STEP THERAPY ALGORITHMS PUP Select Formulary
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1 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 Step Therapy edit, a prior authorization will be needed. STEP THERAPY ALGORITHMS PUP Select Formulary Prior Authorization Department Prior Authorization phone lines provide quicker decisions: (Physician), (Member) Actoplus Met Actoplus Met Therapy b. Thiazolidinedione Step 2: Actoplus Met Actos Actos Therapy c. Insulin d. Byetta Step 2: Actos Advair Diskus, Advair HFA Advair Therapy a. Inhaled corticosteroid b. Long-acting beta agonist c. Inhaled anticholinergic agent d. Theophylline Step 2: Advair Diskus or Advair HFA Allegra suspension Allegra Suspension Therapy Step 1: Cetirizine syrup Step 2 Allegra suspension
2 Glyset, Precose (including acarbose) Alpha Glucosidase Inhibitor Therapy Step 1: Two of the following: c. Thiazolidinedione (TZD) d. Insulin e. Byetta Step 2: Glyset or Precose (including acarbose) Amitiza Amitiza Therapy a. Lactulose b. Polyethylene glycol Step 2: Amitiza Micardis, Micardis HCT Benicar, Benicar HCT, Diovan, Diovan HCT, Atacand, Atacand HCT, Avapro, Avalide, Teveten, Teveten HCT Emsam, Pexeva, Fluoxetine 90 mg DR Angiotensin Receptor Blocker: Group 2 Angiotensin Receptor Blocker: Group 3 Antidepressant Therapy* b. ACE inhibitor/hydrochlorothiazide combination c. ACE inhibitor/calcium channel blocker combination d. Losartan or Losartan/HCTZ Step 2: Micardis or Micardis HCT b. ACE inhibitor/hydrochlorothiazide combination c. ACE inhibitor/calcium channel blocker combination d. Losartan or Losartan/HCTZ Step 2: Benicar, Benicar HCT, Diovan, Diovan HCT Step 3: Atacand, Atacand HCT, Avapro, Avalide, Teveten, or Teveten HCT Step 1: One of the following Tier 1 or Tier 2 antidepressants: a. SSRI b. SNRI c. Bupropion d. Mirtazapine Step 2: Emsam or Pexeva or Fluoxetine 90 mg DR
3 Aricept 23mg Aricept a. Donepezil 10mg b. Donepezil ODT 10mg Step 2: Aricept 23mg Azor Azor Therapy b. ACE inhibitor/hydrochlorothiazide combination c. ACE inhibitor/calcium channel blocker combination d. Angiotensin II Receptor Antagonist e. Angiotensin II Receptor Antagonist Combination Step 2: Azor Evoxac Cholinergic Agonist Therapy Step 1: Pilocarpine Step 2: Evoxac Clarinex Syrup Clarinex Suspension Therapy Step 1: Cetirizine syrup Step 2 Clarinex Syrup Clarinex tablets, Clarinex RDT, Clarinex-D tablets Clarinex Tablet Therapy Step 1: Fexofenadine or Levocetirizine Step 2: Clarinex tablets, Clarinex RDT, or Clarinex-D tablets Strattera CNS Stimulant Therapy a. Amphetamine/dextroamphetamine combinations b. Dextroamphetamine c. Dexmethylphenidate d. Methylphenidate Step 2: Strattera Januvia, Onglyza Dipeptidyl Peptidase 4 Inhibitor Therapy c. Thiazolidinedione (TZD) d. Insulin e. Byetta Step 2: Januvia or Onglyza
4 Janumet Dipeptidyl Peptidase 4 Inhibitor/ Metformin Combination Therapy c. Thiazolidinedione (TZD) d. Insulin e. Byetta Step 2: Janumet Duetact Duetact Therapy a. Sulfonylurea b. Thiazolidinedione Step 2: Duetact Exforge, Exforge HCT Exforge Therapy b. ACE inhibitor/hydrochlorothiazide combination c. ACE inhibitor/calcium channel blocker combination d. Angiotensin II Receptor Antagonist e. Angiotensin II Receptor Antagonist Combination Step 2: Exforge or Exforge HCT Fanapt Fanapt Therapy* Step 1: One of the following atypical antipsychotics: a. Risperidone b. Seroquel/Seroquel XR c. Zyprexa/Zyprexa Zydis Step 2: Fanapt Vesicare Genitourinary Smooth Muscle Relaxant Therapy Step 1: Oxybutynin or Oxybutynin ER AND One of the following: Detrol, Detrol LA, Enablex, Oxytrol or Gelnique Step 2: Vesicare
5 Byetta Incretin Mimetic Therapy c. Insulin d. Thiazolidinedione Step 2: Byetta Aerobid, Asmanex, Alvesco Inhaled Corticosteroid Therapy Step 1: One tier 1 or tier 2 inhaled corticosteroid Step 2: Aerobid, Asmanex, Alvesco Kombiglyze XR Kombiglyze XR Therapy c. Thiazolidinedione (TZD) d. Insulin e. Byetta. Step 2: Kombiglyze XR Lansoprazole (Generic), Lansoprazole ODT Lansoprazole Therapy Step 1: Omeprazole, Pantoprazole, or Nexium Step 2: Lansoprazole (generic) or Lansoprazole ODT (generic) (Generic) Zyflo CR Leukotriene Modifier Asthma Therapy a. Formulary Beta-agonist b. Formulary Inhaled corticosteroid c. Formulary Inhaled Beta-agonist/Corticosteroid combination d. Formulary Oral Corticosteroid Step 2: Zyflo CR Foradil, Serevent Long Acting Beta Agonist Therapy a. Inhaled corticosteroids b. Inhaled anticholinergics Step 2: Foradil or Serevent Lunesta Lunesta Therapy Step 1: Zolpidem or Zolpidem CR Step 2: Lunesta
6 Prandin, Starlix Meglitinide Therapy Step 1: Two of the following: f. Metformin g. Sulfonylurea h. Thiazolidinedione (TZD) i. Insulin j. Byetta. Step 2: Prandin or Starlix Novantrone Injection Novantrone Therapy Step 1: mitoxantrone 2 mg/ml injection Step 2: Novantrone 2 mg/ml injection Xalatan Ophthalmic Prostaglandin Therapy a. Lumigan b. Travatan Z Step 2: Xalatan FML Forte, Vexol Ophthalmic Steroid Therapy Step 1: Ophthalmic prednisolone acetate Step 2: FML Forte or Vexol Ranexa Ranexa Therapy a. Long-acting nitrate b. Beta-blocker c. Calcium-channel blocker Step 2: Ranexa Selfemra Sarafem Therapy* a. Sertraline b. Fluoxetine Step 2: Selfemra Cyclobenzaprine (extended-release) Skeletal Muscle Relaxants Step 1: Cyclobenzaprine (immediate-release) Step 2: Cyclobenzaprine (extended-release) Stalevo Stalevo Therapy Step 1: Carbidopa/levodopa AND Comtan Step 2: Stalevo
7 Altoprev, Lescol, Lescol XL Statin Therapy: Group 1 a. Simvastatin b. Lovastatin c. Pravastatin d. Lipitor e. Crestor Step 2: Altoprev, Lescol, or Lescol XL Vytorin Statin Therapy: Group 4 a. Lipitor b. Crestor Step 2: Vytorin Symbicort Symbicort Therapy a. Inhaled corticosteroid b. Long-acting beta agonist c. Inhaled anticholinergic agent d. theophylline Step 2: Symbicort Tekturna, Tekturna HCT Tekturna Therapy b. ACE inhibitor combination c. Angiotensin II receptor blocker d. Angiotensin II receptor blocker combination Step 2: Tekturna or Tekturna HCT Elidel, Protopic Topical Immunomodulator Therapy Step 1: Topical Corticosteroid Step 2: Elidel or Protopic Tribenzor Tribenzor Therapy b. ACE inhibitor combination c. Angiotensin II receptor blocker d. Angiotensin II receptor blocker combination Step 2: Tribenzor
8 Axert, Frova, Relpax Triptan Therapy Step 1: Naratriptan or Sumatriptan Step 2: Axert, Frova, or Relpax Twynsta Twynsta Therapy b. ACE inhibitor combination c. Angiotensin II Receptor Blocker d. Angiotensin II Receptor Blocker Combination Step 2: Twynsta Uloric Uloric Therapy Step 1: Allopurinol Step 2: Uloric Valturna Valturna Therapy b. ACE inhibitor combination c. Angiotensin II receptor blocker d. Angiotensin II receptor blocker combination e. Tekturna or Tekturna HCT Step 2: Valturna Viibryd Viibryd Therapy* Step 1: One Tier 1 or Tier 2 SSRI or SNRI Step 2: Viibryd Xopenex Nebulizer Xopenex Nebulizer Therapy Step 1: Albuterol (nebulizer) Step 2: Xopenex Nebulizer Zelapar Zelapar Therapy Step 1: Selegiline Step 2: Zelapar
9 Zetia Zetia Therapy a. Lovastatin b. Pravastatin c. Simvastatin d. Crestor e. Lipitor Step 2: Zetia *Step therapy applies to new starts only
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Acyclovir Ointment Mercy Care Plan acyclovir ointment 5 % external Requires use of oral Acyclovir 1 Adcirca ADCIRCA TABLET 20 MG ORAL Requires use of Sildenafil 2 Albenza ALBENZA TABLET 200 MG ORAL Requires
Medication and Dose 10/04/ /05/2016 Total % Change Since 10/2012 ABILIFY 10 MG TABLET $18.76 $ %
Table Comparing NADAC prices for select brand name prescription medications on October 4, 2012 and October 5, 2016 to show how much prices have gone up for these medications. These medications increased
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.
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.
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
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
Primary/Preferred Drug List
April 2012 Primary/Preferred Drug List The CVS Caremark Primary/Preferred Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should
Primary/Preferred Drug List
January 2012 Primary/Preferred Drug List The CVS Caremark Primary/Preferred Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should
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"}
FirstCarolinaCare Insurance Company. Step Therapy Requirements
FirstCarolinaCare Insurance Company Step Therapy Requirements Effective: 12/01/2018 ANTICONVULSANTS APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL 200 MG BANZEL 40 MG/ML ORAL SUSPENSION
Santa Clara Family Health Plan Cal MediConnect Formulary. List of Step Therapy Requirements Effective: 12/01/ E
Santa Clara Family Health Plan Cal MediConnect Formulary List of Step Therapy Requirements Effective: 12/01/2018 13027.12E ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET
Michigan Department of Community Health Quantity Limitations
Abstral (fentanyl) sl tab all strength Acetaminophen Actonel Actonel 35mg Adderall XR 5mg, 10mg, 15mg 240 per 34 days 3 gm/day 2 every 28 days 4 every 28 days Advair Diskus. No more than 180 every 30 days
PA Start Date Therapeutic Class P&T Review Date 7/1/13 TOP$ (Single Drug Reviews) include:
Maryland Department of Health and Mental Hygiene PDL Prior Authorization Implementation Schedule PA Start Therapeutic Class P&T Review 7/1/13 5/2/13 Antidepressants, Other (ForfivoXL) COPD Agents (Tudorza
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
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