Step Therapy Criteria
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- Phoebe Cooper
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1 ADCIRCA ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 ) ELIDEL 76-F ELIDEL Coverage will be provided if the member is at least two years of age AND, the member has filled a prescription for at least one topical corticosteroid of medium or higher potency (at least a 14 day supply within the past 180 ) FANAPT 657-D FANAPT, FANAPT TITRATION PACK GRALISE 656-D GRALISE, GRALISE STARTER Coverage will be provided if the member has filled a prescription for gabapentin (at least a 30 day supply within the past 120 ) HPGST SABA 408-D XOPENEX HFA Coverage will be provided if the member has filled a prescription for ProAir HFA, Proventil HFA or Ventolin HFA (at least a 30 day supply within the past 365 ) INTUNIV 781-D GUANFACINE ER Coverage will be provided if the member has filled a prescription for an amphetamine-dextroamphetamine, dextroamphetamine, methamphetamine, lisdexamfetamine, methylphenidate or dexmethylphenidate product (at least a 30 day supply within the past 180 ) Updated 09/01/2016 1
2 LATUDA 657-D LATUDA LYRICA 656-D LYRICA Coverage will be provided if the member has filled a prescription for gabapentin (at least a 30 day supply within the past 120 ) PDPD AUTOIMMUNE ACTEMRA, CIMZIA, CIMZIA STARTER KIT, KINERET, ORENCIA, ORENCIA CLICKJET, REMICADE, SIMPONI, SIMPONI ARIA, STELARA, XELJANZ Must try Enbrel or Humira PDPD GH GENOTROPIN, GENOTROPIN MINIQUICK, NUTROPIN, NUTROPIN AQ NUSPIN 10, NUTROPIN AQ NUSPIN 5, NUTROPIN AQ PEN, OMNITROPE, SAIZEN, SAIZEN CLICK.EASY Must try Norditropin or Humatrope PROTOPIC 177-F TACROLIMUS Protopic 0.03%: Coverage will be provided if the member is at least two years of age AND filled a prescription for at least one topical corticosteroid of medium or higher potency (at least a 14 day supply within 180 ) Protopic 0.1%: Coverage will be provided if the member is at least 16 years of age AND filled a prescription for at least one topical corticosteroid of medium or higher potency (at lease a 14 day supply within 180 ) RANEXA 658-D RANEXA Coverage will be provided if the member has filled a prescription for a nitrate plus a beta blocker or a calcium channel blocker (at least a 30 day supply within the past 365 ) Updated 09/01/2016 2
3 SAPHRIS 657-D SAPHRIS SEROQUEL/SEROQUEL XR 657-D SEROQUEL XR SIMVA 80MG 981-D SIMVASTATIN Coverage will be provided if the member has filled a prescription for 80mg strength of simvastatin (Zocor) (at least a 290 day supply within the past 365 ) TGST ACNE 771-D ACANYA, AZELEX acne product (at least a 30 day supply within the past 180 ) TGST ARB/RI 376-D BENICAR, EDARBI, TEKTURNA ACE, ACE/HCTZ combination, ARB, or ARB/HCTZ combination (at least a 30 day supply within the past 365 ) TGST BISPHOSPHONATES 377-D FOSAMAX PLUS D bisphosphonate product (at least a 28 day supply within the past 365 ) Updated 09/01/2016 3
4 TGST BPH-ALPHA1 BLCK 606-D CARDURA XL, RAPAFLO Benign Prostatic Hyperplasia (BPH) agent (e.g., alfuzosin ext-rel, doxazosin, tamsulosin, terazosin) (at least a 30 supply within the past 365 ) TGST NSAID 378-D VOLTAREN Coverage will be provided if member has filled a prescription for a generic NSAID product (at least a 30 day supply within the past 180 ) TGST PPI 383-D DEXILANT proton pump inhibitor (at least a 30 day supply within the past 180 ) TGST PROSTAGL ANALOG 613-D LUMIGAN, TRAVATAN Z, ZIOPTAN prostaglandin analogue (at least a 30 day supply within the past 365 ) TGST SLEEP AGENTS 382-D ROZEREM nonbenzodiazepine hypnotic (at least a 30 day supply within the past 180 ) TGST SSRI 384-D VIIBRYD, VIIBRYD STARTER PACK SSRI product (at least a 30 day supply within the past 365 ) TGST TRIPTANS 391-D RELPAX 5HT 1 Agonist (triptan) (at least a 30 day supply within the past 180 ) Updated 09/01/2016 4
5 TGST URINARY ANTISPASMODICS 385-D GELNIQUE, MYRBETRIQ, OXYTROL, TOVIAZ, VESICARE urinary antispasmodic (at least a 30 day supply within the past 180 ) ULORIC 540-D ULORIC Coverage will be provided if the member has filled a prescription for allopurinol (at least a 30 day supply within the past 180 ) VANCOCIN 513-E VANCOMYCIN HCL Coverage will be provided if the member has filled a prescription for metronidazole (at least a 10 day supply within the past 60 ) OR, Vancocin capsules - vancomycin hydrochloride (at least a 7 day supply within the past 60 ) Updated 09/01/2016 5
Step Therapy Criteria
Step Therapy Group ADCIRCA 1772-D ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 Step Therapy Group ANTIPSYCHOTICS
Step Therapy Criteria
ADCIRCA 1772-D ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 AMYLIN ANALOG 676-D SYMLINPEN 120, SYMLINPEN 60 rapid-acting
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 Criteria
Tier 5 Formulary Step Therapy 2016 Updated: 05/24/2016 Effective: 06/01/2016 What is Step Therapy? Some prescription drugs require step therapy (ST). In some cases, the plan requires you to first try certain
STEP THERAPY ALGORITHMS PUP Select Formulary
The Step Therapy drug will be dispensed if the drug has been dispensed within 120 days of current fill or if alternative (Step 1) drugs have been used first. If the member s prescription claim fails the
2015 Step Therapy Prior Authorization Medical Necessity Guidelines
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BRINTELLIX. Step Therapy Criteria HealthTeam Advantage Formulary ID: Version 6 Effective Date: 1/1/2016. PRODUCT(s) AFFECTED BRINTELLIX
BRINTELLIX BRINTELLIX Claim will pay automatically for brintellix if enrollee has a paid claim for at least a 1 days supply of any 2 generic formulary antidepressants in the past 365 days. Otherwise, brintellix
HEALTHTEAM ADVANTAGE PLAN 2017 Step Therapy Criteria Pending CMS Approval
ARISTADA - ARISTADA INJ 441MG/1.6 ARISTADA INJ 662MG/2.4 ARISTADA INJ 882MG/3.2 CLAIM WILL PAY AUTOMATICALLY FOR ARISTADA IF ENROLLEE HAS A PAID CLAIM FOR AT LEAST A 1 DAYS SUPPLY OF ABILIFY MAINTENA AND
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
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
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.
CARE N CARE HEALTH PLAN
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
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
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,
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.
CARE N CARE HEALTH PLAN
ARISTADA Aristada Prefilled Syringe 441 MG/1.6ML Intramuscular Aristada Prefilled Syringe 662 MG/2.4ML Intramuscular Aristada Prefilled Syringe 882 MG/3.2ML Intramuscular Claim will pay automatically for
SmithRx Standard Formulary Step Therapy List
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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,
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
2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements
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2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements
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2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements
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Drugs That Require Step Therapy (ST) Step Therapy Medications
Drugs That Require Step Therapy (ST) In some cases, HealthNow New York Inc. requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.
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
Contents ALPHA BLOCKERS... 3 COLCRYS-PST... 4 DPP-4 INHIBITORS-PST... 5 HIGH RISK MEDICATIONS - SEDATIVE HYPNOTICS... 6
CHRISTUS Health Plan Generations (HMO) 2017 Step Therapy Criteria H1189_PC57 Accepted 11/17/2016 1 Contents ALPHA BLOCKERS... 3 COLCRYS-PST... 4 DPP-4 INHIBITORS-PST... 5 HIGH RISK MEDICATIONS - SEDATIVE
2018 Step Therapy (ST) Criteria
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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
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ALPHA BLOCKERS. Products Affected Step 1: Details. Step 2: Rapaflo 4 mg capsule Rapaflo 8 mg capsule
CHRISTUS Health Plan Generations (HMO) CHRISTUS Health Plan Generations Plus (HMO) 2018 Premier Performance Standard Step Therapy PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS
ANTIDEPRESSANTS. Details. Step Therapy 2018 Last Updated: 8/21/2018
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 ORAL FETZIMA
PPHP 2017 Formulary 2017 Step Therapy Criteria
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
Drugs That Require Step Therapy (ST) Step Therapy Medications
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Simply Step Therapy Document September 2018 Y0114_18_33074_I_009
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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.
ALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Health Choice Generations 1 Tier Gold Effective Date: 11/01/2018.
ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/2018 1 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam
ALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Optima Tier Gold Formulary Date Effective: November 1, 2018.
ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID 18354, Version 15 1 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Trial of two of
BYSTOLIC. Products Affected Step 2: BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET. Details BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET
BYSTOLIC BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET authorization for a Step 2 drug may be given. Step 1 Drug(s): generic beta-blockers and/or combinations,
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