Exchange Formulary 2018 Tier 4 Alternatives. (Preferred Generic)
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1 Exchange Formulary 2018 Tier 4 Alternatives Tier 4 Drug Aciphex Generic available rabeprazole Actemra Alternative agents listed Enbrel, Enbrel SureClick Humira Rituxan Actoplus Met XR Generic available pioglitazone-metformin Advair Diskus Alternative agents listed Combivent Respimat Serevent Diskus Spiriva with Handihaler Stiolto Respimat Striverdi Respimat Advair HFA Alternative agents listed Asmanex Twisthaler Dulera HFA Qvar Serevent Diskus Spiriva Respimat Symbicort HFA Aldactazide Generic available spironolactonehydrochlorothiazide Alocril eye drops Alternative agents listed cromolyn eye drops Alora Generic available estradiol estradiol patch Alphagan P eye drops Generic available brimonidine eye drops Alrex Alternative agents listed dexamethasone eye drops fluorometholone eye drops prednisolone eye drops Amitiza Alternative agents listed bisacodyl docusate magnesium citrate Milk of Magnesia mineral oil
2 polyethylene glycol senna AndroGel Generic available testosterone Anzemet Alternative agents listed ondansetron Apidra Alternative agents listed Humalog Apidra Solostar Alternative agents listed Humalog Aplenzin ER tablet Generic available bupropion, SR, XL Arcapta Neohaler Alternative agents listed Combivent Respimat Serevent Diskus Spiriva with Handihaler Stiolto Respimat Striverdi Respimat Aricept Generic available donepezil Atrovent HFA Alternative agents listed Combivent Respimat Serevent Diskus Spiriva with Handihaler Stiolto Respimat Striverdi Respimat Aubagio Alternative agents listed Avonex Extavia Glatopa Plegridy Avandamet Alternative agents listed pioglitazone-metformin Avandia Alternative agents listed pioglitazone Azasan Generic available azathioprine Azilect Alternative agents listed selegiline Azopt Alternative agents listed dorzolamide Azor Alternative agents listed amlodipine-valsartan Beconase AQ nasal spray Alternative agents listed budesonide nasal spray fluticasone nasal spray mometasone nasal spray
3 triamcinolone nasal spray Belsomra Alternative agents listed eszopiclone zaleplon zolpidem, zolpidem ER Benicar Alternative agents listed candesartan eprosartan irbesartan losartan telmisartan valsartan Benicar HCT Alternative agents listed candesartan-hct irbesartan-hct losartan-hct telmisartan-hct valsartan-hct Betaseron Alternative agents listed Avonex Glatopa Plegridy Boniva Generic available ibandronate bromfenac eye drops Alternative agents listed diclofenac eye drops ketorolac eye drops Brovana Alternative agents listed Combivent Respimat Serevent Diskus Spiriva with Handihaler Stiolto Respimat Striverdi Respimat Bydureon Alternative agents listed Victoza Byetta Alternative agents listed Victoza Bystolic Alternative agents listed acebutolol atenolol betaxolol bisoprolol
4 metoprolol succinate metoprolol tartrate Carbatrol ER Generic available carbamazepine ER CellCept Generic available mycophenolate Cesamet Alternative agents listed granisetron Climara Pro Alternative agents listed estradiol estradiol patch Coartem Alternative agents listed atovaquone-proguanil chloroquine hydroxychloroquine mefloquine primaquine quinidine sulfate quinine Daraprim Copaxone Alternative agents listed Avonex Glatopa Plegridy Coreg CR, Coreg ER Generic available carvedilol Daklinza Alternative agents listed Epclusa Dilantin Generic available phenytoin Divigel Generic available estradiol estradiol patch Donnatal Generic available phenobarbital-hyoscyamineatropine-scopolamine Durezol eye drops Alternative agents listed dexamethasone eye drops fluorometholone eye drops prednisolone eye drops Estrace Dyrenium Generic available triamterene Edarbi Alternative agents listed candesartan eprosartan irbesartan losartan
5 telmisartan valsartan Edecrin Alternative agents listed bumetanide furosemide torsemide Effient Alternative agents listed aspirin-dipyridamole ER capsule cilostazol clopidogrel dipyridamole ticlodipine Elestrin Generic available estradiol estradiol patch Elidel topical cream Alternative agents listed tacrolimus topical ointment Emsam transdermal patch Generic available selegiline EpiPen, EpiPen Jr Generic available epinephrine injection syringe epinephrine auto-injector Equetro Generic available carbamazepine Fanapt Alternative agents listed aripiprazole clozapine olanzapine paliperidone quetiapine risperidone ziprasidone Invega Sustenna IM syringe Risperdal Consta IM syringe Farxiga Alternative agents listed Januvia FazaClo Generic available clozapine Flector transdermal patch Generic available diclofenac gel FML Forte eye drops Generic available fluorometholone eye drops Foradil Aerolizer capsule Alternative agents listed Asmanex Twisthaler Dulera HFA Qvar
6 Serevent Diskus Spiriva Respimat Symbicort HFA Forfivo XL tablet Generic available bupropion XL Fosamax Plus D Alternative agents listed alendronate AND cholecalciferol Fusilev Generic available levoleucovorin Gabitril Generic available tiagabine Gilenya Alternative agents listed Avonex Glatopa Plegridy Harvoni Alternative agents listed Epclusa Invokamet Alternative agents listed Januvia Jalyn Alternative agents listed tamsulosin AND dutasteride Jardiance Alternative agents listed Januvia Kadian Generic available morphine Kineret Alternative agents listed Enbrel, Enbrel SureClick Humira Rituxan Kombiglyze XR Alternative agents listed Jentadueto XR Kristalose oral packet Generic available lactulose Lamictal Starter (Blue, Generic available lamotrigine Green, Orange) Kit Lamictal XR Starter (Blue, Generic available lamotrigine ER Green, Orange) Latuda Alternative agents listed aripiprazole clozapine olanzapine paliperidone quetiapine risperidone ziprasidone Invega Sustenna IM syringe Risperdal Consta IM syringe
7 Levatol Alternative agents listed acebutolol pindolol Lithobid ER Generic available lithium carbonate Livalo Alternative agents listed atorvastatin lovastatin pravastatin rosuvastatin simvastatin Lodosyn Alternative agents listed carbidopa-levodopa Lotronex Generic available alosetron Lumigan eye drops Alternative agents listed latanoprost eye drops Lupron Depot Generic available leuprolide Lupron Depot-Ped Marplan Alternative agents listed tranylcypromine Mestinon Generic available pyridostigmine Monurol oral packet Alternative agents listed methenamine hippurate nitrofurantoin macrocrystal trimethoprim Myfortic Generic available mycophenolate Mysoline Generic available primidone Neoral Generic available cyclosporine Gengraf Nesina Generic available alogliptin Nevanac eye drops Alternative agents listed diclofenac eye drops ketorolac eye drops Nexium Packet granules Generic available esomeprazole Nexium Niaspan ER Generic available niacin, nicacin ER Nitro-Dur transdermal Alternative agents listed isosorbide mononitrate Nitro-Bid patch isosorbide dinitrate Nitrostat SL tablet Nitrolingual spray Alternative agents listed isosorbide mononitrate Nitro-Bid isosorbide dinitrate Nitrostat SL tablet Norpace CR Generic available disopyramide
8 Novolin Alternative agents listed Humalog Novolog Alternative agents listed Humalog Olysio Alternative agents listed Epclusa omega-3 acid ethyl esters Alternative agents listed Fish Oil capsule omega-3-dha-epa-fish oil omega-3-fatty acids-fish oil Super Omega-3 Omnaris nasal spray Alternative agents listed budesonide nasal spray fluticasone nasal spray mometasone nasal spray triamcinolone nasal spray Onglyza Alternative agents listed alogliptin Januvia Orencia Alternative agents listed Enbrel, Enbrel SureClick Humira Rituxan Orkambi Alternative agents listed Kalydeco Perforomist Alternative agents listed Asmanex Twisthaler Dulera HFA Qvar Serevent Diskus Spiriva Respimat Symbicort HFA Praluent Pen Alternative agents listed Repatha SureClick Proventil HFA Alternative agents listed albuterol sulfate Serevent Diskus Ventolin HFA QNASL aerosol spray Alternative agents listed budesonide nasal spray fluticasone nasal spray mometasone nasal spray triamcinolone nasal spray Ranexa ER Alternative agents listed isosorbide mononitrate Nitro-Bid isosorbide dinitrate Nitrostat SL tablet Rapaflo Alternative agents listed alfuzosin
9 doxazosin tamsulosin Rayos DR Generic available prednisone Rebif, Rebif Titration Pack Alternative agents listed Avonex Glatopa Plegridy Relpax Alternative agents listed almotriptan naratriptan rizatriptan sumatriptan zolmitriptan Remicade Alternative agents listed Enbrel, Enbrel SureClick Humira Rituxan Renagel Alternative agents listed calcium acetate Fosrenol Ribasphere RibaPak Generic available ribavirin Rozerem Alternative agents listed melatonin eszopiclone zaleplon zolpidem, zolpidem ER Saphris SL Alternative agents listed aripiprazole clozapine olanzapine paliperidone quetiapine risperidone ziprasidone Savaysa Alternative agents listed enoxaparin SC syringe fondaparinux SC syringe Jantoven warfarin Invega Sustenna IM syringe Risperdal Consta IM syringe Fragmin SC syringe Serostim Alternative agents listed Nutropin AQ Nuspin
10 Silenor Generic available doxepin Simponi Alternative agents listed Enbrel, Enbrel SureClick Humira Rituxan Sovaldi Alternative agents listed Epclusa Stelara Alternative agents listed mesalamine sulfasalazine Strattera Generic available atomoxetine Suboxone film buprenorphine-naloxone SL tablet Sumavel DosePro Generic available sumatriptan SymlinPen Alternative agents listed glimepiride glipizide glyburide insulin metformin Tanzeum Alternative agents listed Victoza Tecfidera Alternative agents listed Avonex Glatopa Plegridy Technivie Alternative agents listed Epclusa Tekturna, Tekturna HCT Alternative agents listed Timoptic OcuDose eye Generic available timolol eye drops drops TobraDex eye drops Generic available tobramycin-dexamethasone eye drops Toujeo SoloStar Basaglar KwikPen Toviaz Alternative agents listed alfuzosin darifenacin doxazosin dutasteride finasteride
11 oxybutynin tamsulosin terazosin tolterodine Alternative agents listed ondansetron Transderm-Scop transdermal patch Travatan eye drops Alternative agents listed latanoprost eye drops Trexall Generic available methotrexate Treximet Alternative agents listed sumatriptan AND naproxen Trulicity Alternative agents listed Victoza Tysabri Alternative agents listed Avonex Glatopa Plegridy Uloric Alternative agents listed allopurinol colchicine probenecid Unithroid Generic available levothyroxine Uptravi Alternative agents listed sildenafil Adcirca Adempas Opsumit Orenitram Remodulin Tracleer Ventavis Vesicare Alternative agents listed alfuzosin darifenacin doxazosin dutasteride finasteride oxybutynin tamsulosin terazosin
12 tolterodine Viekira Pak Alternative agents listed Epclusa Viibryd Alternative agents listed citalopram escitalopram fluoxetine fluvoxamine paroxetine sertraline Vivitrol Generic available naltrexone Vytorin Alternative agents listed atorvastatin lovastatin pravastatin rosuvastatin simvastatin WelChol No generic available. colestipol Cholestyramine Light Prevalite oral powder Xigduo, Xigduo XR Alternative agents listed Januvia Xyrem Alternative agents listed modafinil methylphenidate Xyzal Generic available levocetirizine Zepatier Alternative agents listed Epclusa Zerit Generic available stavudine Zetia Alternative agents listed atorvastatin lovastatin pravastatin rosuvastatin simvastatin Zetonna nasal HFA inhaler Alternative agents listed budesonide nasal spray fluticasone nasal spray mometasone nasal spray triamcinolone nasal spray
13 Ziagen Generic available abacavir Zomig, Zomig ZMT Generic available zolmitriptan Zyflo, Zyflo CR Alternative agents listed montelukast zafirlukast
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DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 702 M %
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5-ASA. Products Affected. Details. Dipentum 250 mg capsule. Lialda 1.2 gram tablet,delayed release
Updated 11/1/17 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
ANTIDEPRESSANTS. Details. dose pack Viibryd 10 mg tablet Viibryd 20 mg tablet Viibryd 40 mg tablet. Criteria
ANTIDEPRESSANTS 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 Requirements. Effective: 05/01/2018
Step Therapy Requirements Effective: 05/01/2018 ANTIDEPRESSANTS 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
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Step Therapy Requirements. Effective: 11/01/2018
Effective: 11/01/2018 Updated 10/2018 ANTIDEPRESSANTS Sharp Health Plan (HMO) TRINTELLIX 10 MG TABLET TRINTELLIX 20 MG TABLET TRINTELLIX 5 MG TABLET VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK
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
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
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
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
THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM
Value Based Tier Drugs are selected for the management of Asthma, Diabetes, Hypertension and Hyperlipidemia. These drugs are covered at no charge or at a reduced cost share. Medications are under continual
ALPHA BLOCKERS. Products Affected Step 1: Details. Step 2: Rapaflo 4 mg capsule Rapaflo 8 mg capsule
CHRISTUS Health Plan Generations (HMO) CHRISTUS Health Plan Generations Plus (HMO) 2018 Premier Performance Standard Step Therapy PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS
Contents ALPHA BLOCKERS... 3 COLCRYS-PST... 4 DPP-4 INHIBITORS-PST... 5 HIGH RISK MEDICATIONS - SEDATIVE HYPNOTICS... 6
CHRISTUS Health Plan Generations (HMO) 2017 Step Therapy Criteria H1189_PC57 Accepted 11/17/2016 1 Contents ALPHA BLOCKERS... 3 COLCRYS-PST... 4 DPP-4 INHIBITORS-PST... 5 HIGH RISK MEDICATIONS - SEDATIVE
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.
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
2018 Step Therapy (ST) Criteria
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ALPHA GLUCOSIDASE INHIBITOR THERAPY
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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
2015 Step Therapy Prior Authorization Medical Necessity Guidelines
Tufts Health Unify 2015 Step Therapy Prior Authorization Medical Necessity Guidelines Effective: 01/01/2015 Updated: 10/01/2015 Tufts Health Plan P.O. Box 9194 Watertown, MA 02471-9194 Phone: 855-393-3154
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ADCIRCA 1772-D ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 AMYLIN ANALOG 676-D SYMLINPEN 120, SYMLINPEN 60 rapid-acting
2017 Step Therapy (ST) Criteria
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Alaska Medicaid 90 Day** Generic Prescription Medication List
1 ACYCLOVIR 200 MG CAPSULE BUPROPION HCL 150 MG TAB ER 24H ACYCLOVIR 200 MG/5ML BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 400 MG TABLET BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 800 MG TABLET BUPROPION HCL
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
Ultimate Health Plans (HMO)
Ultimate Health Plans (HMO) abacavir-lamivudine 600-300 mg abacavir-lamivudine-zidov tab ACTEMRA 162 MG/0.9 ML SYRINGE ADCIRCA 20 MG TABLET ADEMPAS (0.5 MG TABLET, 1 MG TABLET, 1.5 MG TABLET, 2 MG TABLET,