Step Therapy Requirements

Transcription

1 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

2 ABILIFY Abilify 10 mg tablet Abilify 15 mg tablet Abilify 2 mg tablet Abilify 20 mg tablet Abilify 30 mg tablet Abilify 5 mg tablet DRUG(S): ARIPIPRAZOLE. STEP 2 DRUG(S): ABILIFY 2

3 ACTONEL Actonel 150 mg tablet Actonel 30 mg tablet Actonel 35 mg tablet Actonel 5 mg tablet DRUG(S): RISEDRONATE. STEP 2 DRUG(S): ACTONEL Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/2014 3

4 AVODART Avodart 0.5 mg capsule DRUG(S): DUTASTERIDE. STEP 2 DRUG(S): AVODART 4

5 BETA-BLOCKERS Bystolic 10 mg tablet Bystolic 2.5 mg tablet Bystolic 20 mg tablet Bystolic 5 mg tablet DRUG(S): ACEBUTOLOL HCL, ATENOLOL, ATENOLOL- CHLORTHALIDONE, BETAXOLOL HCL, BISOPROLOL FUMARATE, BISOPROLOL-HYDROCHLOROTHIAZIDE, CARVEDILOL, LABETALOL HCL, METOPROLOL SUCCINATE, METOPROLOL TARTRATE, METOPROLOL- HYDROCHLOROTHIAZIDE, NADOLOL, NADOLOL- BENDROFLUMETHIAZIDE, PINDOLOL, PROPRANOLOL HCL, PROPRANOLOL-HYDROCHLOROTHIAZIDE, TIMOLOL MALEATE. STEP 2 DRUG(S): BYSTOLIC Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/2014 5

6 BILE ACID SEQUESTRANTS WelChol 3.75 gram oral powder packet WelChol 625 mg tablet DRUG(S): CHOLESTYRAMINE LIGHT, COLESTIPOL HCL, PREVALITE. STEP 2 DRUG(S): WELCHOL. AUTHORIZATION MAY BE GIVEN FOR WELCHOL IF PATIENTS HAVE A DRUG- DRUG INTERACTION WITH CHOLESTYRAMINE OR COLESTIPOL. AUTHORIZATION MAY BE GIVEN FOR WELCHOL IN PATIENTS WHO ARE PREGNANT. AUTHORIZATION MAY BE GIVEN FOR WELCHOL IN PATIENTS WITH TYPE 2 DIABETES WHO ARE ALSO USING OTHER ANTIDIABETIC AGENTS (EG, INSULIN, METFORMIN, SULFONYLUREA). AUTHORIZATION MAY BE GIVEN FOR WELCHOL IN PATIENTS LESS THAN 18 YEARS OF AGE. 6

7 BONIVA Boniva 150 mg tablet DRUG(S): IBANDRONATE. STEP 2 DRUG(S): BONIVA Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/2014 7

8 DPP4 Janumet 50 mg-1,000 mg tablet Janumet 50 mg-500 mg tablet Janumet XR 100 mg-1,000 mg tablet,extended release Janumet XR 50 mg-1,000 mg tablet,extended release Janumet XR 50 mg-500 mg tablet,extended release Januvia 100 mg tablet Januvia 25 mg tablet Januvia 50 mg tablet Kombiglyze XR 2.5 mg-1,000 mg tablet,extended release Kombiglyze XR 5 mg-1,000 mg tablet,extended release Kombiglyze XR 5 mg-500 mg tablet,extended release Onglyza 2.5 mg tablet Onglyza 5 mg tablet Tradjenta 5 mg tablet DRUG(S): NESINA, KAZANO. STEP 2 DRUG(S): ONGLYZA, JANUVIA, TRADJENTA, JANUMET, JANUMET XR, KOMBIGLYZE 8

9 ENABLEX Enablex 15 mg tablet,extended release Enablex 7.5 mg tablet,extended release DRUG(S): DARIFENACIN ER. STEP 2 DRUG(S): ENABLEX Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/2014 9

10 ENHANCED OVERACTIVE BLADDER Enablex 15 mg tablet,extended release Enablex 7.5 mg tablet,extended release Vesicare 10 mg tablet Vesicare 5 mg tablet DRUG(S): OXYBUTYNIN CHLORIDE, OXYBUTYNIN CHLORIDE ER, TROSPIUM, TROSPIUM ER, TOLTERODINE, TOLTERODINE ER, DARIFENACIN. STEP 2 DRUG(S): VESICARE, ENABLEX 10

11 EVOXAC Evoxac 30 mg capsule DRUG(S): CEVIMELINE. STEP 2 DRUG(S): EVOXAC. Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/

12 EXFORGE Exforge 10 mg-160 mg tablet Exforge 10 mg-320 mg tablet Exforge 5 mg-160 mg tablet Exforge 5 mg-320 mg tablet Exforge HCT 10 mg-160 mg-12.5 mg tablet Exforge HCT 10 mg-160 mg-25 mg tablet Exforge HCT 10 mg-320 mg-25 mg tablet Exforge HCT 5 mg-160 mg-12.5 mg tablet Exforge HCT 5 mg-160 mg-25 mg tablet DRUG(S): AMLODIPINE VALSARTAN, AMLODIPINE VALSARTAN HCTZ. STEP 2 DRUG(S): EXFORGE 12

13 LAMICTAL Lamictal XR 100 mg tablet,extended release Lamictal XR 200 mg tablet,extended release Lamictal XR 25 mg tablet,extended release Lamictal XR 250 mg tablet,extended release Lamictal XR 300 mg tablet,extended release Lamictal XR 50 mg tablet,extended release DRUG(S): LAMOTRIGINE, LAMOTRIGINE XR. STEP 2 DRUG(S): LAMICTAL XR. AUTHORIZATION MAY BE GIVEN FOR A STEP 2 DRUG IF THE PATIENT IS CURRENTLY TAKING THE REQUESTED AGENT. AUTHORIZATION MAY BE GIVEN FOR LAMICTAL XR IF THE PATIENT HAS TAKEN IT AT ANY TIME IN THE PAST. THIS STEP THERAPY PROGRAM APPLIES TO NEW UTILIZERS ONLY. Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/

14 LAMISIL Lamisil 250 mg tablet DRUG(S): TERBINAFINE. STEP 2 DRUG(S): LAMISIL. 14

15 LEVEMIR Levemir 100 unit/ml subcutaneous solution Levemir FlexTouch 100 unit/ml (3 ml) subcutaneous insulin pen DRUGS: LANTUS, TOUJEO. STEP 2 DRUGS: LEVEMIR Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/

16 LIDODERM Lidoderm 5 % topical patch DRUG(S): LIDOCAINE 5% PATCH. STEP 2 DRUG(S): LIDODERM 16

17 LUMIGAN Lumigan 0.01 % eye drops DRUG(S): BIMATOPROST 0.03%, TRAVOPROST, LATANOPROST. STEP 2 DRUG(S): LUMIGAN Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/

18 METFORMIN Riomet 500 mg/5 ml oral solution DRUG(S): METFORMIN HCL, METFORMIN HCL ER. STEP 2 DRUG(S): RIOMET. PARTICIPANT MUST HAVE 30 DAYS OF GENERIC METFORMIN OR GENERIC METFORMIN ER IN CLAIMS HISTORY. AUTHORIZATION MAY BE GIVEN FOR RIOMET PATIENTS WHO ARE UNABLE TO SWALLOW OR HAVE DIFFICULTY SWALLOWING TABLETS CONTAINING METFORMIN. 18

19 MIRAPEX/REQUIP Mirapex ER 2.25 mg tablet,extended release Mirapex ER 3.75 mg tablet,extended release DRUG(S): PRAMIPEXOLE IR, PRAMIPEXOLE ER, ROPINIROLE HCL. STEP 2 DRUG(S): MIRAPEX ER. Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/

20 MYRBETRIQ Myrbetriq 25 mg tablet,extended release Myrbetriq 50 mg tablet,extended release DRUG(S): ENABLEX, VESICARE. STEP 2 DRUG(S):MYRBETRIQ 20

21 NAMENDA XR Namenda XR 14 mg capsule sprinkle,extended release Namenda XR 21 mg capsule sprinkle,extended release Namenda XR 28 mg capsule sprinkle,extended release Namenda XR 7 mg capsule sprinkle,extended release Namenda XR 7 mg-14 mg-21 mg-28 mg capsule,sprinkle,er 24hr,dose pack DRUG(S): MEMANTINE. STEP 2 DRUG(S): NAMENDA XR Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/

22 NAMZARIC Namzaric 14 mg-10 mg capsule sprinkle,extended release Namzaric 21 mg-10 mg capsule sprinkle,extended release Namzaric 28 mg-10 mg capsule sprinkle,extended release Namzaric 7 mg-10 mg capsule sprinkle,extended release Namzaric 7/14/21/28 mg-10 mg capsule,sprinkle,er 24hr,dose pack DRUG(S): MEMANTINE SOLUTION, MEMANTINE TABLETS. STEP 2 DRUG(S): NAMZARIC. 22

23 PATANOL Patanol 0.1 % eye drops DRUG(S): OLOPATADINE. STEP 2 DRUG(S): PATANOL. Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/

24 PPI ENHANCED Dexilant 30 mg capsule, delayed release Dexilant 60 mg capsule, delayed release DRUG(S): GENERIC PROTON PUMP INHIBITORS. STEP 2 DRUG(S): DEXILANT. AUTHORIZATION MAY BE GIVEN FOR A STEP 2 AGENT FOR PATIENTS CONCOMITANTLY RECEIVING CLOPIDOGREL WHO HAVE TRIED A STEP 1 AGENT. 24

25 PREFERRED INSULIN Humalog 100 unit/ml subcutaneous cartridge Humalog 100 unit/ml subcutaneous solution Humalog KwikPen 100 unit/ml subcutaneous Humalog KwikPen 200 unit/ml (3 ml) subcutaneous Humalog Mix unit/ml subcutaneous suspension Humalog Mix KwikPen 100 unit/ml subcutaneous pen Humalog Mix unit/ml subcutaneous suspension Humalog Mix KwikPen 100 unit/ml subcutaneous insulin pen Humulin 70/ unit/ml subcutaneous suspension Humulin N 100 unit/ml subcutaneous suspension Humulin R U unit/ml injection solution Humulin R U-500 (Concentrated) Insulin 500 unit/ml subcutaneous soln DRUGS: NOVOLIN INSULINS, NOVOLOG INSULINS OR LEVEMIR. STEP 2 DRUGS: HUMULIN INSULINS OR HUMALOG INSULINS. Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/

26 PREVPAC Prevpac 500 mg-500 mg-30 mg oral pack DRUG(S): LANSOPRAZOLE AMOXICILLIN CLARITHROMYCIN. STEP 2 DRUG(S): PREVPAC 26

27 SYMBICORT Symbicort 160 mcg-4.5 mcg/actuation HFA aerosol inhaler Symbicort 80 mcg-4.5 mcg/actuation HFA aerosol inhaler DRUG(S): ADVAIR. STEP 2 DRUG(S): SYMBICORT Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/

28 TETRACYCLINES (ORAL) Solodyn 105 mg tablet,extended release Solodyn 115 mg tablet,extended release Solodyn 55 mg tablet,extended release Solodyn 65 mg tablet,extended release Solodyn 80 mg tablet,extended release Vibramycin 50 mg/5 ml syrup DRUG(S): DEMECLOCYCLINE HCL, DOXYCYCLINE, DOXYCYCLINE HYCLATE, DOXYCYCLINE MONOHYDRATE, MINOCYCLINE HCL, TETRACYCLINE HCL STEP 2 DRUG(S): SOLODYN AND VIBRAMYCIN SYRUP. AUTHORIZATION MAY BE GIVEN FOR A STEP 2 AGENT IF THE PATIENT HAS TRIED A GENERIC ORAL TETRACYCLINE-TYPE PRODUCT (DEMECLOCYCLINE, DOXYCYCLINE, MINOCYCLINE, TETRACYCLINE). 28

29 TOPICAL STEROIDS clobetasol 0.05 % lotion clobetasol 0.05 % topical cream clobetasol 0.05 % topical gel clobetasol 0.05 % topical ointment clobetasol-emollient 0.05 % topical cream desonide 0.05 % lotion desonide 0.05 % topical cream desonide 0.05 % topical ointment hydrocortisone valerate 0.2 % topical cream hydrocortisone valerate 0.2 % topical ointment DRUG(S): FLUOCINOLONE ACETONIDE, BETAMETHASONE DIPROPIONATE, MOMETASONE FUROATE, STEP 2 DRUG(S): DESONIDE, HYDROCORTISONE VALERATE, CLOBETASOL PROPIONATE Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/

30 TRAVATAN Z Travatan Z % eye drops DRUG(S): LATANOPROST. STEP 2 DRUG(S): TRAVATAN Z. 30

31 ULORIC Uloric 40 mg tablet Uloric 80 mg tablet DRUG(S): ALLOPURINOL. STEP 2 DRUG(S): ULORIC. AUTHORIZATION MAY BE GIVEN FOR ULORIC IF THE PATIENT HAS TRIED ALLOPURINOL (BRAND OR GENERIC) AT ANY TIME IN THE PAST. AUTHORIZATION MAY BE GIVEN FOR ULORIC IF THE PATIENT HAS RENAL INSUFFICIENCY OR DECREASED RENAL FUNCTION. AUTHORIZATION MAY BE GIVEN FOR ULORIC IF THE PATIENT IS RECEIVING CONCOMITANT MEDICATIONS THAT HAVE SIGNIFICANT DRUG-DRUG INTERACTIONS WITH ALLOPURINOL, WHICH ARE NOT NOTED WITH ULORIC (EG, CYCLOSPORINE, CHLORPROPAMIDE). Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/

32 XIIDRA Xiidra 5 % eye drops in a dropperette DRUG(S): CYCLOSPORINE OPTHALMIC. STEP 2 DRUG(S): XIIDRA 32

33 ZOMIG Zomig 2.5 mg nasal spray Zomig 2.5 mg tablet Zomig 5 mg nasal spray Zomig 5 mg tablet Zomig ZMT 2.5 mg disintegrating tablet Zomig ZMT 5 mg disintegrating tablet DRUG(S): ZOLMITRIPTAN. STEP 2 DRUG(S): ZOMIG, ZOMIG ZMT Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/

34 ZYVOX Zyvox 100 mg/5 ml oral suspension Zyvox 600 mg tablet DRUG(S): LINEZOLDI. STEP 2 DRUG(S): ZYVOX. 34

35 INDEX A Abilify 10 mg tablet... 1 Abilify 15 mg tablet... 1 Abilify 2 mg tablet... 1 Abilify 20 mg tablet... 1 Abilify 30 mg tablet... 1 Abilify 5 mg tablet... 1 Actonel 150 mg tablet... 2 Actonel 30 mg tablet... 2 Actonel 35 mg tablet... 2 Actonel 5 mg tablet... 2 Avodart 0.5 mg capsule... 3 B Boniva 150 mg tablet... 6 Bystolic 10 mg tablet... 4 Bystolic 2.5 mg tablet... 4 Bystolic 20 mg tablet... 4 Bystolic 5 mg tablet... 4 C clobetasol 0.05 % lotion clobetasol 0.05 % topical cream clobetasol 0.05 % topical gel clobetasol 0.05 % topical ointment clobetasol-emollient 0.05 % topical cream 28 D desonide 0.05 % lotion desonide 0.05 % topical cream desonide 0.05 % topical ointment Dexilant 30 mg capsule, delayed release.. 23 Dexilant 60 mg capsule, delayed release.. 23 E Enablex 15 mg tablet,extended release... 8, 9 Enablex 7.5 mg tablet,extended release.. 8, 9 Evoxac 30 mg capsule Exforge 10 mg-160 mg tablet Exforge 10 mg-320 mg tablet Exforge 5 mg-160 mg tablet Exforge 5 mg-320 mg tablet Exforge HCT 10 mg-160 mg-12.5 mg tablet Exforge HCT 10 mg-160 mg-25 mg tablet 11 Exforge HCT 10 mg-320 mg-25 mg tablet 11 Exforge HCT 5 mg-160 mg-12.5 mg tablet Exforge HCT 5 mg-160 mg-25 mg tablet. 11 H Humalog 100 unit/ml subcutaneous cartridge Humalog 100 unit/ml subcutaneous solution Humalog KwikPen 100 unit/ml subcutaneous Humalog KwikPen 200 unit/ml (3 ml) subcutaneous Humalog Mix unit/ml subcutaneous suspension Humalog Mix KwikPen 100 unit/ml subcutaneous pen Humalog Mix unit/ml subcutaneous suspension Humalog Mix KwikPen 100 unit/ml subcutaneous insulin pen Humulin 70/ unit/ml subcutaneous suspension Humulin N 100 unit/ml subcutaneous suspension Humulin R U unit/ml injection solution Humulin R U-500 (Concentrated) Insulin 500 unit/ml subcutaneous soln hydrocortisone valerate 0.2 % topical cream hydrocortisone valerate 0.2 % topical ointment J Janumet 50 mg-1,000 mg tablet... 7 Janumet 50 mg-500 mg tablet... 7 Janumet XR 100 mg-1,000 mg tablet,extended release... 7 Janumet XR 50 mg-1,000 mg tablet,extended release... 7 Janumet XR 50 mg-500 mg tablet,extended release... 7 Januvia 100 mg tablet... 7 Januvia 25 mg tablet... 7 Januvia 50 mg tablet

36 K Kombiglyze XR 2.5 mg-1,000 mg tablet,extended release... 7 Kombiglyze XR 5 mg-1,000 mg tablet,extended release... 7 Kombiglyze XR 5 mg-500 mg tablet,extended release... 7 L Lamictal XR 100 mg tablet,extended release Lamictal XR 200 mg tablet,extended release Lamictal XR 25 mg tablet,extended release Lamictal XR 250 mg tablet,extended release Lamictal XR 300 mg tablet,extended release Lamictal XR 50 mg tablet,extended release Lamisil 250 mg tablet Levemir 100 unit/ml subcutaneous solution Levemir FlexTouch 100 unit/ml (3 ml) subcutaneous insulin pen Lidoderm 5 % topical patch Lumigan 0.01 % eye drops M Mirapex ER 2.25 mg tablet,extended release Mirapex ER 3.75 mg tablet,extended release Myrbetriq 25 mg tablet,extended release.. 19 Myrbetriq 50 mg tablet,extended release.. 19 N Namenda XR 14 mg capsule sprinkle,extended release Namenda XR 21 mg capsule sprinkle,extended release Namenda XR 28 mg capsule sprinkle,extended release Namenda XR 7 mg capsule sprinkle,extended release Namenda XR 7 mg-14 mg-21 mg-28 mg capsule,sprinkle,er 24hr,dose pack Namzaric 14 mg-10 mg capsule sprinkle,extended release Namzaric 21 mg-10 mg capsule sprinkle,extended release Namzaric 28 mg-10 mg capsule sprinkle,extended release Namzaric 7 mg-10 mg capsule sprinkle,extended release Namzaric 7/14/21/28 mg-10 mg capsule,sprinkle,er 24hr,dose pack O Onglyza 2.5 mg tablet... 7 Onglyza 5 mg tablet... 7 P Patanol 0.1 % eye drops Prevpac 500 mg-500 mg-30 mg oral pack 25 R Riomet 500 mg/5 ml oral solution S Solodyn 105 mg tablet,extended release Solodyn 115 mg tablet,extended release Solodyn 55 mg tablet,extended release Solodyn 65 mg tablet,extended release Solodyn 80 mg tablet,extended release Symbicort 160 mcg-4.5 mcg/actuation HFA aerosol inhaler Symbicort 80 mcg-4.5 mcg/actuation HFA aerosol inhaler T Tradjenta 5 mg tablet... 7 Travatan Z % eye drops U Uloric 40 mg tablet Uloric 80 mg tablet V Vesicare 10 mg tablet... 9 Vesicare 5 mg tablet... 9 Vibramycin 50 mg/5 ml syrup W WelChol 3.75 gram oral powder packet... 5 WelChol 625 mg tablet... 5 X Xiidra 5 % eye drops in a dropperette Z Zomig 2.5 mg nasal spray Zomig 2.5 mg tablet

37 Zomig 5 mg nasal spray Zomig 5 mg tablet Zomig ZMT 2.5 mg disintegrating tablet. 32 Zomig ZMT 5 mg disintegrating tablet Zyvox 100 mg/5 ml oral suspension Zyvox 600 mg tablet