WELLCARE/ OHANA HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 08/2015)

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1 WELLCARE/ OHANA HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 08/2015) **To get updated information about the drugs covered by WellCare/ Ohana, please visit our website ( / / or call Customer Service. Our phone number is available on our Contact Us page.

2 ANTI-ANXIETY AGENTS Meprobamate Tablet 200 MG Meprobamate Tablet 400 MG Trial of at least 30 days of two generic alternatives including venlafaxine er, duloxetine, buspirone, or brand or generic paroxetine within the past 100 days. Updated 10/2014

3 ANTIDEPRESSANT AGENTS Viibryd Kit 10 & 20 & 40 MG Viibryd Tablet 10 MG Viibryd Tablet 20 MG Viibryd Tablet 40 MG Trial of at least 30 days of two generic alternatives including duloxetine, citalopram, escitalopram, paroxetine, fluoxetine, sertraline, bupropion, and venlafaxine er capsules within the past 100 days. Updated 04/2015

4 ANTI-INFECTIVE AGENTS Xifaxan Tablet 200 MG Xifaxan Tablet 550 MG Trial of at least 30 days of generic lactulose or at least 6 days of generic neomycin or oral metronidazole within the past 100 days for hepatic encephalopathy. Trial of at least 2 days of generic loperamide, or oral sulfamethoxazole/trimethoprim within the past 100 days for traveler's diarrhea. Updated 11/2014

5 ATYPICAL ANTIPSYCHOTICS Saphris Tablet Sublingual 10 MG Sublingual Saphris Tablet Sublingual 2.5 MG Sublingual Saphris Tablet Sublingual 5 MG Sublingual Trial of at least 30 days of generic risperidone, olanzapine, quetiapine, or ziprasidone within the past 100 days. Updated 08/2015

6 DIABETES AGENTS Glyburide Micronized Tablet 1.5 MG Glyburide Micronized Tablet 3 MG Glyburide Micronized Tablet 6 MG Glyburide Tablet 1.25 MG Glyburide Tablet 2.5 MG Glyburide Tablet 5 MG Glyburide-Metformin Tablet MG Glyburide-Metformin Tablet MG Glyburide-Metformin Tablet MG Trial of at least 30 days of two generic alternatives including glipizide and glimepiride within the past 100 days. Updated 09/2014

7 DOPAMINE AGONIST AGENTS Neupro Patch 24 HR 1 MG/24HR Transdermal Neupro Patch 24 HR 2 MG/24HR Transdermal Neupro Patch 24 HR 3 MG/24HR Transdermal Neupro Patch 24 HR 4 MG/24HR Transdermal Neupro Patch 24 HR 6 MG/24HR Transdermal Neupro Patch 24 HR 8 MG/24HR Transdermal Trial of at least 30 days of both generic immediate release pramipexole and immediate release ropinirole within the past 100 days. Updated 09/2014

8 GOUT AGENTS Uloric Tablet 40 MG Uloric Tablet 80 MG Trial of at least 30 days of generic allopurinol within the past 100 days. Updated 09/2014

9 MUSCLE RELAXANT AGENTS Carisoprodol Tablet 350 MG Cyclobenzaprine HCl Tablet 10 MG Cyclobenzaprine HCl Tablet 5 MG Methocarbamol Tablet 500 MG Methocarbamol Tablet 750 MG Trial of at least 30 days of two generic alternative including baclofen and tizanidine tablets within the past 100 days. Updated 03/2015

10 NSAID AGENTS Indomethacin Capsule 25 MG Indomethacin Capsule 50 MG Trial of at least 30 days of two generic alternatives including diclofenac, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, ketoprofen, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, or sulindac within the past 100 days. Updated 09/2014

11 OSTEOPOROSIS AGENTS Prolia Solution 60 MG/ML Subcutaneous Trial of at least 30 days of oral alendronate, ibandronate, raloxifene, Premarin, Prempro, estradiol, Jinteli, or zoledronic acid 5mg/100ml within the past 365 days. Approve for use to increase bone mass in men receiving androgren deprivation therapy for nonmetastatic prostate cancer and in women receiving aromatase inhibitor therapy for breast cancer. Updated 09/2014

12 POSTHERPETIC NEURALGIA AGENTS Gralise Starter 300 & 600 MG Gralise Tablet 300 MG Gralise Tablet 600 MG Trial of at least 30 days of gabapentin or Lyrica within the past 100 days. Updated 09/2014

13 SGLT2 INHIBITOR AGENTS Invokamet Tablet MG Invokamet Tablet MG Invokamet Tablet MG Invokamet Tablet MG Invokana Tablet 100 MG Invokana Tablet 300 MG Jardiance Tablet 10 MG Jardiance Tablet 25 MG Trial of at least 30 days of metformin or riomet within the past 100 days. Updated 04/2015

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