SelectHealth Advantage 2019 Step Therapy Criteria Previous trial on at least ONE: Generic topical acne treatment
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- Marianna Marion Nash
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1 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 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 BEVESPI BEVESPI Previous trial on Stiolto BUDESONIDE BUDESONIDE TAB Previous trial of ONE of the following: Apriso, Delzicol, Mesalamine, Pentasa CADUET AMLOD/ATORVA atorvastatin, lovastatin, pravastatin, simvastatin AND amlodipine 1
2 CAPEX CAPEX clobetasol shampoo OR ciclopirox shampoo 1% CLENPIQ CLENPIQ Previous trial of Suprep PLENVU CLONIDINE CLONIDINE TAB Previous trial on guanfacine er 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 BUPROPION DESVENLAFAX EMSAM 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 ALOG/PIOGLIT TAB Previous trial on metformin OR metformin ER ALOGLIPTIN TAB ALOGLIPTIN/ TAB GLYXAMBI TAB INVOKAMET TAB INVOKAMET XR TAB INVOKANA TAB JARDIANCE TAB JENTADUETO TAB SYNJARDY TAB SYNJARDY XR TAB TRADJENTA TAB TRULICITY INJ VICTOZA INJ EPLERENONE EPLERENONE spironolactone, spironolactone-hctz EQUETRO EQUETRO CAP carbamezapine er, clozapine, fluoxetine-olanzapine, haloperidol, olanzapine, quetiapine, risperidone, ziprasidone 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 OR desonide EXALGO HYDROMORPHON fentanyl patches, methadone, morphine ER, oxycodone er, oxymorphone ER, Zohydro GABAPENTIN GRALISE GRALISE STAR HORIZANT ER generic gabapentin OR pramipexole 3
4 GASTRO DELZICOL ICS MESALAMINE ALVESCO PULMICORT QVAR REDIHA QVAR REDIHAL Apriso, balsalazide, Pentasa, sulfasalazine Flovent OR Arnuity AND Asmanex LABA-LAMA ANORO ELLIPT Previous trail on BOTH of the following: 1. Tudorza 2. Bevespi LAMA INCRUSE ELPT TUDORZA PRES For Tudorza: Previous trial on Spiriva For Incruse: Previous trial on Tudorza LUNESTA ESZOPICLONE zolpidem or zaleplon MOVANTIK MOVANTIK Previous trial on Symproic NAMENDA MEMANTINE HC NAMENDA XR immediate release Memantine OAB DARIFENACIN GELNIQUE oxybutynin, oxybutynin er, tolterodine, tolterodine er, trospium, trospium er OXYCONTIN OXYCODONE fentanyl patches, hydromorphone er, methadone, morphine ER, oxymorphone ER, Zohydro ER PICATO PICATO GEL 0.015% PICATO GEL 0.05% PPI ESOMEPRA MAG LANSOPRAZOLE 1. Fluorouracil 5% 2. Imiquimod 5% lansoprazole, misoprostol, omeprazole, pantoprazole 4
5 RANEXA RANEXA amlodipine, atenolol, diltiazem, isosorbide dinitrate, isosorbide mononitrate, metoprolol, propranolol, verapamil RAPAFLO RAPAFLO SILODOSIN Previous trial of at least TWO of the following: alfuzosin, doxazosin, dutasteride, dutasteride/tamsulosin, finasteride, prazosin, tamsulosin, terazosin RASUVO RASUVO generic methotrexate 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 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 Ventolin atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin 10 mg, simvastatin 5
6 STEGLATRO SEGLUROMET TAB STEGLATRO TAB STIMULANTS DAYTRANA VYVANSE SYMLIN SYMLINPEN 60 SYMLNPEN 120 TEKTURNA TEKTURNA TEKTURNA HCT TIZANIDINE TIZANIDINE CAP 2MG TIZANIDINE CAP 4MG TIZANIDINE CAP 6MG Jardiance OR Synjardy AND Invokana OR Invokamet Previous trial on at least ONE: generic long-acting stimulant OR Diagnosis of binge eating disorder insulin 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 TOVIAZ TOVIAZ Previous trial on Myrbetriq 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 AURYXIA VELPHORO Renagel OR sevelamer 6
7 VRAYLAR VRAYLAR aripiprazole AND clozapine, fluoxetine-olanzapine, haloperidol, olanzapine, quetiapine, risperidone, ziprasidone VYZULTA RHOPRESSA WELCHOL VYZULTA COLESEVELAM WELCHOL latanoprost atorvastatin, fluvastatin/er, lovastatin, pravastatin, rosuvastatin, simvastatin AND previous trial on at least ONE of the following: cholestyramine, colestipol 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
ACNE ADAPAL/BEN P GEL 0.1-2.5% AZELEX CRE 20% DAPSONE GEL 5% EPIDUO FORTE GEL 0.3-2.5% TRETINOIN GEL 0.04% TRETINOIN GEL 0.05% TRETINOIN GEL 0.1% ACTONEL ANTICONVULSANT ANTIDEPRESSION ANTIPSYCHOTIC ASTHMA
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
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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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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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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
Premium step therapy. Here s how it works:
Premium step therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment
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
2019 Preventive Drug List
2019 Preventive Drug List Managing your health with preventive medications Your pharmacy benefit plan includes special coverage for generic preventive medications. These medications help protect against
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"}
Chronic Medicine. Reduced out-of-pocket costs for the medicine you need Value and Value Plus plans
Chronic Medicine Reduced out-of-pocket costs for the medicine you need Value and Value Plus plans Forget your deductible just pay your copay or coinsurance when buying certain medication. January 1, 2019
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
ASEBP and ARTA TARP Drugs and Reference Price by Categories
ASEBP Pantoprazole Sodium 40 mg (generic) $0.2016 ASEBP Dexlansoprazole 30 mg Dexlansoprazole 60 mg Esomeprazole 10 mg Esomeprazole 20 mg Esomeprazole 40 mg Lansoprazole 15 mg Lansoprazole 30 mg Omeprazole
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
Step Therapy Criteria 2019
Step Therapy 2019 For information on obtaining an updated coverage determination or an exception to a coverage determination please call Freedom Health Member Services at 1-800-401-2740 or, for TTY/TDD
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
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
2013 Step Therapy (ST) Criteria
2013 Step Therapy (ST) Criteria Some drugs require step therapy pre-approval. This means that your doctor must have you first try a different drug to treat your medical condition before we will cover a
STEP THERAPY ALGORITHMS PUP Select Formulary
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
QTY LIMIT COPAY (30 DAY/90 DAY) BENIGN PROSTATIC HYPERPLASIA FINASTERIDE $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8
2019 LiveWELL Health Plan PREVENTIVE DRUG LIST - GENERIC Names ( Copay) - ALPHABETICAL by DRUG CATEGORY You should always check with your prescriber and/or pharmacist to determine if these alternatives
Blue Medicare HMO Essential 2015 Quantity Limit List Blue Medicare Rx Standard 2015 Quantity Limit List
Blue Medicare HMO Essential 2015 Quantity Limit List Blue Medicare Rx Standard 2015 Quantity Limit List Drug Name Monthly Limit (30 days unless otherwise noted) abacavir 300 mg abacavir/lamivudine/zidovudine
A BULLETIN FOR PHARMACY SERVICE PROVIDERS FROM ALBERTA BLUE CROSS. Pan-Canadian Select Molecule Price Initiative for Generic Drugs
Pharmacy Benefact A BULLETIN FOR PHARMACY SERVICE PROVIDERS FROM ALBERTA BLUE CROSS Number 723 February 2018 Pan-Canadian Select Molecule Price Initiative for Generic Drugs Alberta Drug Benefit List prices
Formulary for the JHM Outpatient Medication Assistance Program (OMAP)
Note: The JHM Outpatient is a clinic-based program and may only be used by outpatient clinics and JHCP sites approved to participate in the program. To be eligible for OMAP, the patient must not have any
Step Therapy Information... 4 Prior Authorization Information ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...
Step Therapy Information... 4 Prior Authorization Information... 27 ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...62 Acne Therapy Topical...64 Alcoholism Treatment Agents... 66 Analgesic