Step Therapy Group. Atypical Antipsychotic Agents
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- Osborne Burke
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1 Atypical Antipsychotic Agents Any beneficiary newly enrolled into Community Care, Inc. currently receiving aripiprazole, aripiprazole ODT, risperidone, risperidone ODT, olanzapine, olanzapine ODT, quetiapine, asenapine, paliperidone, ziprasidone, lurasidone, brexpiprazole, cariprazine or iloperidone will not be included in the step therapy process of review. Otherwise beneficiary needs to try risperidone, aripiprazole, aripiprazole ODT, olanzapine, olanzapine ODT, olanzapine IM, risperidone ODT, quetiapine, quetiapine XR, paliperidone, ziprasidone, ziprasidone IM or iloperidone as step one prior to receiving aripiprazole monohydrate IM, aripiprazole lauroxil IM, risperidone IM, paliperidone IM, olanzapine pamoate monohydrate IM, lurasidone, aripiprazole lauroxil, brexpiprazole, cariprazine or asenapine as step two. Beneficiary must try one step one medication before receiving a step two medication 1 Step 2: ABILIFY MAINTENA 300 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE, ABILIFY MAINTENA 300 MG SUSPENSION,EXTENDED REL. INTRAMUSCULAR SYRINGE, ABILIFY MAINTENA 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE, ABILIFY MAINTENA 400 MG SUSPENSION,EXTENDED REL. INTRAMUSCULAR SYRINGE, ARISTADA 1,064 MG/3.9 ML SUSPENSION, EXTEND.REL. IM SYRINGE, ARISTADA 441 MG/1.6 ML SUSPENSION, EXTEND.REL. IM SYRINGE, ARISTADA 662 MG/2.4 ML SUSPENSION, EXTEND.REL. IM SYRINGE, ARISTADA 882 MG/3.2 ML SUSPENSION, EXTEND.REL. IM SYRINGE, INVEGA SUSTENNA 117 MG/0.75 ML INTRAMUSCULAR SYRINGE, INVEGA SUSTENNA 156 MG/ML INTRAMUSCULAR SYRINGE, INVEGA SUSTENNA 234 MG/1.5 ML INTRAMUSCULAR SYRINGE, INVEGA SUSTENNA 39 MG/0.25 ML INTRAMUSCULAR SYRINGE, INVEGA SUSTENNA 78 MG/0.5 ML INTRAMUSCULAR SYRINGE, INVEGA TRINZA 273 MG/0.875 ML INTRAMUSCULAR SYRINGE, INVEGA TRINZA 410 MG/1.315 ML INTRAMUSCULAR SYRINGE, INVEGA TRINZA 546 MG/1.75 ML INTRAMUSCULAR SYRINGE, INVEGA TRINZA 819 MG/2.625 ML INTRAMUSCULAR SYRINGE, LATUDA 120 MG TABLET, LATUDA 20 MG TABLET, LATUDA 40 MG TABLET, LATUDA 60 MG TABLET, LATUDA 80 MG TABLET, REXULTI 0.25 MG TABLET, REXULTI 0.5 MG TABLET, REXULTI 1 MG TABLET, REXULTI 2 MG TABLET, REXULTI 3 MG TABLET, REXULTI 4 MG TABLET, RISPERDAL CONSTA 12.5 MG/2 ML INTRAMUSCULAR SYRINGE, RISPERDAL CONSTA 25 MG/2 ML INTRAMUSCULAR
2 SYRINGE, RISPERDAL CONSTA 37.5 MG/2 ML INTRAMUSCULAR SYRINGE, RISPERDAL CONSTA 50 MG/2 ML INTRAMUSCULAR SYRINGE, SAPHRIS 10 MG SUBLINGUAL TABLET, SAPHRIS 2.5 MG SUBLINGUAL TABLET, SAPHRIS 5 MG SUBLINGUAL TABLET, VRAYLAR 1.5 MG (1)-3 MG (6) CAPSULES IN A DOSE PACK, VRAYLAR 1.5 MG CAPSULE, VRAYLAR 3 MG CAPSULE, VRAYLAR 4.5 MG CAPSULE, VRAYLAR 6 MG CAPSULE, ZYPREXA RELPREVV 210 MG INTRAMUSCULAR SUSPENSION 2
3 Opioid Analgesics Beneficiary must try morphine IR oxycodone IR or morphine SR as step one prior to receiving oxycodone SR as step two. Step 2: oxycodone er 10 mg tablet,crush resistant,extended release 12 hr, oxycodone er 15 mg tablet,crush resistant,extended release 12 hr, oxycodone er 20 mg tablet,crush resistant,extended release 12 hr, oxycodone er 30 mg tablet,crush resistant,extended release 12 hr, oxycodone er 40 mg tablet,crush resistant,extended release 12 hr, oxycodone er 60 mg tablet,crush resistant,extended release 12 hr, oxycodone er 80 mg tablet,crush resistant,extended release 12 hr 3
4 Urinary Antispasmodics Beneficiary must try darifenacin, oxybutynin, tolterodine or trospium as step one prior to receiving mirabegron or the oxybutynin patch as step two. Step 2: MYRBETRIQ 25 MG TABLET,EXTENDED RELEASE, MYRBETRIQ 50 MG TABLET,EXTENDED RELEASE, OXYTROL 3.9 MG/24 HR TRANSDERMAL PATCH 4
5 Xanthine Oxidase Inhibitors Beneficiary must try allopurinol as step one prior to receiving febuxostat as step two. Step 2: ULORIC 40 MG TABLET, ULORIC 80 MG TABLET 5
6 6
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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
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