BRINTELLIX. Step Therapy Criteria HealthTeam Advantage Formulary ID: Version 6 Effective Date: 1/1/2016. PRODUCT(s) AFFECTED BRINTELLIX

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1 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 requires a step therapy exception request indicating: (1) history of inadequate treatment response with any 2 generic formulary antidepressants, OR (2) history of adverse event with any 2 generic formulary antidepressantss, OR (3) any 2 generic formulary antidepressants are contraindicated. PAGE 1 LAST UPDATED 10/21/2015

2 IRENKA IRENKA Claim will pay automatically for Irenka if enrollee has a paid claim for at least a 1 days supply of Duloxetine 40mg capsules in the past 365 days. Otherwise, Irenka requires a step therapy exception request indicating: (1) history of inadequate treatment response with Duloxetine 40mg capsules, OR (2) history of adverse event with Duloxetine 40mg capsules, OR (3) Duloxetine 40mg capsules is contraindicated. PAGE 2 LAST UPDATED 10/21/2015

3 MYRBETRIQ MYRBETRIQ Claim will pay automatically for Myrbetriq if enrollee has a paid claim for at least a 1 days supply of any formulary urinary anticholinergic in the past 365 days. Otherwise, Myrbetriq requires a step therapy exception request indicating: (1) history of inadequate treatment response with formulary urinary anticholinergic, OR (2) history of adverse event with formulary urinary anticholinergic, OR (3) formulary urinary anticholinergic is contraindicated. PAGE 3 LAST UPDATED 10/21/2015

4 PANCREATIC ENZYMES - CREON - PERTZYE 1. The patient is currently stabilized on Creon or Pertzye, OR 2. The patient has had a trial of Zenpep or Pancreaze OR 3. The patient has had an inadequate response after a trial of Zenpep or Pancreaze OR 4. The patient is intolerant to or had an adverse reaction with Zenpep or Pancreaze. PAGE 4 LAST UPDATED 10/21/2015

5 PPI - DEXILANT - KAPIDEX Claim will pay automatically for Dexilant if enrollee has a paid claim for at least a 1 days supply of lansoprazole, omeprazole, pantoprazole, or rabeprazole in the past 120 days. Otherwise, Dexilant requires a step therapy exception request indicating: (1) history of inadequate treatment response with lansoprazole, omeprazole, pantoprazole, or rabeprazole, OR (2) history of adverse event with lansoprazole, omeprazole, pantoprazole, or rabeprazole, OR (3) lansoprazole, omeprazole, pantoprazole, or rabeprazole is contraindicated. PAGE 5 LAST UPDATED 10/21/2015

6 RHEUMATOID ARTHRITIS - ACTEMRA - CIMZIA PREFILLED - KINERET - REMICADE - SIMPONI SOLN PRSYR 100 MG/ML - STELARA SOLN PRSYR 45 MG/0.5ML - CIMZIA - CIMZIA STARTER KIT - ORENCIA - SIMPONI ARIA - SIMPONI SOLN PRSYR 50 MG/0.5ML - XELJANZ Claim will pay automatically for Actrema, Cimzia, Kineret, Orencia, Remicade, Simponi, Stelara, or Xeljanz if enrollee has a paid claim for at least a 1 days supply of Enbrel or Humira in the past 120 days. Otherwise, Actrema, Cimzia, Kineret, Orencia, Remicade, Simponi, Stelara, or Xeljanz requires a step therapy exception request indicating: (1) history of inadequate treatment response with Enbrel or Humira, OR (2) history of adverse event with Enbrel or Humira, OR (3) Enbrel or Humira is contraindicated. For diagnosis cryopyrin-associated periodic syndromes, Kineret will be approved. For diagnosis pediatric ulcerative colitis, Remicade will be approved. PAGE 6 LAST UPDATED 10/21/2015

7 UCERIS UCERIS TAB ER 24H 9 MG Claim will pay automatically for Uceris if enrollee has a paid claim for at least a 1 days supply of any formulary corticosteroid used to treat ulcerative colitis in the past 365 days. Otherwise, Uceris requires a step therapy exception request indicating: (1) history of inadequate treatment response with formulary corticosteroid used to treat ulcerative colitis, OR (2) history of adverse event with formulary corticosteroid used to treat ulcerative colitis, OR (3) formulary corticosteroid used to treat ulcerative colitis is contraindicated. PAGE 7 LAST UPDATED 10/21/2015

8 XTANDI XTANDI Claim will pay automatically for Xtandi if enrollee has a paid claim for at least a 1 days supply of Zytiga in the past 120 days. Otherwise, Xtandi requires a step therapy exception request indicating: (1) history of inadequate treatment response with Zytiga, OR (2) history of adverse event with Zytiga, OR (3) Zytiga is contraindicated. PAGE 8 LAST UPDATED 10/21/2015

9 PAGE 9 LAST UPDATED 10/21/2015

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