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Antidepressants

PHARM-13 Statement of Medical Necessity for Quantity Limits Override.

Antidepressants

Drugs

Quantity Limits

Aplenzin (Bupropion HBR) 174mg, 348mg and 522mg SR Tablets 

 30 Tablets per 30 Days

Celexa (Citalopram Hydrobromide) Tablets 

 10mg and 40mg - 100 Tablets per 100 days                     20mg - 1 1/2 Tablets daily up to 100 Tablets

Cymbalta (Duloxetine HCL) ) Capsules 

 20mg and 30mg - 2 Capsules daily up to 100 Capsules   60mg - 1 Capsule daily up to 100 Capsules

Effexor (Venlafaxine HCL) 25mg, 37.5mg, 50mg, 75mg and 100mg Tablets 

 3 Tablets per day up to 34 days

Effexor XR (Venlafaxine HCL) 37.5mg, 75mg and 150mg SR Capsules 

 37.5mg and 75mg - 1 Capsule daily up to 100 capsules     150mg - 2 Capsules daily up to 100 capsules

Emsam (Selegiline Transderm) 6mg/24hr, 9mg/24hr and 12mg/24hr Patches 

 30 Patches per 30 Days

Lexapro (Escitalopram Oxalate)  5mg, 10mg and 20mg Tablets 

 1 1/2 Tablets daily up to 100 Tablets

Luvox (Fluvoxamine Maleate) Tablets 

25mg - 1 Tablet daily up to 100 tablets
50mg - 2 Tablets daily up to 100 tablets                       100mg - 3 Tablets daily up to 34 days

Paxil (Paroxetine HCL) Tablets 

 10mg and 20mg - 1 Tablet daily up to 100 tablets            30mg - 2 Tablets daily up to 100 tablets                        40mg - 1 1/2 Tablets daily up to 100 tablets

Paxil CR (Paroxetine HCL) 12.5mg, 25mg and 37.5mg SR Tablets 

 1 Tablet daily up to 100 tablets

Pexeva (Paroxetine HCL) 10mg, 20mg, 30mg and 40mg Tablets 

 1 Tablet daily up to 100 tablets

Pristiq (Desvenlafaxine Succinate)  50mg and 100mg SR Tablets 

 100 Tablets per 100 Days

Prozac (Fluoxetine HCL) Capsules 

10mg - 3 Capsules daily up to 34 days
20mg - 4 Capsules daily up to 34 days 
40mg - 1 Capsule daily up to 100 days

Prozac Weekly (Fluoxetine HCL)  90mg Capsules 

 4 Capsules per 28 days

Remeron (Mirtazapine)  7.5mg, 15mg, 30mg and 45mg Tablets 

 1 Tablet daily up to 100 tablets

Remeron (Mirtazapine) 15mg, 30mg and 45mg Rapdis Tablets 

 1 Rapdis Tablet daily up to 100 tablets

Sarafem (Fluoxetine HCL) 10mg, 15mg and 20mg Tablets

  2 Tablets per day up to 100 Tablets

Venlafaxine HCL 37.5mg, 75mg, 150mg and 225mg Tablets

  37.5mg and 75mg - 1 Tablet daily up to 100 tablets        150mg and 225mg - 2 Tablets daily up to 100 tablets

Wellbutrin (Bupropion HCL) 75mg and 100mg Tablets

 3 Tablets per day up to 34 days

Wellbutrin SR (Bupropion HCL) 100mg, 150mg and 200mg  SA Tablets 

 2 Tablets per day up to 100 Tablets

Wellbutrin XL (Bupropion HCL) 150mg and 300mg  SR Tablets 

 100 Tablets per 100 Days

Zoloft (Sertraline HCL) 25mg, 50mg and 100mg Tablets 

 2 Tablets per day up to 100 Tablets
Last Modified on Nov 17, 2020
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Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

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