ACYCLOVIR OINT (CCHP2017)
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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 injection,auto-injector 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 release 24 hr desvenlafaxine ER 50 mg tablet,extended release 24 hr duloxetine 40 mg capsule,delayed release Fetzima 120 mg capsule,extended release Fetzima 20 mg (2)-40 mg (26) capsule,extended release,24 hr,dose pack Fetzima 20 mg capsule,extended release Fetzima 40 mg capsule,extended release Fetzima 80 mg capsule,extended release fluvoxamine ER 100 mg capsule,extended release 24 hr 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 fluvoxamine ER 150 mg capsule,extended release 24 hr Step Therapy requires trial of one of the following generic SSRI's in previous 120 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine 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 release Aplenzin 348 mg tablet,extended release Aplenzin 522 mg tablet,extended release Step Therapy requires trial of bupropion SR or bupropion XL in previous 120 days. 5
6 ARANESP_NVT 2016 Aranesp 10 mcg/0.4 ml (in polysorbate) injection syringe Aranesp 100 mcg/0.5 ml (in polysorbate) injection syringe Aranesp 100 mcg/ml (in polysorbate) Injection Aranesp 150 mcg/0.3 ml (in polysorbate) injection syringe Aranesp 200 mcg/0.4 ml (in polysorbate) injection syringe Aranesp 200 mcg/ml (in polysorbate) Injection Aranesp 25 mcg/0.42 ml (in polysorbate) injection syringe Aranesp 300 mcg/0.6 ml (in polysorbate) injection syringe Aranesp 300 mcg/ml (in polysorbate) Injection Aranesp 40 mcg/0.4 ml (in polysorbate) injection syringe Aranesp 40 mcg/ml (in polysorbate) Injection Aranesp 500 mcg/ml (in polysorbate) injection syringe Aranesp 60 mcg/0.3 ml (in polysorbate) injection syringe Aranesp 60 mcg/ml (in polysorbate) Injection Aranesp 25 mcg/ml (in polysorbate) Injection Step Therapy requires trial of PROCRIT or EPOGEN 6
7 ARICEPT 23_NVT 2015 donepezil 23 mg tablet Step Therapy requires trial of donepezil 10mg in previous 120 days. 7
8 DEXILANT_NVT 2017 Dexilant 30 mg capsule, delayed release Dexilant 60 mg capsule, delayed release Step Therapy requires trial of rabeprazole, omeprazole, lansoprazole or pantoprazole in previous 120 days. 8
9 DIFICID_NVT Dificid 200 mg tablet Step Therapy requires trial of vancomycin. 9
10 DRY EYE OTC (CCHP 2018) Restasis 0.05 % eye drops in a dropperette Step Therapy requires trial of OTC artificial tears. 10
11 ESTRING_NVT 2016 Estring 2 mg (7.5 mcg/24 hour) vaginal ring Step Therapy requires trial of PREMARIN VAGINAL CREAM in previous 120 days. 11
12 METROGEL_NAVITUS Noritate 1 % topical cream Step Therapy requires trial of FINACEA. 12
13 NAMZARIC_NVT Namzaric 14 mg-10 mg capsule sprinkle,extended release Namzaric 21 mg-10 mg capsule sprinkle,extended release Namzaric 28 mg-10 mg capsule sprinkle,extended release Namzaric 7 mg-10 mg capsule sprinkle,extended release Namzaric 7/14/21/28 mg-10 mg capsule,sprinkle,er 24hr,dose pack Patient has tried or was intolerant to donepezil and memantine. 13
14 NASAL CORTICOSTEROIDS_NVT 2017 Beconase AQ 42 mcg (0.042 %) nasal spray budesonide 32 mcg/actuation 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. 14
15 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, ofloxacin, VIGAMOX or MOXEZA in previous 120 days. 15
16 PANCREATIC ENZYMES_NVT 2015 Pancreaze 10,500 unit-35,500 unit-61,500 Pancreaze 16,800 unit-56,800 unit-98,400 Pancreaze 2,600 unit-6,200 unit-10,850 Pancreaze 21,000 unit-54,700 unit-83,900 Pancreaze 4,200 unit-14,200 unit-24,600 Pertzye 16,000 unit-57,500 unit-60,500 Pertzye 4,000 unit-14,375 unit-15,125 Zenpep 10,000 unit-34,000 unit-55,000 Zenpep 15,000 unit-51,000 unit-82,000 Zenpep 20,000 unit-68,000 unit-109,000 Zenpep 25,000 unit-85,000 unit-136,000 Zenpep 3,000 unit-10,000 unit-16,000 Zenpep 40,000 unit-136,000 unit-218,000 Zenpep 5,000 unit-17,000 unit-27,000 Pertzye 8,000 unit-28,750 unit-30,250 Step Therapy requires trial of CREON in previous 120 days. 16
17 PENTASA_NVT 2015 Pentasa 250 mg capsule,controlled release Pentasa 500 mg capsule,controlled release Step Therapy requires trial of one of the following ASACOL, DELZICOL or LIALDA in previous 120 days. 17
18 RYTARY_NVT Rytary mg-95 mg capsule,extended release Rytary mg-145 mg capsule,extended release Rytary mg-195 mg capsule,extended release Rytary mg-245 mg capsule,extended release Step Therapy requires trial of carbidopa/levodopa ER tab. 18
19 ULORIC_NVT 2015 Uloric 40 mg tablet Uloric 80 mg tablet Step Therapy requires trial of allopurinol in previous 120 days. 19
20 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 release Toviaz 8 mg tablet,extended release Step Therapy requires trial of Vesicare OR Myrbetriq in previous 120 days. 20
21 VANCOCIN_NVT vancomycin 125 mg capsule vancomycin 250 mg capsule Step Therapy requires trial of metronidazole in previous 120 days. If for C. difficile-associate diarrhea, step therapy not required if for severe or complicated disease. 21
22 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 ophth soln required for PATADAY/PAZEO. 22
23 ZIOPTAN_NVT Zioptan (PF) % eye drops in a dropperette Step Therapy requires trial of latanoprost. 23
24 INDEX A acyclovir 5 % topical ointment... 1 Alphagan P 0.1 % eye drops... 2 Aplenzin 174 mg tablet,extended release... 5 Aplenzin 348 mg tablet,extended release... 5 Aplenzin 522 mg tablet,extended release... 5 Aranesp 10 mcg/0.4 ml (in polysorbate) injection syringe... 6 Aranesp 100 mcg/0.5 ml (in polysorbate) injection syringe... 6 Aranesp 100 mcg/ml (in polysorbate) Injection... 6 Aranesp 150 mcg/0.3 ml (in polysorbate) injection syringe... 6 Aranesp 200 mcg/0.4 ml (in polysorbate) injection syringe... 6 Aranesp 200 mcg/ml (in polysorbate) Injection... 6 Aranesp 25 mcg/0.42 ml (in polysorbate) injection syringe... 6 Aranesp 25 mcg/ml (in polysorbate) Injection... 6 Aranesp 300 mcg/0.6 ml (in polysorbate) injection syringe... 6 Aranesp 300 mcg/ml (in polysorbate) Injection... 6 Aranesp 40 mcg/0.4 ml (in polysorbate) injection syringe... 6 Aranesp 40 mcg/ml (in polysorbate) Injection... 6 Aranesp 500 mcg/ml (in polysorbate) injection syringe... 6 Aranesp 60 mcg/0.3 ml (in polysorbate) injection syringe... 6 Aranesp 60 mcg/ml (in polysorbate) Injection... 6 B Beconase AQ 42 mcg (0.042 %) nasal spray Besivance 0.6 % eye drops,suspension budesonide 32 mcg/actuation nasal spray. 14 D darifenacin ER 15 mg tablet,extended release 24 hr darifenacin ER 7.5 mg tablet,extended release 24 hr desvenlafaxine ER 100 mg tablet,extended release 24 hr... 4 desvenlafaxine ER 50 mg tablet,extended release 24 hr... 4 Dexilant 30 mg capsule, delayed release... 8 Dexilant 60 mg capsule, delayed release... 8 Dificid 200 mg tablet... 9 donepezil 23 mg tablet... 7 duloxetine 40 mg capsule,delayed release.. 4 E epinephrine 0.15 mg/0.15 ml injection,autoinjector... 3 epinephrine 0.3 mg/0.3 ml injection, injector-auto... 3 Estring 2 mg (7.5 mcg/24 hour) vaginal ring F Fetzima 120 mg capsule,extended release.. 4 Fetzima 20 mg (2)-40 mg (26) capsule,extended release,24 hr,dose pack 4 Fetzima 20 mg capsule,extended release... 4 Fetzima 40 mg capsule,extended release... 4 Fetzima 80 mg capsule,extended release... 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 M mometasone 50 mcg/actuation nasal spray 14 N Namzaric 14 mg-10 mg capsule sprinkle,extended release Namzaric 21 mg-10 mg capsule sprinkle,extended release
25 Namzaric 28 mg-10 mg capsule sprinkle,extended release Namzaric 7 mg-10 mg capsule sprinkle,extended release Namzaric 7/14/21/28 mg-10 mg capsule,sprinkle,er 24hr,dose pack Noritate 1 % topical cream O olopatadine 0.1 % eye drops 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, Pancreaze 16,800 unit-56,800 unit-98, Pancreaze 2,600 unit-6,200 unit-10,850 unit capsule,delayed release Pancreaze 21,000 unit-54,700 unit-83, Pancreaze 4,200 unit-14,200 unit-24, Pazeo 0.7 % eye drops Pentasa 250 mg capsule,controlled release 17 Pentasa 500 mg capsule,controlled release 17 Pertzye 16,000 unit-57,500 unit-60,500 unit capsule,delayed release Pertzye 4,000 unit-14,375 unit-15,125 unit capsule,delayed release Pertzye 8,000 unit-28,750 unit-30,250 unit capsule,delayed release Pexeva 10 mg tablet... 4 Pexeva 20 mg tablet... 4 Pexeva 30 mg tablet... 4 Pexeva 40 mg tablet... 4 Q QNASL 40 mcg/actuation nasal aerosol spray QNASL 80 mcg/actuation nasal aerosol spray R Restasis 0.05 % eye drops in a dropperette10 Rytary mg-95 mg capsule,extended release Rytary mg-145 mg capsule,extended release Rytary mg-195 mg capsule,extended release Rytary mg-245 mg capsule,extended release T Toviaz 4 mg tablet,extended release Toviaz 8 mg tablet,extended release 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 vancomycin 125 mg capsule vancomycin 250 mg capsule 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-34,000 unit-55,000 unit capsule,delayed release Zenpep 15,000 unit-51,000 unit-82,000 unit capsule,delayed release Zenpep 20,000 unit-68,000 unit-109, Zenpep 25,000 unit-85,000 unit-136, Zenpep 3,000 unit-10,000 unit-16,000 unit capsule,delayed release Zenpep 40,000 unit-136,000 unit-218, Zenpep 5,000 unit-17,000 unit-27,000 unit capsule,delayed release Zetonna 37 mcg/actuation nasal HFA inhaler Zioptan (PF) % eye drops in a dropperette
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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
2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Criteria Last Updated 11/1/2015
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ANTICONVULSANTS. Details
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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.
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ANTICONVULSANTS. Details
ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200 mg tablet Banzel 40 mg/ml oral suspension Banzel 400 mg tablet Fycompa 0.5 mg/ml oral suspension
ALZHEIMER'S DRUGS. Details. Step 2: Exelon Patch 13.3 mg/24 hour transdermal Exelon Patch 4.6 mg/24 hr transdermal
ALZHEIMER'S DRUGS Products Affected Step 1: donepezil 10 mg disintegrating tablet donepezil 10 mg tablet donepezil 23 mg tablet donepezil 5 mg disintegrating tablet donepezil 5 mg tablet galantamine 12
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Step Therapy Requirements. Effective: 1/1/2019
Effective: 1/1/2019 Updated 1/2019 AMANTADINE ER Sharp Health Plan (HMO) OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED RELEASE PRIOR CLAIM FOR AMANTADINE
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BRINTELLIX. Step Therapy Criteria HealthTeam Advantage Formulary ID: Version 6 Effective Date: 1/1/2016. PRODUCT(s) AFFECTED BRINTELLIX
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ANTIDIABETIC AGENTS - MISCELLANEOUS
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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
Drugs That Require Step Therapy (ST) Step Therapy Medications
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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
ANTIDIABETIC AGENTS - MISCELLANEOUS
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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
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ARISTADA - ARISTADA INJ 441MG/1.6 ARISTADA INJ 662MG/2.4 ARISTADA INJ 882MG/3.2 CLAIM WILL PAY AUTOMATICALLY FOR ARISTADA IF ENROLLEE HAS A PAID CLAIM FOR AT LEAST A 1 DAYS SUPPLY OF ABILIFY MAINTENA AND
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ARISTADA. Products Affected Step 2: ARISTADA PREFILLED SYRINGE 1064 MG/3.9ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 441 MG/1.
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
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