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Oscar Savella (milnacipran) (PG062) Form


Savella (milnacipran) for the management of fibromyalgia pain

Notes: If all initial authorization criteria are met, Savella (milnacipran) will be approved for 12 months.

Indications

(976406) Is the patient 18 years of age or older? 
(976407) Does the patient have a diagnosis of fibromyalgia? 
(976408) Has the patient documented trial and failure of non-pharmacologic therapy for fibromyalgia (e.g., cognitive behavioral therapy, education, exercise)? 
(976409) Has the patient trialed and failed at least three therapies from at least three different classes such as cyclobenzaprine; gabapentinoids; SNRIs other than milnacipran; or tricyclic antidepressants for a minimum of one month each? 
(976410) Is there clinical chart documentation provided for review to substantiate the above requirements? 

YesNoN/A
YesNoN/A

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Effective Date

NA

Last Reviewed

09/21/2022

Original Document

  Reference



Savella (milnacipran), FDA approved in 2009

Savella (milnacipran), FDA approved in 2009, is a serotonin norepinephrine reuptake inhibitor (SNRI) used for the management of pain caused by fibromyalgia. Fibromyalgia is a multi-symptom condition, commonly presenting as widespread chronic pain, fatigue and sleep issues. Treatment for fibromyalgia usually involves a combination of drugs (to relieve pain, improve sleep or mood) and non-drug treatments, such as cognitive behavioral therapy, relaxation therapy and aerobic exercise.

NOTE: Although Savella (milnacipran) has been used in the treatment of major depressive disorder and is approved for treating depression in some countries outside the US, this indication is not an FDA-labeled use.

Definitions

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