Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18
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1 Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18 Granite Alliance requires step therapy for certain drugs. This means prior to receiving a drug with a step therapy restriction, a similar drug must be tried first. This document contains a list of the drugs that require step therapy and their covered alternatives. Step therapy criteria is based on current medical and prescribing practices, and the clinical recommendations of the physicians and pharmacists on the Granite Alliance Pharmacy and Therapeutics Committee. If you have any questions please contact us, Granite Alliance, at (TTY users call 711), or visit We are available 24 hours a day, seven days a week. Our preferred hours are Monday through Friday 7 a.m. to 7 p.m., Mountain Time. Formulary ID: Version: 14 Granite Alliance Insurance Company is a Medicare-approved Prescription Drug Plan. S3875_FORM18_410L
2 APTIOM APTIOM STEP 1: Patient has a history of filling a 60 day supply of: 2 generic adjunctive AEDs (lamotrigine, topiramate, oxcarbazepine, levetiracetam, zonisamide, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Aptiom. PAGE 2 LAST UPDATED 11/2018
3 ATYPICAL ANTIPSYCHOTICS FANAPT, INVEGA SUSTENNA, LATUDA 120 MG TABLET, LATUDA 20 MG TABLET, LATUDA 40 MG TABLET, LATUDA 80 MG TABLET, REXULTI, SAPHRIS, VRAYLAR STEP 1: Patient has a history of filling a 30 day supply of: aripiprazole, risperidone, olanzapine, olanzapine/fluoxetine quetiapine, or ziprasidone within the last 180 days. STEP 2: Once Step one is met the patient may fill Fanapt, Latuda, Invega, Rexulti, Vraylar or Saphris. PAGE 3 LAST UPDATED 11/2018
4 AUBAGIO AUBAGIO STEP 1: Patient has a history of filling a 30 day supply of one of the following within the past 180 days: peginterferon beta-1a (Plegridy), interferon beta-1a (Avonex), dimethyl fumarate (Tecfidera) or glatiramer (Copaxone). STEP 2: Once step one is met the patient may fill Aubagio. PAGE 4 LAST UPDATED 11/2018
5 BRIVIACT BRIVIACT STEP 1: Patient has a history of filling a 30 day supply of: 2 generic adjunctive AEDs (lamotrigine, topiramate, oxcarbazepine, levetiracetam, zonisamide, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Briviact. PAGE 5 LAST UPDATED 11/2018
6 CHENODAL CHENODAL STEP 1: Patient has a history of filling a 30 day supply of: generic ursodial within the past 180 days. STEP 2: Once step one is met the member may fill Chenodal. PAGE 6 LAST UPDATED 11/2018
7 CIMZIA CIMZIA 200 MG VIAL KIT, CIMZIA 200 MG/ML SYRINGE KIT STEP 1: Patient has a history of filling a 30 day supply of: Humira (adalimumab) or Enbrel (etanercept) within the past 180 days. STEP 2: Once step one is met the patient may fill Cimzia. PAGE 7 LAST UPDATED 11/2018
8 CORLANOR CORLANOR Step 1: Patient has a history of filling a 30 day supply of generic carvedilol, metoprolol succinate, or bisoprolol. Step 2: Once Step One has been met the patient may fill Corlanor. PAGE 8 LAST UPDATED 11/2018
9 COSENTYX COSENTYX (2 SYRINGES), COSENTYX PEN, COSENTYX PEN (2 PENS), COSENTYX SYRINGE STEP 1: Patient has a history of filling a 30 day supply of: Humira (adalimumab) or Enbrel (etanercept) within the past 180 days. STEP 2: Once step one is met the patient may fill Cosentyx. PAGE 9 LAST UPDATED 11/2018
10 DALIRESP DALIRESP STEP 1: Patient has a history of filling a 30 day supply of: 2 agents used in the treatment of COPD (Serevent, Advair, Symbicort, Spiriva, Anoro Ellipta, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Daliresp. PAGE 10 LAST UPDATED 11/2018
11 ELIDEL ELIDEL STEP 1: Patient has a history of filling a 30 day supply of: 2 generic topical steroids (clobetasol, betamethasone, mometasone, hydrocortisone, triamcinolone, nystatin/triamcinolone, betamethasone/clotrimazole) within the past 180 days. STEP 2: Once step one is met the patient may fill Elidel. PAGE 11 LAST UPDATED 11/2018
12 EMSAM EMSAM STEP 1: Patient has a history of filling a 60 day supply of: 2 generic antidepressants (such as citalopram, venlafaxine, bupropion, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Emsam. PAGE 12 LAST UPDATED 11/2018
13 FETZIMA FETZIMA STEP 1: Patient has a history of filling a 60 day supply of: 2 generic antidepressants (such as citalopram, venlafaxine, bupropion, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Fetzima. PAGE 13 LAST UPDATED 11/2018
14 FYCOMPA FYCOMPA 0.5 MG/ML ORAL SUSP, FYCOMPA 10 MG TABLET, FYCOMPA 12 MG TABLET, FYCOMPA 2 MG TABLET, FYCOMPA 4 MG TABLET, FYCOMPA 6 MG TABLET, FYCOMPA 8 MG TABLET STEP 1: Patient has a history of filling a 30 day supply of: 2 generic adjunctive AEDs (lamotrigine, topiramate, oxcarbazepine, levetiracetam, zonisamide, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Fycompa. PAGE 14 LAST UPDATED 11/2018
15 GILENYA GILENYA 0.5 MG CAPSULE STEP 1: Patient has a history of filling a 30 day supply of one of the following within the past 180 days: interferon beta-1a (Avonex), peginterferon beta-1a (Plegridy), dimethyl fumarate (Tecfidera) or glatiramer (Copaxone). STEP 2: Once step one is met the patient may fill Gilenya. PAGE 15 LAST UPDATED 11/2018
16 GLP-1/LA INSULIN COMBO SOLIQUA STEP 1: Patient has a history of filling a 30 day supply of: a long acting insulin (Lantus, Toujeo, Levemir etc.) Or a GLP-1 (Victoza, Trulicity, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Soliqua. PAGE 16 LAST UPDATED 11/2018
17 NEUPRO NEUPRO STEP 1: Patient has a history of filling a 30 day supply of: pramipexole or ropinirole within the past 180 days. STEP 2: Once step one is met the patient may fill Neupro. PAGE 17 LAST UPDATED 11/2018
18 OTREXUP OTREXUP 10 MG/0.4 ML AUTO-INJ, OTREXUP 12.5 MG/0.4 ML AUTOINJ, OTREXUP 15 MG/0.4 ML AUTO-INJ, OTREXUP 17.5 MG/0.4 ML AUTOINJ, OTREXUP 20 MG/0.4 ML AUTO-INJ, OTREXUP 22.5 MG/0.4 ML AUTOINJ, OTREXUP 25 MG/0.4 ML AUTO-INJ STEP 1: Patient has a history of filling a 30 day supply of: generic methotrexate within the past 180 days. STEP 2: Once step one is met the patient may fill Otrexup. PAGE 18 LAST UPDATED 11/2018
19 RANEXA RANEXA STEP 1: Patient has a history of filling a 30 day supply of at least 2 of the following: generic isosorbide, metoprolol, atenolol, diltiazem, verapamil, amlodipine or felodipine within the last 180 days. STEP 2: Once Step one is met the patient may fill Ranexa. PAGE 19 LAST UPDATED 11/2018
20 TEKTURNA TEKTURNA, TEKTURNA HCT STEP 1: Patient has a history of filling a 30 day supply of: 1 generic ACE inhibitor (such as lisinopril, enalapril, ramipril, etc.) OR Angiotensin Receptor Blocker (such as losartan, irbesartan, etc.) within the last 180 days. STEP 2: Once Step one is met the patient may fill Tekturna or Tekturna HCT. PAGE 20 LAST UPDATED 11/2018
21 TRINTELLIX TRINTELLIX STEP 1: Patient has a history of filling a 30 day supply of: 2 generic antidepressants (such as citalopram, venlafaxine, bupropion, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Trintellix. PAGE 21 LAST UPDATED 11/2018
22 TROKENDI TROKENDI XR STEP 1: Patient has a history of filling a 30 day supply of: 2 generic adjunctive AEDs (lamotrigine, topiramate, oxcarbazepine, levetiracetam, zonisamide, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Trokendi. PAGE 22 LAST UPDATED 11/2018
23 ULORIC ULORIC STEP 1: Patient has a history of filling a 30 day supply of: allopurinol within the past 180 days. STEP 2: Once step one is met the patient may fill Uloric. PAGE 23 LAST UPDATED 11/2018
24 VIIBRYD VIIBRYD STEP 1: Patient has a history of filling a 60 day supply of: trazodone within the past 180 days. STEP 2: Once step one is met the patient may fill Viibryd. PAGE 24 LAST UPDATED 11/2018
25 VIMPAT VIMPAT 10 MG/ML SOLUTION, VIMPAT 100 MG TABLET, VIMPAT 150 MG TABLET, VIMPAT 200 MG TABLET, VIMPAT 200 MG/20 ML VIAL, VIMPAT 50 MG TABLET STEP 1: Patient has a history of filling a 30 day supply of: 2 generic adjunctive AEDs (lamotrigine, topiramate, oxcarbazepine, levetiracetam, zonisamide, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Vimpat. PAGE 25 LAST UPDATED 11/2018
26 XELJANZ XELJANZ, XELJANZ XR STEP 1: Patient has a history of filling a 30 day supply of: Humira (adalimumab) or Enbrel (etanercept) within the past 180 days. STEP 2: Once step one is met the patient may fill Xeljanz. PAGE 26 LAST UPDATED 11/2018
27 ZONTIVITY ZONTIVITY STEP 1: Patient has a history of filling a 1 day supply of generic clopidogrel within the past 180 days. STEP 2: Once step one is met the patient may fill Zontivity. PAGE 27 LAST UPDATED 11/2018
28 ZYCLARA ZYCLARA STEP 1: Patient has a history of filling a 1 day supply of: 1 generic topical 5-FU, imiquimod, or branded Picato within the past 180 days. STEP 2: Once step one is met the patient may fill Zyclara.
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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
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