Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
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1 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 frame, the prescription will automatically process at the pharmacy. These step therapy parameters have been instituted to ensure clinically appropriate and cost effective use of these drugs and drug classes. When prior use of a formulary alternative cannot be validated at pharmacy point-of-sale (POS), the following will be required: Trial and failure, intolerance or contraindication to the formulary alternative(s) outlined below.
2 Acyclovir Ointment acyclovir ointment 5 % external Aetna Better Health Pennsylvania Use of oral acyclovir in the previous 130 days EFFECTIVE
3 Adcirca tadalafil (pah) tablet 20 mg oral Requires use of sildenafil 2
4 Albenza albendazole tablet 200 mg oral Use of pyrantel or ivermectin for at least 3 days. When ST therapy requirements are not met, the criteria in the PA guideline must be met for approval. 3
5 Albuterol Nebulizers albuterol sulfate nebulization solution 0.63 mg/3ml inhalation albuterol sulfate nebulization solution 1.25 mg/3ml inhalation Use of albuterol nebulizers 0.083% in past 90 days for 14 day duration 4
6 Azopt AZOPT SUSPENSION 1 % OPHTHALMIC Use of dorzolamide or dorzolamide/timolol in the previous 130 days 5
7 Celecoxib celecoxib capsule 100 mg oral celecoxib capsule 200 mg oral celecoxib capsule 400 mg oral celecoxib capsule 50 mg oral Use of 3 different NSAID's. When ST therapy requirements are not met, the criteria in the PA guideline must be met for approval. 6
8 Clonidine Patches clonidine patch weekly 0.1 mg/24hr transdermal clonidine patch weekly 0.2 mg/24hr transdermal clonidine patch weekly 0.3 mg/24hr Use of clonidine tablets for at least 30 days within the past 130 days. 7
9 Combigan COMBIGAN SOLUTION % OPHTHALMIC Use of 1 of the following for at least 15 days in the previous 130 days: Brimonidine Ophth Solution, Timolol Maleate Ophth Solution 8
10 DPP4 Inhibitors JANUMET TABLET MG ORAL JANUMET TABLET MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL JANUVIA TABLET 100 MG ORAL JANUVIA TABLET 25 MG ORAL JANUVIA TABLET 50 MG ORAL Use of metformin or combination metformin products for at least 60 days in the previous 130 days 9
11 Ezetimibe ezetimibe tablet 10 mg oral Use of a formulary Statin in the previous 60 days 10
12 GLP-1 Receptor Agonists OZEMPIC SOLUTION PEN-INJECTOR 0.25 OR 0.5 MG/DOSE SUBCUTANEOUS OZEMPIC SOLUTION PEN-INJECTOR 1 MG/DOSE SUBCUTANEOUS VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS Use of metformin or combination metformin products for at least 60 days in the previous 130 days 11
13 Griseofulvin griseofulvin microsize suspension 125 mg/5ml oral griseofulvin microsize tablet 500 mg oral griseofulvin ultramicrosize tablet 125 mg oral griseofulvin ultramicrosize tablet 250 mg oral Use of any one: terbinafine tablets, ketoconazole tablets, fluconazole tablets/suspension, itraconazole capsules/solution for at least 7 days within the last 60 days. When step therapy requirements are not met, the criteria in the PA guideline must be met for approval. 12
14 Isotretinoin MYORISAN CAPSULE 10 MG ORAL MYORISAN CAPSULE 20 MG ORAL MYORISAN CAPSULE 30 MG ORAL MYORISAN CAPSULE 40 MG ORAL ZENATANE CAPSULE 10 MG ORAL ZENATANE CAPSULE 20 MG ORAL ZENATANE CAPSULE 30 MG ORAL ZENATANE CAPSULE 40 MG ORAL Use of doxycycline or minocycline for at least 30 days in the previous 130 days 13
15 Levalbuterol HFA levalbuterol tartrate aerosol 45 mcg/act inhalation Use of Ventolin HFA for at least 15 days in the past 130 days 14
16 Lice/Scabicides malathion lotion 0.5 % external Use of permethrin or pyrethrin in the previous day 15
17 Naproxen Suspension naproxen suspension 125 mg/5ml oral Use of ibuprofen suspension for 15 days within the previous 130 days 16
18 Olopatadine Ophthalmic olopatadine hcl solution 0.1 % ophthalmic olopatadine hcl solution 0.2 % ophthalmic Use of ketotifen ophthalmic in previous 15 days 17
19 Omega 3 omega-3-acid ethyl esters capsule 1 gm oral Use of OTC Fish Oil for at least 60 days in the previous 130 days. 18
20 Ophthalmic antihistamines azelastine hcl solution 0.05 % ophthalmic Use of ketotifen ophthalmic in the previous 90 days 19
21 Overactive Bladder tolterodine tartrate er capsule extended release 24 hour 2 mg oral tolterodine tartrate er capsule extended release 24 hour 4 mg oral tolterodine tartrate tablet 1 mg oral tolterodine tartrate tablet 2 mg oral trospium chloride er capsule extended release 24 hour 60 mg oral trospium chloride tablet 20 mg oral Use of oxybutynin IR/ER for at least 30 days within the previous 130 days. 20
22 Oxymorphone ER oxymorphone hcl er tablet extended release 12 hour 10 mg oral oxymorphone hcl er tablet extended release 12 hour 15 mg oral oxymorphone hcl er tablet extended release 12 hour 20 mg oral oxymorphone hcl er tablet extended release 12 hour 30 mg oral oxymorphone hcl er tablet extended release 12 hour 40 mg oral oxymorphone hcl er tablet extended release 12 hour 5 mg oral oxymorphone hcl er tablet extended release 12 hour 7.5 mg oral Use of 2 of the following agents in the previous 130 days: fentanyl, methadone, morphine, oxycodone 21
23 Paricalcitol paricalcitol capsule 1 mcg oral Use of calcitriol in the previous 130 days 22
24 Phosphate Binders AURYXIA TABLET 1 GM 210 MG(FE) ORAL sevelamer carbonate tablet 800 mg oral Use of calcium acetate for at least 30 days within the previous 130 days. 23
25 Ribasphere REBETOL SOLUTION 40 MG/ML ORAL RIBASPHERE CAPSULE 200 MG ORAL RIBASPHERE TABLET 200 MG ORAL Requires a paid claim for a direct-acting antiviral for Hepatitis C or Pegasys in the previous 5 days to assure that patients are taking ribavirin with other appropriate hepatitis C medications and not as monotherapy. 24
26 Rosiglitazone AVANDIA TABLET 2 MG ORAL AVANDIA TABLET 4 MG ORAL Use of both metformin and pioglitazone in the previous 130 days 25
27 Rosuvastatin rosuvastatin calcium tablet 10 mg oral rosuvastatin calcium tablet 20 mg oral rosuvastatin calcium tablet 40 mg oral rosuvastatin calcium tablet 5 mg oral Use of atorvastatin for 60 days in the previous 130 days 26
28 Rozerem ROZEREM TABLET 8 MG ORAL Use of zolpidem AND zaleplon in the previous 130 days 27
29 Savella SAVELLA TABLET 100 MG ORAL SAVELLA TABLET 12.5 MG ORAL SAVELLA TABLET 25 MG ORAL SAVELLA TABLET 50 MG ORAL SAVELLA TITRATION PACK 12.5 & 25 & 50 MG ORAL Use of duloxetine in the past 130 days for 60 day duration 28
30 SGLT2 SEGLUROMET TABLET MG ORAL SEGLUROMET TABLET MG ORAL SEGLUROMET TABLET MG ORAL SEGLUROMET TABLET MG ORAL STEGLATRO TABLET 15 MG ORAL STEGLATRO TABLET 5 MG ORAL Use of metformin or combination metformin products for at least 60 days in the previous 130 days 29
31 Stiolto STIOLTO RESPIMAT AEROSOL SOLUTION MCG/ACT INHALATION Use of Anoro Ellipta or Incruse Ellipta in the previous 130 days 30
32 Timolol Gel timolol maleate gel forming solution 0.25 % ophthalmic timolol maleate gel forming solution 0.5 % ophthalmic Use of Timolol Solution for 15 days in the previous 130 days 31
33 Topical Calcineurin Inhibitors tacrolimus ointment 0.03 % external tacrolimus ointment 0.1 % external Use of 2 topical corticosteroids for at least 14 days each in the previous 130 days 32
34 Topical Retinoids adapalene cream 0.1 % external tretinoin cream % external tretinoin cream 0.05 % external tretinoin cream 0.1 % external tretinoin gel 0.01 % external tretinoin gel % external Use of OTC Differin 0.1% Gel in the previous 130 days 33
35 Topical Steroids clobetasol propionate cream 0.05 % external clobetasol propionate gel 0.05 % external clobetasol propionate ointment 0.05 % external Use of 1 of the following for at least 10 days within the past 60 days: AUG Betamethasone Dip Gel 0.05%, AUG Betamethasone Dip Lotion 0.05%, AUG Betamethasone Dip Ointment 0.05%, Halobetasol 0.05% Cream, Halobetasol 0.05% Ointment 34
36 Uloric ULORIC TABLET 40 MG ORAL ULORIC TABLET 80 MG ORAL Use of allopurinol in the previous 130 days 35
37 Zafirlukast zafirlukast tablet 10 mg oral zafirlukast tablet 20 mg oral Use of montelukast for at least 30 days in the previous 130 days 36
38 Index Header acyclovir ointment 5 % external... 1 adapalene cream 0.1 % external albendazole tablet 200 mg oral... 3 albuterol sulfate nebulization solution 0.63 mg/3ml inhalation... 4 albuterol sulfate nebulization solution 1.25 mg/3ml inhalation... 4 AURYXIA TABLET 1 GM 210 MG(FE) ORAL AVANDIA TABLET 2 MG ORAL AVANDIA TABLET 4 MG ORAL azelastine hcl solution 0.05 % ophthalmic AZOPT SUSPENSION 1 % OPHTHALMIC... 5 celecoxib capsule 100 mg oral... 6 celecoxib capsule 200 mg oral... 6 celecoxib capsule 400 mg oral... 6 celecoxib capsule 50 mg oral... 6 clobetasol propionate cream 0.05 % external clobetasol propionate gel 0.05 % external clobetasol propionate ointment 0.05 % external clonidine patch weekly 0.1 mg/24hr transdermal... 7 clonidine patch weekly 0.2 mg/24hr transdermal... 7 clonidine patch weekly 0.3 mg/24hr transdermal... 7 COMBIGAN SOLUTION % OPHTHALMIC... 8 ezetimibe tablet 10 mg oral griseofulvin microsize suspension 125 mg/5ml oral griseofulvin microsize tablet 500 mg oral griseofulvin ultramicrosize tablet 125 mg oral griseofulvin ultramicrosize tablet 250 mg oral JANUMET TABLET MG ORAL... 9 JANUMET TABLET MG ORAL.. 9 JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL... 9 JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL... 9 JANUMET XR TABLET EXTENDED RELEASE 24 HOUR MG ORAL... 9 JANUVIA TABLET 100 MG ORAL... 9 JANUVIA TABLET 25 MG ORAL... 9 JANUVIA TABLET 50 MG ORAL... 9 levalbuterol tartrate aerosol 45 mcg/act inhalation malathion lotion 0.5 % external MYORISAN CAPSULE 10 MG ORAL MYORISAN CAPSULE 20 MG ORAL MYORISAN CAPSULE 30 MG ORAL MYORISAN CAPSULE 40 MG ORAL naproxen suspension 125 mg/5ml oral olopatadine hcl solution 0.1 % ophthalmic.. 17 olopatadine hcl solution 0.2 % ophthalmic.. 17 omega-3-acid ethyl esters capsule 1 gm oral oxymorphone hcl er tablet extended release 12 hour 10 mg oral oxymorphone hcl er tablet extended release 12 hour 15 mg oral oxymorphone hcl er tablet extended release 12 hour 20 mg oral oxymorphone hcl er tablet extended release 12 hour 30 mg oral oxymorphone hcl er tablet extended release 12 hour 40 mg oral oxymorphone hcl er tablet extended release 12 hour 5 mg oral oxymorphone hcl er tablet extended release 12 hour 7.5 mg oral OZEMPIC SOLUTION PEN- INJECTOR 0.25 OR 0.5 MG/DOSE SUBCUTANEOUS OZEMPIC SOLUTION PEN- INJECTOR 1 MG/DOSE SUBCUTANEOUS paricalcitol capsule 1 mcg oral REBETOL SOLUTION 40 MG/ML ORAL RIBASPHERE CAPSULE 200 MG ORAL
39 RIBASPHERE TABLET 200 MG ORAL rosuvastatin calcium tablet 10 mg oral rosuvastatin calcium tablet 20 mg oral rosuvastatin calcium tablet 40 mg oral rosuvastatin calcium tablet 5 mg oral ROZEREM TABLET 8 MG ORAL SAVELLA TABLET 100 MG ORAL SAVELLA TABLET 12.5 MG ORAL SAVELLA TABLET 25 MG ORAL SAVELLA TABLET 50 MG ORAL SAVELLA TITRATION PACK 12.5 & 25 & 50 MG ORAL SEGLUROMET TABLET MG ORAL SEGLUROMET TABLET MG ORAL SEGLUROMET TABLET MG ORAL SEGLUROMET TABLET MG ORAL sevelamer carbonate tablet 800 mg oral STEGLATRO TABLET 15 MG ORAL STEGLATRO TABLET 5 MG ORAL STIOLTO RESPIMAT AEROSOL SOLUTION MCG/ACT INHALATION tacrolimus ointment 0.03 % external tacrolimus ointment 0.1 % external tadalafil (pah) tablet 20 mg oral... 2 timolol maleate gel forming solution 0.25 % ophthalmic timolol maleate gel forming solution 0.5 % ophthalmic tolterodine tartrate er capsule extended release 24 hour 2 mg oral tolterodine tartrate er capsule extended release 24 hour 4 mg oral tolterodine tartrate tablet 1 mg oral tolterodine tartrate tablet 2 mg oral tretinoin cream % external tretinoin cream 0.05 % external tretinoin cream 0.1 % external tretinoin gel 0.01 % external tretinoin gel % external trospium chloride er capsule extended release 24 hour 60 mg oral...20 trospium chloride tablet 20 mg oral ULORIC TABLET 40 MG ORAL ULORIC TABLET 80 MG ORAL VICTOZA SOLUTION PEN- INJECTOR 18 MG/3ML SUBCUTANEOUS zafirlukast tablet 10 mg oral zafirlukast tablet 20 mg oral ZENATANE CAPSULE 10 MG ORAL ZENATANE CAPSULE 20 MG ORAL ZENATANE CAPSULE 30 MG ORAL ZENATANE CAPSULE 40 MG ORAL
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