Step Therapy Approval Criteria
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1 Effective Date: 10/01/2016 This document contains Step Therapy Approval Criteria for the following medications: 1. Colcrys (colchicine) 2. Cymbalta (duloxetine) 3. Dovonex (calcipotriene) 4. Enbrel (etanercept) 5. Fenofibrate 6. Humira (adalimumab) 7. Imitrex Injection vial and STATdose (sumatriptan succinate) 8. Nexium (esomeprazole) 9. Relpax (eletriptan) 10. Soriatane (acitretin) 11. Xarelto 20 mg (rivaroxaban) 12. Xifaxan (rifaximin)
2 Colcrys (colchicine) colchicine Colcrys Antigout; antiinflammatory Gout, treatment and prophylaxis Familial Mediterranean fever Previous failure of one of the following in the past 365 days: o A formulary NSAID o A formulary glucocorticoid o Allopurinol o Probenecid/colchicine Quantity Limit (QL) of 60 tablets per 30 days Initial: October 2016
3 Cymbalta (duloxetine) duloxetine Cymbalta Serotonin-Norepinephrine reuptake inhibitor Chronic musculoskeletal pain Diabetic peripheral neuropathic pain Fibromyalgia Generalized anxiety disorder Major depressive disorder Previous failure of one of the following in the past 365 days: o Gabapentin o Venlafaxine ER o Formulary SSRI o Formulary TCA o Formulary muscle relaxant Quantity Limit (QL) of 60 capsules per 30 days Initial: 01/01/ /01/2015, 10/01/2015
4 Dovonex (calcipotriene) calcipotriene Dovonex Antipsoriatic, Synthetic Vitamin D3 Plaque psoriasis Scalp psoriasis Previous failure of a formulary topical corticosteroid in the past 365 days Initial: January 2016
5 Enbrel (etanercept) etanercept Enbrel TNF inhibitor; immune suppressant Ankylosing spondylitis Juvenile idiopathic arthritis Plaque psoriasis Psoriatic arthritis Rheumatoid arthritis Previous failure of one of the following in the past 365 days: o Asacol o Balsalazide o Dipentum o Methotrexate o Rowasa o Azathioprine o Cyclosporine o Hydroxychloroquine o Hydroxyurea o Leflunomide o Mercaptopurine o Soriatane o Sulfasalazine Quantity limit (QL) of 4 injections per 28 days Initial: 10/01/ /01/2015, 10/01/2016
6 Fenofibrate Brand names: fenofibrate 54 mg, 134 mg and 160 mg Lofibra Fibric acid; antihyperlipidemic Hypercholesterolemia Previous failure of gemfibrozil in the past 180 days Quantity limit of 30 pills per month Initial: 04/01/2014
7 Humira (adalimumab) adalimumab Humira TNF inhibitor; monoclonal antibody; antirheumatic Ankylosing spondylitis Crohn s disease Juvenile idiopathic arthritis Plaque psoriasis Psoriatic arthritis Rheumatoid arthritis Ulcerative colitis Previous failure of one of the following in the past 365 days: o Asacol o Balsalazide o Dipentum o Methotrexate o Rowasa o Azathioprine o Cyclosporine o Hydroxychloroquine o Hydroxyurea o Leflunomide o Mercaptopurine o Soriatane o Sulfasalazine Quantity limit (QL) of 4 injections per 28 days Initial: 10/01/ /01/2015, 10/01/2016
8 Imitrex Injection vial and STATdose (sumatriptan succinate) sumatriptan Imitrex Injection vial and Imitrex STATdose 5HT-1 serotonin receptor agonist; antimigraine Acute migraine Cluster headache Previous failure of sumatriptan oral tablets or sumatriptan nasal spray in the past 365 days Quantity limit (QL) of 6 doses (3 ml) per 30 days Initial: 10/01/2013
9 Nexium (esomeprazole) esomeprazole Nexium Proton pump inhibitor H. pylori duodenal ulcer disease Erosive esophagitis Gastroesophageal reflux disease NSAID-associated gastric ulcer prophylaxis Zollinger-Ellison syndrome Previous failure of omeprazole in the past 365 days Step 2: Previous failure of pantoprazole in the past 365 days Quantity Limit (QL) of 30 capsules per 30 days Initial: 01/01/ /01/2015
10 Relpax (eletriptan) eletriptan Relpax 5-HT1 serotonin receptor agonist; antimigraine Acute migraine Previous failure of a formulary triptan medication (sumatriptan tablet, sumatriptan nasal spray, sumatriptan injection, zolmitriptan tablet or zolmitriptan oral-disintegrating tablet) in the past 180 days Quantity limit (QL) of 6 tablets per 30 days Initial: 10/01/2013
11 Soriatane (acitretin) acitretin Soriatane Retinoid Severe psoriasis Previous failure of methotrexate in the past 365 days. Initial: October 2016
12 Xarelto 20 mg (rivaroxaban) rivaroxaban Xarelto Factor Xa inhibitor Reduction of risk of stroke and systemic embolism in nonvalvular atrial fibrillation Deep vein thrombosis (DVT) Pulmonary embolism (PE) Reduction and risk of recurrence of DVT and PE Prophylaxis of DVT following hip or knee replacement surgery Previous failure of warfarin in the past 365 days Quantity limit (QL) of 30 tablets per 30 days Initial: 01/01/2016
13 Xifaxan (rifaximin) rifaximin Xifaxan Rifamycin Hepatic encephalopathy, prophylaxis Traveler s diarrhea Previous failure of lactulose, ciprofloxacin or azithromycin in the past 180 days Quantity limit (QL) of 60 tablets per 30 days for the 550 mg tablets Quantity limit (QL) of 180 tablets per 30 days for the 200 mg tablets Initial: 07/01/2015
Step Therapy Approval Criteria
Effective Date: 07/01/2015 This document contains for the following medications: 1. Ambien CR (zolpidem ER) 2. Chantix Continuing Month (varenicline) 3. Chantix Starting Month (varenicline) 4. Cymbalta
Step Therapy Approval Criteria
Effective Date: 01/01/2018 This document contains Step Therapy Approval Criteria for the following medications: 1. Colcrys (colchicine) 2. Dovonex (calcipotriene) 3. Enbrel (etanercept) 4. Humira (adalimumab)
Step Therapy Approval Criteria
Effective Date: 01/01/2019 This document contains for the following medications: 1. Colcrys (colchicine) 2. Dovonex (calcipotriene) 3. Enbrel (etanercept) 4. Humira (adalimumab) 5. Imitrex Injection vial
INFLIXIMAB Remicade (infliximab), Inflectra (infliximab-dyyb), Ixifi* (infliximabqbtx), Renflexis (infliximab-abda)
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1 P a g e. Systemic Juvenile Idiopathic Arthritis (SJIA) (1.3) Patients 2 years of age and older with active systemic juvenile idiopathic arthritis.
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Circle Yes or No Y N. [If no, skip to question 7.] 2. Does the patient have a diagnosis of ulcerative colitis? Y N. [If no, skip to question 4.
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2. Does the patient have a diagnosis of Crohn s disease? Y N
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