ACYCLOVIR OINT (CCHP2017)
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- Imogene Welch
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1 ACYCLOVIR OINT (CCHP2017) acyclovir 5 % topical ointment Step Therapy requires trial of one (1) of the following: oral generic acyclovir, oral generic famciclovir, oral generic valacyclovir. 1
2 ALPHAGAN (CCHP2017) ALPHAGAN P 0.1 % EYE DROPS Step Therapy requires trial of brimonidine 0.15%. 2
3 ANAPHYLAXIS_NVT 2015 epinephrine 0.15 mg/0.15 ml auto-injector (for 33 to 66 lb patients) epinephrine 0.3 mg/0.3 ml injection, injector-auto Step Therapy requires trial of EPIPEN or EPINEPHRINE 0.15MG/0.3ML AUTO-INJECTOR in previous 120 days. 3
4 ANTIDEPRESSANT_NVT 2017 DESVENLAFAXINE ER 100 MG TABLET,EXTENDED 24 HR DESVENLAFAXINE ER 50 MG TABLET,EXTENDED 24 HR DESVENLAFAXINE FUMARATE ER 100 MG TABLET, EXTENDED 24 HR DESVENLAFAXINE FUMARATE ER 50 MG TABLET, EXTENDED 24 HR duloxetine 40 mg capsule,delayed release EMSAM 12 MG/24 HR TRANSDERMAL 24 HOUR PATCH EMSAM 6 MG/24 HR TRANSDERMAL 24 HOUR PATCH EMSAM 9 MG/24 HR TRANSDERMAL 24 HOUR PATCH FETZIMA 120 MG CAPSULE,EXTENDED FETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED,24 HR,DOSE PACK FETZIMA 20 MG CAPSULE,EXTENDED FETZIMA 40 MG CAPSULE,EXTENDED FETZIMA 80 MG CAPSULE,EXTENDED fluvoxamine er 100 mg capsule,extended release 24 hr fluvoxamine er 150 mg capsule,extended release 24 hr MARPLAN 10 MG TABLET PEXEVA 10 MG TABLET PEXEVA 20 MG TABLET PEXEVA 30 MG TABLET PEXEVA 40 MG TABLET TRINTELLIX 10 MG TABLET TRINTELLIX 20 MG TABLET TRINTELLIX 5 MG TABLET VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK VIIBRYD 10 MG TABLET VIIBRYD 20 MG TABLET VIIBRYD 40 MG TABLET Step Therapy requires trial of one of the following generic SSRI's in previous 120 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine, Paxil oral solution, or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 4
5 APLENZIN_NVT 2015 APLENZIN 174 MG TABLET,EXTENDED APLENZIN 348 MG TABLET,EXTENDED APLENZIN 522 MG TABLET,EXTENDED Step Therapy requires trial of bupropion SR or bupropion XL in previous 120 days. 5
6 ARICEPT 23_NVT 2015 donepezil 10 mg disintegrating tablet donepezil 5 mg disintegrating tablet Step Therapy requires trial of regular donepezil 5 mg or 10mg oral tablets in previous 120 days. 6
7 DEXILANT_2019 DEXILANT 30 MG CAPSULE, DELAYED DEXILANT 60 MG CAPSULE, DELAYED Step therapy requires trial of lansoprazole in the previous 120 days. 7
8 DIFICID_NVT DIFICID 200 MG TABLET Step Therapy requires trial of vancomycin. 8
9 DRY EYE OTC (CCHP 2018) RESTASIS 0.05 % EYE DROPS IN A DROPPERETTE Step Therapy requires trial of OTC artificial tears. 9
10 ESTRING_NVT 2016 ESTRING 2 MG (7.5 MCG/24 HOUR) VAGINAL RING FEMRING 0.05 MG/24 HR VAGINAL FEMRING 0.1 MG/24 HR VAGINAL PREMARIN MG/GRAM VAGINAL CREAM Step Therapy requires trial of ESTRADIOL VAGINAL CREAM OR TABLET in previous 120 days. 10
11 NASAL CORTICOSTEROIDS_NVT 2017 BECONASE AQ 42 MCG (0.042 %) NASAL SPRAY mometasone 50 mcg/actuation nasal spray OMNARIS 50 MCG NASAL SPRAY QNASL 40 MCG/ACTUATION NASAL AEROSOL SPRAY QNASL 80 MCG/ACTUATION NASAL AEROSOL SPRAY ZETONNA 37 MCG/ACTUATION NASAL HFA INHALER Step Therapy requires trial of TWO (2) formulary generic Nasal Corticosteroids. If for nasal polyps, step therapy not required for BECONASE AQ. If for prophylaxis of seasonal allergic rhinitis, step therapy not required for mometasone. If for seasonal and perennial vasomotor nonallergic rhinitis, trial of fluticasone only required for BECONASE AQ. 11
12 OPHTHALMIC ANTI-INFECTIVES_NVT 2015 BESIVANCE 0.6 % EYE DROPS,SUSPENSION gatifloxacin 0.5 % eye drops Step Therapy requires trial of one of the following ciprofloxacin, levofloxacin, or ofloxacinin previous 120 days. 12
13 PANCREATIC ENZYMES_NVT 2015 PANCREAZE 10,500 UNIT-35,500 UNIT-61,500 UNIT CAPSULE,DELAYED PANCREAZE 16,800 UNIT-56,800 UNIT-98,400 UNIT CAPSULE,DELAYED PANCREAZE 2,600 UNIT-6,200 UNIT- 10,850 UNIT CAPSULE,DELAYED PANCREAZE 21,000 UNIT-54,700 UNIT-83,900 UNIT CAPSULE,DELAYED PANCREAZE 4,200 UNIT-14,200 UNIT- 24,600 UNIT CAPSULE,DELAYED PERTZYE 16,000 UNIT-57,500 UNIT- 60,500 UNIT CAPSULE,DELAYED PERTZYE 24,000-86,250-90,750 UNIT CAPSULE,DELAYED PERTZYE 4,000 UNIT-14,375 UNIT- 15,125 UNIT CAPSULE,DELAYED PERTZYE 8,000 UNIT-28,750 UNIT- 30,250 UNIT CAPSULE,DELAYED ZENPEP 10,000 UNIT-32,000 UNIT- 42,000 UNIT CAPSULE,DELAYED ZENPEP 10,000 UNIT-34,000 UNIT- 55,000 UNIT CAPSULE,DELAYED ZENPEP 15,000 UNIT-47,000 UNIT- 63,000 UNIT CAPSULE,DELAYED ZENPEP 15,000 UNIT-51,000 UNIT- 82,000 UNIT CAPSULE,DELAYED ZENPEP 20,000 UNIT-63,000 UNIT- 84,000 UNIT CAPSULE,DELAYED ZENPEP 25,000 UNIT-79,000 UNIT- 105,000 UNIT CAPSULE,DELAYED ZENPEP 25,000 UNIT-85,000 UNIT- 136,000 UNIT CAPSULE,DELAYED ZENPEP 3,000 UNIT-10,000 UNIT- 14,000 UNIT CAPSULE,DELAYED ZENPEP 3,000 UNIT-10,000 UNIT- 16,000 UNIT CAPSULE,DELAYED ZENPEP 40,000 UNIT-126,000 UNIT- 168,000 UNIT CAPSULE,DELAYED ZENPEP 5,000 UNIT-17,000 UNIT- 24,000 UNIT CAPSULE,DELAYED ZENPEP 5,000 UNIT-17,000 UNIT- 27,000 UNIT CAPSULE,DELAYED Step Therapy requires trial of CREON in previous 120 days. 13
14 PENTASA_NVT 2015 APRISO GRAM CAPSULE,EXTENDED DELZICOL 400 MG CAPSULE (DR TABLETS INSIDE) LIALDA 1.2 GRAM TABLET,DELAYED PENTASA 250 MG CAPSULE,CONTROLLED PENTASA 500 MG CAPSULE,CONTROLLED Step Therapy requires trial of one of the following: mesalamine delayedrelease 1.2gm, or mesalamine DR 800 mg in previous 120 days. 14
15 RYTARY_NVT RYTARY MG-95 MG CAPSULE,EXTENDED RYTARY MG-145 MG CAPSULE,EXTENDED RYTARY MG-195 MG CAPSULE,EXTENDED RYTARY MG-245 MG CAPSULE,EXTENDED Step Therapy requires trial of carbidopa/levodopa ER tab. 15
16 ST_RIVASTIGMINE_2019 rivastigmine 13.3 mg/24 hour transdermal patch rivastigmine 4.6 mg/24 hour transdermal patch rivastigmine 9.5 mg/24 hour transdermal patch Step Therapy requires trial of rivastigmine tablets in past 120 days. 16
17 ST_SMOKINGCESS_2019 ZYBAN 150 MG TABLET,EXTENDED Step therapy requires trial of Nicoderm patches in previous 120 days. 17
18 ULORIC_NVT 2015 ULORIC 40 MG TABLET ULORIC 80 MG TABLET Step Therapy requires trial of allopurinol in previous 120 days. 18
19 URINARY ANTISPASMOTICS_NVT darifenacin er 15 mg tablet,extended release 24 hr darifenacin er 7.5 mg tablet,extended release 24 hr OXYTROL 3.9 MG/24 HR TRANSDERMAL PATCH TOVIAZ 4 MG TABLET,EXTENDED TOVIAZ 8 MG TABLET,EXTENDED Step Therapy requires trial of Vesicare OR Myrbetriq in previous 120 days. 19
20 ZADITOR OTC (CCHP2017) olopatadine 0.1 % eye drops Step 3: olopatadine 0.2 % eye drops PAZEO 0.7 % EYE DROPS Step Therapy requires trial of OTC zaditor/ketotifen for olopatadine ophth soln. Trial of olopatadine 1 mg/ml ophth soln required for olopatadine 2 mg/ml and PAZEO 20
21 ZIOPTAN_NVT ZIOPTAN (PF) % EYE DROPS IN A DROPPERETTE Step Therapy requires trial of latanoprost. 21
22 INDEX A acyclovir 5 % topical ointment... 1 ALPHAGAN P 0.1 % EYE DROPS... 2 APLENZIN 174 MG TABLET,EXTENDED... 5 APLENZIN 348 MG TABLET,EXTENDED... 5 APLENZIN 522 MG TABLET,EXTENDED... 5 APRISO GRAM CAPSULE,EXTENDED B BECONASE AQ 42 MCG (0.042 %) NASAL SPRAY BESIVANCE 0.6 % EYE DROPS,SUSPENSION D darifenacin er 15 mg tablet,extended release 24 hr darifenacin er 7.5 mg tablet,extended release 24 hr DELZICOL 400 MG CAPSULE (DR TABLETS INSIDE) DESVENLAFAXINE ER 100 MG TABLET,EXTENDED 24 HR... 4 DESVENLAFAXINE ER 50 MG TABLET,EXTENDED 24 HR... 4 DESVENLAFAXINE FUMARATE ER 100 MG TABLET, EXTENDED 24 HR... 4 DESVENLAFAXINE FUMARATE ER 50 MG TABLET, EXTENDED 24 HR... 4 DEXILANT 30 MG CAPSULE, DELAYED... 7 DEXILANT 60 MG CAPSULE, DELAYED... 7 DIFICID 200 MG TABLET... 8 donepezil 10 mg disintegrating tablet... 6 donepezil 5 mg disintegrating tablet... 6 duloxetine 40 mg capsule,delayed release.. 4 E EMSAM 12 MG/24 HR TRANSDERMAL 24 HOUR PATCH... 4 EMSAM 6 MG/24 HR TRANSDERMAL 24 HOUR PATCH... 4 EMSAM 9 MG/24 HR TRANSDERMAL 24 HOUR PATCH... 4 epinephrine 0.15 mg/0.15 ml auto-injector (for 33 to 66 lb patients)... 3 epinephrine 0.3 mg/0.3 ml injection, injector-auto... 3 ESTRING 2 MG (7.5 MCG/24 HOUR) VAGINAL RING F FEMRING 0.05 MG/24 HR VAGINAL.. 10 FEMRING 0.1 MG/24 HR VAGINAL FETZIMA 120 MG CAPSULE,EXTENDED... 4 FETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED,24 HR,DOSE PACK... 4 FETZIMA 20 MG CAPSULE,EXTENDED... 4 FETZIMA 40 MG CAPSULE,EXTENDED... 4 FETZIMA 80 MG CAPSULE,EXTENDED... 4 fluvoxamine er 100 mg capsule,extended release 24 hr... 4 fluvoxamine er 150 mg capsule,extended release 24 hr... 4 G gatifloxacin 0.5 % eye drops L LIALDA 1.2 GRAM TABLET,DELAYED M MARPLAN 10 MG TABLET... 4 mometasone 50 mcg/actuation nasal spray 11 O olopatadine 0.1 % eye drops
23 olopatadine 0.2 % eye drops OMNARIS 50 MCG NASAL SPRAY OXYTROL 3.9 MG/24 HR TRANSDERMAL PATCH P PANCREAZE 10,500 UNIT-35,500 UNIT- 61,500 UNIT CAPSULE,DELAYED PANCREAZE 16,800 UNIT-56,800 UNIT- 98,400 UNIT CAPSULE,DELAYED PANCREAZE 2,600 UNIT-6,200 UNIT- 10,850 UNIT CAPSULE,DELAYED PANCREAZE 21,000 UNIT-54,700 UNIT- 83,900 UNIT CAPSULE,DELAYED PANCREAZE 4,200 UNIT-14,200 UNIT- 24,600 UNIT CAPSULE,DELAYED PAZEO 0.7 % EYE DROPS PENTASA 250 MG CAPSULE,CONTROLLED 14 PENTASA 500 MG CAPSULE,CONTROLLED 14 PERTZYE 16,000 UNIT-57,500 UNIT- 60,500 UNIT CAPSULE,DELAYED PERTZYE 24,000-86,250-90,750 UNIT CAPSULE,DELAYED PERTZYE 4,000 UNIT-14,375 UNIT- 15,125 UNIT CAPSULE,DELAYED PERTZYE 8,000 UNIT-28,750 UNIT- 30,250 UNIT CAPSULE,DELAYED PEXEVA 10 MG TABLET... 4 PEXEVA 20 MG TABLET... 4 PEXEVA 30 MG TABLET... 4 PEXEVA 40 MG TABLET... 4 PREMARIN MG/GRAM VAGINAL CREAM Q QNASL 40 MCG/ACTUATION NASAL AEROSOL SPRAY QNASL 80 MCG/ACTUATION NASAL AEROSOL SPRAY R RESTASIS 0.05 % EYE DROPS IN A DROPPERETTE... 9 rivastigmine 13.3 mg/24 hour transdermal patch rivastigmine 4.6 mg/24 hour transdermal patch rivastigmine 9.5 mg/24 hour transdermal patch RYTARY MG-95 MG CAPSULE,EXTENDED RYTARY MG-145 MG CAPSULE,EXTENDED RYTARY MG-195 MG CAPSULE,EXTENDED RYTARY MG-245 MG CAPSULE,EXTENDED T TOVIAZ 4 MG TABLET,EXTENDED TOVIAZ 8 MG TABLET,EXTENDED TRINTELLIX 10 MG TABLET... 4 TRINTELLIX 20 MG TABLET... 4 TRINTELLIX 5 MG TABLET... 4 U ULORIC 40 MG TABLET ULORIC 80 MG TABLET V VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK... 4 VIIBRYD 10 MG TABLET... 4 VIIBRYD 20 MG TABLET... 4 VIIBRYD 40 MG TABLET... 4 Z ZENPEP 10,000 UNIT-32,000 UNIT- 42,000 UNIT CAPSULE,DELAYED
24 ZENPEP 10,000 UNIT-34,000 UNIT- 55,000 UNIT CAPSULE,DELAYED ZENPEP 15,000 UNIT-47,000 UNIT- 63,000 UNIT CAPSULE,DELAYED ZENPEP 15,000 UNIT-51,000 UNIT- 82,000 UNIT CAPSULE,DELAYED ZENPEP 20,000 UNIT-63,000 UNIT- 84,000 UNIT CAPSULE,DELAYED ZENPEP 25,000 UNIT-79,000 UNIT- 105,000 UNIT CAPSULE,DELAYED ZENPEP 25,000 UNIT-85,000 UNIT- 136,000 UNIT CAPSULE,DELAYED ZENPEP 3,000 UNIT-10,000 UNIT-14,000 UNIT CAPSULE,DELAYED ZENPEP 3,000 UNIT-10,000 UNIT-16,000 UNIT CAPSULE,DELAYED ZENPEP 40,000 UNIT-126,000 UNIT- 168,000 UNIT CAPSULE,DELAYED ZENPEP 5,000 UNIT-17,000 UNIT-24,000 UNIT CAPSULE,DELAYED ZENPEP 5,000 UNIT-17,000 UNIT-27,000 UNIT CAPSULE,DELAYED ZETONNA 37 MCG/ACTUATION NASAL HFA INHALER ZIOPTAN (PF) % EYE DROPS IN A DROPPERETTE ZYBAN 150 MG TABLET,EXTENDED
ACYCLOVIR OINT (CCHP2017)
ACYCLOVIR OINT (CCHP2017) acyclovir 5 % topical ointment Step Therapy requires trial of one (1) of the following: oral generic acyclovir, oral generic famciclovir, oral generic valacyclovir. 1 ALPHAGAN
ACYCLOVIR OINT (CCHP2017)
ACYCLOVIR OINT (CCHP2017) acyclovir 5 % topical ointment Step Therapy requires trial of one (1) of the following: oral generic acyclovir, oral generic famciclovir, oral generic valacyclovir. 1 ALPHAGAN
ACYCLOVIR OINT (CCHP2017)
ACYCLOVIR OINT (CCHP2017) acyclovir 5 % topical ointment Step Therapy requires trial of one (1) of the following: oral generic acyclovir, oral generic famciclovir, oral generic valacyclovir. 1 ALPHAGAN
ACYCLOVIR OINT (CCHP2017)
ACYCLOVIR OINT (CCHP2017) acyclovir 5 % topical ointment Step Therapy requires trial of one (1) of the following: oral generic acyclovir, oral generic famciclovir, oral generic valacyclovir. 1 ALPHAGAN
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5-ASA. Products Affected Dipentum 250 mg capsule. Details. Lialda 1.2 gram tablet,delayed release
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Step Therapy Requirements. Effective: 11/01/2018
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BYSTOLIC. Products Affected Step 2: BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET. Details BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET
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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.
ANTICONVULSANTS. Details
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ANTICONVULSANTS. Details
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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ALPHA BLOCKERS RAPAFLO 4 MG CAPSULE RAPAFLO 8 MG CAPSULE drug may be given. alfuzosin extended release tablet doxazosin tablet tamsulosin capsule terazosin capsule 1 ANTIDEPRESSANTS - SNRI FETZIMA 10 MG
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
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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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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
Step Therapy Requirements. Effective: 1/1/2019
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2018 GRS Premier Step Therapy Document. September 2018 Y0114_18_33177_I_010
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ANTIDIABETIC AGENTS - MISCELLANEOUS GLYXAMBI 10 MG-5 MG GLYXAMBI 25 MG-5 MG INVOKAMET 150 MG-1,000 MG INVOKAMET 150 MG-500 MG INVOKAMET 50 MG-1,000 MG INVOKAMET 50 MG-500 MG INVOKAMET XR 150 MG-1,000 MG,
2018 Step Therapy FID 18088
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Step Therapy Simply Health Care 2014 Formulary ID: 14406 Version: 14 Last Updated: 08/01/2014 ADHD STIMULANTS-S(SHC) Daytrana Focalin Xr Strattera Patient needs to have a paid claim for one Step 1 drug
CRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication.
ADHD STIMULANTS ATOMOXETINE HCL, DEXEDRINE 10 MG TABLET, DEXEDRINE 5 MG TABLET, DEXMETHYLPHENIDATE HCL, DEXMETHYLPHENIDATE HCL ER, DEXTROAMPHETAMINE 10 MG TAB, DEXTROAMPHETAMINE 5 MG TAB, DEXTROAMPHETAMINE
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.
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
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
ANTIDIABETIC AGENTS - MISCELLANEOUS
ANTIDIABETIC AGENTS - MISCELLANEOUS Glyxambi 10 mg-5 mg tablet Glyxambi 25 mg-5 mg tablet Invokamet 150 mg-1,000 mg tablet Invokamet 150 mg-500 mg tablet Invokamet 50 mg-1,000 mg tablet Invokamet 50 mg-500
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 04/01/2019
VNSNY CHOICE FIDA Complete Step Therapy Requirements Effective: 04/01/2019 Updated 03/2019 AMANTADINE ER OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED
Simply Step Therapy Document September 2018 Y0114_18_33074_I_009
2018 2018 Simply Step Therapy Document September 2018 Aptiom APTIOM 200 MG TABLET APTIOM 400 MG TABLET Y0114_18_33074_I_009 APTIOM 600 MG TABLET APTIOM 800 MG TABLET Criteria If the patient has tried a
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
HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES
Generic Brand HICL GCN Exception/Other BUPROPION HCL WELLBUTRIN, 01653 WELLBUTRIN SR, WELLBUTRIN XL BUPROPION HBR APLENZIN 17050 16996 26198 CITALOPRAM CELEXA 10321 GPID 16344 HYDROBROMIDE DESVENLAFAXINE
Medicare Part D Drugs that Require Step Therapy Effective 12/01/2017
Medicare Part D Drugs that Require Step Therapy Effective 12/01/2017 Providers may call the Pharmacy Help Desk at 800-641-8921 for more information or questions about criteria. The formulary may change
Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Value Rx (HMO), Stride SM Value Rx Plus (HMO) and Stride SM Gain Rx (HMO)
Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Value Rx (HMO), Stride SM Value Rx Plus (HMO) and Stride SM Gain Rx (HMO) Step Therapy Requirements Effective 4/1/2019 Updated 3/2019 BRAND
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
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
BRINTELLIX. Step Therapy Criteria HealthTeam Advantage Formulary ID: Version 6 Effective Date: 1/1/2016. PRODUCT(s) AFFECTED BRINTELLIX
BRINTELLIX BRINTELLIX Claim will pay automatically for brintellix if enrollee has a paid claim for at least a 1 days supply of any 2 generic formulary antidepressants in the past 365 days. Otherwise, brintellix
Alprazolam 0.25mg, 0.5mg, 1mg tablets
Presbyterian Senior Care (HMO) / Presbyterian MediCare PPO Quantity Limits Effective November 1, 2014 For the most recent list of drugs or other questions, please contact the Presbyterian Customer Service
ANTICONVULSANTS. Details. Step Therapy Criteria Date Effective: April 1, 2019
Step Therapy Date Effective: April 1, 2019 ANTICONVULSANTS APTIOM TABLET 200 MG ORAL APTIOM TABLET 400 MG ORAL APTIOM TABLET 600 MG ORAL APTIOM TABLET 800 MG ORAL BANZEL SUSPENSION 40 MG/ML ORAL BANZEL
ANTICONVULSANT THERAPY
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
Step Therapy Criteria
Tier 5 Formulary Step Therapy 2016 Updated: 05/24/2016 Effective: 06/01/2016 What is Step Therapy? Some prescription drugs require step therapy (ST). In some cases, the plan requires you to first try certain
Aetna Better Health of Illinois Medicaid Formulary Updates
October 2017 o DOXYLAMINE SUCCINATE 25mg-QL o DULOXETINE CAP 40MG DR-QL o GUANFACIN ER TABS (all strengths)-ql o TOBRAMYCIN NEBU SOLUTION- PA August 2017 Aetna Better Health of Illinois Medicaid 2017 Formulary
Step Therapy Requirements
An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 05/01/2018 Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/2014 1 BETA-BLOCKERS BYSTOLIC 10 MG
CARE N CARE HEALTH PLAN
ARISTADA Aristada Prefilled Syringe 441 MG/1.6ML Intramuscular Aristada Prefilled Syringe 662 MG/2.4ML Intramuscular Aristada Prefilled Syringe 882 MG/3.2ML Intramuscular Claim will pay automatically for
Mercy Care Plan. Acyclovir Ointment. Products Affected. acyclovir ointment 5 % external Details. Criteria. Requires use of oral Acyclovir
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
Oral Agents. Fml Limits. Available Strengths NF NF
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Allergy Medications LAST REVIEW: 9/12/2017 THERAPEUTIC CLASS: Rheumatologic/Immunologic REVIEW HISTORY: 9/16, 5/15, 9/14
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
Step Therapy Medications
Step Therapy Medications Step Therapy (ST PA ) is an automated form of prior authorization. It encourages the use of therapies that should be tried first, before other treatments are covered, based on
Y0133_StepTherapyCriteria _C 10/18/18 Y0133_StepTherapyCriteria _C es 10/18/18
Step Therapy Grid Certain cost-effective drugs must be used before other more expensive drugs are covered. For example, certain brand-name medications will only be covered if a generic alternative has
2018 Medicare Part D Formulary Change
2018 Medicare Part D Formulary Change We may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorizations, quantity limits and/or step therapy
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
AETNA BETTER HEALTH January 2017 Formulary Change(s)
AETNA BETTER HEALTH January 2017 Formulary Change(s) The following updates will be made to the Aetna Better Health of MI formulary on March 1, 2017 Drug Name, Strength, Dosage Form ALFUZOSIN HCL ER 10
You ll find the most up-to-date comprehensive version of our formulary on our website, Click on Drug Finder.
3/1/2018 Medicare Part D Formulary Change In an effort to cover the most needed, cost-effective prescriptions, the AlohaCare Advantage Plus (HMO SNP) Formulary is updated monthly. The following are drugs
**CRITERIA UNDER CMS REVIEW**
**CRITERIA UNDER CMS REVIEW** ANTICONVULSANTS APTIOM TABLET 200 MG APTIOM TABLET 400 MG APTIOM TABLET 600 MG APTIOM TABLET 800 MG BANZEL SUSPENSION 40 MG/ML BANZEL TABLET 200 MG BANZEL TABLET 400 MG BRIVIACT
ALPHA GLUCOSIDASE INHIBITOR THERAPY
ALPHA GLUCOSIDASE INHIBITOR THERAPY GLYSET Step 1: One generic formulary product containing one of the following ingredients: glimeperide, glipizide, metformin or pioglitazone. Step 2: Glyset PAGE 1 LAST
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*
CARE N CARE HEALTH PLAN
ARISTADA ARISTADA PREFILLED SYRINGE 1064 MG/3.9ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 441 MG/1.6ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 662 MG/2.4ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 882
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017
Effective: 01/01/2017 Updated 11/2016 ANTI-INFLAMMATORY AGENTS - GI DIPENTUM PRIOR CLAIM FOR BALSALAZIDE OR APRISO WITHIN THE PAST 120 DAYS. ANTICONVULSANTS APTIOM BANZEL FYCOMPA GABITRIL OXTELLAR XR POTIGA
Oral Agents. Formulary Limits. Available Strengths. IR: 4mg ER: 12mg Syrup: 2mg/5ml
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Seasonal Allergy Medications LAST REVIEW: 9/20/2016 THERAPEUTIC CLASS: Rheumatologic/Immunologic REVIEW HISTORY: 5/16, 5/15,
Quarterly pharmacy formulary change notice
Provider Bulletin October 2018 Quarterly pharmacy formulary change notice The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus patients. The changes listed in the table
The Medical Letter. on Drugs and Therapeutics. Drug Some Formulations OTC/Rx Usual Dosage Comments Class Comments Cost 1
The Medical Letter publications are protected by US and international copyright laws. Forwarding, copying or any other distribution of this material is strictly prohibited. For further information call:
Quarterly pharmacy formulary change notice
Quarterly pharmacy formulary change notice The formulary changes listed in the table below were reviewed and approved at our second quarter 2018 Pharmacy and Therapeutics Committee meeting. Effective October
2019 STEP THERAPY CRITERIA UCare Individual & Family Plans UCare Individual & Family Plans with Fairview
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
ALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Health Choice Generations 1 Tier Gold Effective Date: 11/01/2018.
ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/2018 1 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam
Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
Medications that require Step Therapy (ST) require trial and failure of preferred formulary agents prior to their authorization. If the prerequisite medications have been filled within the specified time
ALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Optima Tier Gold Formulary Date Effective: November 1, 2018.
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
Quarterly pharmacy formulary change notice
MEDICAID PROVIDER BULLETIN October 2018 The formulary changes listed in the table below were reviewed and approved at the second-quarter 2018 Pharmacy and Therapeutics Committee meeting. Effective October
ALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Farm Bureau Health Plans Date Effective: November 1, 2018.
ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID 18351, Version 15 1 ANTIDEPRESSANTS - SCORE Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Trial of two of the following