SelectHealth Advantage 2018 Step Therapy Criteria. Previous trial on at least ONE: Generic topical acne treatment. Previous trial on: alendronate
|
|
|
- Regina Walsh
- 6 years ago
- Views:
Transcription
1 ACNE ACZONE ADAPAL/BEN P AZELEX DAPSONE EPIDUO EPIDUO FORTE TRETINOIN ACTONEL RISEDRON SOD RISEDRONATE SelectHealth Advantage Previous trial on at least ONE: Generic topical acne treatment alendronate ANTICONVULSANT ANTIDEPRESSION ANTIPSYCHOTIC ASTHMA APTIOM SPRITAM FETZIMA KHEDEZLA TRINTELLIX ARIPIPRAZOLE ARISTADA FANAPT LATUDA PALIPERIDONE SAPHRIS ADVAIR DISKU ADVAIR HFA BREO ELLIPTA carbamezapine, divalproex, epitol, ethosuximide, felbamate, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, tiagabine, topiramate, valproic acid, zonisamide bupropion, citalopram, escitalopram, fluoxetine, fluvoxamine, maprotiline, mirtazapine, paroxetine, sertraline, venlafaxine clozapine, fluoxetine-olanzapine, haloperidol, olanzapine, quetiapine, risperidone, ziprasidone Previous trial on ONE of the following: 1. Symbicort 2. Fluticasone/Salmeterol BELSOMRA BELSOMRA eszopiclone, zaleplon, zolpidem, zolpidem ER CADUET AMLOD/ATORVA atorvastatin, lovastatin, pravastatin, simvastatin AND amlodipine 2
2 CAPEX CAPEX clobetasol shampoo CORDRAN CORDRAN 80X3 Previous trial on at least ONE: Generic topical steroid CORLANOR CORLANOR acebutolol, atenolol, bisoprolol, labetolol, metoprolol, nadolol, pindolol, propranolol, timolol DEMSER DEMSER phenoxybenzamine DEPRESSION APLENZIN DESVENLAFAX EMSAM FORFIVO XL PEXEVA VIIBRYD bupropion, citalopram, escitalopram, fluoxetine, fluvoxamine, maprotiline, mirtazapine, paroxetine, sertraline, venlafaxine DERM ELIDEL tacrolimus AND betamethasone, clobetasol, hydrocortisone, triamcinolone DEXILANT DEXILANT lansoprazole, omeprazole, pantoprazole DIABETES GLYXAMBI INVOKAMET INVOKAMET XR INVOKANA JARDIANCE JENTADUETO SYNJARDY TRULICITY VICTOZA metformin OR metformin ER AND acarbose, Actoplus Met XR, alogliptin, alogliptin-metformin, alogliptin-pioglitazone, glimepiride, glimepiride-pioglitazone, glipizide, glipizide-metformin, Jentadueto, miglitol, nateglinide, pioglitazone, pioglitazone-metformin, repaglinide, repaglinide-metformin, tolazamide, tolbutamide, Tradjenta EPLERENONE EPLERENONE spironolactone, spironolactone-hctz 3
3 EURAX EURAX Lindane Shampoo OR Permethrin Cream EXALGO HYDROMORPHON fentanyl patches, methadone, morphine ER, oxycodone er, oxymorphone ER, Zohydro ER GABAPENTIN GASTRO ICS LABA-LAMA LAMA GRALISE GRALISE STAR HORIZANT DELZICOL MESALAMINE AEROSPAN ALVESCO PULMICORT QVAR ANORO ELLIPT UTIBRON INCRUSE ELPT SEEBRI NEOHA generic gabapentin OR pramipexole Apriso, balsalazide, Pentasa, sulfasalazine Flovent OR Arnuity AND Asmanex Previous trail on at least ONE of the following: Spiriva OR Tudorza, AND Stiolto OR Bevespi Spiriva AND Tudorza LUNESTA ESZOPICLONE zolpidem or zaleplon NAMENDA NAMENDA XR immediate release Memantine OAB DARIFENACIN GELNIQUE MYRBETRIQ TOVIAZ VESICARE oxybutynin, oxybutynin er, tolterodine, tolterodine er, trospium, trospium er 4
4 OXYCONTIN OXYCODONE fentanyl patches, hydromorphone er, methadone, morphine ER, oxymorphone ER, Zohydro ER PPI ESOMEPRA MAG PREVACID lansoprazole, misoprostol, omeprazole, pantoprazole RANEXA RANEXA amlodipine, atenolol, diltiazem, isosorbide dinitrate, isosorbide mononitrate, metoprolol, propranolol, verapamil RASUVO RASUVO generic methotrexate REXULTI REXULTI Previous therapy on: aripiprazole AND Latuda OR quetiapine ER RYTARY RYTARY carbidopa/levodopa SA OPIOID OXYMORPHONE APAP/codeine, codiene sulfate, hydrocodone/apap, hydrocodone/ibu, hydromorphone, morphine IR, oxycodone, oxycodone/apap, oxycodone/asa, oxycodone/ibu SABA PROAIR HFA PROAIR RESPI PROVENTIL Ventolin 5
5 STATIN 10-10MG 10-20MG 10-40MG 10-80MG LIVALO TAB 1MG LIVALO TAB 2MG LIVALO TAB 4MG STIMULANTS DAYTRANA VYVANSE SelectHealth Advantage SYMLIN SYMLINPEN 60 SYMLNPEN 120 insulin SYMPROIC SYMPROIC Movantik TACLONEX TACLONEX TEKTURNA TIZANIDINE TEKTURNA TEKTURNA HCT TIZANIDINE CAP 2MG TIZANIDINE CAP 4MG TIZANIDINE CAP 6MG atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin 10 mg, simvastatin Previous trial on at least ONE: generic long-acting stimulant OR Diagnosis of binge eating disorder calcipotriene-betamethasone ointment benazepril, benazepril-hctz, captopril, captopril-hctz, enalapril, enalapril-hctz, fosinopril, fosinopril-hctz, lisinopril, lisinopril-hctz, quinapril, quinapril-hctz, ramipril AND candesartan, candesartan-hctz, eprosartan, irbesartan, irbesartan-hctz, losartan, losartan-hctz, olmesartan, olmesartan-hctz, telmisartan, telmisartan-hctz, valsartan, valsartan-hctz tizanidine tablets TRELEGY TRELEGY Previous trial on of Stiolto, Symbicort, or Fluticasone/Salmeterol 6
6 TRIPTAN FROVATRIPTAN sumatriptan OR rizatriptan UCERIS FOAM UCERIS colocort enema, hydrocortisone enema, or mesalamine enema ULORIC ULORIC allopurinol VELPHORO AURYXIA VELPHORO Renagel OR Renvela VRAYLAR VRAYLAR aripiprazole AND clozapine, fluoxetine-olanzapine, haloperidol, olanzapine, quetiapine, risperidone, ziprasidone VYZULTA VYZULTA latanoprost ZELAPAR ZELAPAR selegiline ZOHYDRO ZOHYDRO ER fentanyl patches, hydromorphone er, methadone, morphine ER, oxycodone er, oxymorphone ER 7
SelectHealth Advantage 2018 Step Therapy Criteria Previous trial on at least ONE: Generic topical acne treatment
ACNE ADAPAL/BEN P GEL 0.1-2.5% AZELEX CRE 20% DAPSONE GEL 5% EPIDUO FORTE GEL 0.3-2.5% TRETINOIN GEL 0.04% TRETINOIN GEL 0.05% TRETINOIN GEL 0.1% ACTONEL ANTICONVULSANT ANTIDEPRESSION ANTIPSYCHOTIC ASTHMA
SelectHealth Advantage 2019 Step Therapy Criteria Previous trial on at least ONE: Generic topical acne treatment
ACNE ADAPAL/BEN P AZELEX DAPSONE TRETINOIN ACTONEL ANTICONVULSANT ANTIDEPRESSION ANTIPSYCHOTIC ASTHMA RISEDRON SOD RISEDRONATE APTIOM OXTELLAR XR SPRITAM FETZIMA KHEDEZLA TRINTELLIX ARISTADA FANAPT LATUDA
Step Therapy Group Algorithm Steps
Step Therapy Group Algorithm Steps ACTONEL AMITIZA ANTICONVULSANT ANTIDEPRESSION Previous trial on alendronate Step 1: ALENDRONATE SODIUM Step 2: RISEDRONATE SODIUM, RISEDRONATE SODIUM DR Previous trial
Cigna Drug and Biologic Coverage Policy
Cigna Drug and Biologic Coverage Policy Subject Step Therapy Individual and Family Plan Table of Contents Coverage Policy... 1 General Background... 5 References... 5 Effective Date... 3/15/2018 Next Review
2017 Step Therapy Criteria
FRESENIUS TOTAL HEALTH 2017 Step Therapy Updated 07/01/2017. For more recent information or other questions, please contact Fresenius Total Health Customer Service at 1-855-598-6774 / TTY 1-844-209-9094.
ANGIOTENSIN RECEPTOR BLOCKERS STEP THERAPY
South Country Health Alliance 2017 Step Therapy Formulary ID: 17431 Last Updated: 10/20/2017 Effective Date: 11-01-2017 ANGIOTENSIN RECEPTOR BLOCKERS STEP THERAPY BENICAR 20 MG BENICAR 40 MG BENICAR 5
ALLERGIC CONJUNCTIVITIS AGENTS
2018 5 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: 18390 Last Updated: 04/2018 Effective Date: 05-01-2018 ALLERGIC CONJUNCTIVITIS AGENTS epinastine 0.05 % eye drops
ATYPICAL ANTIPSYCHOTICS
Step Therapy CareOregon 2018 Last Updated: 07/27/2018 ATYPICAL ANTIPSYCHOTICS Fanapt Fanapt Titration Pack Paliperidone Er Vraylar The following criteria applies to members who newly start on the drug:
ADHD STIMULANTS-S(SHC)
Step Therapy Simply Health Care 2014 Formulary ID: 14406 Version: 14 Last Updated: 08/01/2014 ADHD STIMULANTS-S(SHC) Daytrana Focalin Xr Strattera Patient needs to have a paid claim for one Step 1 drug
ANTICONVULSANTS. Details
ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET APTIOM 800 MG TABLET BANZEL 200 MG TABLET BANZEL 40 MG/ML ORAL SUSPENSION BANZEL 400 MG TABLET FYCOMPA 0.5 MG/ML ORAL SUSPENSION
ANTICONVULSANTS. Details
ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200 mg tablet Banzel 40 mg/ml oral suspension Banzel 400 mg tablet Fycompa 0.5 mg/ml oral suspension
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017
Effective: 01/01/2017 Updated 11/2016 ANTI-INFLAMMATORY AGENTS - GI DIPENTUM PRIOR CLAIM FOR BALSALAZIDE OR APRISO WITHIN THE PAST 120 DAYS. ANTICONVULSANTS APTIOM BANZEL FYCOMPA GABITRIL OXTELLAR XR POTIGA
Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18
Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18 Granite Alliance requires step therapy for certain drugs. This means prior to receiving a drug with a step therapy
CRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication.
ADHD STIMULANTS ATOMOXETINE HCL, DEXEDRINE 10 MG TABLET, DEXEDRINE 5 MG TABLET, DEXMETHYLPHENIDATE HCL, DEXMETHYLPHENIDATE HCL ER, DEXTROAMPHETAMINE 10 MG TAB, DEXTROAMPHETAMINE 5 MG TAB, DEXTROAMPHETAMINE
ANTIDEPRESSANTS. Details. dose pack Viibryd 10 mg tablet Viibryd 20 mg tablet Viibryd 40 mg tablet. Criteria
ANTIDEPRESSANTS Trintellix 10 mg tablet Trintellix 20 mg tablet Trintellix 5 mg tablet Viibryd 10 mg (7)-20 mg (23) tablets in a dose pack Viibryd 10 mg tablet Viibryd 20 mg tablet Viibryd 40 mg tablet
FirstCarolinaCare Insurance Company. Step Therapy Requirements
FirstCarolinaCare Insurance Company Step Therapy Requirements Effective: 12/01/2018 ANTICONVULSANTS APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL 200 MG BANZEL 40 MG/ML ORAL SUSPENSION
Santa Clara Family Health Plan Cal MediConnect Formulary. List of Step Therapy Requirements Effective: 12/01/ E
Santa Clara Family Health Plan Cal MediConnect Formulary List of Step Therapy Requirements Effective: 12/01/2018 13027.12E ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET
AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details
AMANTADINE ER OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED RELEASE PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS. 1 ANTICONVULSANTS
AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details
AMANTADINE ER OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, EXTENDED RELEASE OSMOLEX ER 258 MG TABLET, PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS.
Step Therapy Requirements. Effective: 12/01/2016
Effective: 12/01/2016 H2986_PD_049 Updated 11/2016 ALPHA 1-PROTEINASE INHIBITOR GLASSIA PRIOR CLAIM FOR ARALAST NP OR ZEMAIRA WITHIN THE PAST 120 DAYS. ANALGESICS, NARCOTICS KADIAN MORPHINE SULFATE ER
Step Therapy Requirements. Effective: 05/01/2018
Step Therapy Requirements Effective: 05/01/2018 ANTIDEPRESSANTS TRINTELLIX 10 MG TABLET TRINTELLIX 20 MG TABLET TRINTELLIX 5 MG TABLET VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK VIIBRYD 10 MG
Step Therapy Requirements. Effective: 11/01/2018
Effective: 11/01/2018 Updated 10/2018 ANTIDEPRESSANTS Sharp Health Plan (HMO) TRINTELLIX 10 MG TABLET TRINTELLIX 20 MG TABLET TRINTELLIX 5 MG TABLET VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK
Step Therapy Requirements
Step Therapy Requirements Denver Health Medicare Choice (HMO SNP)/Medicare Select (HMO) Effective: 09/01/2017 Updated 08/2017 ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet
Step Therapy Medications
Step Therapy Medications Step Therapy Group APTIOM Step-2: APTIOM 200 MG TABLET or APTIOM 400 MG TABLET or APTIOM 600 MG TABLET or APTIOM 800 MG TABLET Step 1 Drug(s): Oxcarbazepine immediate-release,
ANTICONVULSANTS. Details
ANTICONVULSANTS APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL 200 MG BANZEL 40 MG/ML ORAL SUSPENSION BANZEL 400 MG FYCOMPA 0.5 MG/ML ORAL SUSPENSION FYCOMPA 10 MG FYCOMPA 12 MG FYCOMPA
Step Therapy Requirements. Effective: 1/1/2019
Effective: 1/1/2019 Updated 1/2019 AMANTADINE ER Sharp Health Plan (HMO) OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED RELEASE PRIOR CLAIM FOR AMANTADINE
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017
VNSNY CHOICE FIDA Complete Step Therapy Requirements Effective: 01/01/2017 Updated 12/23/2016 ANTICONVULSANTS Aptiom 200 mg tablet Potiga 200 mg tablet Aptiom 400 mg tablet Potiga 300 mg tablet Aptiom
AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details
AMANTADINE ER OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, EXTENDED RELEASE OSMOLEX ER 258 MG TABLET, PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS.
ANTICONVULSANT STEP THERAPY
2019 First Choice VIP Care Plus Formulary Document: 2019 Step Therapy Formulary ID: 19391 Last Updated: 2/2019 Effective Date: 03-01-2019 ANTICONVULSANT STEP THERAPY APTIOM 200 MG APTIOM 400 MG APTIOM
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 04/01/2019
VNSNY CHOICE FIDA Complete Step Therapy Requirements Effective: 04/01/2019 Updated 03/2019 AMANTADINE ER OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED
ALPHA GLUCOSIDASE INHIBITOR THERAPY
ALPHA GLUCOSIDASE INHIBITOR THERAPY GLYSET Step 1: One generic formulary product containing one of the following ingredients: glimeperide, glipizide, metformin or pioglitazone. Step 2: Glyset PAGE 1 LAST
ANTICONVULSANTS. Details
ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200 mg tablet Banzel 40 mg/ml oral suspension Banzel 400 mg tablet Fycompa 0.5 mg/ml oral suspension
2018 Step Therapy Criteria
2018 Step Therapy Criteria ANGIOTENSIN RECEPTOR BLOCKERS... 2 ANTIDEPRESSANTS... 3 ANTIDEPRESSANTS, MISCELLANEOUS... 4 ANTIDEPRESSANTS, OTHER... 5 ANTIDIABETIC AGENTS... 6 ANTIGOUT AGENTS... 7 ANTIHYPERTENSIVE
ANTIDIABETIC AGENTS - MISCELLANEOUS
ANTIDIABETIC AGENTS - MISCELLANEOUS Glyxambi 10 mg-5 mg tablet Glyxambi 25 mg-5 mg tablet Invokamet 150 mg-1,000 mg tablet Invokamet 150 mg-500 mg tablet Invokamet 50 mg-1,000 mg tablet Invokamet 50 mg-500
2015 Step Therapy Prior Authorization Medical Necessity Guidelines
Tufts Health Unify 2015 Step Therapy Prior Authorization Medical Necessity Guidelines Effective: 01/01/2015 Updated: 10/01/2015 Tufts Health Plan P.O. Box 9194 Watertown, MA 02471-9194 Phone: 855-393-3154
ANTIDIABETIC AGENTS - MISCELLANEOUS
ANTIDIABETIC AGENTS - MISCELLANEOUS GLYXAMBI 10 MG-5 MG GLYXAMBI 25 MG-5 MG INVOKAMET 150 MG-1,000 MG INVOKAMET 150 MG-500 MG INVOKAMET 50 MG-1,000 MG INVOKAMET 50 MG-500 MG INVOKAMET XR 150 MG-1,000 MG,
SmithRx Standard Formulary Step Therapy List
SmithRx Standard Formulary Step Therapy List Revised: January 27, 2017 The following medications require prior use of at least one other medication for coverage. Please note that any plan-specific customizations
TEST ANTICONVULSANT THERAPY. Products Affected. Step 2: Network Health Insurance Corporation NetworkCares Step Therapy Criteria Last Updated 11/2018
TEST Network Health Insurance Corporation NetworkCares Step Therapy Last Updated 11/2018 ANTICONVULSANT THERAPY Aptiom Banzel Briviact Celontin Dilantin 30 Mg Capsule Equetro Fycompa 0.5 Mg/ml Oral Susp
ANTIDIABETIC AGENTS - MISCELLANEOUS
ANTIDIABETIC AGENTS - MISCELLANEOUS Glyxambi 10 mg-5 mg tablet Glyxambi 25 mg-5 mg tablet Invokamet 150 mg-1,000 mg tablet Invokamet 150 mg-500 mg tablet Invokamet 50 mg-1,000 mg tablet Invokamet 50 mg-500
Simply Step Therapy Document September 2018 Y0114_18_33074_I_009
2018 2018 Simply Step Therapy Document September 2018 Aptiom APTIOM 200 MG TABLET APTIOM 400 MG TABLET Y0114_18_33074_I_009 APTIOM 600 MG TABLET APTIOM 800 MG TABLET Criteria If the patient has tried a
Drug Regimen Optimization
Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Clinical Criteria Information Included in this Document Excluding Valsartan / Ramipril Prior authorization criteria logic: a description
ABILIFY INJ. Products Affected Step 2: ABILIFY MAINTENA PREFILLED SYRINGE 300 MG INTRAMUSCULAR ABILIFY MAINTENA PREFILLED SYRINGE 400 MG INTRAMUSCULAR
ABILIFY INJ ABILIFY MAINTENA PREFILLED SYRINGE 300 MG ABILIFY MAINTENA PREFILLED SYRINGE 400 MG ABILIFY MAINTENA SUSPENSION RECONSTITUTED ER 300 MG Claim will pay automatically for ABILIFY MAINTENA if
Alaska Medicaid 90 Day** Generic Prescription Medication List
1 ACYCLOVIR 200 MG CAPSULE BUPROPION HCL 150 MG TAB ER 24H ACYCLOVIR 200 MG/5ML BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 400 MG TABLET BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 800 MG TABLET BUPROPION HCL
ANTICONVULSANTS. Details. Step Therapy Criteria Date Effective: April 1, 2019
Step Therapy Date Effective: April 1, 2019 ANTICONVULSANTS APTIOM TABLET 200 MG ORAL APTIOM TABLET 400 MG ORAL APTIOM TABLET 600 MG ORAL APTIOM TABLET 800 MG ORAL BANZEL SUSPENSION 40 MG/ML ORAL BANZEL
Medicare Part D Drugs that Require Step Therapy Effective 12/01/2017
Medicare Part D Drugs that Require Step Therapy Effective 12/01/2017 Providers may call the Pharmacy Help Desk at 800-641-8921 for more information or questions about criteria. The formulary may change
Step Therapy Requirements. Effective: 03/01/2015
Effective: 03/01/2015 Updated 02/2015 ANTI-INFLAMMATORY AGENTS - GI DIPENTUM PRIOR CLAIM FOR BALSALAZIDE OR APRISO WITHIN THE PAST 120 DAYS. ANTICONVULSANTS APTIOM BANZEL FYCOMPA OXTELLAR XR POTIGA QUDEXY
Step Therapy Medications
Step Therapy Medications Step Therapy (ST PA ) is an automated form of prior authorization. It encourages the use of therapies that should be tried first, before other treatments are covered, based on
Step Therapy Criteria 2019
Step Therapy 2019 For information on obtaining an updated coverage determination or an exception to a coverage determination please call Freedom Health Member Services at 1-800-401-2740 or, for TTY/TDD
Step therapy Premium. Utilization management updates - January 1, Here s how it works:
Utilization management updates - January 1, 2019 Step therapy Premium Most medical conditions have many medication options. Although their clinical effectiveness may be the same, the cost can be very different.
2019 Simply Step Therapy Document
Aggrenox 2019 Simply Step Therapy Document AGGRENOX 25 MG-200 MG CAPSULE, EXTENDED aspirin 25 mg-dipyridamole 200 mg capsule,ext.release 12 hr multiphase drug may be given. Step 1 Drug(s): clopidigrel.
Ambetter 90-Day-Supply Maintenance Drug List
Ambetter 90-Day-Supply Maintenance Drug List What is the Ambetter 90-Day-Supply Maintenance Drug List? Ambetter 90-Day-Supply Maintenance Drug List is a list of maintenance medications that are available
Try a Step 1 medication first
Premium step therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment
**CRITERIA UNDER CMS REVIEW**
**CRITERIA UNDER CMS REVIEW** ANTICONVULSANTS APTIOM TABLET 200 MG APTIOM TABLET 400 MG APTIOM TABLET 600 MG APTIOM TABLET 800 MG BANZEL SUSPENSION 40 MG/ML BANZEL TABLET 200 MG BANZEL TABLET 400 MG BRIVIACT
STEP THERAPY ALGORITHMS PUP Select Formulary
The Step Therapy drug will be dispensed if the drug has been dispensed within 120 days of current fill or if alternative (Step 1) drugs have been used first. If the member s prescription claim fails the
DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 759 M %
June 2016 On 13th May, the DH announced that there would be reductions to Category M prices from June until September. http://psnc.org.uk/our-news/contractor-notice-category-m-price-reduction/ This has
Avoid paying too much for your prescriptions
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2017 Aetna Rx Step Program Medicine List Avoid paying too much for your prescriptions It s important to try to
While there is around a 3% increase shown in costs for Category M lines, I think this is due to the inclusion of more lines in Category M.
April 2018 The usual quarterly of Category M prices Another set of similar comments as I made in January: significant increases in many lines which have been subject to price concessions but even more
Step Therapy Criteria
Tier 5 Formulary Step Therapy 2016 Updated: 05/24/2016 Effective: 06/01/2016 What is Step Therapy? Some prescription drugs require step therapy (ST). In some cases, the plan requires you to first try certain
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. Products Affected. Details. Step Therapy Criteria Optima Tier Gold Formulary Date Effective: November 1, 2018.
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
Premium step therapy. Here s how it works:
Premium step therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment
QTY LIMIT COPAY (30 DAY/90 DAY) BENIGN PROSTATIC HYPERPLASIA FINASTERIDE $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8
2019 LiveWELL Health Plan PREVENTIVE DRUG LIST - GENERIC Names ( Copay) - ALPHABETICAL by DRUG CATEGORY You should always check with your prescriber and/or pharmacist to determine if these alternatives
DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 702 M %
December 16 No Category M changes so the reductions imposed in May which were only supposed to last until September continue As in November, most changes are Category A lines with a few Category C. Significant
THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM
Value Based Tier Drugs are selected for the management of Asthma, Diabetes, Hypertension and Hyperlipidemia. These drugs are covered at no charge or at a reduced cost share. Medications are under continual
ANTICONVULSANT THERAPY
Network Health Insurance Corporation NetworkCares Step Therapy Last Updated: 7/2017 ANTICONVULSANT THERAPY Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200
2018 PDP Premier Step Therapy Document September 2018 Y0114_18_33144_I_009
2018 PDP Premier Step Therapy Document September 2018 Aggrenox Y0114_18_33144_I_009 aspirin 25 mg-dipyridamole 200 mg capsule,ext.release 12 hr multiphase drug may be given. Step 1 Drug(s): clopidigrel.
2019 Preventive Drug List
2019 Preventive Drug List Managing your health with preventive medications Your pharmacy benefit plan includes special coverage for generic preventive medications. These medications help protect against
5-ASA. Products Affected Dipentum 250 mg capsule. Details. Lialda 1.2 gram tablet,delayed release
5-ASA Dipentum 250 mg capsule Lialda 1.2 gram tablet,delayed release You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda or Dipentum.
Quantity Limits 2016 Paramount Medicare Formulary Formulary ID: Version 26 Updated: 11/1/2016
Quantity Limits 2016 Paramount Medicare Formulary Formulary ID: 16162 Version 26 Updated: 11/1/2016 ANALGESICS acetaminophen w/ codeine (300-15 mg, 300-30 mg, 300-60 mg) acetaminophen w/ codeine soln 120-12
DT Description Price Category Price change
Tariff T Watch October 2014 Readers are no doubt aware of this quarter's bad news for primary care prescribing allocations: NHS England has d the remuneration mechanism for community pharmacies gaining
Introducing exciting new Rx benefits 2019
Introducing exciting new x benefits 2019 In 2019, the Middlesex prescription plan is aligning with best-in-class evidence-based practices. Two new tiers will be added that evaluate drugs on the basis of
STEP THERAPY CRITERIA
STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered under your medical or prescription
Blue Medicare HMO Essential 2015 Quantity Limit List Blue Medicare Rx Standard 2015 Quantity Limit List
Blue Medicare HMO Essential 2015 Quantity Limit List Blue Medicare Rx Standard 2015 Quantity Limit List Drug Name Monthly Limit (30 days unless otherwise noted) abacavir 300 mg abacavir/lamivudine/zidovudine
Before a Step 2 medication is covered You get a prescription
Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment
JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET BYDUREON BCISE 2 MG/0.
ANTI DIABETICS BYDUREON 2 MG SUBCUTANEOUS JANUVIA 25 MG TABLET EXTENDED RELEASE SUSPENSION JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET
Premium Step Therapy. Here s how it works:
Premium Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment
Step Therapy Requirements
An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 12/01/2017 Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/2014 1 ABILIFY Abilify 10 mg tablet
ASEBP and ARTA TARP Drugs and Reference Price by Categories
ASEBP Pantoprazole Sodium 40 mg (generic) $0.2016 ASEBP Dexlansoprazole 30 mg Dexlansoprazole 60 mg Esomeprazole 10 mg Esomeprazole 20 mg Esomeprazole 40 mg Lansoprazole 15 mg Lansoprazole 30 mg Omeprazole
2019 PacificSource Health Plans Step Therapy Criteria. Last Modified: 02/22/2019 (All criteria reviewed at least once per year)
2019 PacificSource Health Plans Step Therapy Criteria Last Modified: 02/22/2019 (All criteria reviewed at least once per year) Table of Contents ACTICLATE... 3 AMITIZA/LINZESS... 4 ANTIDIABETICS Farxiga,
5-ASA. Products Affected DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED RELEASE. Details
5-ASA DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda or Dipentum. 1 ANTIEMETICS
5-ASA. Products Affected. Details. Dipentum 250 mg capsule. Lialda 1.2 gram tablet,delayed release
Updated 11/1/17 5-ASA Dipentum 250 mg capsule Lialda 1.2 gram tablet,delayed release You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda
2013 Step Therapy (ST) Criteria
2013 Step Therapy (ST) Criteria Some drugs require step therapy pre-approval. This means that your doctor must have you first try a different drug to treat your medical condition before we will cover a
Step Therapy Information... 4 Prior Authorization Information ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...
Step Therapy Information... 4 Prior Authorization Information... 27 ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...62 Acne Therapy Topical...64 Alcoholism Treatment Agents... 66 Analgesic
Hospital Unit Dose Unit Dose Plus Liquid Unit Dose. BARCODE LISTING Spring See our new Barcode Scanning Guide on page 26
Hospital Unit Dose Unit Dose Plus Liquid Unit Dose BARCODE LISTING Spring 2018 See our new Barcode Scanning Guide on page 26 YOU ASKED. WE DELIVERED! New proprietary offering from AHP! LIQUID UNIT DOSE
Relative Cost/Month. Less than $10. Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*
Allergy Chlorpheniramine Tablet* Diphenhydramine Tablet* Diphenhydramine Liquid* Loratadine Tablet* Cetirizine Tablet* Loratadine 10mg ODT* Less than $10 Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*
DT Description Price Category Price change Percentage
June 2017 A slight inflationary pressure in most CCGs from mainly Category A increases. Significant price increases: Most of low concern although those involving the less frequently used tamoxifen strengths
THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM
Value Based Tier Drugs are selected for the management of Asthma, Diabetes, Hypertension and Hyperlipidemia. These drugs are covered at no charge or at a reduced cost share. Medications are under continual