Limited coverage criteria – vortioxetine

Last updated on March 24, 2025

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Generic name		vortioxetine hydrobromide
Strength & form		5 mg, 10 mg, and 20 mg oral tablets

Special Authority criteria	Approval period
Major depressive disorder (MDD) in adult patients AND Treatment failure or intolerance to at least 2 other specified antidepressants for MDD treatment	Indefinite

Special Authority criteria

Approval period

Major depressive disorder (MDD) in adult patients

AND

Treatment failure or intolerance to at least 2 other specified antidepressants for MDD treatment

Indefinite

Practitioner exemptions

None

Special notes

Criteria applicable to all plans, including Plan G

Special Authority request form(s)

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HLTH 5328 – General Special Authority request (PDF, 656KB)

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