ALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Golden State Medicare Health Plan, Golden (HMO) Last Updated: 09/01/2018
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1 Step Therapy Golden State Medicare Health Plan, Golden (HMO) Last Updated: 09/01/2018 ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir 1
2 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Trial of two of the following formulary products: bupropion, mirtazapine, generic SSRI, or generic SNRI. 2
3 ANTIGOUT -SCORE Uloric Trial of allopurinol 3
4 ATYPICAL ANTIPSYCHOTICS - SCORE Fanapt Fanapt Titration Pack Vraylar Trial of two generic formulary atypical antipsychotic agents 4
5 BISPHOSPHONATES -SCORE Fosamax Plus D Trial of one generic formulary oral bisphosphonate agent 5
6 DPP4 INHIBITORS - SCORE Janumet Janumet Xr Januvia Jentadueto Jentadueto Xr Kombiglyze Xr Onglyza Tradjenta Trial of one generic formulary metformin or metformin combination 6
7 EPINEPHRINE -SCORE Adrenaclick Epinephrine INJ 0.15MG/0.15ML Trial of one of the following: generic epinephrine (generic Epipen or generic EpiPen Jr, by manufacturer: Mylan, NDCs ** and **), brand Epipen, or brand Epipen Jr. 7
8 FILGRASTIM - SCORE Granix Neupogen Trial of Zarxio 8
9 GABAPENTIN - SCORE Gralise Gralise Starter Trial of generic gabapentin 9
10 GLP1 AGONIST - SCORE Bydureon Bydureon Bcise Bydureon Pen Trulicity Victoza Trial of one generic formulary metformin or metformin combination 10
11 LAMA - SCORE Tudorza Pressair Trial of Spiriva 11
12 LEUKOTRIENE MODIFIERS - SCORE Zileuton Er Zyflo Trial of generic montelukast or generic zafirlukast 12
13 LONG-ACTING OPIOID - SCORE Arymo Er Trial of Embeda 13
14 OPHTHALMIC NSAID - SCORE Bromsite Trial of one generic ophthalmic NSAID solution: diclofenac, flurbiprofen, ketorolac, AND one brand from: Nevanac, Prolensa, Ilevro. 14
15 PD AGENTS - SCORE Neupro Trial of one generic formulary dopamine agonist agent 15
16 RYTARY - SCORE Rytary Trial of any generic antiparkinson agent 16
17 SGLT2 - SCORE Glyxambi Invokamet Invokamet Xr Invokana Jardiance Synjardy Synjardy Xr Trial of one generic formulary metformin or metformin combination 17
18 STATINS - SCORE Livalo Trial of any one generic formulary HMG-CoA reductase inhibitor (statin) 18
19 Beneficiaries must use network pharmacies to access their prescription drug benefit. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1 of each year. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: MEDICARE ( ). TTY users should call , 24 hours a day/ 7 days a week; the Social Security Office at between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, ; or your state Medicaid office. This information is available for free in other languages. Please contact our customer service number at (877) or TTY at (877) from 8 a.m. to 8 p.m. Monday through Friday and daily during the enrollment period. Esta información está disponible de forma gratuita en otros idiomas. Por favor, póngase en contacto con nuestro número de servicio al cliente al (877) o TTY al (877) de 8 am a 8 pm de lunes a viernes, y todos los dias durante el periodo de inscripcion. This document may be available in an alternate format such as Braille, larger print or audio. Golden State Medicare Health Plan is an HMO plan with a Medicare contract. Enrollment in Golden State Medicare Health Plan depends on contract renewal. Formulary ID# B H2241_001_5015_ST_2013 CMS Approved
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ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID 18354, Version 15 1 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Trial of two of
ALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Health Choice Generations 1 Tier Gold Effective Date: 11/01/2018.
ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/2018 1 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam
ALBUTEROL - SCORE{XE "ALBUTEROL - SCORE"}
Step Therapy ALBUTEROL - SCORE{XE "ALBUTEROL - SCORE"} Ventolin Hfa{XE "Ventolin Hfa"} Trial of ProAir Formulary ID# 00018097 Last Updated: 04/01/2018 1 ANTIDEPRESSANTS - SCORE{XE "ANTIDEPRESSANTS - SCORE"}
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ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID 18351, Version 15 1 ANTIDEPRESSANTS - SCORE Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Trial of two of the following
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