MHCP Enrolled Providers – Pharmacies
Fee-for-Service PA Criteria Sheet – Viibryd
(February 2013)
Drug
Therapeutic Area
Viibryd (vilazodone) [Forest]
Antidepressant
Approval Criteria
 Patient is 18 years of age or older AND
 Patient has a diagnosis of major depressive disorder AND
 Patient has tried and failed two separate 2 month trials of 2 preferred SSRIs AND
 Patient has a documented intolerance/contraindication to OR has tried and failed a 2 month trial of 1 other preferred new
generation antidepressant (i.e. venlafaxine, buproprion, mirtazapine or a tri-cyclic antidepressant).
Selective Serotonin Reuptake Inhibitors
Preferred
Non preferred
citalopram
Celexa
escitalopram
Lexapro
fluoxetine
Paxil /Paxil CR
paroxetine
Prozac
Pexeva
Fluoxetine DR (weekly)
Prozac Weekly
sertraline
paroxetine suspension
Sarafem
Viibryd*
Zoloft
* individual PA criteria apply
New Generation Antidepressants
Preferred
Non preferred
bupropion IR, SA, XL
Aplenzin* (bupropion HBr)
fluvoxamine
Cymbalta
mirtazapine
nefazodone
trazodone
venlafaxine extended release
venlafaxine extend release capsules
(generic EffexorXR)
venlafaxine extended release
tablets (generic)
Desyrel
Effexor, Effexor XR
Luvox CR *
Pristiq *
Remeron
Wellbutrin/ SR / XL
* individual PA criteria apply
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Quantity Limits
Metabolism by CYP3A4 is a major elimination pathway for vilazodone. Patients must start Viibryd using the Patient Starter Kit or
the 40 mg dose. If the prescriber is requesting 10 mg or 20 mg strengths, documentation that Viibryd is being used for
maintenance therapy and is being co-administered with a strong inhibitor of CYP3A4.
 Quantity Limit = 34 (All strengths)
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Background information
Viibryd (vilazodone) is a selective serotonin reuptake inhibitor (SSRI) and a serotonin (5-HT1A) receptor partial agonist indicated
for the treatment of major depressive disorder (MDD) in adults. Vilazodone is titrated to the recommended dose of 40 mg once
daily with food. There are many other drugs indicated in the initial treatment of MDD including: tricyclic antidepressants (TCAs),
SSRIs, SNRIs, bupropion and mirtazapine.
Rationale
The most recent guidelines published by Kaiser Permanente Care Management Institute in 2006 for the treatment of depression in
primary care recommend SSRIs, TCAs, serotonin norepinephrine reuptake inhibitors SNRIs, and dopamine agonists as first-line
treatment of MDD. The preference of antidepressant is based on patient’s history with drug treatment, clinician choice, adverse
effects, among other factors. Vilazodone is the first FDA approved antidepressant with a dual serotonergic mechanism of action
acting as both a SSRI and a partial serotonergic agonist. There are no clinical trials comparing the efficacy or safety of vilazodone
to other antidepressants. It is not clear if vilazodone offers any unique efficacy or safety advantage over existing therapies.
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MHCP Provider Call Center 651-431-2700 or 1-800-366-5411