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Xxxxxx Antidepressants Xxxxxx (Miscellaneous)
8
Name AETNA BCBSMA BMCHP FCHP HPHC HNE NHP NTWK MAHLTH THP
BUPROPION XL [Wellbutrin XL] DL* sT NC DL DL PA D 1 sT 2 NC PA sT 2
sT
CLOMIPRAMINE X* X* X X X X X X X X
DEsIPRAMINE X* X* X X X X X X X X
DEsVENLAFAXINE [Pristiq] DL FE NC DL DL PA sT 2 DL PA sT 2 *
sT* sT
DOXEPIN X* X* X X X X X X X X
DULOXETINE [Cymbalta] DL* sT sT DL PA sT 2 DL sT PA DL sT 2
FLUVOXAMINE CR (Luvox CR) DL FE NC DL DL PA sT 2 PA PA NC
sT sT
IMIPRAMINE HyDROCHLORIDE X* X* X X X X X X X X
IMIPRAMINE PAMOATE X* X* X X X X X
IMIPRAMINE PAMOATE [Tofranil PM] X X sT X X
MAPROTILINE DL* X* X X X X X X X X
MILNACIPRAN [savella] DL* X* X DL PA DL sT
MIRTAzAPINE DL* DL* DL X X X X X X X*
MIRTAzAPINE [Remeron] DL sT NC DL X NC X
MIRTAzAPINE orally disintegrating
tablet
DL* DL* DL X X X X X PA X
NEFAzODONE FE sT DL* X X X X X X X X
NORTRIPTyLINE X* X* X X X X X X X X
OLANzAPINE/FLUOXETINE
[symbyax]
DL DL X PA X
PHENELzINE [Nardil] X X* X X X X X X X X
PROTRIPTyLINE X* X* X X X X X X
PROTRIPTyLINE [Vivactil] X X* PA X X NC PA X
sELEgILINE transdermal [Emsam] DL FE NC X X PA PA sT2 TRANyLCyPROMINE X* X* X X X X X X X X
TRANyLCyPROMINE [Parnate] X X PA X X NC PA X
TRAzODONE X* X* X X X X X X3 X4 X
TRIMIPRAMINE X* X* X X X X X X X
TRIMIPRAMINE [surmontil] X X X X X PA X
VENLAFAXINE DL* X* DL X X DL DL sT X X X*
1 30
2 ≥18 yrs old
3 300 mg excluded