ALLERGIC RHINITIS-NASAL

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1 ALLERGIC RHINITIS-NASAL FLUNISOLIDE Patient needs to have paid claims for any one of the following Step 1 drugs: NasaCort OTC, fluticasone Rx, fluticasone OTC, Budesonide OTC. Prior to filling the Step 2 drug: flunisolide. PAGE 1 LAST UPDATED 04/2019

2 ALPHA REDUCTASE INHIBITOR DUTASTERIDE Patient needs to have paid claims for any one of the following Step 1 drugs: 5 Alpha Reductase Inhibitor (finasteride). Prior to filling the Step 2 drug: 5 Alpha Reductase Inhibitor (dutasteride). PAGE 2 LAST UPDATED 04/2019

3 ANTI-MIGRAINE SUMATRIPTAN Patient needs to have paid claims for any one of the following Step 1 drugs: Rizatriptan benzoate, Naratriptan HCl, Sumatriptan (oral), Sumatriptan succinate (inj). Prior to filling the Step 2 drug: Sumatriptan (spray). PAGE 3 LAST UPDATED 04/2019

4 BPH ALFUZOSIN HCL ER Patient needs to have paid claims for any one of the following Step 1 drugs: Alpha 1 Blockers (Terazosin, Prazosin, Doxazosin, tamsulosin). Prior to filling the Step 2 drug: Alfuzosin. PAGE 4 LAST UPDATED 04/2019

5 BRILINTA BRILINTA Patient needs to have a 30 day supply paid claim for any one of the following Step 1 drug: clopidogrel. Prior to filling the Step 2 Drug: Brilinta. PAGE 5 LAST UPDATED 04/2019

6 DDP4 INHIBITORS JANUMET, JANUMET XR, JANUVIA, KOMBIGLYZE XR, ONGLYZA Patient needs to have paid claims for any one of the following Step 1 drugs: metformin, metformin ER, glipizide/metformin, glyburide/metformin, canagliflozin/metformin, canagliflozin/metformin XR, empagliflozin/metformin, empagliflozin/metformin XR. Prior to filling the Step 2 Drugs: Januvia, Janumet, Janumet XR, Onglyza, Kombiglyze XR PAGE 6 LAST UPDATED 04/2019

7 GLP-1 AGONISTS TRULICITY, VICTOZA 2-PAK, VICTOZA 3-PAK Patient needs to have paid claims for any one metformin containing agents Step 1 drugs: metformin, metformin ER, glipizide/metformin, glyburide/metformin, canagliflozin/metformin, canagliflozin/metformin XR, empagliflozin/metformin, empagliflozin/metformin XR, sitagliptin/metformin, sitagliptin/metformin XR, alogliptin/metformin, saxagliptin/metformin XR. Prior to filling the Step 2 Drugs: Victoza, Trulicity PAGE 7 LAST UPDATED 04/2019

8 INFLAMMATION CELECOXIB Patient needs to have paid claims for any two of the following Step 1 drugs: NSAIDS (diflunisal, oral diclofenac sodium, diclofenac sodium/misoprostol, diclofenac potassium, etodolac, fenoprofen, flurbiprofen, OTC ibuprofen, RX ibuprofen, indomethacin, ketoprofen, meclofenamate, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin). Prior to filling the Step 2 drug: Celecoxib. PAGE 8 LAST UPDATED 04/2019

9 INHALED CORTICOSTEROIDS FLOVENT HFA Patient needs to have paid claims for any one of the following Step 1 drugs: QVAR REDIHALER, ASMANEX Twisthaler PAGE 9 LAST UPDATED 04/2019

10 LORATADINE CLARINEX 0.5 MG/ML (2.5 MG/5), CLARINEX-D 12 HOUR, DESLORATADINE, LEVOCETIRIZINE DIHYDROCHLORIDE Patient needs to have paid claims for one of the following Step 1 drugs: Children's Zyrtec, Chrilden's Clariton, CHILDREN'S ALLEGRA ALLERGY, Allegra OTC, Allegra/pseudoephedrine combination OTC, cetirizine OTC, cetirizine/pseudoephedrine combination OTC, loratadine OTC, loratadine/pseudoephedrine combination OTC. Prior to filling the Step 2 drugs: other low or nonsedating antihistamines (including pseudoephedrine combination of the following) desloratadine. PAGE 10 LAST UPDATED 04/2019

11 OVERACTIVE BLADDER DARIFENACIN ER, TOLTERODINE TARTRATE ER Patient needs to have paid claims for one of the following Step 1 drugs: Oxybutynin, Oxybutynin XL, Tolterodine, Oxytrol OTC. Prior to filling the Step 2 drug: Darifenacin ER, Tolterodine ER. PAGE 11 LAST UPDATED 04/2019

12 PATIROMER CALCIUM VELTASSA Patient needs to have paid claims for a 30 day supply for any one of the following Step 1 drug(s): sodium polystyrene sulfonate (SPS). Prior to filling the Step 2 drug: Patiromer calcium. PAGE 12 LAST UPDATED 04/2019

13 PROTON PUMP INHIBITORS RABEPRAZOLE SODIUM Patient needs to have paid claims for two of the following Step 1 drugs: omeprazole OTC, omeprazole rx, Prevacid OTC, lansoprazole OTC, lansoprazole rx, Zegerid OTC, pantoprazole. Prior to filling the Step 2 drug: rabeprazole. PAGE 13 LAST UPDATED 04/2019

14 RHOPRESSA RHOPRESSA PATIENT NEEDS TO HAVE PAID CLAIMS FOR ANY TWO OF THE FOLLOWING STEP 1 DRUGS: BIMATOPROST 0.02%, LATANOPROST 0.005%, LUMIGAN 0.01%, ZIOPTAN %, VYZULTA 0.024%, BETAXOLOL HCL 0.5%, CARTEOLOL HCL 1%, LEVOBUNOLOL 0.5%, METIPRANOLOL 0.3%, TIMOLOL MALEATE 0.25%, TIMOLOL MALEATE 0.5%, APRACLONIDINE HCL 0.5%, IOPIDINE 1%, BRIMONIDINE 0.2%, BRIMONIDINE TARTRATE 0.15%, ALPHAGAN P 0.1%, AZOPT 1%. PRIOR TO FILLING THE STEP 2 DRUG: RHOPRESSA 0.02% PAGE 14 LAST UPDATED 04/2019

15 ROTIGOTINE NEUPRO Patient needs to have a 30 day supply paid claim for any one of the following Step 1 drug: ropinirole, pramipexole, or pramipexole ER. Prior to filling the Step 2 Drug: Neupro. PAGE 15 LAST UPDATED 04/2019

16 SIMBRINZA SIMBRINZA PATIENT NEEDS TO HAVE PAID CLAIMS FOR ANY ONE OF THE FOLLOWING STEP 1 DRUGS: VYZULTA 0.024%, BIMATOPROST 0.03%, LATANOPROST 0.005%, LUMIGAN 0.01%, TRAVATAN Z 0.004%, ZIOPTAN %. PRIOR TO FILLING THE STEP 2 DRUG: SIMBRINZA 1%-0.2% PAGE 16 LAST UPDATED 04/2019

17 SKELETAL MUSCLE RELAXANT CARISOPRODOL COMPOUND, CARISOPRODOL-ASPIRIN, ORPHENADRINE CITRATE ER Patient needs to have paid claims for any one of the following oral agents: Carisoprodol, Cyclobenzaprine, Methocarbamol. Prior to filling the Step 2 drug: Orphenadrine, Carisoprodol/Aspirin. PAGE 17 LAST UPDATED 04/2019

18 TOPICAL IMMUNOMODULATORS ELIDEL, PIMECROLIMUS, TACROLIMUS 0.03% OINTMENT, TACROLIMUS 0.1% OINTMENT Patient needs to have paid claims for two or more of the following Step 1 drugs: Topical Corticosteroids (alclometasone dipropionate, desonide, fluocinolone acetonide, betamethasone valerate, fluocinonide (-plus emollient), fluticasone propionate, prescription hydrocortisone, OTC hydrocortisone, OTC HYDROCORTISONE ACETATE, hydrocortisone valerate, hydrocortisone butyrate (-plus emollient), mometasone furoate, triamcinolone acetonide, amcinonide, betamethasone dipropionate, betamethason diproprionate/prop gly, augmented betamethasone dipropionate, desoximetasone, diflorasone diacetate, clobetasol propionate (-plus emollient), halobetasol propionate, prednicarbate) Prior to filling the Step 2 drug: Topical Immunomodulators (pimecrolimus, tacrolimus). PAGE 18 LAST UPDATED 04/2019

19 ULORIC ULORIC Patient needs to have paid claims for any one of the following Step 1 drug: allopurinol. Prior to filling the Step 2 Drug: Uloric. PAGE 19 LAST UPDATED 04/2019

20 VYZULTA VYZULTA PATIENT NEEDS TO HAVE PAID CLAIMS FOR ANY TWO OF THE FOLLOWING STEP 1 DRUGS: BIMATOPROST 0.03%, LATANOPROST 0.005%, LUMIGAN 0.01%, TRAVATAN Z 0.004%, ZIOPTAN %. PRIOR TO FILLING THE STEP 2 DRUG: VYZULTA PAGE 20 LAST UPDATED 04/2019

21 XOPENEX LEVALBUTEROL CONCENTRATE, LEVALBUTEROL HCL, LEVALBUTEROL TARTRATE HFA Patient needs to have paid claims for any one of the following Step 1 agents: albuterol inhaler, albuterol nebulization. Prior to filling the Step 2 agent: levalbuterol inhaler, levalbuterol nebulization. PAGE 21 LAST UPDATED 04/2019

22 ZETIA EZETIMIBE Patient needs to have paid claims for any one of the following Step 1 drugs: pravastatin, lovastatin, simvastatin, atorvastatin, rosuvastatin. Prior to filling the Step 2 Drug: Ezetimibe. Members may request an exception and Ezetimibe will be allowed as first line treatment for homozygous sitosterolemia. PAGE 22 LAST UPDATED 04/2019

23 ZIOPTAN ZIOPTAN PATIENT NEEDS TO HAVE PAID CLAIMS FOR ANY TWO OF THE FOLLOWING STEP 1 DRUGS: BIMATOPROST 0.03%, LATANOPROST 0.005%, LUMIGAN 0.01%, TRAVATAN Z 0.004%, VYZULTA 0.024%. PRIOR TO FILLING THE STEP 2 DRUG: ZIOPTAN PAGE 23 LAST UPDATED 04/2019

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