ALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Health Choice Generations 1 Tier Gold Effective Date: 11/01/2018.

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1 ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/2018 1

2 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Trial of two of the following formulary products: bupropion, mirtazapine, generic SSRI, or generic SNRI. Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/2018 2

3 ANTIGOUT -SCORE Uloric Trial of allopurinol Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/2018 3

4 ATYPICAL ANTIPSYCHOTICS - SCORE Fanapt Fanapt Titration Pack Vraylar Trial of two generic formulary atypical antipsychotic agents Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/2018 4

5 BISPHOSPHONATES -SCORE Fosamax Plus D Trial of one generic formulary oral bisphosphonate agent Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/2018 5

6 DPP4 INHIBITORS - SCORE Janumet Janumet Xr Januvia Jentadueto Jentadueto Xr Kombiglyze Xr Onglyza Tradjenta Trial of one generic formulary metformin or metformin combination Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/2018 6

7 EPINEPHRINE -SCORE Adrenaclick Epinephrine INJ 0.15MG/0.15ML Trial of one of the following: generic epinephrine (generic Epipen or generic EpiPen Jr, by manufacturer: Mylan, NDCs ** and **), brand Epipen, or brand Epipen Jr. Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/2018 7

8 FILGRASTIM - SCORE Granix Neupogen Trial of Zarxio Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/2018 8

9 GABAPENTIN - SCORE Gralise Gralise Starter Trial of generic gabapentin Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/2018 9

10 GLP1 AGONIST - SCORE Bydureon Bydureon Bcise Bydureon Pen Trulicity Victoza Trial of one generic formulary metformin or metformin combination Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/

11 LAMA - SCORE Tudorza Pressair Trial of Spiriva Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/

12 LEUKOTRIENE MODIFIERS - SCORE Zileuton Er Zyflo Trial of generic montelukast or generic zafirlukast Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/

13 LONG-ACTING OPIOID - SCORE Arymo Er Trial of Embeda Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/

14 OPHTHALMIC NSAID - SCORE Bromsite Trial of one generic ophthalmic NSAID solution: diclofenac, flurbiprofen, ketorolac, AND one brand from: Nevanac, Prolensa, Ilevro. Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/

15 PD AGENTS - SCORE Neupro Trial of one generic formulary dopamine agonist agent Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/

16 RHOPRESSA - SCORE Rhopressa Trial of one of the following: generic latanoprost, generic bimatoprost, Lumigan, Travatan Z, Alphagan P, Azopt, Combigan, Simbrinza. Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/

17 RYTARY - SCORE Rytary Trial of any generic antiparkinson agent Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/

18 SGLT2 - SCORE Glyxambi Invokamet Invokamet Xr Invokana Jardiance Synjardy Synjardy Xr Trial of one generic formulary metformin or metformin combination Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/

19 STATINS - SCORE Livalo Trial of any one generic formulary HMG-CoA reductase inhibitor (statin) Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/

20 INDEX A Adrenaclick... 7 Albuterol - Score... 1 Antidepressants - Score... 2 Antigout -score... 3 Aplenzin... 2 Arymo Er Atypical Antipsychotics - Score... 4 B Bisphosphonates -score... 5 Bromsite Bydureon Bydureon Bcise Bydureon Pen D Desvenlafaxine Er... 2 Dpp4 Inhibitors - Score... 6 E Emsam... 2 Epinephrine... 7 Epinephrine -score... 7 F Fanapt... 4 Fanapt Titration Pack... 4 Fetzima... 2 Fetzima Titration Pack... 2 Filgrastim - Score... 8 Fosamax Plus D... 5 G Gabapentin - Score... 9 Glp1 Agonist - Score Glyxambi Gralise... 9 Gralise Starter... 9 Granix... 8 I Invokamet Invokamet Xr Invokana J Janumet... 6 Janumet Xr... 6 Januvia... 6 Jardiance Jentadueto... 6 Jentadueto Xr... 6 K Kombiglyze Xr... 6 L Lama - Score Leukotriene Modifiers - Score Livalo Long-acting Opioid - Score N Neupogen... 8 Neupro O Onglyza... 6 Ophthalmic Nsaid - Score P Pd Agents - Score Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/

21 R Rhopressa Rhopressa - Score Rytary Rytary - Score S Sglt2 - Score Statins - Score Synjardy Synjardy Xr T Tradjenta... 6 Trulicity Tudorza Pressair U Uloric... 3 V Ventolin Hfa... 1 Victoza Vraylar... 4 Z Zileuton Er Zyflo Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/

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