2019 STEP THERAPY CRITERIA UCare Individual & Family Plans UCare Individual & Family Plans with Fairview
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1 2019 STEP THERAPY CRITERIA UCare Individual & Family Plans UCare Individual & Family Plans with Fairview In some cases, UCare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, UCare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, UCare will then cover Drug B. This is a list of drugs that require these steps for us to provide coverage. Updated 1/2019 Effective 2/1/2019 IFP_IFPFV_1_IA ( ) U6508 (10/18)
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4 Inhaled Corticosteroids Products Affected ASMANEX HFA 100 MCG/ACTUATION AEROSOL INHALER ASMANEX HFA 200 MCG/ACTUATION AEROSOL INHALER ASMANEX TWISTHALER 110 MCG (30 ASMANEX TWISTHALER 110 MCG (7 Details ASMANEX TWISTHALER 220 MCG (120 ASMANEX TWISTHALER 220 MCG (14 ASMANEX TWISTHALER 220 MCG (30 ASMANEX TWISTHALER 220 MCG (60 Criteria If patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 drug(s): Flovent and Qvar. Step 2 drug(s): Asmanex 1
5 NOVEL ANTIPSYCHOTICS Products Affected aripiprazole 10 mg tablet aripiprazole 15 mg tablet aripiprazole 2 mg tablet aripiprazole 20 mg tablet aripiprazole 30 mg tablet aripiprazole 5 mg tablet clozapine 100 mg disintegrating tablet clozapine 12.5 mg disintegrating tablet clozapine 25 mg disintegrating tablet LATUDA 120 MG TABLET LATUDA 20 MG TABLET LATUDA 40 MG TABLET LATUDA 60 MG TABLET LATUDA 80 MG TABLET olanzapine 10 mg disintegrating tablet olanzapine 15 mg disintegrating tablet olanzapine 20 mg disintegrating tablet olanzapine 5 mg disintegrating tablet quetiapine er 150 mg tablet,extended Details quetiapine er 200 mg tablet,extended quetiapine er 300 mg tablet,extended quetiapine er 400 mg tablet,extended quetiapine er 50 mg tablet,extended release 24 hr risperidone 0.25 mg disintegrating tablet risperidone 0.5 mg disintegrating tablet risperidone 1 mg disintegrating tablet risperidone 2 mg disintegrating tablet risperidone 3 mg disintegrating tablet risperidone 4 mg disintegrating tablet SAPHRIS (BLACK CHERRY) 10 MG SUBLINGUAL TABLET SAPHRIS (BLACK CHERRY) 5 MG SUBLINGUAL TABLET SAPHRIS 2.5 MG SUBLINGUAL TABLET Criteria If patient has tried Step 1 drug, then authorization for Step 2 drug may be given. Step 1 drug(s): clozapine, olanzapine, quetiapine, risperidone, haloperidol, ziprasidone Step 2 drug(s): Latuda, quetiapine ER, clozapine ODT, risperidone ODT, olanzapine ODT, Saphris, aripiprazole. Authorization for the following drugs may be given without a trial of a Step 1 drug: quetiapine ER, if the patient has a diagnosis of major depressive disorder and currently on an antidepressant, aripiprazole, if patient has a diagnosis of Major Depressive Disorder and receiving antidepressants. 2
6 Index aripiprazole 10 mg tablet... 2 aripiprazole 15 mg tablet... 2 aripiprazole 2 mg tablet... 2 aripiprazole 20 mg tablet... 2 aripiprazole 30 mg tablet... 2 aripiprazole 5 mg tablet... 2 ASMANEX HFA 100 MCG/ACTUATION AEROSOL INHALER...1 ASMANEX HFA 200 MCG/ACTUATION AEROSOL INHALER...1 ASMANEX TWISTHALER 110 MCG ( ASMANEX TWISTHALER 110 MCG ( ASMANEX TWISTHALER 220 MCG ( ASMANEX TWISTHALER 220 MCG ( ASMANEX TWISTHALER 220 MCG ( ASMANEX TWISTHALER 220 MCG ( clozapine 100 mg disintegrating tablet... 2 clozapine 12.5 mg disintegrating tablet... 2 clozapine 25 mg disintegrating tablet... 2 LATUDA 120 MG TABLET... 2 LATUDA 20 MG TABLET... 2 LATUDA 40 MG TABLET... 2 LATUDA 60 MG TABLET... 2 LATUDA 80 MG TABLET... 2 olanzapine 10 mg disintegrating tablet... 2 olanzapine 15 mg disintegrating tablet... 2 olanzapine 20 mg disintegrating tablet... 2 olanzapine 5 mg disintegrating tablet... 2 quetiapine er 150 mg tablet,extended...2 quetiapine er 200 mg tablet,extended...2 quetiapine er 300 mg tablet,extended...2 quetiapine er 400 mg tablet,extended...2 quetiapine er 50 mg tablet,extended...2 risperidone 0.25 mg disintegrating tablet...2 risperidone 0.5 mg disintegrating tablet...2 risperidone 1 mg disintegrating tablet...2 risperidone 2 mg disintegrating tablet...2 risperidone 3 mg disintegrating tablet...2 risperidone 4 mg disintegrating tablet...2 SAPHRIS (BLACK CHERRY) 10 MG SUBLINGUAL TABLET... 2 SAPHRIS (BLACK CHERRY) 5 MG SUBLINGUAL TABLET... 2 SAPHRIS 2.5 MG SUBLINGUAL TABLET...2 3
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