2017 Step Therapy (ST) Criteria

Size: px

Start display at page:

Download "2017 Step Therapy (ST) Criteria"

Raymond Porter
6 years ago
Views:

1 2017 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 drug that needs step therapy pre-approval. Below you will find a table of drugs that require step therapy pre-approval. If you find your drug on this list, talk to your doctor about what other drugs you could try first. To see if your drug is on the list refer to the index located at the end of this document for the medication you are looking for.

2 ANTIDIABETICS Products Affected Step 1: metformin 1,000 mg tablet metformin 500 mg tablet metformin 850 mg tablet metformin ER 1,000 mg 24 hr tablet,extended release metformin ER 1,000 mg tablet,extended release 24hr metformin ER 500 mg 24 hr tablet,extended release Step 2: Actoplus Met XR 15 mg-1,000 mg tablet,extended release Details metformin ER 500 mg tablet,extended metformin ER 500 mg tablet,extended release 24hr metformin ER 750 mg tablet,extended pioglitazone 15 mg-metformin 500 mg tablet pioglitazone 15 mg-metformin 850 mg tablet Actoplus Met XR 30 mg-1,000 mg tablet,extended release Cycloset 0.8 mg tablet Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of generic Metformin containing product, then the member has met the criteria for coverage of Cycloset and/or ACTOPLUS MET XR at the applicable copayment/coinsurance. 1

3 COREG CR Products Affected Step 1: carvedilol 12.5 mg tablet carvedilol 25 mg tablet Step 2: Coreg CR 10 mg capsule, extended release Coreg CR 20 mg capsule, extended release Details carvedilol mg tablet carvedilol 6.25 mg tablet Coreg CR 40 mg capsule, extended release Coreg CR 80 mg capsule, extended release Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of generic Carvedilol, then the member has met the criteria for coverage of Brand Coreg CR at the applicable copayment/coinsurance. 2

4 ELIDEL Products Affected Step 1: alclometasone 0.05 % topical cream alclometasone 0.05 % topical ointment amcinonide 0.1 % lotion amcinonide 0.1 % topical cream amcinonide 0.1 % topical ointment betamethasone dipropionate 0.05 % lotion betamethasone dipropionate 0.05 % topical cream betamethasone dipropionate 0.05 % topical ointment betamethasone valerate 0.1 % lotion betamethasone valerate 0.1 % topical cream betamethasone valerate 0.1 % topical ointment betamethasone valerate 0.12 % topical foam betamethasone, augmented 0.05 % lotion betamethasone, augmented 0.05 % topical cream betamethasone, augmented 0.05 % topical gel betamethasone, augmented 0.05 % topical ointment clobetasol 0.05 % lotion clobetasol 0.05 % scalp solution clobetasol 0.05 % shampoo clobetasol 0.05 % topical foam clobetasol 0.05 % topical gel diflorasone 0.05 % topical ointment fluocinolone 0.01 % topical body oil fluocinolone 0.01 % topical cream fluocinolone 0.01 % topical solution fluocinolone % topical cream fluocinolone % topical ointment fluocinonide 0.05 % topical cream fluocinonide 0.05 % topical gel fluocinonide 0.05 % topical ointment fluocinonide 0.05 % topical solution fluocinonide 0.1 % topical cream Fluocinonide-E 0.05% topical cream fluticasone % topical ointment fluticasone 0.05 % lotion fluticasone 0.05 % topical cream halobetasol propionate 0.05 % topical cream halobetasol propionate 0.05 % topical ointment hydrocortisone 1 % topical cream hydrocortisone 1 % topical ointment hydrocortisone 2.5 % lotion hydrocortisone 2.5 % topical cream hydrocortisone 2.5 % topical ointment hydrocortisone butyrate 0.1 % topical ointment hydrocortisone butyrate 0.1 % topical solution hydrocortisone butyrate-emollient 0.1 % clobetasol 0.05 % topical ointment topical cream clobetasol-emollient 0.05 % topical cream hydrocortisone valerate 0.2 % topical desonide 0.05 % lotion cream desonide 0.05 % topical cream hydrocortisone valerate 0.2 % topical desonide 0.05 % topical ointment ointment desoximetasone 0.05 % topical cream mometasone 0.1 % topical cream desoximetasone 0.05 % topical gel mometasone 0.1 % topical ointment desoximetasone 0.05 % topical ointment mometasone 0.1 % topical solution desoximetasone 0.25 % topical cream prednicarbate 0.1 % topical cream desoximetasone 0.25 % topical ointment prednicarbate 0.1 % topical ointment diflorasone 0.05 % topical cream triamcinolone acetonide % lotion 3

5 triamcinolone acetonide % topical cream triamcinolone acetonide % topical ointment triamcinolone acetonide 0.1 % lotion triamcinolone acetonide 0.1 % topical cream triamcinolone acetonide 0.1 % topical ointment triamcinolone acetonide 0.5 % topical cream triamcinolone acetonide 0.5 % topical ointment Triderm 0.1 % topical cream Step 2: Elidel 1 % topical cream Details Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of one topical generic Corticosteroid, then the member has met the criteria for coverage of Elidel at the applicable copayment/coinsurance. 4

6 GLYBURIDE Products Affected Step 1: glimepiride 1 mg tablet glimepiride 2 mg tablet glimepiride 4 mg tablet glipizide 10 mg tablet glipizide 2.5 mg-metformin 250 mg tablet glipizide 2.5 mg-metformin 500 mg tablet glipizide 5 mg tablet glipizide 5 mg-metformin 500 mg tablet glipizide ER 10 mg tablet, extended Step 2: glyburide 1.25 mg tablet glyburide 1.25 mg-metformin 250 mg tablet glyburide 2.5 mg tablet glyburide 2.5 mg-metformin 500 mg tablet Details glipizide ER 2.5 mg tablet, extended glipizide ER 5 mg tablet, extended release 24 hr pioglitazone 30 mg-glimepiride 2 mg tablet pioglitazone 30 mg-glimepiride 4 mg tablet glyburide 5 mg tablet glyburide 5 mg-metformin 500 mg tablet glyburide micronized 1.5 mg tablet glyburide micronized 3 mg tablet glyburide micronized 6 mg tablet Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of one step one agent then the member has met the criteria for coverage of step 2 agent at the applicable copayment/coinsurance 5

7 IMMUNOMODULATORS Products Affected Step 1: Humira 10 mg/0.2 ml subcutaneous syringe kit Humira 20 mg/0.4 ml subcutaneous syringe kit Humira 40 mg/0.8 ml subcutaneous syringe kit Humira Pediatric Crohn's Starter 40 mg/0.8 ml subcutaneous syringe kit Step 2: Actemra 200 mg/10 ml (20 mg/ml) intravenous solution Actemra 400 mg/20 ml (20 mg/ml) intravenous solution Actemra 80 mg/4 ml (20 mg/ml) intravenous solution Humira Pediatric Crohn's Starter 40 mg/0.8 ml subcutaneous syringe kit (6 pack) Humira Pen 40 mg/0.8 ml subcutaneous Humira Pen Crohn's-Ulc Colitis-Hid Sup Starter 40 mg/0.8 ml subcut kit Humira Pen Psoriasis-Uveitis Starter 40 mg/0.8 ml subcutaneous kit Cimzia 400 mg/2 ml (200 mg/ml x 2) subcutaneous syringe kit Cimzia Powder for Recon 400 mg (200 mg x 2 vials) subcutaneous kit Xeljanz 5 mg tablet Xeljanz XR 11 mg tablet,extended release Details Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of Humira, then the member has met the criteria for coverage of Actemra, Xeljanz, Xeljanz XR or Cimzia at the applicable copayment/coinsurance. 6

8 OPHTHALMIC ANTIHISTAMINES Products Affected Step 1: epinastine 0.05 % eye drops Lastacaft 0.25 % eye drops olopatadine 0.1 % eye drops Step 2: Pataday 0.2 % eye drops olopatadine 0.2 % eye drops Pazeo 0.7 % eye drops Details Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of generic ophthalmic antihistamine, Lastacaft solution, or Pazeo then the member has met the criteria for coverage of Pataday solution at the applicable copayment/coinsurance. 7

9 OVERACTIVE BLADDER Products Affected Step 1: darifenacin ER 15 mg tablet,extended darifenacin ER 7.5 mg tablet,extended oxybutynin chloride 5 mg tablet oxybutynin chloride 5 mg/5 ml syrup oxybutynin chloride ER 10 mg tablet,extended oxybutynin chloride ER 15 mg tablet,extended Step 2: Gelnique 10 % (100 mg/gram) transdermal gel packet Details oxybutynin chloride ER 5 mg tablet,extended tolterodine 1 mg tablet tolterodine 2 mg tablet tolterodine ER 2 mg capsule,extended tolterodine ER 4 mg capsule,extended trospium 20 mg tablet trospium ER 60 mg capsule,extended Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of one step one agent then the member has met the criteria for coverage of step 2 agent at the applicable copayment/coinsurance 8

10 VOLTAREN GEL Products Affected Step 1: celecoxib 100 mg capsule celecoxib 200 mg capsule celecoxib 400 mg capsule celecoxib 50 mg capsule diclofenac 1 % topical gel diclofenac 50 mg-misoprostol 200 mcg tablet,immed.and delayed release diclofenac 75 mg-misoprostol 200 mcg tablet,immediate,delayed release diclofenac ER 100 mg tablet,extended diclofenac potassium 50 mg tablet diclofenac sodium 25 mg tablet,delayed release diclofenac sodium 50 mg tablet,delayed release diclofenac sodium 75 mg tablet,delayed release diflunisal 500 mg tablet etodolac 200 mg capsule etodolac 300 mg capsule etodolac 400 mg tablet etodolac 500 mg tablet etodolac ER 400 mg tablet,extended etodolac ER 500 mg tablet,extended etodolac ER 600 mg tablet,extended fenoprofen 600 mg tablet flurbiprofen 100 mg tablet flurbiprofen 50 mg tablet ibuprofen 100 mg/5 ml oral suspension Step 2: Voltaren 1 % topical gel ibuprofen 400 mg tablet ibuprofen 600 mg tablet ibuprofen 800 mg tablet ketoprofen 50 mg capsule ketoprofen 75 mg capsule ketoprofen ER 200 mg 24 hr capsule,extended release meclofenamate 100 mg capsule meclofenamate 50 mg capsule mefenamic acid 250 mg capsule meloxicam 15 mg tablet meloxicam 7.5 mg tablet nabumetone 500 mg tablet nabumetone 750 mg tablet Naprelan CR 750 mg tab,extended release 24 hr mphase naproxen 125 mg/5 ml oral suspension naproxen 250 mg tablet naproxen 375 mg tablet naproxen 375 mg tablet,delayed release naproxen 500 mg tablet naproxen 500 mg tablet,delayed release naproxen sodium 275 mg tablet naproxen sodium 550 mg tablet naproxen sodium ER 375 mg tablet,extended release 24hr mphase oxaprozin 600 mg tablet piroxicam 10 mg capsule piroxicam 20 mg capsule sulindac 150 mg tablet sulindac 200 mg tablet tolmetin 400 mg capsule tolmetin 600 mg tablet Details 9

11 Details Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of one step one agent then the member has met the criteria for coverage of step 2 agent at the applicable copayment/coinsurance 10

12 Index A Actemra 200 mg/10 ml (20 mg/ml) intravenous solution... 6 Actemra 400 mg/20 ml (20 mg/ml) intravenous solution... 6 Actemra 80 mg/4 ml (20 mg/ml) intravenous solution... 6 Actoplus Met XR 15 mg-1,000 mg tablet,extended release... 1 Actoplus Met XR 30 mg-1,000 mg tablet,extended release... 1 alclometasone 0.05 % topical cream... 3, 4 alclometasone 0.05 % topical ointment.. 3, 4 amcinonide 0.1 % lotion... 3, 4 amcinonide 0.1 % topical cream... 3, 4 amcinonide 0.1 % topical ointment... 3, 4 B betamethasone dipropionate 0.05 % lotion 3, 4 betamethasone dipropionate 0.05 % topical cream... 3, 4 betamethasone dipropionate 0.05 % topical betamethasone valerate 0.1 % lotion... 3, 4 betamethasone valerate 0.1 % topical cream... 3, 4 betamethasone valerate 0.1 % topical betamethasone valerate 0.12 % topical foam... 3, 4 betamethasone, augmented 0.05 % lotion3, 4 betamethasone, augmented 0.05 % topical cream... 3, 4 betamethasone, augmented 0.05 % topical gel... 3, 4 betamethasone, augmented 0.05 % topical C carvedilol 12.5 mg tablet... 2 carvedilol 25 mg tablet... 2 carvedilol mg tablet... 2 carvedilol 6.25 mg tablet... 2 celecoxib 100 mg capsule... 9, 10 celecoxib 200 mg capsule... 9, celecoxib 400 mg capsule... 9, 10 celecoxib 50 mg capsule... 9, 10 Cimzia 400 mg/2 ml (200 mg/ml x 2) subcutaneous syringe kit... 6 Cimzia Powder for Recon 400 mg (200 mg x 2 vials) subcutaneous kit... 6 clobetasol 0.05 % lotion... 3, 4 clobetasol 0.05 % scalp solution... 3, 4 clobetasol 0.05 % shampoo... 3, 4 clobetasol 0.05 % topical foam... 3, 4 clobetasol 0.05 % topical gel... 3, 4 clobetasol 0.05 % topical ointment... 3, 4 clobetasol-emollient 0.05 % topical cream 3, 4 Coreg CR 10 mg capsule, extended release 2 Coreg CR 20 mg capsule, extended release 2 Coreg CR 40 mg capsule, extended release 2 Coreg CR 80 mg capsule, extended release 2 Cycloset 0.8 mg tablet... 1 D darifenacin ER 15 mg tablet,extended... 8 darifenacin ER 7.5 mg tablet,extended... 8 desonide 0.05 % lotion... 3, 4 desonide 0.05 % topical cream... 3, 4 desonide 0.05 % topical ointment... 3, 4 desoximetasone 0.05 % topical cream... 3, 4 desoximetasone 0.05 % topical gel... 3, 4 desoximetasone 0.05 % topical ointment 3, 4 desoximetasone 0.25 % topical cream... 3, 4 desoximetasone 0.25 % topical ointment 3, 4 diclofenac 1 % topical gel... 9, 10 diclofenac 50 mg-misoprostol 200 mcg tablet,immed.and delayed release... 9, 10 diclofenac 75 mg-misoprostol 200 mcg tablet,immediate,delayed release... 9, 10 diclofenac ER 100 mg tablet,extended... 9, 10 diclofenac potassium 50 mg tablet... 9, 10 diclofenac sodium 25 mg tablet,delayed release... 9, 10 diclofenac sodium 50 mg tablet,delayed release... 9, 10

13 diclofenac sodium 75 mg tablet,delayed release... 9, 10 diflorasone 0.05 % topical cream... 3, 4 diflorasone 0.05 % topical ointment... 3, 4 diflunisal 500 mg tablet... 9, 10 E Elidel 1 % topical cream... 3, 4 epinastine 0.05 % eye drops... 7 etodolac 200 mg capsule... 9, 10 etodolac 300 mg capsule... 9, 10 etodolac 400 mg tablet... 9, 10 etodolac 500 mg tablet... 9, 10 etodolac ER 400 mg tablet,extended release 24 hr... 9, 10 etodolac ER 500 mg tablet,extended release 24 hr... 9, 10 etodolac ER 600 mg tablet,extended release 24 hr... 9, 10 F fenoprofen 600 mg tablet... 9, 10 fluocinolone 0.01 % topical body oil... 3, 4 fluocinolone 0.01 % topical cream... 3, 4 fluocinolone 0.01 % topical solution... 3, 4 fluocinolone % topical cream... 3, 4 fluocinolone % topical ointment... 3, 4 fluocinonide 0.05 % topical cream... 3, 4 fluocinonide 0.05 % topical gel... 3, 4 fluocinonide 0.05 % topical ointment... 3, 4 fluocinonide 0.05 % topical solution... 3, 4 fluocinonide 0.1 % topical cream... 3, 4 Fluocinonide-E 0.05% topical cream... 3, 4 flurbiprofen 100 mg tablet... 9, 10 flurbiprofen 50 mg tablet... 9, 10 fluticasone % topical ointment... 3, 4 fluticasone 0.05 % lotion... 3, 4 fluticasone 0.05 % topical cream... 3, 4 G Gelnique 10 % (100 mg/gram) transdermal gel packet... 8 glimepiride 1 mg tablet... 5 glimepiride 2 mg tablet... 5 glimepiride 4 mg tablet... 5 glipizide 10 mg tablet... 5 glipizide 2.5 mg-metformin 250 mg tablet. 5 glipizide 2.5 mg-metformin 500 mg tablet. 5 glipizide 5 mg tablet glipizide 5 mg-metformin 500 mg tablet... 5 glipizide ER 10 mg tablet, extended release 24 hr... 5 glipizide ER 2.5 mg tablet, extended release 24 hr... 5 glipizide ER 5 mg tablet, extended release 24 hr... 5 glyburide 1.25 mg tablet... 5 glyburide 1.25 mg-metformin 250 mg tablet... 5 glyburide 2.5 mg tablet... 5 glyburide 2.5 mg-metformin 500 mg tablet 5 glyburide 5 mg tablet... 5 glyburide 5 mg-metformin 500 mg tablet... 5 glyburide micronized 1.5 mg tablet... 5 glyburide micronized 3 mg tablet... 5 glyburide micronized 6 mg tablet... 5 H halobetasol propionate 0.05 % topical cream... 3, 4 halobetasol propionate 0.05 % topical Humira 10 mg/0.2 ml subcutaneous syringe kit... 6 Humira 20 mg/0.4 ml subcutaneous syringe kit... 6 Humira 40 mg/0.8 ml subcutaneous syringe kit... 6 Humira Pediatric Crohn's Starter 40 mg/0.8 ml subcutaneous syringe kit... 6 Humira Pediatric Crohn's Starter 40 mg/0.8 ml subcutaneous syringe kit (6 pack)... 6 Humira Pen 40 mg/0.8 ml subcutaneous... 6 Humira Pen Crohn's-Ulc Colitis-Hid Sup Starter 40 mg/0.8 ml subcut kit... 6 Humira Pen Psoriasis-Uveitis Starter 40 mg/0.8 ml subcutaneous kit... 6 hydrocortisone 1 % topical cream... 3, 4 hydrocortisone 1 % topical ointment... 3, 4 hydrocortisone 2.5 % lotion... 3, 4 hydrocortisone 2.5 % topical cream... 3, 4 hydrocortisone 2.5 % topical ointment... 3, 4 hydrocortisone butyrate 0.1 % topical hydrocortisone butyrate 0.1 % topical solution... 3, 4

14 hydrocortisone butyrate-emollient 0.1 % topical cream... 3, 4 hydrocortisone valerate 0.2 % topical cream... 3, 4 hydrocortisone valerate 0.2 % topical I ibuprofen 100 mg/5 ml oral suspension... 9, 10 ibuprofen 400 mg tablet... 9, 10 ibuprofen 600 mg tablet... 9, 10 ibuprofen 800 mg tablet... 9, 10 K ketoprofen 50 mg capsule... 9, 10 ketoprofen 75 mg capsule... 9, 10 ketoprofen ER 200 mg 24 hr capsule,extended release... 9, 10 L Lastacaft 0.25 % eye drops... 7 M meclofenamate 100 mg capsule... 9, 10 meclofenamate 50 mg capsule... 9, 10 mefenamic acid 250 mg capsule... 9, 10 meloxicam 15 mg tablet... 9, 10 meloxicam 7.5 mg tablet... 9, 10 metformin 1,000 mg tablet... 1 metformin 500 mg tablet... 1 metformin 850 mg tablet... 1 metformin ER 1,000 mg 24 hr tablet,extended release... 1 metformin ER 1,000 mg tablet,extended release 24hr... 1 metformin ER 500 mg 24 hr tablet,extended release... 1 metformin ER 500 mg tablet,extended... 1 metformin ER 500 mg tablet,extended release 24hr... 1 metformin ER 750 mg tablet,extended... 1 mometasone 0.1 % topical cream... 3, 4 mometasone 0.1 % topical ointment... 3, 4 mometasone 0.1 % topical solution... 3, 4 N nabumetone 500 mg tablet... 9, 10 nabumetone 750 mg tablet... 9, Naprelan CR 750 mg tab,extended release 24 hr mphase... 9, 10 naproxen 125 mg/5 ml oral suspension 9, 10 naproxen 250 mg tablet... 9, 10 naproxen 375 mg tablet... 9, 10 naproxen 375 mg tablet,delayed release 9, 10 naproxen 500 mg tablet... 9, 10 naproxen 500 mg tablet,delayed release 9, 10 naproxen sodium 275 mg tablet... 9, 10 naproxen sodium 550 mg tablet... 9, 10 naproxen sodium ER 375 mg tablet,extended release 24hr mphase. 9, 10 O olopatadine 0.1 % eye drops... 7 olopatadine 0.2 % eye drops... 7 oxaprozin 600 mg tablet... 9, 10 oxybutynin chloride 5 mg tablet... 8 oxybutynin chloride 5 mg/5 ml syrup... 8 oxybutynin chloride ER 10 mg tablet,extended... 8 oxybutynin chloride ER 15 mg tablet,extended... 8 oxybutynin chloride ER 5 mg tablet,extended... 8 P Pataday 0.2 % eye drops... 7 Pazeo 0.7 % eye drops... 7 pioglitazone 15 mg-metformin 500 mg tablet... 1 pioglitazone 15 mg-metformin 850 mg tablet... 1 pioglitazone 30 mg-glimepiride 2 mg tablet 5 pioglitazone 30 mg-glimepiride 4 mg tablet 5 piroxicam 10 mg capsule... 9, 10 piroxicam 20 mg capsule... 9, 10 prednicarbate 0.1 % topical cream... 3, 4 prednicarbate 0.1 % topical ointment... 3, 4 S sulindac 150 mg tablet... 9, 10 sulindac 200 mg tablet... 9, 10 T tolmetin 400 mg capsule... 9, 10 tolmetin 600 mg tablet... 9, 10 tolterodine 1 mg tablet... 8 tolterodine 2 mg tablet... 8

15 tolterodine ER 2 mg capsule,extended... 8 tolterodine ER 4 mg capsule,extended... 8 triamcinolone acetonide % lotion. 3, 4 triamcinolone acetonide % topical cream... 3, 4 triamcinolone acetonide % topical triamcinolone acetonide 0.1 % lotion... 3, 4 triamcinolone acetonide 0.1 % topical cream... 3, 4 triamcinolone acetonide 0.1 % topical triamcinolone acetonide 0.5 % topical cream... 3, 4 triamcinolone acetonide 0.5 % topical Triderm 0.1 % topical cream... 3, 4 trospium 20 mg tablet... 8 trospium ER 60 mg capsule,extended release 24 hr... 8 V Voltaren 1 % topical gel... 9, 10 X Xeljanz 5 mg tablet... 6 Xeljanz XR 11 mg tablet,extended release. 6 14

16 GuildNet Gold Plus FIDA Plan is a managed care plan that contracts with both Medicare and New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. Beneficiaries must use network pharmacies to access their premium and/or copayment/coinsurance may change on January 1, This document includes GuildNet Gold Plus FIDA Plan s partial formulary as of September 1, For a complete, updated formulary, please visit our website at or call (TTY ). For alternative formats or language, please call Participant Services toll free at: , Monday through Sunday from 8am to 8pm. TTY/TDD users should call You can get this information for free in other languages. Call and TTY/TDD during 8am to 8pm. The call is free. Usted puede obtener esta información en otros idiomas gratis. Llame al o TTY/TDD al , de lunes a domingo de 8am a 8pm. La llamada es gratis. Queste informazioni sono disponibili gratuitamente in altre lingue. Chiamare il numero verde o mediante un telefono testuale per non udenti (TTY/TDD), da lunedì a domenica, dalle 8 alle 20. La chiamata è gratuita. 您可以免費獲得本信息的其他語言版本請撥打或聽障 / 語障人士專線 (TTY/TDD) , 星期一至星期日上午 8 時至晚上 8 時撥打該電話免費 Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang. Rele nimewo oswa TTY/TDD , lendi jiska dimanch, depi 8am jiska 8pm. Koutfil la gratis. 다른언어로작성된이정보를무료로얻으실수있습니다. 월요일 - 일요일오전 8 시부터오후 8 시사이에 번이나 TTY/TDD 번으로전화주세요. 통화는무료입니다. Вы можете бесплатно получить эту информацию на других языках. Позвоните по телефону и TTY/TDD Служба работает с понедельника по воскресенье с 08:00 до 20:00 ч. Звонок бесплатный. The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by GuildNet Gold Plus FIDA Plan. ICAN may be reached toll-free at or online at icannys.org v16 15

2018 Step Therapy (ST) Criteria

2018 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