Alprazolam 0.25mg, 0.5mg, 1mg tablets

Size: px
Start display at page:

Download "Alprazolam 0.25mg, 0.5mg, 1mg tablets"

Transcription

1 Presbyterian Senior Care (HMO) / Presbyterian MediCare PPO Quantity Limits Effective November 1, 2014 For the most recent list of drugs or other questions, please contact the Presbyterian Customer Service Center at (505) or , or for TTY/TDD users, call , Monday through Sunday from 8:00 a.m. to 8:00 p.m., or visit Abilify tablets Acetaminophen/codeine tablets Acyclovir ointment Alprazolam 0.25mg, 0.5mg, 1mg tablets Alprazolam 2mg tablets Amphetamine/dextroamphetamine XR 5mg, 10mg, 15mg capsules Amphetamine/dextroamphetamine XR 20mg, 25mg, 30mg capsules Amphetamine/dextroamphetamine tablets Androderm patches Androgel 50mg/5gm Androgel 1% pump Androgel 1.62% 1.25gm packet Androgel 1.62% 2.5gm packet Androgel 1.62% pump Apriso capsules Asacol tablets Bosulif 100mg tablets 30 grams Per 30 Days 135 Per 30 Days 30 patches Per 30 Days 300 grams Per 30 Days 300 grams Per 30 Days 150 grams Per 30 Days Y0055_MPC111332_NSR_ Updated 10/2014 Formulary ID Version 35 Page 1 of 8

2 Bosulif 500mg tablets Brintellix tablets Buprenorphine/naloxone tablets Bupropion XL 150mg tablets Chantix Starter Pack Chantix 0.5mg, 1mg tablets Chlordiazepoxide capsules Citalopram solution Citalopram 10mg tablets Clonazepam 0.5mg, 1mg tablets Clonazepam ODT 0.125mg, 0.25mg, 0.5mg, 1mg tablets Clorazepate tablets Codeine tablets Combivent Respimat Delzicol capsules Denavir cream Dextroamphetamine tablets Diazepam gel Diazepam solution Diazepam tablets Dificid tablets Dihydroergotamine 4mg/mL solution Donepezil 10mg tablets 106 Per 365 Days 360 Per 365 Days 600 ml Per 30 Days 45 Per 30 Days 2 inhalers Per 30 Days 1.5 grams per 30 Days 10 Per 30 Days 1200mL per 30 Days 20 Per 30 Days 8mL Per 28 Days Page 2 of 8

3 Donepezil 5mg tablets Donepezil 10mg ODT Donepezil 5mg ODT Dronabinol capsules Duloxetine capsules Emend capsules Ergomar Escitalopram 5mg, 20mg tablets Escitalopram 10mg tablets Eszopiclone tablets Fentanyl patches Fentanyl Citrate Transmucosal Lollipop 400mcg, 600mcg, 800mcg, 1200mcg, 1600mcg Flurazepam capsules Fortesta gel Granisetron tablets Humalog Humalog Kwikpen Humalog Mix 50/50 Humalog Mix 50/50 Kwikpen Humalog Mix 75/25 Humalog Mix 75/25 Kwikpen Humulin 70/30 Humulin 70/30 Pen 12 Per 30 Days 20 Per 28 Days 45 Per 30 Days 10 Per 30 Days 4 Per 1 Day 120 grams Per 30 Days Page 3 of 8

4 Humulin N Humulin N U-100 Pen Humulin R Hydrocodone/acetaminophen 7.5/750mg, 10/750mg tablets Hydrocodone/acetaminophen 5/325mg, 7.5/325mg, 10/325mg, 2.5/500mg, 5/500mg, 7.5/500mg, 10/500mg, 7.5/650mg, 10/650mg, 10/660mg tablets Hydrocodone/acetaminophen solution Hydrocodone/ibuprofen 7.5/200mg tablets Hydromorphone 2mg, 4mg tablets Hydromorphone 8mg tablets Imbruvica capsules Incivek tablets Khedezla ER tablets Lantus Lantus Solostar Lazanda Levemir Levemir Flexpen Levemir Flextouch Pen Lidocaine patches Linzess capsules Lorazepam tablets Metadate CD 20mg, 30mg, 40mg capsules 150 Per 30 Days 3,600mL Per 30 Days 45mL Per 30 days Page 4 of 8

5 Methadone concentration Methadone 10mg tablets Methadone 5mg tablets Methylphenidate CD capsules Methylphenidate IR tablets Migranal solution Modafinil tablets Montelukast chewable, tablets Morphine sulfate ER 15mg, 30mg capsules Morphine sulfate ER 60mg, 100mg, 200mg capsules Morphine sulfate IR 15mg tablets Morphine sulfate IR 30mg tablets Naratriptan tablets Nicotrol inhaler Nicotrol nasal spray Novolin 70/30 Novolin N Novolin R Novolog Novolog Flexpen Novolog Mix 70/30 Novolog Mix 70/30 Prefilled Flexpen Novolog Penfill 120mL Per 30 Days 8mL Per 30 Days 18 Per 30 Days 3024 inhalers Per 365 Days 720 ml Per 365 Days Page 5 of 8

6 Nuvigil tablets Olanzapine ODT Omeprazole DR capsules Ondansetron 4mg, 8mg tablets Ondansetron ODT Onfi tablets Opana ER crush resistant tablets Oxycodone 5mg, 10mg tablets Oxycodone 15mg tablets Oxycodone 20mg tablets Oxycodone 30mg tablets Oxycodone/acetaminophen tablets Pantoprazole tablets Pen Needles Pentasa capsules Pomalyst capsules Pradaxa capsules Pristiq tablets Procrit 2000 units/ml, 3000 units/ml, 4000 units/ml injection Protopic 0.03% ointment Protopic 0.1% ointment Rabeprazole capsules Relistor injection 150 Per 30 Days 100 Per 30 Days 240 Per 30 Days 21 Per 28 Days 15 ml Per 30 Days 100 grams Per 60 Days 120 grams Per 60 Days Page 6 of 8

7 Relpax tablets Rivastigmine Tartrate capsules Rizatriptan tablets, ODT Rozerem tablets Sildenafil tablets Simbrinza ophthalmic suspension Stivarga 40mg tablets Sumatriptan 20mg/Actuation solution Sumatriptan Succinate 4mg/0.5mL injection Sumatriptan Succinate 6mg/0.5mL injection Sumatriptan Succinate tablets Tamiflu 30mg capsules Tamiflu 45mg, 75mg capsules Tamiflu 6mg/mL suspension Temazepam capsules Terbinafine tablets Tobi Podhaler Tramadol 50mg tablets Tramadol ER 100mg tablets Tramadol ER 200mg tablets Triazolam tablets Uloric tablets Vascepa capsules 18 Per 30 Days 18 Per 30 Days 8 ml Per 30 Days 6 Per 30 Days 2 ml Per 30 Days 5 ml Per 30 Days 18 Per 30 Days 56 Per 180 Days 28 Per 180 Days 360 ml Per 180 Days 224 Per 28 Days 240 Per 30 Days Page 7 of 8

8 Venlafaxine ER 37.5mg, 150mg tablets, capsules Venlafaxine ER 75mg tablets, capsules Venlafaxine ER 225mg tablets Victrelis capsules Viibryd tablets Vimpat tablets Voriconazole 200mg tablets Vyvanse capsules Xtandi capsules Zaleplon capsules Zolpidem IR tablets Zolpidem ER tablets Zortress tablets Zovirax cream Zyflo CR tablets Zykadia 150mg capsule 3 5 grams Per 30 Days #150 Per 30 Days Page 8 of 8

APREPITANT ARMODAFINIL BELSOMRA BUPAP BUPRENORPHINE HCL BUTALBITAL-ACETAMINOPHEN BUTALBITAL-APAP-CAFF-COD BUTALBITAL-APAP-CAFFEINE

APREPITANT ARMODAFINIL BELSOMRA BUPAP BUPRENORPHINE HCL BUTALBITAL-ACETAMINOPHEN BUTALBITAL-APAP-CAFF-COD BUTALBITAL-APAP-CAFFEINE APREPITANT Aprepitant Oral Capsule 125, 40, 80 Aprepitant Oral Capsule 80 & 125 Quantity Limit: 8 EA Per 30 Days Quantity Limit: 12 EA Per 30 Days ARMODAFINIL Armodafinil Oral Tablet 150, 200, 250, 50

More information

Kansas Health Advantage (HMO SNP) 2018 Formulary Quantity Limit Criteria

Kansas Health Advantage (HMO SNP) 2018 Formulary Quantity Limit Criteria APREPITANT Kansas Health Advantage (HMO SNP) 2018 Formulary Aprepitant Oral Capsule 125, 40, 80 Aprepitant Oral Capsule 80 & 125 Quantity Limit: 8 EA Per 30 Days Quantity Limit: 12 EA Per 30 Days ARMODAFINIL

More information

Tribute 2018 Formulary 2018 Quantity Limit Criteria

Tribute 2018 Formulary 2018 Quantity Limit Criteria APREPITANT Aprepitant ORAL CAPSULE 125, 40, 80 Aprepitant Oral CAPSULE 80 & 125 Quantity Limit: 8 EA Per 30 Days Quantity Limit: 12 EA Per 30 Days ARMODAFINIL Armodafinil ORAL TABLET 150, 200, 250, 50

More information

Tribute 2018 Formulary 2018 Quantity Limit Criteria

Tribute 2018 Formulary 2018 Quantity Limit Criteria APREPITANT Aprepitant Oral Capsule 125, 40, 80 Aprepitant Oral Capsule 80 & 125 Quantity Limit: 8 EA Per 30 Days Quantity Limit: 12 EA Per 30 Days ARMODAFINIL Armodafinil Oral Tablet 150, 200, 250, 50

More information

Relative Cost/Month. Less than $10. Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*

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*

More information

Step Therapy Medications

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,

More information

2014 Quantity Limits (QL) Criteria

2014 Quantity Limits (QL) Criteria 2014 Quantity Limits (QL) Criteria Certain drugs covered through your EmblemHealth Medicare HMO/PPO Medicare Plan are covered for only a limited quantity. We do this to ensure compliance with the US Food

More information

2015 Step Therapy Prior Authorization Medical Necessity Guidelines

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

More information

Aetna Better Health of Illinois Medicaid Formulary Updates

Aetna Better Health of Illinois Medicaid Formulary Updates October 2017 o DOXYLAMINE SUCCINATE 25mg-QL o DULOXETINE CAP 40MG DR-QL o GUANFACIN ER TABS (all strengths)-ql o TOBRAMYCIN NEBU SOLUTION- PA August 2017 Aetna Better Health of Illinois Medicaid 2017 Formulary

More information

Simply Step Therapy Document September 2018 Y0114_18_33074_I_009

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

More information

2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Criteria Last Updated 11/1/2015

2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Criteria Last Updated 11/1/2015 2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Last Updated 11/1/2015 APLENZIN TAB 174MG, 348MG, 522MG Step Therapy requires trial of bupropion SR or bupropion XL in previous 180

More information

ANTIDEPRESSANTS. Details. dose pack Viibryd 10 mg tablet Viibryd 20 mg tablet Viibryd 40 mg tablet. Criteria

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

More information

Step Therapy Requirements. Effective: 11/01/2018

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

More information

Step Therapy Requirements. Effective: 05/01/2018

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

More information

ALPHA BLOCKERS. Products Affected Step 1: Details. Step 2: Rapaflo 4 mg capsule Rapaflo 8 mg capsule

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

More information

2018 Step Therapy (ST) Criteria

2018 Step Therapy (ST) Criteria 2018 Step Therapy (ST) 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 drug that

More information

2019 Simply Step Therapy Document

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.

More information

Step Therapy Medications

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

More information

SmithRx Standard Formulary Step Therapy List

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

More information

2017 Step Therapy (ST) Criteria

2017 Step Therapy (ST) Criteria 2017 Step Therapy (ST) 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 drug that

More information

U T I L I Z A T I O N E D I T S

U T I L I Z A T I O N E D I T S I N D I A N A H E A L T H C O V E R A G E P R O G R A M S U T I L I Z A T I O N E D I T S A P R I L 1 9, 2 0 1 2 s for s Refer to Provider Bulletin BT200709 for additional information regarding the Mental

More information

Plan Year CCHP Senior Program (HMO) Step Therapy Criteria (ST)

Plan Year CCHP Senior Program (HMO) Step Therapy Criteria (ST) Plan Year 2016 CCHP Senior Program (HMO) Step Therapy Criteria (ST) Step Therapy: In some cases, CCHP Senior Program (HMO) requires you to first try certain drugs to treat your medical condition before

More information

5-ASA. Products Affected DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED RELEASE. Details

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

More information

5-ASA. Products Affected. Details. Dipentum 250 mg capsule. Lialda 1.2 gram tablet,delayed release

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

More information

5-ASA. Products Affected Dipentum 250 mg capsule. Details. Lialda 1.2 gram tablet,delayed release

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.

More information

Memorial Hermann Advantage HMO February 2019 Formulary Addendum

Memorial Hermann Advantage HMO February 2019 Formulary Addendum Memorial Hermann Advantage HMO February 2019 Formulary Addendum Changes may have occurred since the printing of your current Memorial Hermann Advantage HMO Formulary. Medications that may have been added

More information

2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements

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

More information

Peach State Health Plan routinely reviews the medications available on the Preferred Drug

Peach State Health Plan routinely reviews the medications available on the Preferred Drug Effective date: December 27, 2016 Peach State Health Plan Preferred Drug List (PDL) Updates Q4 2016 Peach State Health Plan routinely reviews the medications available on the Preferred Drug List (PDL).

More information

5-ASA. Products Affected Dipentum 250 mg capsule. Details. Lialda 1.2 gram tablet,delayed release

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.

More information

2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements

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

More information

2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements

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

More information

2017 Step Therapy Criteria

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.

More information

ALLERGIC CONJUNCTIVITIS AGENTS

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

More information

ADHD STIMULANTS-S(SHC)

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

More information

Contents ALPHA BLOCKERS... 3 COLCRYS-PST... 4 DPP-4 INHIBITORS-PST... 5 HIGH RISK MEDICATIONS - SEDATIVE HYPNOTICS... 6

Contents ALPHA BLOCKERS... 3 COLCRYS-PST... 4 DPP-4 INHIBITORS-PST... 5 HIGH RISK MEDICATIONS - SEDATIVE HYPNOTICS... 6 CHRISTUS Health Plan Generations (HMO) 2017 Step Therapy Criteria H1189_PC57 Accepted 11/17/2016 1 Contents ALPHA BLOCKERS... 3 COLCRYS-PST... 4 DPP-4 INHIBITORS-PST... 5 HIGH RISK MEDICATIONS - SEDATIVE

More information

Alameda Alliance for Health Pharmacy & Therapeutics (P&T) Committee Decisions

Alameda Alliance for Health Pharmacy & Therapeutics (P&T) Committee Decisions Alameda Alliance for Health FORMULARY UPDATE Effective: October 27, 2017. Drugs notated with an * have an undetermined implementation date Alameda Alliance for Health Pharmacy & Therapeutics (P&T) Committee

More information

See Important Reminder at the end of this policy for important regulatory and legal information.

See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: Step Therapy Reference Number: HIM.PA.109 Effective Date: 08.01.17 Last Review Date: 05.18 Line of Business: Health Insurance Marketplace Revision Log See Important Reminder at the end

More information

ACYCLOVIR OINT (CCHP2017)

ACYCLOVIR OINT (CCHP2017) ACYCLOVIR OINT (CCHP2017) acyclovir 5 % topical ointment Step Therapy requires trial of one (1) of the following: oral generic acyclovir, oral generic famciclovir, oral generic valacyclovir. 1 ALPHAGAN

More information

Xyrem (Sodium Oxybate)

Xyrem (Sodium Oxybate) Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Clinical Criteria Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization

More information

Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria

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

More information

ACYCLOVIR OINT (CCHP2017)

ACYCLOVIR OINT (CCHP2017) ACYCLOVIR OINT (CCHP2017) acyclovir 5 % topical ointment Step Therapy requires trial of one (1) of the following: oral generic acyclovir, oral generic famciclovir, oral generic valacyclovir. 1 ALPHAGAN

More information

Medications with Quantity Limits Effective: 5/1/2018

Medications with Quantity Limits Effective: 5/1/2018 Medications with Quantity Limits Effective: 5/1/2018 The following table lists medications with managed dose limits. Certain products are subject to managed dose limitations (MDL) based on FDA-approved

More information

Drugs That Require Step Therapy (ST) Step Therapy Medications

Drugs That Require Step Therapy (ST) Step Therapy Medications Drugs That Require Step Therapy (ST) In some cases, BlueShield of Northeastern New York requires you to first try certain drugs to treat your medical condition before we will cover another drug for that

More information

Step Therapy Requirements

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

More information

Drugs That Require Step Therapy (ST) Step Therapy Medications

Drugs That Require Step Therapy (ST) Step Therapy Medications Drugs That Require Step Therapy (ST) In some cases, BlueCross BlueShield of WNY requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.

More information

ANGIOTENSIN RECEPTOR BLOCKERS STEP THERAPY

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

More information

ACYCLOVIR OINT (CCHP2017)

ACYCLOVIR OINT (CCHP2017) ACYCLOVIR OINT (CCHP2017) acyclovir 5 % topical ointment Step Therapy requires trial of one (1) of the following: oral generic acyclovir, oral generic famciclovir, oral generic valacyclovir. 1 ALPHAGAN

More information

See Important Reminder at the end of this policy for important regulatory and legal information.

See Important Reminder at the end of this policy for important regulatory and legal information. Clinical Policy: Step Therapy Reference Number: HIM.PA.109 Effective Date: 08.01.17 Last Review Date: 05.18 Line of Business: Health Insurance Marketplace Revision Log See Important Reminder at the end

More information

True Health New Mexico List of Medications with Quantity Limits

True Health New Mexico List of Medications with Quantity Limits True Health New Mexico List of Medications with Quantity Limits Specialty Medications Contact True Health New Mexico Pharmacy Services at 1-866- 341-8561 for quantity limits on specialty medications. Maximum

More information

Drugs That Require Step Therapy (ST) Step Therapy Medications

Drugs That Require Step Therapy (ST) Step Therapy Medications Drugs That Require Step Therapy (ST) In some cases, BlueShield of Northeastern New York requires you to first try certain drugs to treat your medical condition before we will cover another drug for that

More information

ABILIFY INJ. Products Affected Step 2: ABILIFY MAINTENA PREFILLED SYRINGE 300 MG INTRAMUSCULAR ABILIFY MAINTENA PREFILLED SYRINGE 400 MG INTRAMUSCULAR

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

More information

Medicines Formulary BNF Section 4 Central Nervous System

Medicines Formulary BNF Section 4 Central Nervous System Medicines BNF Section 4 4.1 Hypnotics and anxiolytics Chloral Hydrate 500mg/5ml Solution Clomethiazole 192mg Capsules Lormetazepam Tablets Melatonin Capsules Nitrazepam Suspension Nitrazepam Tablets Temazepam

More information

Step Therapy Approval Criteria

Step Therapy Approval Criteria Effective Date: 01/01/2019 This document contains for the following medications: 1. Colcrys (colchicine) 2. Dovonex (calcipotriene) 3. Enbrel (etanercept) 4. Humira (adalimumab) 5. Imitrex Injection vial

More information

AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details

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.

More information

Step Therapy Requirements. Effective: 1/1/2019

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

More information

JULY 2017 ADDITIONS. NP Thyroid 120mg NP Thyroid 15mg JUNE 2017 CHANGES

JULY 2017 ADDITIONS. NP Thyroid 120mg NP Thyroid 15mg JUNE 2017 CHANGES APRIL 2017 Ivermectin, Pin-X and Reeses (Pyrantel Pamoate) Selzentry 25mg and 75mg tablets Linzess 72 mcg capsule-with QLL Levalbuterol Tartrate Inhal Aerosol (Generic Xopenex HFA) with ST & QLL Jentadueto

More information

AETNA BETTER HEALTH January 2017 Formulary Change(s)

AETNA BETTER HEALTH January 2017 Formulary Change(s) AETNA BETTER HEALTH January 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on February 1, 2017 Drug Name, Strength, Dosage Form IVERMECTIN 3 MG TABLET

More information

UPDATE Ohana QUEST Integration Medicaid

UPDATE Ohana QUEST Integration Medicaid UPDATE Ohana QUEST Integration Medicaid Preferred Drug List June 29, 2015 Dear Provider: At the June 04, 2015 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes

More information

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 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

More information

Step Therapy Criteria 2019

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

More information

2017 Formulary Changes Year to Date

2017 Formulary Changes Year to Date 2017 Formulary Changes Year to Date Health Choice Arizona may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, add prior authorization, quantity limits and/or

More information

CRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication.

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

More information

ALOGLIPTIN STEP. Details. Step Therapy Requirements Effective November 1, 2017

ALOGLIPTIN STEP. Details. Step Therapy Requirements Effective November 1, 2017 ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone 15 mg tablet alogliptin 12.5 mg-pioglitazone

More information

Step Therapy Requirements

Step Therapy Requirements An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 05/01/2018 Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/2014 1 BETA-BLOCKERS BYSTOLIC 10 MG

More information

HYSINGLA ER (hydrocodone bitartrate) Prior authorization is not required if prescribed by an oncologist.

HYSINGLA ER (hydrocodone bitartrate) Prior authorization is not required if prescribed by an oncologist. Pre - PA Allowance None Prior authorization is not required if prescribed by an oncologist. Prior-Approval Requirements Age 18 years of age or older Diagnosis Patient must have the following: 1. Pain,

More information

Pre - PA Allowance. Prior-Approval Requirements LEVORPHANOL TARTRATE. None

Pre - PA Allowance. Prior-Approval Requirements LEVORPHANOL TARTRATE. None Pre - PA Allowance None Prior-Approval Requirements Prior authorization is not required if prescribed by an oncologist and/or the member has paid pharmacy claims for an oncology medication(s) in the past

More information

Step Therapy Approval Criteria

Step Therapy Approval Criteria Effective Date: 01/01/2018 This document contains Step Therapy Approval Criteria for the following medications: 1. Colcrys (colchicine) 2. Dovonex (calcipotriene) 3. Enbrel (etanercept) 4. Humira (adalimumab)

More information

Upper Peninsula Health Plan Advantage (HMO) (List of Covered Drugs)

Upper Peninsula Health Plan Advantage (HMO) (List of Covered Drugs) Analgesics Opioid Analgesics, Long-acting fentanyl 100 mcg/hr patch td72 morphine sulfate 30 mg tablet er Opioid Analgesics, Short-acting fentanyl citrate 200 mcg lozenge hd hydrocodone/acetaminophen 5

More information

Part D Pharmacy. An Independent Licensee of the Blue Cross Blue Shield Association ( )

Part D Pharmacy. An Independent Licensee of the Blue Cross Blue Shield Association ( ) Part D Pharmacy 1 An Independent Licensee of the Blue Cross Blue Shield Association 044507 (12-21-2017) New MA pharmacy partner We ve selected CVS Caremark to manage our part D pharmacy benefits Providence

More information

Step Therapy Requirements

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

More information

AETNA BETTER HEALTH January 2017 Formulary Change(s)

AETNA BETTER HEALTH January 2017 Formulary Change(s) AETNA BETTER HEALTH January 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on March 1, 2017 Drug Name, Strength, Dosage Form ALFUZOSIN HCL ER 10

More information

How do I request an exception to the Liberty Health Advantage s Formulary?

How do I request an exception to the Liberty Health Advantage s Formulary? QUANTITY LIMITATIONS How do I request an exception to the Liberty Health Advantage s Formulary? You can ask Liberty Health Advantage to make an exception to our coverage rules. There are several types

More information

2014 Medicare Part D Formulary Formulary Additions

2014 Medicare Part D Formulary Formulary Additions Formulary Additions Used For Coverage Tier Bromday Ophthalmic Anti-inflammatory Invokana 100 mg Invokana 300 mg Namenda 14 mg ER Dementia Namenda 28 Titration Pack Dementia Namenda 21 mg ER Dementia Namenda

More information

Quarterly pharmacy formulary change notice

Quarterly pharmacy formulary change notice Provider Bulletin June 2017 The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus patients. These changes were reviewed and approved at the first quarter Pharmacy and Therapeutics

More information

ANTICONVULSANT STEP THERAPY

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

More information

AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details

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.

More information

WellCare s South Carolina Preferred Drug List Update

WellCare s South Carolina Preferred Drug List Update WellCare s South Carolina Preferred Drug List Update This is a list of changes to our preferred drug list. These are a result of the latest WellCare Pharmacy & Therapeutics meeting held on 09/03/2015.

More information

ANTIDEPRESSANTS. Details. Step Therapy 2018 Last Updated: 8/21/2018

ANTIDEPRESSANTS. Details. Step Therapy 2018 Last Updated: 8/21/2018 ANTIDEPRESSANTS 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 ORAL FETZIMA

More information

STATE OF TENNESSEE DEPARTMENT OF FINANCE AND ADMINISTRATION DIVISION OF HEALTH CARE FINANCE AND ADMINISTRATION BUREAU OF TENNCARE

STATE OF TENNESSEE DEPARTMENT OF FINANCE AND ADMINISTRATION DIVISION OF HEALTH CARE FINANCE AND ADMINISTRATION BUREAU OF TENNCARE STATE OF TENNESSEE DEPARTMENT OF FINANCE AND ADMINISTRATION DIVISION OF HEALTH CARE FINANCE AND ADMINISTRATION BUREAU OF TENNCARE 310 Great Circle Road NASHVILLE, TENNESSEE 37243 This notice is to advise

More information

**CRITERIA UNDER CMS REVIEW**

**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

More information

Drugs That Require Step Therapy (ST)

Drugs That Require Step Therapy (ST) Choice Drugs That Require Step Therapy (ST) In some cases, Express Scripts Medicare (PDP) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that

More information

Michigan Department of Community Health Quantity Limitations

Michigan Department of Community Health Quantity Limitations Abstral (fentanyl) sl tab all strength Acetaminophen Actonel Actonel 35mg Adderall XR 5mg, 10mg, 15mg 240 per 34 days 3 gm/day 2 every 28 days 4 every 28 days Advair Diskus. No more than 180 every 30 days

More information

Michigan Department of Community Health Co-pay and Quantity Limitations

Michigan Department of Community Health Co-pay and Quantity Limitations Michigan Department of Community Health Co-pay and Quantity Limitations Benefit Plan Co-pay Information Group ID Coverage Co-pay INCARCE Incarcerated Medicaid No coverage No coverage patients SHPDUAL CSHCSCAID

More information

Drugs That Require Step Therapy (ST) Step Therapy Medications

Drugs That Require Step Therapy (ST) Step Therapy Medications Drugs That Require Step Therapy (ST) In some cases, HealthNow New York Inc. requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.

More information

PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary October 1, 2018 Updates. Formulary. Alternatives

PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary October 1, 2018 Updates. Formulary. Alternatives PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select October 1, 2018 Updates Drug Name efavirenz 600mg (Brand = Sustiva ) trientine (Brand = Syprine ) hydrocortisone lot 0.1% (Brand = Locoid ) sumatriptan-naproxen

More information

Drugs That Require Step Therapy (ST)

Drugs That Require Step Therapy (ST) Saver Drugs That Require Step Therapy (ST) In some cases, Express Scripts Medicare (PDP) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that

More information

ANTIDEPRESSANTS. Details. Step Therapy 2017 Last Updated: 5/23/2017

ANTIDEPRESSANTS. Details. Step Therapy 2017 Last Updated: 5/23/2017 ANTIDEPRESSANTS 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

More information

ALZHEIMER'S DRUGS. Details. Step 2: Exelon Patch 13.3 mg/24 hour transdermal Exelon Patch 4.6 mg/24 hr transdermal

ALZHEIMER'S DRUGS. Details. Step 2: Exelon Patch 13.3 mg/24 hour transdermal Exelon Patch 4.6 mg/24 hr transdermal ALZHEIMER'S DRUGS Products Affected Step 1: donepezil 10 mg disintegrating tablet donepezil 10 mg tablet donepezil 23 mg tablet donepezil 5 mg disintegrating tablet donepezil 5 mg tablet galantamine 12

More information