Y0133_StepTherapyCriteria _C 10/18/18 Y0133_StepTherapyCriteria _C es 10/18/18
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- Coral Parker
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1 Step Therapy Grid Certain cost-effective drugs must be used before other more expensive drugs are covered. For example, certain brand-name medications will only be covered if a generic alternative has been tried first. Criterios de terapia escalonada Se deben utilizar medicamentos genéricos antes de que se cubran otros medicamentos más caros. Por ejemplo, ciertos medicamentos de marca registrada solo estarán cubiertos si primero se ha probado su alternativa genérica. Steward Health Choice Generations HMO SNP is a Health Plan with a Medicare contract and a contract with the state Medicaid program. Enrollment in Steward Health Choice Generations HMO SNP depends on contract renewal. This information is available in other formats, such as Braille, large print, and audio. Steward Health Choice Generations HMO SNP es un plan de salud con un contrato con Medicare y un contrato con el programa estatal de Medicaid. La inscripción en Steward Health Choice Generations HMO SNP depende de la renovación del contrato. También puede pedir esta información en otros formatos, como audio, sistema Braille o en letra grande. Y0133_StepTherapy _C 10/18/18 Y0133_StepTherapy _C es 10/18/18
2 Antidepressants - score APLENZIN TABLET EXTENDED RELEASE 24 HOUR 174 MG APLENZIN TABLET EXTENDED RELEASE 24 HOUR 348 MG APLENZIN TABLET EXTENDED RELEASE 24 HOUR 522 MG desvenlafaxine er tablet extended release 24 hour 100 mg oral desvenlafaxine er tablet extended release 24 hour 50 mg oral DESVENLAFAXINE FUMARATE ER TABLET EXTENDED RELEASE 24 HOUR 100 MG DESVENLAFAXINE FUMARATE ER TABLET EXTENDED RELEASE 24 HOUR 50 MG EMSAM PATCH 24 HOUR 12 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 6 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 9 MG/24HR TRANSDERMAL FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 120 MG FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 20 MG FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 40 MG FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 80 MG FETZIMA TITRATION CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG Trial of two of the following formulary products: bupropion, mirtazapine, generic SSRI, or generic SNRI. 1
3 Antigout -score ULORIC TABLET 40 MG ULORIC TABLET 80 MG Trial of allopurinol 2
4 Atypical Antipsychotics - score FANAPT TABLET 1 MG FANAPT TABLET 10 MG FANAPT TABLET 12 MG FANAPT TABLET 2 MG FANAPT TABLET 4 MG FANAPT TABLET 6 MG FANAPT TABLET 8 MG FANAPT TITRATION PACK TABLET 1 & 2 & 4 & 6 MG VRAYLAR CAPSULE 1.5 MG VRAYLAR CAPSULE 3 MG VRAYLAR CAPSULE 4.5 MG VRAYLAR CAPSULE 6 MG VRAYLAR CAPSULE THERAPY PACK 1.5 & 3 MG Trial of two generic formulary atypical antipsychotic agents 3
5 Bisphosphonates -score FOSAMAX PLUS D TABLET MG-UNIT FOSAMAX PLUS D TABLET MG-UNIT Trial of one generic formulary oral bisphosphonate agent 4
6 DPP4 inhibitors - score JANUMET TABLET MG JANUMET TABLET MG JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG JANUVIA TABLET 100 MG JANUVIA TABLET 25 MG JANUVIA TABLET 50 MG JENTADUETO TABLET MG JENTADUETO TABLET MG JENTADUETO TABLET MG JENTADUETO XR TABLET EXTENDED RELEASE 24 HOUR MG JENTADUETO XR TABLET EXTENDED RELEASE 24 HOUR MG TRADJENTA TABLET 5 MG Trial of one generic formulary metformin or metformin combination 5
7 DPP4 INHIBITORS NON-PREFERRED - score KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG ONGLYZA TABLET 2.5 MG ONGLYZA TABLET 5 MG Trial of one of the following: Janumet, Janumet XR, Januvia, Jentadueto, Jentadueto XR, or Tradjenta 6
8 FILGRASTIM - score GRANIX SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML SUBCUTANEOUS GRANIX SOLUTION PREFILLED SYRINGE 480 MCG/0.8ML SUBCUTANEOUS NEUPOGEN SOLUTION 300 MCG/ML INJECTION NEUPOGEN SOLUTION 480 MCG/1.6ML INJECTION NEUPOGEN SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML INJECTION NEUPOGEN SOLUTION PREFILLED SYRINGE 480 MCG/0.8ML INJECTION Trial of Zarxio 7
9 GLP1 Agonist - score BYDUREON BCISE AUTO-INJECTOR 2 MG/0.85ML SUBCUTANEOUS BYDUREON PEN-INJECTOR 2 MG SUBCUTANEOUS BYDUREON SUSPENSION RECONSTITUTED ER 2 MG SUBCUTANEOUS TRULICITY SOLUTION PEN-INJECTOR 0.75 MG/0.5ML SUBCUTANEOUS TRULICITY SOLUTION PEN-INJECTOR 1.5 MG/0.5ML SUBCUTANEOUS VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS Trial of one generic formulary metformin or metformin combination 8
10 LAMA - score TUDORZA PRESSAIR AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT INHALATION TUDORZA PRESSAIR AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT INHALATION (30 ACTUATE) Trial of Spiriva or Incruse Ellipta 9
11 Leukotriene modifiers - score zileuton er tablet extended release 12 hour 600 mg oral ZYFLO TABLET 600 MG Trial of generic montelukast or generic zafirlukast 10
12 Long-Acting Opioid_1 - score ARYMO ER TABLET EXTENDED RELEASE ABUSE-DETERRENT 15 MG ARYMO ER TABLET EXTENDED RELEASE ABUSE-DETERRENT 30 MG ARYMO ER TABLET EXTENDED RELEASE ABUSE-DETERRENT 60 MG XTAMPZA ER CAPSULE ER 12 HOUR ABUSE-DETERRENT 13.5 MG XTAMPZA ER CAPSULE ER 12 HOUR ABUSE-DETERRENT 18 MG XTAMPZA ER CAPSULE ER 12 HOUR ABUSE-DETERRENT 27 MG XTAMPZA ER CAPSULE ER 12 HOUR ABUSE-DETERRENT 36 MG XTAMPZA ER CAPSULE ER 12 HOUR ABUSE-DETERRENT 9 MG Trial of Embeda 11
13 PD agents - score NEUPRO PATCH 24 HOUR 1 MG/24HR TRANSDERMAL NEUPRO PATCH 24 HOUR 2 MG/24HR TRANSDERMAL NEUPRO PATCH 24 HOUR 3 MG/24HR TRANSDERMAL NEUPRO PATCH 24 HOUR 4 MG/24HR TRANSDERMAL NEUPRO PATCH 24 HOUR 6 MG/24HR TRANSDERMAL NEUPRO PATCH 24 HOUR 8 MG/24HR TRANSDERMAL Trial of one generic formulary dopamine agonist agent 12
14 RHOPRESSA -score RHOPRESSA SOLUTION 0.02 % OPHTHALMIC Trial of one of the following ophthalmic solutions: generic latanoprost, generic bimatoprost, Lumigan, Travatan Z, Alphagan P, Azopt, Combigan, Simbrinza, timolol, betaxolol, carteolol, metipranolol, levobunolol, dorzolamide/timolol, dorzolamide, brimonidine 13
15 RYTARY - score RYTARY CAPSULE EXTENDED RELEASE MG RYTARY CAPSULE EXTENDED RELEASE MG RYTARY CAPSULE EXTENDED RELEASE MG RYTARY CAPSULE EXTENDED RELEASE MG Trial of any generic antiparkinson agent 14
16 SGLT2 - score INVOKAMET TABLET MG INVOKAMET TABLET MG INVOKAMET TABLET MG INVOKAMET TABLET MG INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR MG INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR MG INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR MG INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR MG INVOKANA TABLET 100 MG INVOKANA TABLET 300 MG JARDIANCE TABLET 10 MG JARDIANCE TABLET 25 MG SYNJARDY TABLET MG SYNJARDY TABLET MG SYNJARDY TABLET MG SYNJARDY TABLET MG SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR MG SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR MG SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR MG SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR MG Trial of one generic formulary metformin or metformin combination 15
17 SGLT2 DPP4 Combo Therapy - score GLYXAMBI TABLET 10-5 MG GLYXAMBI TABLET 25-5 MG Trial of one generic formulary metformin or metformin combination 16
18 Statins - score LIVALO TABLET 1 MG LIVALO TABLET 2 MG LIVALO TABLET 4 MG Trial of any one generic formulary HMG-CoA reductase inhibitor (statin) 17
19 Index of Drugs A APLENZIN TABLET EXTENDED RELEASE 24 HOUR 174 MG... 1 APLENZIN TABLET EXTENDED RELEASE 24 HOUR 348 MG... 1 APLENZIN TABLET EXTENDED RELEASE 24 HOUR 522 MG... 1 ARYMO ER TABLET EXTENDED RELEASE ABUSE-DETERRENT 15 MG ARYMO ER TABLET EXTENDED RELEASE ABUSE-DETERRENT 30 MG ARYMO ER TABLET EXTENDED RELEASE ABUSE-DETERRENT 60 MG B BYDUREON BCISE AUTO-INJECTOR 2 MG/0.85ML SUBCUTANEOUS... 8 BYDUREON PEN-INJECTOR 2 MG SUBCUTANEOUS... 8 BYDUREON SUSPENSION RECONSTITUTED ER 2 MG SUBCUTANEOUS... 8 D desvenlafaxine er tablet extended release 24 hour 100 mg oral... 1 desvenlafaxine er tablet extended release 24 hour 50 mg oral... 1 DESVENLAFAXINE FUMARATE ER TABLET EXTENDED RELEASE 24 HOUR 100 MG... 1 DESVENLAFAXINE FUMARATE ER TABLET EXTENDED RELEASE 24 HOUR 50 MG... 1 E EMSAM PATCH 24 HOUR 12 MG/24HR TRANSDERMAL... 1 EMSAM PATCH 24 HOUR 6 MG/24HR TRANSDERMAL... 1 EMSAM PATCH 24 HOUR 9 MG/24HR TRANSDERMAL... 1 F FANAPT TABLET 1 MG... 3 FANAPT TABLET 10 MG... 3 FANAPT TABLET 12 MG... 3 FANAPT TABLET 2 MG... 3 FANAPT TABLET 4 MG... 3 FANAPT TABLET 6 MG... 3 FANAPT TABLET 8 MG... 3 FANAPT TITRATION PACK TABLET 1 & 2 & 4 & 6 MG... 3 FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 120 MG... 1 FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 20 MG... 1 FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 40 MG... 1 FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 80 MG... 1 FETZIMA TITRATION CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG... 1 FOSAMAX PLUS D TABLET MG- UNIT... 4 FOSAMAX PLUS D TABLET MG- UNIT... 4 G GLYXAMBI TABLET 10-5 MG GLYXAMBI TABLET 25-5 MG GRANIX SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML SUBCUTANEOUS... 7 GRANIX SOLUTION PREFILLED SYRINGE 480 MCG/0.8ML SUBCUTANEOUS... 7 I INVOKAMET TABLET MG INVOKAMET TABLET MG INVOKAMET TABLET MG INVOKAMET TABLET MG 15 INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR MG INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR MG INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR MG INVOKAMET XR TABLET EXTENDED RELEASE 24 HOUR MG INVOKANA TABLET 100 MG INVOKANA TABLET 300 MG J JANUMET TABLET MG
20 JANUMET TABLET MG... 5 JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG... 5 JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG... 5 JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG 5 JANUVIA TABLET 100 MG... 5 JANUVIA TABLET 25 MG... 5 JANUVIA TABLET 50 MG... 5 JARDIANCE TABLET 10 MG JARDIANCE TABLET 25 MG JENTADUETO TABLET MG... 5 JENTADUETO TABLET MG... 5 JENTADUETO TABLET MG... 5 JENTADUETO XR TABLET EXTENDED RELEASE 24 HOUR MG... 5 JENTADUETO XR TABLET EXTENDED RELEASE 24 HOUR MG 5 K KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG... 6 KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG 6 KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR MG.. 6 L LIVALO TABLET 1 MG LIVALO TABLET 2 MG LIVALO TABLET 4 MG N NEUPOGEN SOLUTION 300 MCG/ML INJECTION... 7 NEUPOGEN SOLUTION 480 MCG/1.6ML INJECTION... 7 NEUPOGEN SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML INJECTION 7 NEUPOGEN SOLUTION PREFILLED SYRINGE 480 MCG/0.8ML INJECTION 7 NEUPRO PATCH 24 HOUR 1 MG/24HR TRANSDERMAL NEUPRO PATCH 24 HOUR 2 MG/24HR TRANSDERMAL NEUPRO PATCH 24 HOUR 3 MG/24HR TRANSDERMAL NEUPRO PATCH 24 HOUR 4 MG/24HR TRANSDERMAL NEUPRO PATCH 24 HOUR 6 MG/24HR TRANSDERMAL NEUPRO PATCH 24 HOUR 8 MG/24HR TRANSDERMAL O ONGLYZA TABLET 2.5 MG... 6 ONGLYZA TABLET 5 MG... 6 R RHOPRESSA SOLUTION 0.02 % OPHTHALMIC RYTARY CAPSULE EXTENDED RELEASE MG RYTARY CAPSULE EXTENDED RELEASE MG RYTARY CAPSULE EXTENDED RELEASE MG RYTARY CAPSULE EXTENDED RELEASE MG S SYNJARDY TABLET MG SYNJARDY TABLET MG 15 SYNJARDY TABLET MG.. 15 SYNJARDY TABLET MG SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR MG SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR MG SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR MG SYNJARDY XR TABLET EXTENDED RELEASE 24 HOUR MG T TRADJENTA TABLET 5 MG... 5 TRULICITY SOLUTION PEN-INJECTOR 0.75 MG/0.5ML SUBCUTANEOUS... 8 TRULICITY SOLUTION PEN-INJECTOR 1.5 MG/0.5ML SUBCUTANEOUS... 8 TUDORZA PRESSAIR AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT INHALATION
21 TUDORZA PRESSAIR AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT INHALATION (30 ACTUATE)9 U ULORIC TABLET 40 MG... 2 ULORIC TABLET 80 MG... 2 V VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS... 8 VRAYLAR CAPSULE 1.5 MG... 3 VRAYLAR CAPSULE 3 MG... 3 VRAYLAR CAPSULE 4.5 MG... 3 VRAYLAR CAPSULE 6 MG... 3 VRAYLAR CAPSULE THERAPY PACK 1.5 & 3 MG... 3 X XTAMPZA ER CAPSULE ER 12 HOUR ABUSE-DETERRENT 13.5 MG 11 XTAMPZA ER CAPSULE ER 12 HOUR ABUSE-DETERRENT 18 MG XTAMPZA ER CAPSULE ER 12 HOUR ABUSE-DETERRENT 27 MG XTAMPZA ER CAPSULE ER 12 HOUR ABUSE-DETERRENT 36 MG XTAMPZA ER CAPSULE ER 12 HOUR ABUSE-DETERRENT 9 MG Z zileuton er tablet extended release 12 hour 600 mg oral ZYFLO TABLET 600 MG
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
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 Farm Bureau Health Plans Date Effective: November 1, 2018.
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
ALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Golden State Medicare Health Plan, Golden (HMO) Last Updated: 09/01/2018
Step Therapy Golden State Medicare Health Plan, Golden (HMO) Last Updated: 09/01/2018 ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir 1 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG
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"}
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
ADHD STIMULANTS - SCORE
ADHD STIMULANTS - SCORE Step Therapy Strattera Patient needs to have a paid claim for two generic formulary ADHD stimulant medications. Formulary ID# 00017034 Last Updated: 08/01/2017 1 ALPHA GLUCOSIDASE
ADHD STIMULANTS - SCORE
Step Therapy Trillium 5 Tier Effective Date: 12/01/2017 Approval Date: 10/24/2017 ADHD STIMULANTS - SCORE Strattera Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant
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
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
DPP4 INHIBITORS. Products Affected Step 2: Janumet 50 mg-1,000 mg tablet Janumet 50 mg-500 mg tablet Januvia 100 mg tablet Januvia 25 mg tablet
DPP4 INHIBITORS Janumet 50 mg-1,000 mg tablet Janumet 50 mg-500 mg tablet Januvia 100 mg tablet Januvia 25 mg tablet Januvia 50 mg tablet Onglyza 2.5 mg tablet Onglyza 5 mg tablet Tradjenta 5 mg tablet
DPP4 INHIBITORS. Details. Step Therapy Criteria Health Alliance Plan 2019 Date Effective: 04/01/2019
DPP4 INHIBITORS Janumet 50 mg-1,000 mg tablet Januvia 50 mg tablet Janumet 50 mg-500 mg tablet Onglyza 2.5 mg tablet Januvia 100 mg tablet Onglyza 5 mg tablet Januvia 25 mg tablet Tradjenta 5 mg tablet
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
Mercy Care Plan. Acyclovir Ointment. Products Affected. acyclovir ointment 5 % external Details. Criteria. Requires use of oral Acyclovir
Acyclovir Ointment Mercy Care Plan acyclovir ointment 5 % external Requires use of oral Acyclovir 1 Adcirca ADCIRCA TABLET 20 MG ORAL Requires use of Sildenafil 2 Albenza ALBENZA TABLET 200 MG ORAL Requires
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
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
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
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
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
Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
Medications that require Step Therapy (ST) require trial and failure of preferred formulary agents prior to their authorization. If the prerequisite medications have been filled within the specified time
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
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. 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
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
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
BYSTOLIC. Products Affected Step 2: BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET. Details BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET
BYSTOLIC BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET authorization for a Step 2 drug may be given. Step 1 Drug(s): generic beta-blockers and/or combinations,
2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements
2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for
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
2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements
2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for
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
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
2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements
2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for
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.
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.
ALPHA BLOCKERS. Products Affected Step 1: Details. Step 2: Rapaflo 4 mg capsule Rapaflo 8 mg capsule
CHRISTUS Health Plan Generations (HMO) CHRISTUS Health Plan Generations Plus (HMO) 2018 Premier Performance Standard Step Therapy PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS
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
2018 Step Therapy Criteria (List of Step Therapy Criteria)
Step Therapy Criteria Last Updated: March 20, 2018 Effective Date: April 1, 2018 2018 Step Therapy Criteria (List of Step Therapy Criteria) PLEASE READ CAREFULLY: IEHP DUALCHOICE CAL MEDICONNECT PLAN (MEDICARE-MEDICAID
TEST ANTICONVULSANT THERAPY. Products Affected. Step 2: Network Health Insurance Corporation NetworkCares Step Therapy Criteria Last Updated 11/2018
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