CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Trintellix (vortioxetine) coverage for Major Depressive Disorder

Defines coverage criteria for Trintellix (vortioxetine) for adults with major depressive disorder (MDD), continuation criteria, and a quantity limit. Non‑FDA indications are considered experimental/investigational and not medically necessary.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTrintellix (vortioxetine) coverage for Major Depressive Disorder

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization demonstrating member is >=18, has a diagnosis of MDD, and documentation of failure or intolerance to at least two formulary antidepressants.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes.

1Covered Indication (MDD)

>=2Required prior antidepressant trials

12Authorization duration (months)

1/dayQuantity limit

Coverage Summary

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Trintellix (vortioxetine) is FDA‑approved for the treatment of major depressive disorder (MDD) in adults. Coverage is limited to FDA‑approved indications; all other uses are considered experimental/investigational and not medically necessary. This policy defines coverage criteria for Trintellix for adults with MDD, continuation/renewal requirements, and a quantity limit. Coverage stance: covered_with_criteria. Status: CURRENT.

Initial Therapy Criteria

Indications / Initial Authorization

Trintellix is covered for FDA‑approved indication when ALL of the following are met:

ALL of the following

Indication is major depressive disorder (MDD)
Trintellix is indicated for treatment of MDD in adults; all other indications are experimental/investigational and not medically necessary
Member is 18 years of age or older>= 18 years
Member has documentation of failure or intolerance to at least two formulary antidepressants>= 2 formulary antidepressants
Examples listed: citalopram, duloxetine, escitalopram, fluoxetine, sertraline, venlafaxine

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Authorization Duration

If initial criteria met:

Authorization may be granted for 12 months

Continuation Therapy Criteria

Continuation of Therapy

Criteria for renewal/continued payment:

At least one paid claim for at least a 30-day supply of Trintellix within the last 365 days>= 1 paid claim for >=30-day supply within last 365 days

Continuation payment contingent on evidence of recent use

Provider Actions / Prior Authorization

Prior Authorization

Initial authorization requirements

Obtain prior authorization demonstrating member is 18 years of age or older, has a diagnosis of major depressive disorder (MDD), and retain documentation showing failure or intolerance to at least two formulary antidepressants (examples: citalopram, duloxetine, escitalopram, fluoxetine, sertraline, venlafaxine).

Prior Authorization

Continuation authorization evidence

For renewal/continuation, ensure there is at least one paid claim for at least a 30-day supply of Trintellix within the prior 365 days to support continued coverage.

Documentation Required

Documentation of prior trials

Retain and provide upon request documentation of trials or intolerance to at least two formulary antidepressants when seeking coverage for Trintellix.

Billing Rule

Quantity limit billing

Prescriptions and claims should not exceed one tablet per day across available strengths (5 mg, 10 mg, 20 mg).

Background

Trintellix is FDA‑approved for the treatment of major depressive disorder (MDD) in adults. The policy is intended to limit coverage to FDA‑approved indications; all other indications are considered experimental/investigational and not medically necessary. Initial authorization criteria require the member be 18 years of age or older, have a diagnosis of MDD, and have documentation of failure or intolerance to at least two formulary antidepressants (examples include citalopram, duloxetine, escitalopram, fluoxetine, sertraline, venlafaxine). An authorization of 12 months may be granted when criteria are met. For continuation, at least one paid claim for a ≥30‑day supply within the last 365 days is required. Quantity limit: 1 tablet per day across 5 mg, 10 mg, and 20 mg strengths.