Step Therapy Medications
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- Nora Fleming
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1 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, Lamotrigine immediate-release, Zonisamide, Levetiracetam, Levetiracetam XR, Topiramate. Step 2 Drug(s): Aptiom (eslicarbazepine). Applies to New Starts Only. Number of days for claims review for step 1 drugs: 180 days COREG CR Step-2: COREG CR 10 MG CAPSULE, EXTENDED RELEASE or COREG CR 20 MG CAPSULE, EXTENDED RELEASE or COREG CR 40 MG CAPSULE, EXTENDED RELEASE or COREG CR 80 MG CAPSULE, EXTENDED RELEASE Step 1 Drug(s): cavedilol regular release. Step 2 Drug(s): Coreg CR. Applies to New Starts Only CYCLOSET DEXILANT Step-2: CYCLOSET 0.8 MG TABLET Step-2: DEXILANT 30 MG CAPSULE, DELAYED RELEASE or DEXILANT 60 MG CAPSULE, DELAYED RELEASE Step 1 Drug(s): metformin. Step 2 Drug(s): Cycloset (bromocriptine mesylate) If the patient has tried a Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): omeprazole, pantoprazole, or lansoprazole. Step 2 Drug(s): Dexilant Y0114_17_29357_010 10/4/ Updated 10/2017
2 DOXEPIN HRM - B Step-2: doxepin 10 mg capsule or doxepin 10 mg/ml oral concentrate or doxepin 100 mg capsule or doxepin 150 mg capsule or doxepin 25 mg capsule or doxepin 50 mg capsule or doxepin 75 mg capsule given. Step 1 Drug(s): bupropion, buspirone, citalopram, desipramine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nortriptyline, paroxetine CR, paroxetine, Pristiq, sertraline, trazodone, venlafaxine IR/ER, Viibryd. Step 2 Drug(s): Doxepin. Applies to New Starts Only. Number of days for claims review for step 1 drugs: 180 days FANAPT Step-2: FANAPT 1 MG TABLET or FANAPT 10 MG TABLET or FANAPT 12 MG TABLET or FANAPT 1MG(2)-2 MG(2)- 4MG(2)-6 MG(2) TABLETS IN A DOSE PACK or FANAPT 2 MG TABLET or FANAPT 4 MG TABLET or FANAPT 6 MG TABLET or FANAPT 8 MG TABLET Step 1 Drug(s): risperidone, olanzapine, quetiapine fumarate, ziprasidone, paliperidone. Step 2 Drug(s): Fanapt (iloperidone), Fanapt Titration Pack (iloperidone). Applies to New Starts Only. Number of days for claims review for step 1 drugs: 180 days Y0114_17_29357_010 10/4/ Updated 10/2017
3 FENTANYL PATCH-E Step-2: fentanyl 100 mcg/hr 12 mcg/hr transdermal patch or fentanyl 25 mcg/hr 37.5 mcg/hour transdermal patch or fentanyl 50 mcg/hr 62.5 mcg/hour transdermal patch or fentanyl 75 mcg/hr 87.5 mcg/hour transdermal patch Step 1 Drug(s): hydromorphone er, methadone, morphine sulfate ER/CR, tramadol ER. Step 2 Drug(s): fentanyl td patch. New starts Only. Look back 180 days GELNIQUE Step-2: GELNIQUE 10 % (100 MG/GRAM) TRANSDERMAL GEL PACKET If the patient has tried Toviaz/VESIcare/Myrbetriq and one of the following: oxybutynin, oxybutynin solution, oxybutynin ER, tolterodine IR/ER, OR trospium IR/ER. Then Gelnique (oxybutynin) may be authorized. KHEDEZLA Step-2: KHEDEZLA 100 MG TABLET,EXTENDED RELEASE or KHEDEZLA 50 MG TABLET,EXTENDED RELEASE given. Step 1 Drug(s): Bupropion, Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Mirtazapine, Paroxetine, Sertraline, Venlafaxine (immediate or extended-release products). Step 2 Drug(s): Khedezla. Applies to New Starts Only. Number of days for claims review for step 1 drugs: 180 days NASAL STEROID - B Step-2: budesonide 32 mcg/actuation nasal spray Step 1 Drug(s): fluticasone propionate or flunisolide nasal. Step 2 Drug(s): budesonide nasal may be authorized. Look back 180 days. Y0114_17_29357_010 10/4/ Updated 10/2017
4 NP BISPHOSPHONAT ES - B Step-2: FOSAMAX PLUS D 70 MG-2,800 UNIT TABLET or FOSAMAX PLUS D 70 MG-5,600 UNIT TABLET or risedronate 150 mg tablet or risedronate 30 mg tablet or risedronate 35 mg tablet or risedronate 35 mg tablet (12 pack) or risedronate 35 mg tablet (4 pack) or risedronate 5 mg tablet Step 1 Drug(s): Alendronate, ibandronate tablets. Step 2 Drug(s): Risedronate, Fosamax plus D. Look back 180 days. NP RAPID INSULIN Step-2: APIDRA 100 UNIT/ML SUBCUTANEOUS SOLUTION or APIDRA SOLOSTAR 100 UNIT/ML SUBCUTANEOUS INSULIN PEN Step 1 Drug(s): Novolog, Humalog. Step 2 Drug(s): Apidra. New starts Only. Y0114_17_29357_010 10/4/ Updated 10/2017
5 OXYCONTIN - B Step-2: oxycodone er 10 mg hr or oxycodone er 15 mg hr or oxycodone er 20 mg hr or oxycodone er 30 mg hr or oxycodone er 40 mg hr or oxycodone er 60 mg hr or OXYCODONE ER 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR or OXYCONTIN 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE or OXYCONTIN 15 MG TABLET,CRUSH RESISTANT,EXTENDED Step 1 Drug(s): Fentanyl Patch, methadone, morphine sulfate ER/CR. Step 2 Drug(s): OxyContin (oxycodone controlled-release). New Starts. Look back 180 days. Y0114_17_29357_010 10/4/ Updated 10/2017
6 RANEXA Step-2: RANEXA 1,000 MG TABLET,EXTENDED RELEASE or RANEXA 500 MG TABLET,EXTENDED RELEASE Step 1 Drug(s): any formulary Beta-blocker, Calcium-channel blocker, or Long-acting nitrate. Step 2 Drug(s): Ranexa (ranolazine) THIORIDAZINE HRM Step-2: thioridazine 10 mg tablet or thioridazine 100 mg tablet or thioridazine 25 mg tablet or thioridazine 50 mg tablet given. Step 1 Drug(s): Fanapt (iloperidone), paliperidone, Risperidone, aripiprazole, Latuda, Olanzapine, Quetiapine, Ziprasidone. Step 2 Drug(s): Thioridazine. New Starts Only TRINTELLIX Step-2: TRINTELLIX 10 MG TABLET or TRINTELLIX 20 MG TABLET or TRINTELLIX 5 MG TABLET given. Step 1 Drug(s): citalopram, fluoxetine, paroxetine, paroxetine CR, sertraline, venlafaxine, venlafaxine er, escitalopram, fluvoxamine. Step 2 Drug(s): Trintellix (Vortioxetine). Applies to New Starts Only. Number of days for claims review for step 1 drugs: 180 days ULORIC Step-2: ULORIC 40 MG TABLET or ULORIC 80 MG TABLET Step 1 Drug(s): allopurinol. Step 2 Drug(s): Uloric. Approve without trial of step 1 drug if Patient has contraindication to allopurinol use. VIIBRYD Step-2: VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK or VIIBRYD 10 MG TABLET or VIIBRYD 20 MG TABLET or VIIBRYD 40 MG TABLET given. Step 1 Drug(s): citalopram, fluoxetine, fluvoxamine, paroxetine, paroxetine CR, sertraline, venlafaxine IR/ER, escitalopram. Step 2 Drug(s): Viibryd, Viibryd Titration Pack. Applies to New Starts Only. Number of days for claims review for step 1 drugs: 180 days Y0114_17_29357_010 10/4/ Updated 10/2017
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
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.
2018 PDP Premier Step Therapy Document September 2018 Y0114_18_33144_I_009
2018 PDP Premier Step Therapy Document September 2018 Aggrenox Y0114_18_33144_I_009 aspirin 25 mg-dipyridamole 200 mg capsule,ext.release 12 hr multiphase drug may be given. Step 1 Drug(s): clopidigrel.
2019 PDP Basic Step Therapy Document
Aggrenox 2019 PDP Basic 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.
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
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
2018 GRS Premier Step Therapy Document. September 2018 Y0114_18_33177_I_010
2018 GRS Premier Step Therapy Document September 2018 Aggrenox Y0114_18_33177_I_010 AGGRENOX 25 MG-200 MG CAPSULE, EXTENDED RELEASE aspirin 25 mg-dipyridamole 200 mg capsule,ext.release 12 hr multiphase
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
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.
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
Step Therapy Group. Atypical Antipsychotic Agents
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2019 GRS Premier Step Therapy Document
Aggrenox 2019 GRS Premier Step Therapy Document AGGRENOX 25 MG-200 MG CAPSULE, EXTENDED RELEASE aspirin 25 mg-dipyridamole 200 mg capsule,ext.release 12 hr multiphase drug may be given. Step 1 Drug(s):
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
2018 Step Therapy FID 18088
2018 Step Therapy FID 18088 Step Therapy ANTIDEPRESSANTS, SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS LEON 2018 Desvenlafaxine Er Fetzima Fetzima Titration Pack Khedezla Paxil SUSP Pristiq Trintellix
ANTICONVULSANTS. Details
ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200 mg tablet Banzel 40 mg/ml oral suspension Banzel 400 mg tablet Fycompa 0.5 mg/ml oral suspension
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
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
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
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
2015 Step Therapy Prior Authorization Medical Necessity Guidelines
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ANTICONVULSANTS. Details
ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET APTIOM 800 MG TABLET BANZEL 200 MG TABLET BANZEL 40 MG/ML ORAL SUSPENSION BANZEL 400 MG TABLET FYCOMPA 0.5 MG/ML ORAL SUSPENSION
ANTICONVULSANTS. Details
ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200 mg tablet Banzel 40 mg/ml oral suspension Banzel 400 mg tablet Fycompa 0.5 mg/ml oral suspension
2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+)
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VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017
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Step Therapy Requirements
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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.
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.
ANTICONVULSANTS. Details
ANTICONVULSANTS APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL 200 MG BANZEL 40 MG/ML ORAL SUSPENSION BANZEL 400 MG FYCOMPA 0.5 MG/ML ORAL SUSPENSION FYCOMPA 10 MG FYCOMPA 12 MG FYCOMPA
Santa Clara Family Health Plan Cal MediConnect Formulary. List of Step Therapy Requirements Effective: 12/01/ E
Santa Clara Family Health Plan Cal MediConnect Formulary List of Step Therapy Requirements Effective: 12/01/2018 13027.12E ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET
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, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED RELEASE PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS. 1 ANTICONVULSANTS
Step Therapy Requirements. Effective: 03/01/2015
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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
ATYPICAL ANTIPSYCHOTICS
Step Therapy CareOregon 2018 Last Updated: 07/27/2018 ATYPICAL ANTIPSYCHOTICS Fanapt Fanapt Titration Pack Paliperidone Er Vraylar The following criteria applies to members who newly start on the drug:
ANTIDEPRESSANTS. Details. Step Therapy 2018 Last Updated: 8/21/2018
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2018 Step Therapy Criteria
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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*
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Effective: 01/01/2017 Updated 11/2016 ANTI-INFLAMMATORY AGENTS - GI DIPENTUM PRIOR CLAIM FOR BALSALAZIDE OR APRISO WITHIN THE PAST 120 DAYS. ANTICONVULSANTS APTIOM BANZEL FYCOMPA GABITRIL OXTELLAR XR POTIGA
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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
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Contents ALPHA BLOCKERS... 3 COLCRYS-PST... 4 DPP-4 INHIBITORS-PST... 5 HIGH RISK MEDICATIONS - SEDATIVE HYPNOTICS... 6
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Alprazolam 0.25mg, 0.5mg, 1mg tablets
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ANALGESICS, NARCOTICS KADIAN MORPHINE SULFATE ER PRIOR CLAIM FOR MORPHINE SULFATE SUSTAINED ACTION TABLET (MS CONTIN) WITHIN THE PAST 120 DAYS. ANTIBACTERIALS (EENT) BESIVANCE PRIOR CLAIM FOR CIPROFLOXACIN
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ARISTADA. Products Affected Step 2: ARISTADA PREFILLED SYRINGE 1064 MG/3.9ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 441 MG/1.
ARISTADA ARISTADA PREFILLED SYRINGE 1064 MG/3.9ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 441 MG/1.6ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 662 MG/2.4ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 882
2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Criteria Last Updated 11/1/2015
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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.
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
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
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
SelectHealth Advantage 2018 Step Therapy Criteria Previous trial on at least ONE: Generic topical acne treatment
ACNE ADAPAL/BEN P GEL 0.1-2.5% AZELEX CRE 20% DAPSONE GEL 5% EPIDUO FORTE GEL 0.3-2.5% TRETINOIN GEL 0.04% TRETINOIN GEL 0.05% TRETINOIN GEL 0.1% ACTONEL ANTICONVULSANT ANTIDEPRESSION ANTIPSYCHOTIC ASTHMA
ALPHA BLOCKERS. Products Affected Step 1: Details. Step 2: Rapaflo 4 mg capsule Rapaflo 8 mg capsule
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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
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
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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
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
DPP4 INHIBITORS. Details. Step Therapy Criteria Health Alliance Plan 2019 Date Effective: 04/01/2019
DPP4 INHIBITORS Janumet 50 mg-1,000 mg tablet Januvia 50 mg tablet Janumet 50 mg-500 mg tablet Onglyza 2.5 mg tablet Januvia 100 mg tablet Onglyza 5 mg tablet Januvia 25 mg tablet Tradjenta 5 mg tablet
ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION FORMULARY
ANTIDEPRESSANTS Serotonin Selective Reuptake Inhibitors citalopram 10, 20, 40 mg, 10 mg/5cc $ 0.40 No escitalopram 10, 20 mg $ 2.60 Yes fluoxetine 10, 20 mg, 20 mg/5 ml $ 0.40 Yes fluvoxamine 25, 50, 100
Cigna Drug and Biologic Coverage Policy
Cigna Drug and Biologic Coverage Policy Subject Step Therapy Individual and Family Plan Table of Contents Coverage Policy... 1 General Background... 5 References... 5 Effective Date... 3/15/2018 Next Review
WELLCARE/ OHANA HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 08/2015)
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 (https://www.wellcare.com
DPP4 INHIBITORS. Products Affected Step 2: Janumet 50 mg-1,000 mg tablet Janumet 50 mg-500 mg tablet Januvia 100 mg tablet Januvia 25 mg tablet
DPP4 INHIBITORS Janumet 50 mg-1,000 mg tablet Janumet 50 mg-500 mg tablet Januvia 100 mg tablet Januvia 25 mg tablet Januvia 50 mg tablet Onglyza 2.5 mg tablet Onglyza 5 mg tablet Tradjenta 5 mg tablet
ANTICONVULSANTS. Details. Step Therapy Criteria Date Effective: April 1, 2019
Step Therapy Date Effective: April 1, 2019 ANTICONVULSANTS APTIOM TABLET 200 MG ORAL APTIOM TABLET 400 MG ORAL APTIOM TABLET 600 MG ORAL APTIOM TABLET 800 MG ORAL BANZEL SUSPENSION 40 MG/ML ORAL BANZEL
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
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.
Alaska Medicaid 90 Day** Generic Prescription Medication List
1 ACYCLOVIR 200 MG CAPSULE BUPROPION HCL 150 MG TAB ER 24H ACYCLOVIR 200 MG/5ML BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 400 MG TABLET BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 800 MG TABLET BUPROPION HCL
DIFICID. Products Affected Step 2: DIFICID TABLET 200 MG ORAL. Details
DIFICID DIFICID TABLET 200 MG ORAL Claim will pay automatically for Dificid if enrollee has a paid claim for at least a 1 days supply of vancomycin in the past. Otherwise, Dificid requires a step therapy
SelectHealth Advantage 2018 Step Therapy Criteria. Previous trial on at least ONE: Generic topical acne treatment. Previous trial on: alendronate
ACNE ACZONE ADAPAL/BEN P AZELEX DAPSONE EPIDUO EPIDUO FORTE TRETINOIN ACTONEL RISEDRON SOD RISEDRONATE SelectHealth Advantage Previous trial on at least ONE: Generic topical acne treatment alendronate
Judges Reference Table for the March 2016 Psychotropic Medication Utilization Parameters for Foster Children
Judges Reference Table for the Psychotropic Medication Utilization Parameters for Foster Children Stimulants for treatment of ADHD Preschool (Ages 3-5 years) Child (Ages 6-12 years) Adolescent (Ages 13-17
HEALTHTEAM ADVANTAGE 2018 Step Therapy Criteria
GLP1-INSULIN XULTOPHY SOLUTION PEN- INJECTOR 100-3.6 UNIT-MG/ML Claim will pay automatically for Xultophy if enrollee has a paid claim for at least a one day supply for step level 1 agent (LANTUS, LEVEMIR,
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.
HEALTHTEAM ADVANTAGE 2018 Step Therapy Criteria
GLP1-INSULIN XULTOPHY SOLUTION PEN- INJECTOR 100-3.6 UNIT-MG/ML HEALTHTEAM ADVANTAGE Claim will pay automatically for Xultophy if enrollee has a paid claim for at least a one day supply for step level
ALPHA GLUCOSIDASE INHIBITOR THERAPY
ALPHA GLUCOSIDASE INHIBITOR THERAPY GLYSET Step 1: One generic formulary product containing one of the following ingredients: glimeperide, glipizide, metformin or pioglitazone. Step 2: Glyset PAGE 1 LAST
DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 759 M %
June 2016 On 13th May, the DH announced that there would be reductions to Category M prices from June until September. http://psnc.org.uk/our-news/contractor-notice-category-m-price-reduction/ This has
2016 Step Therapy (ST) Criteria
2016 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
CARE N CARE HEALTH PLAN
PPI DEXILANT CAPSULE DELAYED RELEASE 30 MG ORAL DEXILANT CAPSULE DELAYED RELEASE 60 MG ORAL Claim will pay automatically for Dexilant if enrollee has a paid claim for at least a 1 days supply of lansoprazole,