SmithRx Standard Formulary Step Therapy List

Size: px
Start display at page:

Download "SmithRx Standard Formulary Step Therapy List"

Transcription

1 SmithRx Standard Formulary Step Therapy List Revised: January 27, 2017 The following medications require prior use of at least one other medication for coverage. Please note that any plan-specific customizations are not reflected in this list. Step criteria are listed on pages 2-9 as well as in the SmithRx Clinical Criteria document. ACIPHEX 2 ACTICLATE 2 ADDERALL 2 ADDERALL XR 2 ADOXA 2 ADZENYS XR-ODT 2 AMBIEN 2 AMBIEN CR 2 AMTURNIDE 3 APIDRA 2 APIDRA SOLOSTAR 2 ARCAPTA NEOHALER 2 ARICEPT 2 ATELVIA 2 BELSOMRA 2 BEVESPI AEROSPHERE 2 BRINTELLIX 2 BYVALSON 2 CARDURA XL 2 CONCERTA 2 COREG CR 2 CORLANOR 2 DAYTRANA 2 DESOXYN 2 DEXILANT 2 DORYX 2 DORYX MPC 2 DYANAVEL XR 2 EDARBI 2 EDARBYCLOR 3 EDLUAR 2 ELIDEL 3 EURAX 2 EVEKEO 3 FANAPT 2 FETZIMA 2 FOCALIN XR 2 GEODON 2 GRALISE 2 INDERAL XL 2 INNOPRAN XL 2 INTERMEZZO 2 INVEGA 2 KAPVAY 2 LASTACAFT 2 LINZESS 2 LUNESTA 2 METADATE CD 2 MIRAPEX ER 2 MITIGARE 2 NAMENDA XR 2 NAMZARIC 2 NATROBA 2 ONZETRA XSAIL 2 ORACEA 2 OVIDE 2 PICATO 2 PRESTALIA 2 PREVACID 2 PRILOSEC 2 PROCENTRA 2 PROTONIX 2 PROTOPIC 3 QUILLICHEW ER 2 QUILLIVANT XR 2 RITALIN LA 2 ROZEREM 2 SAPHRIS 2 SAVELLA 2 SKLICE 2 SOLODYN 2 SONATA 2 STRIVERDI RESPIMAT 2 TACROLIMUS 2 TARGADOX 2 TEKTURNA 2 TEKTURNA HCT 2 TOLAK 2 TREXIMET 2 TRINTELLIX 2 ULESFIA 2 ULORIC 2 UTIBRON NEOHALER 2 VIBRAMYCIN 2 VIMOVO 3 ZEGERID 2 ZEMBRACE SYMTOUCH 2 SmithRx Step Therapy List Page 1

2 ADDERALL, ADDERALL XR STEP 2 At least TWO of the following formulary CNS stimulants: dexmethylphenidate (generic), ADZENYS XR, ADZENYS XR-ODT STEP 2 At least TWO of the following generic formulary CNS stimulants: dexmethylphenidate, methylphenidate, dextroamphetamine, modafinil, guanfacine AMBIEN, AMBIEN CR STEP 2 Eszopiclone zolpidem (generic) or zaleplon (generic) AMTURNIDE STEP 3 Any ONE of the following (generics only): ACE inhibitor, ACE inhibitor combination, Angiotensin II Receptor Blocker, Angiotensin II Receptor Blocker combination, amlodipine-benazepril, trandolapril-verapamil Step 2: Tekturna or Tekturna HCT ANTIPARASITICS: EURAX, NATROBA, OVIDE, SKLICE, ULESFIA STEP 2 Permethrin APIDRA, APIDRA SOLOSTAR STEP 2 Humalog or Novolog ARCAPTA NEOHALER STEP 2 Any TWO of the following: Advair HFA/ Diskus, Breo Ellipta, Serevent, Symbicort SmithRx Step Therapy List Page 2

3 ARICEPT 23MG STEP 2 At least 10mg of Aricept/Aricept ODT ATELVIA STEP 2 Alendronate BELSOMRA STEP 2 Zolpidem or zaleplon or eszopiclone BEVESPI AEROSPHERE STEP 2 Any one of the following: Advair HFA/ Diskus, Breo Ellipta, Serevent, Symbicort Spiriva BRINTELLIX, TRINTELLIX STEP 2 Any TWO of the following preferred agents: citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, olanzapine-fluoxetine, paroxetine, sertraline, venlafaxine, bupropion, mirtazapine BYVALSON STEP 2 Must try generic first (nebivolol/valsartan) CARDURA XL STEP 2 Tamsulosin or terazosin Cardura CONCERTA STEP 2 At least TWO of the following formulary CNS stimulants: dexmethylphenidate (generic), SmithRx Step Therapy List Page 3

4 COREG CR STEP 2 Carvedilol or Coreg CORLANOR STEP 2 Any beta blocker DAYTRANA STEP 2 DESOXYN STEP 2 DYNAVEL XR STEP 2 Any TWO of the following generic formulary CNS stimulants: dexmethylphenidate, methylphenidate, dextroamphetamine, modafinil, guanfacine EDARBI STEP 2 Any ONE of the following (generics only): ACE inhibitor, ACE inhibitor combination, Angiotensin II Receptor Blocker, Angiotensin II Receptor Blocker combination, amlodipine-benazepril, trandolapril-verapamil EDARBYCLOR STEP 3 Any ONE of the following (generics only): ACE inhibitor, ACE inhibitor combination, Angiotensin II Receptor Blocker, Angiotensin II Receptor Blocker combination, amlodipine-benazepril, trandolapril-verapamil Step 2: Edarbi SmithRx Step Therapy List Page 4

5 EDLUAR STEP 2 Zolpidem or Ambien ELIDEL STEP 3 Topical corticosteroid Step 2: Tacrolimus EVEKEO STEP 3 Any TWO of the following generic formulary CNS stimulants: dexmethylphenidate, methylphenidate, dextroamphetamine, modafinil, guanfacine FANAPT STEP 2 Any TWO of the following: olanzapine, quetiapine, risperidone, Seroquel XR, Abilify FETZIMA STEP 2 Any TWO of the following preferred SNRIs: desvenlafaxine, duloxetine, venlafaxine FOCALIN XR STEP 2 GEODON STEP 2 Any TWO of the following: olanzapine, quetiapine, risperidone, Seroquel XR, Abilify GRALISE STEP 2 Gabapentin INNOPRAN, INDERAL STEP 2 Must try propranolol ER generics SmithRx Step Therapy List Page 5

6 INTERMEZZO STEP 2 Zolpidem or Ambien INVEGA STEP 2 Any TWO of the following: olanzapine, quetiapine, risperidone, Seroquel XR, Abilify KAPVAY STEP 2 LASTACAFT STEP 2 Patanol or Pataday or Optivar LINZESS STEP 2 For patients >18 years old: Polyethylene glycol or lactulose LUNESTA STEP 2 Zolpidem (generic) or zaleplon (generic) METADATE CD STEP 2 MIRAPEX ER STEP 2 Ropinirole or pramipexole MITIGARE STEP 2 Colcrys SmithRx Step Therapy List Page 6

7 NAMENDA XR STEP 2 Namenda NAMZARIC STEP 2 Generic donepezil and memantine ONZETRA XSAIL STEP 2 Any TWO of the following preferred serotonin 5HT1 agonists: almotriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan PICATO STEP 2 Topical fluorouracil or imiquimod PPIs: ACIPHEX, DEXILANT, PREVACID, PRILOSEC, PROTONIX, ZEGERID STEP 2 Pantoprazole or lansoprazole (rx) omeprazole, OTC Prilosec, OTC Prevacid, or OTC Zegerid PRESTALIA STEP 2 Amlodipine or perindopril Tribenzor or Azor PROCENTRA STEP 2 PROTOPIC STEP 3 Topical corticosteroid Step 2: SmithRx Step Therapy List Page 7

8 Tacrolimus QUILLICHEW ER STEP 2 Any TWO of the following generic formulary CNS stimulants: dexmethylphenidate, methylphenidate, dextroamphetamine, modafinil, guanfacine QUILLIVANT XR STEP 2 RITALIN LA STEP 2 ROZEREM STEP 2 Eszopiclone, zolpidem, or zaleplon SAPHRIS STEP 2 Any TWO of the following: olanzapine, quetiapine, risperidone, Seroquel XR, Abilify SAVELLA STEP 2 Any ONE of the following: amitriptyline, cyclobenzaprine, Cymbalta SOLODYN STEP 2 Must try 2 minocycline generics SONATA STEP 2 Eszopiclone Zolpidem (generic) or zaleplon (generic) SmithRx Step Therapy List Page 8

9 STRIVERDI RESPIMAT STEP 2 Any TWO of the following: Advair HFA/Diskus, Breo Ellipta, Serevent, Symbicort TACROLIMUS OINTMENT STEP 2 Topical corticosteroid TEKTURNA, TEKTURNA HCT STEP 2 Any ONE of the following (generics only): ACE inhibitor, ACE inhibitor combination, Angiotensin II Receptor Blocker, Angiotensin II Receptor Blocker combination, amlodipine-benazepril, trandolapril-verapamil TETRACYCLINES STEP 2 Must try 2 doxycycline generics TOLAK STEP 2 Any TWO of the following preferred agents: fluorouracil 0.5%, fluorouracil 2%, Carac, or Fluoroplex TREXIMET STEP 2 Sumatriptan Any NSAID (Rx only) ULORIC STEP 2 Allopurinol UTIBRON NEOHALER STEP 2 Any ONE of the following: Advair HFA/Diskus, Breo Ellipta, Serevent, Symbicort Spiriva SmithRx Step Therapy List Page 9

10 VIMOVO STEP 3 Arthrotec Step 2: Any TWO NSAIDs ZEMBRACE SYMTOUCH STEP 2 Any TWO of the following preferred serotonin 5HT1 agonists: almotriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan SmithRx Step Therapy List Page 10

Step Therapy Program Precision Formulary

Step Therapy Program Precision Formulary Step Therapy Program Precision Formulary Physician Guidelines Failure of previous steps in the Step Therapy Program: For most therapies, Magellan Rx Management will review the most recent 180 days of claim

More information

Try a Step 1 medication first

Try a Step 1 medication first Premium step therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment

More information

Premium step therapy. Here s how it works:

Premium step therapy. Here s how it works: Premium step therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment

More information

Relative Cost/Month. Less than $10. Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*

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*

More information

Step therapy Premium. Utilization management updates - January 1, Here s how it works:

Step therapy Premium. Utilization management updates - January 1, Here s how it works: Utilization management updates - January 1, 2019 Step therapy Premium Most medical conditions have many medication options. Although their clinical effectiveness may be the same, the cost can be very different.

More information

Premium Step Therapy. Here s how it works:

Premium Step Therapy. Here s how it works: Premium Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment

More information

Avoid paying too much for your prescriptions

Avoid paying too much for your prescriptions Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2017 Aetna Rx Step Program Medicine List Avoid paying too much for your prescriptions It s important to try to

More information

2015 Step Therapy Prior Authorization Medical Necessity Guidelines

2015 Step Therapy Prior Authorization Medical Necessity Guidelines Tufts Health Unify 2015 Step Therapy Prior Authorization Medical Necessity Guidelines Effective: 01/01/2015 Updated: 10/01/2015 Tufts Health Plan P.O. Box 9194 Watertown, MA 02471-9194 Phone: 855-393-3154

More information

ADHD STIMULANTS-S(SHC)

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

More information

ClearScript Step Therapy Drug List

ClearScript Step Therapy Drug List ClearScript Step Therapy Drug List The ClearScript Step Therapy Program requires a trial of one or more first step drugs before a second step or target drug is covered. For example, if two drugs are used

More information

Judges Reference Table for the March 2016 Psychotropic Medication Utilization Parameters for Foster Children

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

More information

Commissioner for the Department for Medicaid Services Selections for Preferred Products

Commissioner for the Department for Medicaid Services Selections for Preferred Products Commissioner for the Department for Medicaid Services Selections for Preferred Products This is a summary of the final Preferred Drug List (PDL) selections made by the Commissioner for the Department for

More information

Before a Step 2 medication is covered You get a prescription

Before a Step 2 medication is covered You get a prescription Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment

More information

Step Therapy Medications

Step Therapy Medications Step Therapy Medications Step Therapy (ST PA ) is an automated form of prior authorization. It encourages the use of therapies that should be tried first, before other treatments are covered, based on

More information

AGGRENOX. Products Affected. Details. First Health Part D Value Plus (PDP) Last Updated: 10/01/2017. Aggrenox

AGGRENOX. Products Affected. Details. First Health Part D Value Plus (PDP) Last Updated: 10/01/2017. Aggrenox First Health Part D Value Plus (PDP) Last Updated: 10/01/2017 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_3742 09/2014 Formulary ID: 18059:

More information

FirstCarolinaCare Insurance Company Step Therapy Requirements

FirstCarolinaCare Insurance Company Step Therapy Requirements 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

More information

STEP THERAPY ALGORITHMS PUP Select Formulary

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

More information

Step Therapy Requirements. Effective: 03/01/2015

Step Therapy Requirements. Effective: 03/01/2015 Effective: 03/01/2015 Updated 02/2015 ANTI-INFLAMMATORY AGENTS - GI DIPENTUM PRIOR CLAIM FOR BALSALAZIDE OR APRISO WITHIN THE PAST 120 DAYS. ANTICONVULSANTS APTIOM BANZEL FYCOMPA OXTELLAR XR POTIGA QUDEXY

More information

Cigna Drug and Biologic Coverage Policy

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

More information

Lower your costs. Save money with preferred generic and preferred brand-name drugs 2018 Aetna Rx Step Program Medicine List

Lower your costs. Save money with preferred generic and preferred brand-name drugs 2018 Aetna Rx Step Program Medicine List Call out bold Call out light Contact information, call X-XXX-XXX-XXXX or visit www.aetna.com Call to action small copy (especially related to mobile apps). Hendani adionse rferum faceatis incte voluptassi

More information

Step Therapy. Here s how it works:

Step Therapy. Here s how it works: Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment

More information

Attention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Preferred Drug List Changes - UPDATE

Attention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Preferred Drug List Changes - UPDATE Attention: Behavioral Health Providers, Pharmacists and Prescribers N.C. Medicaid and N.C. Health Choice Drug List Changes - UPDATE Note: This article was previously published in the December 2014 Medicaid

More information

SelectHealth Advantage 2018 Step Therapy Criteria Previous trial on at least ONE: Generic topical acne treatment

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

More information

AGGRENOX. Products Affected. Details. GRP B2 Last Updated: 09/01/2018. Aggrenox

AGGRENOX. Products Affected. Details. GRP B2 Last Updated: 09/01/2018. Aggrenox GRP B2 Last Updated: 09/01/2018 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_3742 09/2014 Formulary ID: 18066: version 15 1 ANTICONVULSANTS

More information

Drugs That Require Step Therapy (ST) Step Therapy Medications

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.

More information

North Dakota Medicaid Therapeutic Duplication Edits

North Dakota Medicaid Therapeutic Duplication Edits North Dakota Medicaid Therapeutic Duplication Edits This document is meant to serve as a guide to ND Medicaid s Therapeutic Duplication Edit which is reported as NCPDP Reject Code: 88 DUR REJECT ERROR.

More information

SelectHealth Advantage 2018 Step Therapy Criteria. Previous trial on at least ONE: Generic topical acne treatment. Previous trial on: alendronate

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

More information

If you have questions about the Step Therapy Program, contact ClearScript Member Services at the number on the back of your ID Card.

If you have questions about the Step Therapy Program, contact ClearScript Member Services at the number on the back of your ID Card. Step Therapy The ClearScript Step Therapy program promotes the cost-effective use of clinically appropriate medications when more than one drug is available to treat a medical condition. What is Step Therapy?

More information

SelectHealth Advantage 2019 Step Therapy Criteria Previous trial on at least ONE: Generic topical acne treatment

SelectHealth Advantage 2019 Step Therapy Criteria Previous trial on at least ONE: Generic topical acne treatment ACNE ADAPAL/BEN P AZELEX DAPSONE TRETINOIN ACTONEL ANTICONVULSANT ANTIDEPRESSION ANTIPSYCHOTIC ASTHMA RISEDRON SOD RISEDRONATE APTIOM OXTELLAR XR SPRITAM FETZIMA KHEDEZLA TRINTELLIX ARISTADA FANAPT LATUDA

More information

Simply Step Therapy Document September 2018 Y0114_18_33074_I_009

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

More information

Schedule FDA & literature based indications

Schedule FDA & literature based indications Psychotropic Medication List Recommended dosages are intended to serve only as a guide for children. Recommended doses are literature based. Clinicians should consult package insert of medications for

More information

If you have questions about the Step Therapy Program, contact ClearScript Member Services at the number on the back of your ID Card.

If you have questions about the Step Therapy Program, contact ClearScript Member Services at the number on the back of your ID Card. Step Therapy The ClearScript Step Therapy program promotes the cost-effective use of clinically appropriate medications when more than one drug is available to treat a medical condition. What is Step Therapy?

More information

Core and Select Step Therapy

Core and Select Step Therapy Core and Select Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get

More information

Step Therapy Requirements. Effective: 12/01/2016

Step Therapy Requirements. Effective: 12/01/2016 Effective: 12/01/2016 H2986_PD_049 Updated 11/2016 ALPHA 1-PROTEINASE INHIBITOR GLASSIA PRIOR CLAIM FOR ARALAST NP OR ZEMAIRA WITHIN THE PAST 120 DAYS. ANALGESICS, NARCOTICS KADIAN MORPHINE SULFATE ER

More information

VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017

VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017 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

More information

High-Cost Drug Exclusions

High-Cost Drug Exclusions PHARMACY SERVICES High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at

More information

U T I L I Z A T I O N E D I T S

U T I L I Z A T I O N E D I T S I N D I A N A H E A L T H C O V E R A G E P R O G R A M S U T I L I Z A T I O N E D I T S A P R I L 1 9, 2 0 1 2 s for s Refer to Provider Bulletin BT200709 for additional information regarding the Mental

More information

Step Therapy. Here s how it works: Move on to a Step 2 drug if necessary

Step Therapy. Here s how it works: Move on to a Step 2 drug if necessary Step Therapy Most medical conditions can be treated with several different drug options. There are many drugs that cost much less than others despite working the same way and being just as effective. The

More information

Select Step Therapy. Here s how it works:

Select Step Therapy. Here s how it works: Select Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment

More information

ABILIFY INJ. Products Affected Step 2: ABILIFY MAINTENA PREFILLED SYRINGE 300 MG INTRAMUSCULAR ABILIFY MAINTENA PREFILLED SYRINGE 400 MG INTRAMUSCULAR

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

More information

Alprazolam 0.25mg, 0.5mg, 1mg tablets

Alprazolam 0.25mg, 0.5mg, 1mg tablets Presbyterian Senior Care (HMO) / Presbyterian MediCare PPO Quantity Limits Effective November 1, 2014 For the most recent list of drugs or other questions, please contact the Presbyterian Customer Service

More information

ANTIDIABETIC AGENTS - MISCELLANEOUS

ANTIDIABETIC AGENTS - MISCELLANEOUS ANTIDIABETIC AGENTS - MISCELLANEOUS Glyxambi 10 mg-5 mg tablet Glyxambi 25 mg-5 mg tablet Invokamet 150 mg-1,000 mg tablet Invokamet 150 mg-500 mg tablet Invokamet 50 mg-1,000 mg tablet Invokamet 50 mg-500

More information

South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina

South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206 Pharmacy and Therapeutics (P&T) Committee Meeting MINUTES 1. Call to Order A meeting of the

More information

Select Step Therapy Programs January 2016

Select Step Therapy Programs January 2016 Anti-infectives Oral Brand Tetracyclines Acticlate, Adoxa, Doryx, Targadox doxycycline Otic Agents Cetraxal Cardiovascular ofloxacin Beta Blockers Coreg CR Calcium Channel Blockers Prestalia Renin-Angiotensin

More information

AGGRENOX. Products Affected. Details. Open 1 Last Updated: 10/01/2018. Aggrenox

AGGRENOX. Products Affected. Details. Open 1 Last Updated: 10/01/2018. Aggrenox Open 1 Last Updated: 10/01/2018 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_3742 09/2014 Formulary ID: 19076: version 7 1 ANTIDEPRESSANTS

More information

High-Cost Drug Exclusions

High-Cost Drug Exclusions Pharmacy Services High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at

More information

ANTIDEPRESSANTS. Details. dose pack Viibryd 10 mg tablet Viibryd 20 mg tablet Viibryd 40 mg tablet. Criteria

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

More information

Step Therapy Information... 4 Prior Authorization Information ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...

Step Therapy Information... 4 Prior Authorization Information ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy... Step Therapy Information... 4 Prior Authorization Information... 27 ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...62 Acne Therapy Topical...64 Alcoholism Treatment Agents... 66 Analgesic

More information

ALLERGIC CONJUNCTIVITIS AGENTS

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

More information

CRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication.

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

More information

2017 Step Therapy Criteria

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.

More information

Step Therapy Medications

Step Therapy Medications 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,

More information

Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18

Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18 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

More information

ANTIDIABETIC AGENTS - MISCELLANEOUS

ANTIDIABETIC AGENTS - MISCELLANEOUS ANTIDIABETIC AGENTS - MISCELLANEOUS GLYXAMBI 10 MG-5 MG GLYXAMBI 25 MG-5 MG INVOKAMET 150 MG-1,000 MG INVOKAMET 150 MG-500 MG INVOKAMET 50 MG-1,000 MG INVOKAMET 50 MG-500 MG INVOKAMET XR 150 MG-1,000 MG,

More information

New Patient Questionnaire

New Patient Questionnaire 4 Embarcadero Center, Suite 1400, San Francisco, CA 94111 (415) 926-7774 phone; (415) 591-7760 office@sanfranciscopsych.com New Patient Questionnaire Thank you for trusting San Francisco Psychiatry with

More information

Select Step Therapy. Here s how it works:

Select Step Therapy. Here s how it works: Select Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment

More information

A Brief Overview of Psychiatric Pharmacotherapy. Joel V. Oberstar, M.D. Chief Executive Officer

A Brief Overview of Psychiatric Pharmacotherapy. Joel V. Oberstar, M.D. Chief Executive Officer A Brief Overview of Psychiatric Pharmacotherapy Joel V. Oberstar, M.D. Chief Executive Officer Disclosures Some medications discussed are not approved by the FDA for use in the population discussed/described.

More information

Appendix: Psychotropic Medication Reference Tables

Appendix: Psychotropic Medication Reference Tables Appendix: Psychotropic Medication Reference Tables How to Use these Tables These reference tables are designed to provide clinic staff with specific medication related criteria for the Polypharmacy, Cardiometabolic

More information

ANTICONVULSANTS. Details. Step Therapy Criteria Date Effective: April 1, 2019

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

More information

Step Therapy Requirements. Effective: 05/01/2018

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

More information

Step Therapy Criteria

Step Therapy Criteria 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

More information

ANGIOTENSIN RECEPTOR BLOCKERS STEP THERAPY

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

More information

Step Therapy Requirements. Effective: 11/01/2018

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

More information

AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details

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.

More information

Management. Quantity. What Is Quantity Management? What Happens at the Pharmacy? Which Medications Are Included? January 2017

Management. Quantity. What Is Quantity Management? What Happens at the Pharmacy? Which Medications Are Included? January 2017 Quantity January 2017 Management What Is Quantity Management? It s a quality and safety program that promotes the safe use of medications. The program limits the amount of some medications that we cover.

More information

Generics. Lead with. Prescription Step Therapy Program

Generics. Lead with. Prescription Step Therapy Program Lead with Generics Prescription Step Therapy Program WWW.BCBSLA.COM 04HQ3972 R11/10 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company GENERIC DRUGS: A

More information

Prescription Step Therapy Program

Prescription Step Therapy Program Prescription Step Therapy Program 04HQ3972 R11/17 Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company. HMO Louisiana, Inc. is a subsidiary of Blue Cross

More information

ALPHA GLUCOSIDASE INHIBITOR THERAPY

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

More information

Step Therapy Criteria

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

More information

ANTICONVULSANTS. Details

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

More information

CONTRAINDICATIONS TABLE

CONTRAINDICATIONS TABLE CONTRAINDICATIONS TABLE Generic Name Brand Name Contraindications Amphetamine Salts Adderall, Adderall XR Hypersensitivity to amphetamine, dextroamphetamine, or other sympathomimetic amines Advanced arteriosclerosis

More information

Quantity Management. October 2017

Quantity Management. October 2017 Quantity Management October 2017 What Is Quantity Management? It s a quality and safety program that promotes the safe use of medications. The program limits the amount of some medications we cover. We

More information

AGGRENOX. Products Affected. Details. Open 1 Last Updated: 12/01/2018. Aggrenox

AGGRENOX. Products Affected. Details. Open 1 Last Updated: 12/01/2018. Aggrenox Open 1 Last Updated: 12/01/2018 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_3742 09/2014 Formulary ID: 18066: version 17 1 ANTICONVULSANTS

More information

TEST ANTICONVULSANT THERAPY. Products Affected. Step 2: Network Health Insurance Corporation NetworkCares Step Therapy Criteria Last Updated 11/2018

TEST ANTICONVULSANT THERAPY. Products Affected. Step 2: Network Health Insurance Corporation NetworkCares Step Therapy Criteria Last Updated 11/2018 TEST Network Health Insurance Corporation NetworkCares Step Therapy Last Updated 11/2018 ANTICONVULSANT THERAPY Aptiom Banzel Briviact Celontin Dilantin 30 Mg Capsule Equetro Fycompa 0.5 Mg/ml Oral Susp

More information

Pharmacy Updates Summary

Pharmacy Updates Summary All of the following changes were reviewed and approved by the SFHP Pharmacy & Therapeutics (P&T) Committee on 4/16/2014 Effective date: 5/15/2014 Therapeutic Classes reviewed: ADHD Ophthalmic antihistamines

More information

ANTIDIABETIC AGENTS - MISCELLANEOUS

ANTIDIABETIC AGENTS - MISCELLANEOUS ANTIDIABETIC AGENTS - MISCELLANEOUS Glyxambi 10 mg-5 mg tablet Glyxambi 25 mg-5 mg tablet Invokamet 150 mg-1,000 mg tablet Invokamet 150 mg-500 mg tablet Invokamet 50 mg-1,000 mg tablet Invokamet 50 mg-500

More information

VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017

VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017 VNSNY CHOICE FIDA Complete Step Therapy Requirements Effective: 01/01/2017 Updated 12/23/2016 ANTICONVULSANTS Aptiom 200 mg tablet Potiga 200 mg tablet Aptiom 400 mg tablet Potiga 300 mg tablet Aptiom

More information

ATYPICAL ANTIPSYCHOTICS

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:

More information

ANTICHOLINERGIC BRONCHODILATORS ANTICHOLINERGIC BETA-AGONIST COMBO'S CORTICOSTEROID / BRONCHODILATOR COMBO'S NASAL STEROIDS LEUKOTRIENE MODIFIERS

ANTICHOLINERGIC BRONCHODILATORS ANTICHOLINERGIC BETA-AGONIST COMBO'S CORTICOSTEROID / BRONCHODILATOR COMBO'S NASAL STEROIDS LEUKOTRIENE MODIFIERS 1 of 5 ALLERGY / ASTHMA THERAPIES ANTIHISTAMINES, MINIMALLY SEDATING cetirizine fexofenadine loratadine ANTIHISTAMINE/DECONGESTANT COMBINATIONS cetirizine/pseudoephedrine fexofenadine/pseudoephedrine loratadine/pseudoephedrine

More information

Step Therapy Requirements. Effective: 1/1/2019

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

More information

Step Therapy Group Algorithm Steps

Step Therapy Group Algorithm Steps Step Therapy Group Algorithm Steps ACTONEL AMITIZA ANTICONVULSANT ANTIDEPRESSION Previous trial on alendronate Step 1: ALENDRONATE SODIUM Step 2: RISEDRONATE SODIUM, RISEDRONATE SODIUM DR Previous trial

More information

AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details

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.

More information

Management. Quantity. What Is Quantity Management? What Happens at the Pharmacy? Which Medications Are Included? January 2016

Management. Quantity. What Is Quantity Management? What Happens at the Pharmacy? Which Medications Are Included? January 2016 January 2016 Quantity Management What Is Quantity Management? It s a quality and safety program that promotes the safe use of medications. The program limits the amount of some medications that we cover.

More information

Medications, By Class, in TBI

Medications, By Class, in TBI Medications, By Class, in TBI Generic/Brand Name Drawback Advantage Mood Stabilizers (anti-seizure medications) Carbamazepine (Carbatrol ) (Equetro ) (Tegretol ) Gabapentin (Neurontin ) Lamotrigine (Lamictal

More information

2018 Step Therapy Criteria

2018 Step Therapy Criteria 2018 Step Therapy Criteria ANGIOTENSIN RECEPTOR BLOCKERS... 2 ANTIDEPRESSANTS... 3 ANTIDEPRESSANTS, MISCELLANEOUS... 4 ANTIDEPRESSANTS, OTHER... 5 ANTIDIABETIC AGENTS... 6 ANTIGOUT AGENTS... 7 ANTIHYPERTENSIVE

More information

ALPHA BLOCKERS. Products Affected. Details. Step 2: RAPAFLO 4 MG CAPSULE. Step 1: alfuzosin extended release tablet doxazosin tablet

ALPHA BLOCKERS. Products Affected. Details. Step 2: RAPAFLO 4 MG CAPSULE. Step 1: alfuzosin extended release tablet doxazosin tablet ALPHA BLOCKERS RAPAFLO 4 MG CAPSULE RAPAFLO 8 MG CAPSULE drug may be given. alfuzosin extended release tablet doxazosin tablet tamsulosin capsule terazosin capsule 1 ANTIDEPRESSANTS - SNRI FETZIMA 10 MG

More information

Step Therapy Requirements

Step Therapy Requirements Step Therapy Requirements Denver Health Medicare Choice (HMO SNP)/Medicare Select (HMO) Effective: 09/01/2017 Updated 08/2017 ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet

More information

2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements

2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements 2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for

More information

ADHD Medications Table

ADHD Medications Table Stimulants are the first line treatment of choice for ADHD followed by Non-Stimulants, then off-label medications. We are providing this list of medications so that you can be familiar with the common

More information

2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements

2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements 2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for

More information

2018 PDP Premier Step Therapy Document September 2018 Y0114_18_33144_I_009

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.

More information

NEW PATIENT INTAKE FORM

NEW PATIENT INTAKE FORM NEW PATIENT INTAKE FORM Please fill out the following form to the best of your ability. Some sections may not apply to you. We will discuss your responses in greater detail during your first appointment.

More information

2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Criteria Last Updated 11/1/2015

2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Criteria Last Updated 11/1/2015 2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Last Updated 11/1/2015 APLENZIN TAB 174MG, 348MG, 522MG Step Therapy requires trial of bupropion SR or bupropion XL in previous 180

More information

Adult Initial Assessment / Patient Questionnaire Page 1

Adult Initial Assessment / Patient Questionnaire Page 1 Page 1 Patient Name: Date: Age: Date of Birth: / / Please read the following questions and answer to the best of your ability by placing a checkmark in the appropriate boxes or filling in the blank as

More information