Selegiline TD (Emsam) Prior Authorization Criteria (Platino)

General Prior Authorization Request Form

Covered Uses

All FDA-approved indications not otherwise excluded from Part D

• Major depressive disorder

Exclusion Criteria

None

Required Medical Information

Document previous use of oral MAO inhibitors

Age Restrictions

None

Prescriber Restrictions

None

Coverage Duration

1 year

Other Criteria

None