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Date of onset:
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Date of onset:
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Aetna REQUIRES 2 ADAs (2 diff. classes) AND REQUIRES 1 augmentation trial--both at minimum effective dose for 8 weeks, past 5 yr
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Acceptable Augmentation: Abilify, Rexulti, Seroquel XR, Zyprexa
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2 Antidepressants (see req. above)
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Medication Name
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Medication Dose
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Dates of Medication Trial
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Ineffective? or Side Effects?
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Medication Name
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Medication Dose
|
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Dates of Medication Trial
|
Ineffective? or Side Effects?
|
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Augmentor(s) (see req. above)
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|
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Medication Name
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Medication Dose
|
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Dates of Medication Trial
|
Ineffective? or Side Effects?
|
|
Medication Name
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Medication Dose
|
|
Dates of Medication Trial
|
Ineffective? or Side Effects?
|
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Diagnosis
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Other or Additional Diagnosis
|
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PHQ-9 Score (20+)
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PHQ- 9 Score:
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Previous/ Current Therapist
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Therapist Name & Licensure
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Ineffective Therapy Trial
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Declined ECT
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Risk/ Benefits Statement
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Other Considerations?
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