SelectHealth Advantage 2018 Step Therapy Criteria Previous trial on at least ONE: Generic topical acne treatment
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1 ACNE ADAPAL/BEN P GEL % AZELEX CRE 20% DAPSONE GEL 5% EPIDUO FORTE GEL % TRETINOIN GEL 0.04% TRETINOIN GEL 0.05% TRETINOIN GEL 0.1% ACTONEL ANTICONVULSANT ANTIDEPRESSION ANTIPSYCHOTIC ASTHMA RISEDRON SOD RISEDRONATE APTIOM SPRITAM FETZIMA KHEDEZLA TRINTELLIX ARISTADA FANAPT LATUDA PALIPERIDONE SAPHRIS ADVAIR DISKU ADVAIR HFA BREO ELLIPTA Previous trial on at least ONE: Generic topical acne treatment alendronate carbamezapine, divalproex, epitol, ethosuximide, felbamate, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, tiagabine, topiramate, valproic acid, zonisamide bupropion, citalopram, escitalopram, fluoxetine, fluvoxamine, maprotiline, mirtazapine, paroxetine, sertraline, venlafaxine aripiprazole, clozapine, fluoxetine-olanzapine, haloperidol, olanzapine, quetiapine, risperidone, ziprasidone Previous trial on ONE of the following: 1. Symbicort 2. Fluticasone/Salmeterol BELSOMRA BELSOMRA eszopiclone, zaleplon, zolpidem, zolpidem ER BUDESONIDE BUDESONIDE TAB Previous trial of ONE of the following: Apriso, Delzicol, Mesalamine, Pentasa 1
2 CADUET AMLOD/ATORVA atorvastatin, lovastatin, pravastatin, simvastatin AND amlodipine CAPEX CAPEX clobetasol shampoo CLENPIQ CLENPIQ Previous trial of Suprep CORDRAN CORDRAN 80X3 Previous trial on at least ONE: Generic topical steroid CORLANOR CORLANOR acebutolol, atenolol, bisoprolol, labetolol, metoprolol, nadolol, pindolol, propranolol, timolol DEMSER DEMSER phenoxybenzamine DEPRESSION APLENZIN DESVENLAFAX EMSAM FORFIVO XL PEXEVA VIIBRYD bupropion, citalopram, escitalopram, fluoxetine, fluvoxamine, maprotiline, mirtazapine, paroxetine, sertraline, venlafaxine DERM ELIDEL tacrolimus AND betamethasone, clobetasol, hydrocortisone, triamcinolone DEXILANT DEXILANT lansoprazole, omeprazole, pantoprazole 2
3 DIABETES GLYXAMBI Previous trial on at metformin OR metformin ER INVOKAMET INVOKAMET XR INVOKANA JARDIANCE JENTADUETO SYNJARDY SYNJARDY XR TRULICITY VICTOZA EPLERENONE EPLERENONE spironolactone, spironolactone-hctz EUCRISA EUCRISA OIN Previous trial of at least ONE of the following: 1. Topical Corticosteroid 2. Topical tacrolimus EURAX EURAX Lindane Shampoo OR Permethrin Cream EXALGO HYDROMORPHON fentanyl patches, methadone, morphine ER, oxycodone er, oxymorphone ER, Zohydro GABAPENTIN GASTRO ICS GRALISE GRALISE STAR HORIZANT DELZICOL MESALAMINE ALVESCO PULMICORT QVAR REDIHA QVAR REDIHAL ER generic gabapentin OR pramipexole Apriso, balsalazide, Pentasa, sulfasalazine Flovent OR Arnuity AND Asmanex 3
4 LABA-LAMA ANORO ELLIPT UTIBRON Previous trail on at least ONE of the following: Stiolto OR Bevespi LAMA INCRUSE ELPT SEEBRI NEOHA Spiriva AND Tudorza LUNESTA ESZOPICLONE zolpidem or zaleplon NAMENDA MEMANTINE HC OAB NAMENDA XR DARIFENACIN GELNIQUE TOVIAZ VESICARE immediate release Memantine oxybutynin, oxybutynin er, tolterodine, tolterodine er, trospium, trospium er OXYCONTIN OXYCODONE fentanyl patches, hydromorphone er, methadone, morphine ER, oxymorphone ER, Zohydro ER PPI ESOMEPRA MAG CAP 20MG DR ESOMEPRA MAG CAP 40MG DR LANSOPRAZOLE TAB 15MG LANSOPRAZOLE TAB 30MG lansoprazole capsules, misoprostol, omeprazole, pantoprazole RANEXA RANEXA amlodipine, atenolol, diltiazem, isosorbide dinitrate, isosorbide mononitrate, metoprolol, propranolol, verapamil RASUVO RASUVO generic methotrexate 4
5 REXULTI REXULTI Previous therapy on: aripiprazole AND Latuda OR quetiapine ER RYTARY RYTARY carbidopa/levodopa SA OPIOID OXYMORPHONE APAP/codeine, codiene sulfate, hydrocodone/apap, hydrocodone/ibu, hydromorphone, morphine IR, oxycodone, oxycodone/apap, oxycodone/asa, oxycodone/ibu SABA STATIN STEGLATRO STIMULANTS PROAIR HFA PROAIR RESPI PROVENTIL EZETIM/SIMVA TAB 10-10MG EZETIM/SIMVA TAB 10-20MG EZETIM/SIMVA TAB 10-40MG EZETIM/SIMVA TAB 10-80MG LIVALO TAB 1MG LIVALO TAB 2MG LIVALO TAB 4MG SEGLUROMET TAB STEGLATRO TAB DAYTRANA VYVANSE SYMLIN SYMLINPEN 60 SYMLNPEN 120 Ventolin atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin 10 mg, simvastatin Jardiance OR Synjardy AND Invokana OR Invokamet Previous trial on at least ONE: generic long-acting stimulant OR Diagnosis of binge eating disorder insulin 5
6 SYMPROIC SYMPROIC Movantik TACLONEX TACLONEX TEKTURNA TIZANIDINE TEKTURNA TEKTURNA HCT TIZANIDINE CAP 2MG TIZANIDINE CAP 4MG TIZANIDINE CAP 6MG calcipotriene-betamethasone ointment benazepril, benazepril-hctz, captopril, captopril-hctz, enalapril, enalapril-hctz, fosinopril, fosinopril-hctz, lisinopril, lisinopril-hctz, quinapril, quinapril-hctz, ramipril AND candesartan, candesartan-hctz, eprosartan, irbesartan, irbesartan-hctz, losartan, losartan-hctz, olmesartan, olmesartan-hctz, telmisartan, telmisartan-hctz, valsartan, valsartan-hctz tizanidine tablets TRIPTAN FROVATRIPTAN sumatriptan OR rizatriptan TRULANCE TRULANCE Previous trial on Linzess UCERIS FOAM UCERIS colocort enema, hydrocortisone enema, or mesalamine enema ULORIC ULORIC allopurinol VELPHORO VELPHORO Renagel OR sevelamer VRAYLAR VRAYLAR aripiprazole AND clozapine, fluoxetine-olanzapine, haloperidol, olanzapine, quetiapine, risperidone, ziprasidone VYZULTA RHOPRESSA VYZULTA latanoprost 6
7 ZELAPAR ZELAPAR selegiline ZOHYDRO ZOHYDRO ER fentanyl patches, hydromorphone er, methadone, morphine ER, oxycodone er, oxymorphone ER 7
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
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
Step Therapy Group Algorithm Steps
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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
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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, 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
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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.
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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
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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
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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.
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VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017
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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
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
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
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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
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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
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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
JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET BYDUREON BCISE 2 MG/0.
ANTI DIABETICS BYDUREON 2 MG SUBCUTANEOUS JANUVIA 25 MG TABLET EXTENDED RELEASE SUSPENSION JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET
DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 702 M %
December 16 No Category M changes so the reductions imposed in May which were only supposed to last until September continue As in November, most changes are Category A lines with a few Category C. Significant
5-ASA. Products Affected Dipentum 250 mg capsule. Details. Lialda 1.2 gram tablet,delayed release
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5-ASA. Products Affected DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED RELEASE. Details
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DT Description Price Category Price change
Tariff T Watch October 2014 Readers are no doubt aware of this quarter's bad news for primary care prescribing allocations: NHS England has d the remuneration mechanism for community pharmacies gaining
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Network Health Insurance Corporation NetworkCares Step Therapy Last Updated: 7/2017 ANTICONVULSANT THERAPY Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200
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*
STEP THERAPY CRITERIA
STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered under your medical or prescription
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.
DT Description Price Category Price change Percentage
June 2017 A slight inflationary pressure in most CCGs from mainly Category A increases. Significant price increases: Most of low concern although those involving the less frequently used tamoxifen strengths
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
Step Therapy Requirements
An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 12/01/2017 Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/2014 1 ABILIFY Abilify 10 mg tablet
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
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
ANTIDEPRESSANTS. Details. Step Therapy 2017 Last Updated: 5/23/2017
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
2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+)
2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+) In some cases, UCare requires you to first try certain drugs to
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.
Mercy Care ALBENDAZOLE. Products Affected. ALBENZA TABLET 200 MG ORAL Details. Criteria. Refer to PA Guideline for approval criteria
ALBENDAZOLE Mercy Care ALBENZA TABLET 200 MG ORAL Refer to PA Guideline for approval criteria 1 BRIMONIDINE-TIMOLOL COMBIGAN SOLUTION 0.2-0.5 % OPHTHALMIC Requires use of separate ingredients for at least
Hospital Unit Dose Unit Dose Plus Liquid Unit Dose. BARCODE LISTING Spring See our new Barcode Scanning Guide on page 26
Hospital Unit Dose Unit Dose Plus Liquid Unit Dose BARCODE LISTING Spring 2018 See our new Barcode Scanning Guide on page 26 YOU ASKED. WE DELIVERED! New proprietary offering from AHP! LIQUID UNIT DOSE
ALBUTEROL - SCORE{XE "ALBUTEROL - SCORE"}
Step Therapy ALBUTEROL - SCORE{XE "ALBUTEROL - SCORE"} Ventolin Hfa{XE "Ventolin Hfa"} Trial of ProAir Formulary ID# 00018097 Last Updated: 04/01/2018 1 ANTIDEPRESSANTS - SCORE{XE "ANTIDEPRESSANTS - SCORE"}