) — Prior Authorization Coverage Criteria

Prior authorization requirements for coverage of Emsam (selegiline transdermal system) for adults with major depressive disorder (MDD); coverage approved when patient is an adult with MDD and has trialed (or has intolerance/contraindication to) an SNRI, SSRI, mirtazapine, or bupropion, or is unable to swallow oral formulations.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyEmsam (selegiline transdermal system) — Prior Authorization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization documenting adult MDD diagnosis and prior trial/intolerance/contraindication to an SNRI, SSRI, mirtazapine, or bupropion (or document inability to swallow oral formulations).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1FDA-approved indication listed (MDD)

2Primary coverage pathways

4Referenced source list items

Coverage Criteria for Emsam (selegiline transdermal system)

inv-01: Coverage criteria

Covered with prior authorization when ONE of the following is met:

Pathway A: The requested drug is being prescribed for the treatment of an adult patient with major depressive disorder (MDD) AND the patient has experienced an inadequate treatment response, intolerance, or has a contraindication to at least one of: a serotonin and norepinephrine reuptake inhibitor (SNRI), a selective serotonin reuptake inhibitor (SSRI), mirtazapine, or bupropion.

Standard step-therapy pathway requiring prior trial or documented intolerance/contraindication to listed oral agents.

Pathway B: The requested drug is being prescribed for the treatment of an adult patient with major depressive disorder (MDD) AND the patient is unable to swallow oral formulations.

Alternate pathway allowing transdermal formulation without prior oral trials.

This policy addresses coverage for Emsam (selegiline transdermal system) only for its FDA‑approved indication: treatment of adults with major depressive disorder (MDD). No coverage language is provided in this document for indications other than adult MDD. Requests for use of Emsam for non‑FDA‑approved indications should be submitted through the standard off‑label/medical‑exception request pathway and must include supporting clinical justification and evidence.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyEmsam (selegiline transdermal system) — Prior Authorization Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Emsam (selegiline transdermal system). Coverage may be approved when the patient is an adult with a diagnosis of major depressive disorder (MDD) and the criteria below are met.

Applies to Emsam (selegiline transdermal system)
Member must be an adult with diagnosed MDD

Step Therapy

Step Therapy Requirement

A trial of at least one of the following oral antidepressants is required prior to approval, unless there is documented intolerance or a contraindication: an SNRI, an SSRI, mirtazapine, or bupropion. Alternatively, approval may be considered if the member is unable to swallow oral formulations.

Required trial: SNRI OR SSRI OR mirtazapine OR bupropion (unless intolerance/contraindication documented)
Exception: inability to swallow oral formulations

Documentation Required

Required Clinical Documentation

Documentation must confirm the patient is an adult with a diagnosis of major depressive disorder (MDD) and must include evidence of an inadequate response to, intolerance of, or contraindication to the required prior agents (SNRI, SSRI, mirtazapine, or bupropion) — or documentation that the patient is unable to swallow oral formulations.

Confirm adult patient and diagnosis of MDD
Provide records showing inadequate response, intolerance, or contraindication to required agents, or documentation of inability to swallow oral medications
Include prior medication names, doses, dates of trial, and reason for discontinuation

Denial Risk

Failure to Meet Listed Criteria

Requests that do not include the required documentation or that fail to demonstrate the patient is an adult with MDD or lacks the required prior trial/intolerance/contraindication will be denied.

Denial risk if documentation of diagnosis or prior trials/intolerance/contraindication is missing
Ensure submission includes medication trial history and clinical rationale

OpenPayer

Emsam (selegiline transdermal system) — Prior Authorization Coverage Criteria

Coverage Criteria for Emsam (selegiline transdermal system)

Provider Actions and Authorization Requirements

Transdermal MAOI (Emsam) — Treatment Modality

Definitions

Background