2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Criteria Last Updated 11/1/2015
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- Arthur Ethelbert Wilkerson
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1 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 days. 1
2 ARANESP ALBUMIN FREE INJ 100MCG, 150MCG, 200MCG, 300MCG, 500MCG Step Therapy requires trial of PROCRIT. 2
3 ARANESP ALBUMIN FREE INJ 10MCG, 25MCG, 60MCG Step Therapy requires trial of PROCRIT. 3
4 ARANESP ALBUMIN FREE INJ 40MCG Step Therapy requires trial of PROCRIT. 4
5 ARICEPT TAB 23MG Step Therapy requires trial of donepezil 10mg in previous 180 days. 5
6 ATELVIA TAB 35MG Step Therapy requires a trial of alendronate in previous 180 days. 6
7 AUVI-Q INJ 0.15MG, 0.3MG Step Therapy requires trial of EPIPEN in previous 180 days. 7
8 BECONASE AQ NASAL 42MCG Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 8
9 BESIVANCE OPHTH SUSP 0.6% Step Therapy requires trial of one of the following ciprofloxacin, levofloxacin, ofloxacin, VIGAMOX or MOXEZA in previous 180 days. 9
10 BETASERON INJ 0.3MG Step Therapy requires trial of EXTAVIA in previous 180 days. 10
11 BONIVA INJ 3MG/3ML Step Therapy requires a trial of alendronate in previous 180 days. 11
12 BONIVA TAB 150MG Step Therapy requires a trial of alendronate in previous 180 days. 12
13 BRINTELLIX TAB 5MG, 10MG, 20MG Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 13
14 budesonide nasal inhaler 32mcg Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 14
15 BYETTA INJ 5MCG, 10MCG Step Therapy requires trial of Victoza 15
16 DESVENLAFAXINE ER TAB 50MG, 100MG Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 16
17 DEXILANT CAP 30MG, 60MG Step Therapy requires trial of omeprazole, lansoprazole or pantoprazole in previous 180 days. 17
18 DIFICID TAB 200MG Step Therapy requires trial of VANCOCIN. 18
19 donepezil tab 23mg Step Therapy requires trial of donepezil 10mg in previous 180 days. 19
20 EPINEPHRINE INJ 0.15MG/0.15ML, 0.3MG/0.3ML, Step Therapy requires trial of EPIPEN in previous 180 days. 20
21 EPOGEN INJ 2000UNIT/ML, 10000UNIT/ML, 20000UNIT/ML Step Therapy requires trial of PROCRIT in past 180 days 21
22 EPOGEN INJ 3000UNIT/ML, 4000UNIT/ML Step Therapy requires trial of PROCRIT in past 180 days 22
23 eszopiclone tab 1mg, 2mg, 3mg Step Therapy requires trial of zolpidem or zaleplon in previous 180 days. 23
24 EXTAVIA INJ 0.3MG Step Therapy requires trial of two of the following: AVONEX, REBIF or COPAXONE 24
25 FARXIGA TAB 5MG, 10MG Step Therapy requires trial of INVOKANA in previous 180 days. 25
26 FETZIMA CAP TITRATION PACK Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 26
27 FETZIMA ER CAP 20MG, 40MG, 80MG, 120MG Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 27
28 fluvoxamine ER cap 100mg, 150mg Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 28
29 gatifloxacin ophth soln 0.5% Step Therapy requires trial of one of the following ciprofloxacin, levofloxacin, ofloxacin, VIGAMOX or MOXEZA in previous 180 days. 29
30 guanfacine ER tab 1mg, 2mg, 3mg, 4mg Step Therapy requires trial of guanfacine IR in previous 180 days. 30
31 ibandronate inj 3mg/3ml Step Therapy requires a trial of alendronate in previous 180 days. 31
32 ibandronate prefilled syringe 3mg/3ml Step Therapy requires a trial of alendronate in previous 180 days. 32
33 ibandronate tab 150mg Step Therapy requires a trial of alendronate in previous 180 days. 33
34 INTUNIV TAB 1MG, 2MG, 3MG, 4MG Step Therapy requires trial of guanfacine IR in previous 180 days. 34
35 KHEDEZLA TAB 50MG, 100MG Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 35
36 LUNESTA TAB 1MG, 2MG, 3MG Step Therapy requires trial of zolpidem or zaleplon in previous 180 days. 36
37 METROGEL 1% Step Therapy requires trial of FINACEA. 37
38 NORITATE CREAM 1% Step Therapy requires trial of FINACEA. 38
39 OMNARIS NASAL 50MCG Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 39
40 PANCREAZE CAP (ALL STRENGTHS) Step Therapy requires trial of CREON in previous 180 days. 40
41 PENTASA CAP 250MG, 500MG Step Therapy requires trial of one of the following ASACOL, DELZICOL or LIALDA in previous 180 days. 41
42 PERTZYE CAP (ALL STRENGTHS) Step Therapy requires trial of CREON in previous 180 days. 42
43 PEXEVA TAB 10MG, 20MG, 30MG, 40MG Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 43
44 PRISTIQ TAB 25MG, 50MG, 100MG Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 44
45 QNASL CHILDRENS NASAL SPRAY 0.04MG Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 45
46 QNASL NASAL SPRAY 80MCG Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 46
47 RHINOCORT AQUA NASAL SPRAY 32MCG Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 47
48 RYTARY CAP (ALL STRENGTHS) Step Therapy requires trial of carbidopa/levodopa ER tab. 48
49 ULORIC TAB 40MG, 80MG Step Therapy requires trial of allopurinol in previous 180 days. 49
50 ULTRESA CAP (ALL STRENGTHS) Step Therapy requires trial of CREON in previous 180 days. 50
51 VANCOCIN CAP 125MG Step Therapy requires trial of metronidazole in previous 180 days 51
52 VANCOCIN CAP 250MG Step Therapy requires trial of metronidazole in previous 180 days 52
53 vancomycin cap 125mg, 250mg Step Therapy requires trial of metronidazole in previous 180 days 53
54 VIIBRYD TAB 10MG, 20MG, 40MG Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 54
55 XOPENEX HFA INHALER 45MCG Step Therapy requires trial of VENTOLIN HFA in previous 180 days. 55
56 ZENPEP CAP (ALL STRENGTHS) Step Therapy requires trial of CREON in previous 180 days. 56
57 ZETONNA NASAL SPRAY 37MCG Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 57
58 ZIOPTAN OPHTH SOLN % Step Therapy requires trial of latanoprost. 58
59 ZYMAXID OPHTH SOLN 0.5% Step Therapy requires trial of one of the following ciprofloxacin, levofloxacin, ofloxacin, VIGAMOX or MOXEZA in previous 180 days. 59
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