Can I obtain a prior authorization for vortioxetine (Trintellix) 20 mg daily for a patient with major depressive disorder and attention‑deficit/hyperactivity disorder who has been stable on this medication since [date] and has failed trials of brexpiprazole (Rexulti), escitalopram (Lexapro), sertraline (Zoloft), bupropion (Wellbutrin), and fluoxetine (Prozac) due to a change in insurance?

Prior Authorization Support for Vortioxetine (Trintellix) 20 mg

Your patient meets clear criteria for continued vortioxetine therapy based on documented treatment failure to multiple adequate antidepressant trials and established clinical stability on her current regimen.

Justification for Vortioxetine Continuation

Treatment-Resistant Depression Criteria Met

Your patient has documented failure of at least five different antidepressant medications with different mechanisms of action, which establishes treatment-resistant depression (TRD) 1:

• Failed SSRIs: escitalopram (Lexapro), sertraline (Zoloft), fluoxetine (Prozac)
• Failed atypical antidepressant: bupropion (Wellbutrin)
• Failed atypical antipsychotic augmentation: brexpiprazole (Rexulti)

The consensus definition of TRD requires failure of at least two antidepressants with different mechanisms of action at adequate doses for at least 4 weeks each 1. Your patient far exceeds this threshold with five documented failures.

Guideline-Supported Antidepressant Selection

The American College of Physicians recommends selecting second-generation antidepressants based on adverse effect profiles, cost, and patient preferences when multiple agents show similar efficacy 1, 2. Since vortioxetine has demonstrated clinical effectiveness for this patient where five other agents failed, continuing this medication is the evidence-based approach 1.

Vortioxetine shows equivalent efficacy to other second-generation antidepressants but demonstrates superior tolerability metrics, being 5.1 times more likely to produce response than discontinuation due to adverse events compared to placebo 3. This favorable tolerability profile is particularly relevant given your patient's history of multiple medication failures, which may have included tolerability issues 3.

Established Clinical Stability

For patients achieving satisfactory response to antidepressant therapy, the American College of Physicians strongly recommends continuing treatment for 4-9 months after initial response, with even longer duration for patients with recurrent depression 1, 2. Your patient has been stable on vortioxetine since [DATE], demonstrating sustained benefit that should not be interrupted.

Discontinuing effective therapy risks relapse, which occurs in 32.5% of patients switched to placebo versus only 17.4% continuing vortioxetine 20 mg 4. The risk of relapse is particularly concerning given her history of treatment resistance 4.

Vortioxetine-Specific Clinical Evidence

Dose-Dependent Efficacy

Vortioxetine 20 mg demonstrates superior and more rapid symptomatic response compared to 10 mg, with 51.4% achieving response at 20 mg versus 46.0% at 10 mg 5. Your patient's current 20 mg dose represents the optimal therapeutic dosing supported by clinical trials 5.

Patients on vortioxetine 20 mg achieve sustained response from week 4 (26.0% vs 19.1% on 10 mg), increasing to 36.0% versus 29.8% by week 8 5. This dose-dependent benefit justifies maintaining the 20 mg dose rather than attempting dose reduction 5.

Unique Pharmacological Profile

Vortioxetine's multimodal mechanism—combining serotonin transporter inhibition with 5-HT3 and 5-HT7 receptor antagonism and 5-HT1A receptor agonism—provides a distinct pharmacological approach that may explain its efficacy when other antidepressants failed 6. This is particularly relevant for patients with comorbid ADHD, as vortioxetine demonstrates procognitive effects in preclinical and clinical studies 6.

Prior Authorization Documentation Points

Include the following in your prior authorization request:

• Diagnosis: Major depressive disorder (document severity and duration of current episode) 7
• Treatment history: List all five failed antidepressant trials with specific medications, doses, durations, and reasons for discontinuation 1
• Current response: Document clinical stability since [DATE] with specific symptom improvement metrics if available 1
• Dose justification: Vortioxetine 20 mg is FDA-approved and represents the dose with greatest efficacy in clinical trials 7, 5
• Risk of discontinuation: Emphasize 32.5% relapse risk with medication discontinuation versus 17.4% with continuation 4

Monitoring Requirements

The American College of Physicians recommends assessing therapeutic response and adverse effects regularly, beginning within 1-2 weeks of any treatment modification 1. If the insurance requires a trial of alternative medication, document that this represents inappropriate interruption of effective therapy and request expedited appeal based on established clinical stability 1.

The FDA label supports vortioxetine 20 mg as within the approved dosing range (5-20 mg daily), with the recommendation that doses be increased to 20 mg as tolerated 7. Your patient has tolerated this dose successfully, further supporting continuation 7.