CRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication.
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- Robyn Oliver
- 5 years ago
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1 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 SULFATE ER, DEXTROAMPHETAMINE-AMPHET ER, DEXTROAMPHETAMINE-AMPHETAMINE, METADATE ER, METHYLPHENIDATE ER, METHYLPHENIDATE 10 MG CHEW TAB, METHYLPHENIDATE 10 MG TABLET, METHYLPHENIDATE 10 MG/5 ML SOL, METHYLPHENIDATE 2.5 MG CHEW TB, METHYLPHENIDATE 20 MG TABLET, METHYLPHENIDATE 5 MG CHEW TAB, METHYLPHENIDATE 5 MG TABLET, METHYLPHENIDATE 5 MG/5 ML SOLN, METHYLPHENIDATE HCL CD, METHYLPHENIDATE HCL ER, METHYLPHENIDATE LA, METHYLPHENIDATE SR STRATTERA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication. PAGE 1 LAST UPDATED 12/2017
2 ALPHA GLUCOSIDASE INHIBITOR GLIMEPIRIDE, GLIMEPIRIDE, GLIPIZIDE 10 MG TABLET, GLIPIZIDE 5 MG TABLET, GLIPIZIDE 5 MG TABLET, GLIPIZIDE ER, GLIPIZIDE ER, GLIPIZIDE XL, GLIPIZIDE-METFORMIN, GLIPIZIDE- METFORMIN, GLYBURIDE 1.25 MG TABLET, GLYBURIDE 2.5 MG TABLET, GLYBURIDE 5 MG TABLET, GLYBURIDE 1.25 MG TABLET, GLYBURIDE 2.5 MG TABLET, GLYBURIDE 5 MG TABLET, GLYBURIDE MICRONIZED, GLYBURIDE-METFORMIN HCL, GLYBURIDE-METFORMIN HCL, METFORMIN HCL 1,000 MG TABLET, METFORMIN HCL 500 MG TABLET, METFORMIN HCL 850 MG TABLET, METFORMIN HCL 1,000 MG TABLET, METFORMIN HCL 500 MG TABLET, METFORMIN HCL 850 MG TABLET, METFORMIN HCL ER 500 MG OSM-TB, METFORMIN HCL ER 500 MG TABLET, METFORMIN HCL ER 750 MG TABLET, METFORMIN HCL ER 500 MG TABLET, METFORMIN HCL ER 750 MG TABLET, PIOGLITAZONE HCL, PIOGLITAZONE HCL, PIOGLITAZONE-GLIMEPIRIDE, PIOGLITAZONE-METFORMIN, PIOGLITAZONE-METFORMIN, REPAGLINIDE-METFORMIN HCL, TOLAZAMIDE, TOLBUTAMIDE GLYSET Patient needs to have a paid claim for generic formulary metformin or metformin combinations, generic sulfonylureas, or generic thiazolidinediones PAGE 2 LAST UPDATED 12/2017
3 ANTIDEPRESSANTS BUPROPION HCL 100 MG TABLET, BUPROPION HCL 75 MG TABLET, BUPROPION HCL SR, BUPROPION XL, CITALOPRAM HBR, DESVENLAFAXINE SUCCINATE ER, DULOXETINE HCL DR 20 MG CAP, DULOXETINE HCL DR 30 MG CAP, DULOXETINE HCL DR 40 MG CAP, DULOXETINE HCL DR 60 MG CAP, ESCITALOPRAM OXALATE, FLUOXETINE DR, FLUOXETINE 20 MG/5 ML SOLUTION, FLUOXETINE HCL 10 MG CAPSULE, FLUOXETINE HCL 10 MG TABLET, FLUOXETINE HCL 20 MG CAPSULE, FLUOXETINE HCL 20 MG TABLET, FLUOXETINE HCL 40 MG CAPSULE, FLUOXETINE HCL 60 MG TABLET, FLUVOXAMINE MALEATE, FLUVOXAMINE MALEATE ER, MIRTAZAPINE, PAROXETINE CR, PAROXETINE ER, PAROXETINE HCL, SERTRALINE 20 MG/ML ORAL CONC, SERTRALINE HCL 100 MG TABLET, SERTRALINE HCL 25 MG TABLET, SERTRALINE HCL 50 MG TABLET, VENLAFAXINE HCL, VENLAFAXINE HCL ER APLENZIN, DESVENLAFAXINE ER, DESVENLAFAXINE FUMARATE ER, EMSAM, FETZIMA, KHEDEZLA, PEXEVA Patient needs to have a paid claim for TWO of the following formulary products: bupropion, mirtazapine, generic SSRI, or generic SNRI. PAGE 3 LAST UPDATED 12/2017
4 ANTIGOUT ALLOPURINOL 100 MG TABLET, ALLOPURINOL 300 MG TABLET, ALLOPURINOL 100 MG TABLET, ALLOPURINOL 300 MG TABLET ULORIC Patient needs to have a paid claim for allopurinol PAGE 4 LAST UPDATED 12/2017
5 ATYPICAL ANTIPSYCHOTICS ARIPIPRAZOLE 10 MG TABLET, ARIPIPRAZOLE 15 MG TABLET, ARIPIPRAZOLE 2 MG TABLET, ARIPIPRAZOLE 20 MG TABLET, ARIPIPRAZOLE 30 MG TABLET, ARIPIPRAZOLE 5 MG TABLET, ARIPIPRAZOLE 10 MG TABLET, ARIPIPRAZOLE 15 MG TABLET, ARIPIPRAZOLE 2 MG TABLET, ARIPIPRAZOLE 20 MG TABLET, ARIPIPRAZOLE 30 MG TABLET, ARIPIPRAZOLE 5 MG TABLET, ARIPIPRAZOLE ODT, OLANZAPINE, OLANZAPINE 15 MG TABLET, OLANZAPINE 20 MG TABLET, OLANZAPINE ODT, PALIPERIDONE ER, PALIPERIDONE ER 3 MG TABLET, PALIPERIDONE ER 6 MG TABLET, QUETIAPINE FUMARATE, QUETIAPINE FUMARATE, RISPERIDONE, RISPERIDONE ODT, ZIPRASIDONE HCL, ZIPRASIDONE HCL FANAPT, SAPHRIS, VRAYLAR Patient needs to have a paid claim for two generic formulary atypical antipsychotic agents PAGE 5 LAST UPDATED 12/2017
6 BISPHOSPHONATES ALENDRONATE SODIUM, ALENDRONATE SODIUM 10 MG TAB, ALENDRONATE SODIUM 35 MG TAB, ALENDRONATE SODIUM 40 MG TAB, ALENDRONATE SODIUM 5 MG TABLET, ALENDRONATE SODIUM 70 MG TAB, IBANDRONATE SODIUM 150 MG TAB, IBANDRONATE SODIUM 150 MG TAB, RISEDRONATE SODIUM, RISEDRONATE SODIUM, RISEDRONATE SODIUM DR FOSAMAX PLUS D Patient needs to have a paid claim for one generic formulary oral bisphosphonate agent PAGE 6 LAST UPDATED 12/2017
7 DPP4 INHIBITORS GLIMEPIRIDE, GLIPIZIDE 10 MG TABLET, GLIPIZIDE 5 MG TABLET, GLIPIZIDE ER, GLIPIZIDE XL, GLIPIZIDE-METFORMIN, GLYBURIDE 1.25 MG TABLET, GLYBURIDE 2.5 MG TABLET, GLYBURIDE 5 MG TABLET, GLYBURIDE MICRONIZED, GLYBURIDE-METFORMIN HCL, METFORMIN HCL 1,000 MG TABLET, METFORMIN HCL 500 MG TABLET, METFORMIN HCL 850 MG TABLET, METFORMIN ER 1,000 MG OSM-TAB, METFORMIN HCL ER 500 MG TABLET, METFORMIN HCL ER 750 MG TABLET, PIOGLITAZONE HCL, PIOGLITAZONE-GLIMEPIRIDE, PIOGLITAZONE-METFORMIN, REPAGLINIDE-METFORMIN HCL, TOLAZAMIDE, TOLBUTAMIDE JANUMET, JANUMET XR, JANUVIA, JENTADUETO, JENTADUETO XR, KOMBIGLYZE XR, ONGLYZA, TRADJENTA Trial of one generic metformin containing products, generic sulfonylureas, or generic thiazolidinediones PAGE 7 LAST UPDATED 12/2017
8 EPINEPHRINE EPIPEN 2-PAK, EPIPEN JR 2-PAK ADRENACLICK History of trial and failure, or intolerance to one of the following: EpiPen or EpiPen Jr or epinephrine (generic EpiPen or EpiPen Jr) PAGE 8 LAST UPDATED 12/2017
9 GLP1 AGONIST GLIMEPIRIDE, GLIMEPIRIDE, GLIPIZIDE 10 MG TABLET, GLIPIZIDE 5 MG TABLET, GLIPIZIDE 5 MG TABLET, GLIPIZIDE ER, GLIPIZIDE ER, GLIPIZIDE XL, GLIPIZIDE-METFORMIN, GLIPIZIDE- METFORMIN, GLYBURIDE 1.25 MG TABLET, GLYBURIDE 2.5 MG TABLET, GLYBURIDE 5 MG TABLET, GLYBURIDE 1.25 MG TABLET, GLYBURIDE 2.5 MG TABLET, GLYBURIDE 5 MG TABLET, GLYBURIDE MICRONIZED, GLYBURIDE-METFORMIN HCL, GLYBURIDE-METFORMIN HCL, METFORMIN HCL 1,000 MG TABLET, METFORMIN HCL 500 MG TABLET, METFORMIN HCL 850 MG TABLET, METFORMIN HCL 1,000 MG TABLET, METFORMIN HCL 500 MG TABLET, METFORMIN HCL 850 MG TABLET, METFORMIN ER 1,000 MG OSM-TAB, METFORMIN HCL ER 500 MG OSM-TB, METFORMIN HCL ER 500 MG TABLET, METFORMIN HCL ER 750 MG TABLET, METFORMIN ER 1,000 MG OSM-TAB, METFORMIN HCL ER 500 MG TABLET, METFORMIN HCL ER 750 MG TABLET, PIOGLITAZONE HCL, PIOGLITAZONE HCL, PIOGLITAZONE-GLIMEPIRIDE, PIOGLITAZONE-METFORMIN, PIOGLITAZONE-METFORMIN, REPAGLINIDE-METFORMIN HCL, TOLAZAMIDE, TOLBUTAMIDE BYDUREON, BYDUREON PEN, BYETTA, TRULICITY, VICTOZA 2-PAK, VICTOZA 3-PAK Patient needs to have a paid claim for generic formulary metformin or metformin combinations, generic sulfonylureas, or generic thiazolidinediones PAGE 9 LAST UPDATED 12/2017
10 LAMA SPIRIVA, SPIRIVA RESPIMAT TUDORZA PRESSAIR Patient needs to have a paid claim for Spiriva PAGE 10 LAST UPDATED 12/2017
11 LEUKOTRIENE MODIFIERS MONTELUKAST SOD 10 MG TABLET, MONTELUKAST SOD 4 MG GRANULES, MONTELUKAST SOD 4 MG TAB CHEW, MONTELUKAST SOD 5 MG TAB CHEW, ZAFIRLUKAST ZILEUTON ER, ZYFLO, ZYFLO CR Trial of generic montelukast or generic zafirlukast. PAGE 11 LAST UPDATED 12/2017
12 NASONEX BRAND BUDESONIDE 32 MCG NASAL SPRAY, FLUNISOLIDE 0.025% SPRAY, FLUTICASONE PROP 50 MCG SPRAY, MOMETASONE FUROATE 50 MCG SPRY, TRIAMCINOLONE 55 MCG NASAL SPR NASONEX Patient needs to have a paid claim for any one generic intranasal corticosteroid PAGE 12 LAST UPDATED 12/2017
13 PD AGENTS PRAMIPEXOLE DIHYDROCHLORIDE, PRAMIPEXOLE ER, ROPINIROLE ER, ROPINIROLE HCL NEUPRO Patient needs to have a paid claim for one generic formulary dopamine agonist agent PAGE 13 LAST UPDATED 12/2017
14 SGLT2 GLIMEPIRIDE, GLIPIZIDE 10 MG TABLET, GLIPIZIDE 5 MG TABLET, GLIPIZIDE ER, GLIPIZIDE XL, GLIPIZIDE-METFORMIN, GLYBURIDE 1.25 MG TABLET, GLYBURIDE 2.5 MG TABLET, GLYBURIDE 5 MG TABLET, GLYBURIDE MICRONIZED, GLYBURIDE-METFORMIN HCL, METFORMIN HCL 1,000 MG TABLET, METFORMIN HCL 500 MG TABLET, METFORMIN HCL 850 MG TABLET, METFORMIN ER 1,000 MG OSM-TAB, METFORMIN HCL ER 500 MG TABLET, METFORMIN HCL ER 750 MG TABLET, PIOGLITAZONE HCL, PIOGLITAZONE-GLIMEPIRIDE, PIOGLITAZONE-METFORMIN, REPAGLINIDE-METFORMIN HCL, TOLAZAMIDE, TOLBUTAMIDE INVOKAMET, INVOKAMET XR, INVOKANA, JARDIANCE, SYNJARDY Paid claim for generic formulary metformin or metformin combinations, generic sulfonylureas, or generic thiazolidinediones. Jardiance, Synjardy only: ST does not apply for patients with CV disease, defined as one of the following: h/o MI, multi-vessel CAD, left main CAD, h/o stroke, Occlusive PAD, single-vessel CAD with documentation of unstable angina or a positive stress test for ischemia. PAGE 14 LAST UPDATED 12/2017
15 STATINS ATORVASTATIN CALCIUM, FLUVASTATIN ER, FLUVASTATIN SODIUM, LOVASTATIN, PRAVASTATIN SODIUM, SIMVASTATIN ALTOPREV, LIVALO Livalo: Trial of one generic formulary HMG-CoA reductase inhibitor (statin). Altoprev: Trial of two generic formulary HMG-CoA reductase inhibitors (statin). PAGE 15 LAST UPDATED 12/2017
16 ZURAMPIC ULORIC ZURAMPIC History of trial and failure, or intolerance to Uloric PAGE 16 LAST UPDATED 12/2017
17 PAGE 17 LAST UPDATED 12/2017
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
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ALBUTEROL - SCORE{XE "ALBUTEROL - SCORE"}
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Y0133_StepTherapyCriteria _C 10/18/18 Y0133_StepTherapyCriteria _C es 10/18/18
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