ModifiedPremera Blue Cross of WashingtonPolicy N/A

Zurzuvae (zuranolone) for Postpartum Depression

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This policy governs pharmacy-benefit coverage and prior authorization for oral Zurzuvae (zuranolone) in adults with postpartum depression who meet specified diagnostic, severity, postpartum timing, age, and treatment-duration requirements.

Policy Summary

PayerPremera Blue Cross of Washington

PolicyZurzuvae (zuranolone) for Postpartum Depression

Policy CodePolicy N/A

Change TypeModified

Effective DateN/A

Last ReviewNov 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization for Zurzuvae coverage under the pharmacy benefit.

SourceLink

POLICY UPDATE CHANGES

Coverage criteria for Zulresso (brexanolone) were removed.

A Not Medically Necessary table was added for Zurzuvae (zuranolone).

The policy clarified that Zurzuvae uses not meeting the policy criteria are not medically necessary.

The policy removed reference to non-formulary exception review.

18+Minimum age

≤12 monthsMaximum postpartum interval

14 daysTreatment course

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ModifiedPremera Blue Cross of WashingtonPolicy N/A

Zurzuvae (zuranolone) for Postpartum Depression

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Sign up for all premerabluecrossofwashington policy alerts

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Policy Summary

PayerPremera Blue Cross of Washington

PolicyZurzuvae (zuranolone) for Postpartum Depression

Policy CodePolicy N/A

Change TypeModified

Effective DateN/A

Last ReviewNov 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization for Zurzuvae coverage under the pharmacy benefit.

SourceLink

POLICY UPDATE CHANGES

Coverage criteria for Zulresso (brexanolone) were removed.

A Not Medically Necessary table was added for Zurzuvae (zuranolone).

The policy clarified that Zurzuvae uses not meeting the policy criteria are not medically necessary.

The policy removed reference to non-formulary exception review.

18+Minimum age

≤12 monthsMaximum postpartum interval

14 daysTreatment course

Courses per pregnancy

50 mgRecommended dose

Medical Necessity and Exclusions

Initial Therapy

Zurzuvae (zuranolone) may be considered medically necessary for the treatment of postpartum depression when ALL of the following criteria are met:

ALL of the following

The individual is aged 18 years or older.
Medical record documentation confirms DSM-5 diagnostic criteria for Major Depressive Disorder with peripartum onset.
The current episode of depression is moderate to severe, as demonstrated by documentation of the individual's symptoms and their severity or by one or more standardized depression rating scales.
The individual is 12 months or less postpartum.

All uses of Zurzuvae (zuranolone) that do not meet the policy criteria within the Medical Necessity section are excluded from medically necessary coverage.

Treatment beyond 14 days in a single treatment course per pregnancy is not medically necessary.

Uses of Zurzuvae (zuranolone) that do not meet the Medical Necessity criteria are considered not medically necessary.

Future re-authorization of Zurzuvae (zuranolone) beyond 14 days in a single treatment course per pregnancy is not medically necessary.

All uses of Zurzuvae (zuranolone) that do not meet the policy criteria within the Medical Necessity section are considered not medically necessary.

Coding and Severity Assessment

Removed HCPCS CodeHCPCS

J1632

HCPCS code removed from the policy in 2026 with removal of Zulresso (brexanolone) coverage criteria.

Hamilton Depression Rating Scale (HAM-D)

RemissionHAM-D score below 10

MildHAM-D score 10–13

Mild to moderateHAM-D score 14–17

Moderate to severeHAM-D score ≥18

Montgomery-Asberg Depression Rating Scale (MADRS)

NoneMADRS score 0–6

MildMADRS score 7–19

Authorization and Documentation Requirements

Prior Authorization

Obtain prior authorization for initial therapy

Prior authorization is required for Zurzuvae coverage under the pharmacy benefit. Initial authorization may be approved for one 14-day single treatment course per pregnancy when all Medical Necessity criteria are met.

Documentation Required

Submit complete medical records and office notes

Submit medical records documenting that Medical Necessity criteria are met. Include office visit notes containing the relevant history and physical evaluation information.

Documentation Required

Document clinical eligibility

Postpartum Depression Background

Postpartum depression is a major depressive episode occurring after childbirth. It may include depressed mood, loss of interest or pleasure, impaired concentration, guilt or worthlessness, and suicidal thoughts. Zurzuvae (zuranolone) is a neuroactive steroid and positive allosteric modulator of GABA-A receptors indicated for postpartum depression; clinical trials evaluated a 14-day oral course in individuals up to 12 months postpartum and showed greater symptom improvement than placebo.

Clinical Definitions

DSM-5 Diagnostic Criteria for a Major Depressive Episode

Symptom count and durationFive or more symptoms must be present during the same two-week period.

Change from baselineThe symptoms must represent a change from previous functioning.

Required symptomAt least one symptom must be depressed mood or loss of interest or pleasure.

Functional impactSymptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Diagnostic exclusionsThe episode must not be attributable to a substance or medical condition, better explained by a psychotic disorder, or occur with a history of a manic or hypomanic episode unless substance- or medically induced.

Standardized Depression Severity Rating Scales

Initial Treatment for Postpartum Depression

Initial coverage may be considered when all criteria are met:

Zurzuvae initial therapy: The individual is aged 18 years or older; medical records document DSM-5 criteria for Major Depressive Disorder with peripartum onset; the current depressive episode is moderate to severe based on documented symptoms and severity or a standardized depression rating scale; and the individual is 12 months or less postpartum.Age ≥18 years; postpartum ≤12 months; moderate-to-severe current episode

Zurzuvae is subject to the product's U.S. Food and Drug Administration dosage and administration prescribing information.

Continuation and Re-authorization

Re-authorization Limitation

Continuation or re-authorization is limited to the remaining duration of the single treatment course per pregnancy.

Continuation limitation: No treatment beyond a total of 14 days in a single treatment course per pregnancy may be authorized.14 days per pregnancy

Additional treatment beyond the 14-day course is not medically necessary.

Treatment Duration Limit

Zurzuvae (zuranolone)

MedicationZurzuvae (zuranolone)

Quantity limit14 days

Course limitationOne single treatment course per pregnancy

Policy Summary

PayerPremera Blue Cross of Washington

PolicyZurzuvae (zuranolone) for Postpartum Depression

Policy CodePolicy N/A

Change TypeModified

Effective DateN/A

Last ReviewNov 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization for Zurzuvae coverage under the pharmacy benefit.

SourceLink

On This Page

ModerateMADRS score 20–34

SevereMADRS score ≥35

Quick Inventory of Depressive Symptomatology (QIDS-SR)

NoneQIDS-SR score 0–5

MildQIDS-SR score 6–10

ModerateQIDS-SR score 11–15

SevereQIDS-SR score 16–20

Very severeQIDS-SR score ≥21

Patient Health Questionnaire-9 (PHQ-9)

NonePHQ-9 score 0–4

MildPHQ-9 score 5–9

ModeratePHQ-9 score 10–14

Moderately severePHQ-9 score 15–19

SeverePHQ-9 score ≥20

Likely major depressionPHQ-9 score ≥10

Documentation should establish the DSM-5 diagnosis of Major Depressive Disorder with peripartum onset, the current moderate-to-severe depressive episode, symptoms and their severity or a standardized depression rating scale, the individual's age, and postpartum timing.

Denial Risk

Avoid requests that exceed coverage criteria or one course

Uses of Zurzuvae that do not meet the policy criteria are considered not medically necessary. Treatment beyond a 14-day single treatment course per pregnancy, including future re-authorization beyond 14 days, is also considered not medically necessary.

Denial Risk

Ensure all Medical Necessity criteria are met

Zurzuvae uses that do not meet the policy criteria within the Medical Necessity section are considered not medically necessary and are excluded from medically necessary coverage.

HAM-DA score ≥18 indicates moderate to severe depression.

MADRSScores 20–34 indicate moderate depression; scores ≥35 indicate severe depression.

QIDS-SRScores 11–15 indicate moderate, 16–20 severe, and ≥21 very severe depression.

PHQ-9Scores 10–14 indicate moderate, 15–19 moderately severe, and ≥20 severe depression; a score ≥10 indicates likely major depression.

Postpartum Period

DefinitionThe postpartum period referenced for consideration of zuranolone is within 12 months after delivery.

Policy timing thresholdCoverage criteria require the individual to be 12 months or less postpartum.

Clinical referenceACOG recommends consideration of zuranolone within 12 months postpartum for qualifying depression onset.

Moderate to Severe Depression

Documentation method 1Document the individual's depressive symptoms and their severity.

Documentation method 2Use one or more standardized depression rating scales to demonstrate severity.

Severity levelThe documented findings must demonstrate moderate to severe depression.