These medications will require preauthorization (PA) for HMSA Medicare Part D members.

Size: px
Start display at page:

Download "These medications will require preauthorization (PA) for HMSA Medicare Part D members."

Transcription

1 Medicare Part D November 2014 CHANGES TO HMSA S MEDICARE FORMULARY As part of HMSA s ongoing efforts to provide our members a sustainable and affordable health plan option, it s necessary to make adjustments to the HMSA Medicare Part D formulary. The changes, which will go into effect on January 1, 2015, are designed to encourage you and your patients to consider lower-cost alternative medications, as well as address quality and safety concerns that are associated with high-risk medications. New Preauthorization Medications Table 1 These medications will require preauthorization (PA) for HMSA Medicare Part D members. Table 1: Medicare Formulary New Preauthorization Effective January 1, 2015 Drug Name Drug Class Rationale/Criteria Banzel Anticonvulsants FDA approved indications/appropriate use Emend, 40 mg Antiemetics Part B vs. Part D determination ketoconazole, 200 mg Antifungals FDA approved indications/appropriate use methylprednisolone acetate, injection Glucocorticoids Part B vs. Part D determination methylprednisolone tablet, dose pack Glucocorticoids Part B vs. Part D determination methylprednisolone, sodium succinate, injection Glucocorticoids Part B vs. Part D determination Namenda XR Antidementia *Criteria under CMS review Namenda, solution Antidementia *Criteria under CMS review prednisolone, solution Glucocorticoids Part B vs. Part D determination prednisone tablet, dose pack, solution Glucocorticoids Part B vs. Part D determination Quinine Antimalarials FDA approved indications/appropriate use temazepam Hypnotics *Criteria under CMS review Versacloz Antipsychotics FDA approved indications/appropriate use Xyrem Narcolepsy/Cataplexy FDA approved indications/appropriate use * Pending CMS approval Hawai i Medical Service Association 818 Keeaumoku St. (808) P.O. Box 860 Honolulu, HI hmsa.com hhin.hmsa.com Provider Resource Center hmsa.com/portal/provider An Independent Licensee of the Blue Cross and Blue Shield Association

2 2 Medicare Part D November 2014 Non-Formulary Medications Table 2 These medications will be removed from the Medicare Part D formulary because equally effective, safe, and lower-cost alternatives are available. This is not a comprehensive list of all drugs being removed. It s a listing of drugs being removed effective January 1, 2015, that may cause the most potential impact. Table 2: Medicare Formulary Non-Formulary Medications Effective January 1, 2015 Drug Name Drug Class Alternative Formulary Drug(s) Actonel, tablet Bisphosphonates alendronate, ibandronate amlodipine/atorvastatin Calcium Channel Blocker/Antilipemic Combinations amlodipine and atorvastatin separately AndroGel Androgens Testim Apidra Antidiabetics Novolog Avelox Fluoroquinolones ciprofloxacin, levofloxacin Bydureon Antidiabetics Victoza Byetta Antidiabetics Victoza candesartan Angiotensin II Receptor Antagonists losartan, irbesartan, valsartan Carac Dermatology fluorouracil, imiquimod Carafate (tablet, susp) Miscellaneous sucralfate tablet, famotidine, ranitidine Cimetidine H2-Receptor Antagonists famotidine, ranitidine Clobetasol Dermatology diflorasone, halobetasol, betamethasone dipropionate Coreg CR Beta-Blockers carvedilol desloratadine Antihistamines levocetirizine Detrol LA Urinary Antispasmodics tolterodine ER Estrace, vaginal cream Estrogens Premarin cream, Vagifem Evista Selective Estrogen Receptor Modulators raloxifene glyburide Antidiabetics glipizide, glimepiride glyburide/metformin Antidiabetics glipizide/metformin Humalog Antidiabetics Novolog Humalog Mix Antidiabetics Novolog Mix Kombiglyze Antidiabetics Janumet, Jentadueto lansoprazole Proton Pump Inhibitors omeprazole, pantoprazole Lipitor Antilipemics atorvastatin Lovaza Antilipemics omega-3-acid metronidazole, gel 1% Dermatology metronidazole, gel 0.75% mupirocin, cream 2% Dermatology mupirocin, ointment Onglyza Antidiabetics Januvia, Tradjenta Oxycontin Opioid Analgesics oxycodone, morphine ER pioglitazone/metformin Antidiabetics pioglitazone and metformin separately Progesterone, capsule Progestins medroxyprogesterone Proventil HFA Beta Agonists Proair HFA rabeprazole Proton Pump Inhibitors omeprazole, pantoprazole ranitidine, capsule H2-Receptor Antagonists ranitidine, tablet Rapaflo Benign Prostatic Hyperplasia tamsulosin, alfuzosin telmisartan Angiotestin II Receptor Antagonists losartan, irbesartan, valsartan triamcinolone, nasal spray Nasal Steroids fluticasone, flunisolide Ventolin HFA Beta Agonists Proair HFA Vytorin Antilipemics atorvastatin Zioptan Antiglaucoma latanoprost, Lumigan, Travatan Z zolpidem ER Hypnotics trazodone, Silenor, temazepam

3 3 Medicare Part D November 2014 New Quantity Limits Table 3 These medications will require a preauthorization for HMSA Medicare Part D members when the prescribed amounts exceed the quantity limit listed. Quantity limits are based on FDA prescribing maximum limits for safe and effective use. Patients using these medications in amounts lower than the amount listed won t need a PA. This is not a comprehensive list of all drugs with new quantity limits. It s a listing of drugs with new quantity limits effective January 1, 2015, that may cause the most potential impact. Please review the therapies of your patients whose current medications exceed the listed quantity limits to determine if their prescription strengths are appropriate. Table 3: Medicare Formulary New Quantity Limits Effective January 1, 2015 Drug Name Strength Rationale/Criteria Limit Drug Class Abilify, solution 1 mg/ml Amount: 900.0, Days: 30 Antipsychotics Abilify, tablet All Amount: 30.0, Days: 30 Antipsychotics alendronate, tablet 35 mg Amount: 4.0, Days: 28 Bisphosphonates 70 mg amlodipine/benazepril, capsule mg Amount: 30.0, Days: 30 Ace Inhibitor Combinations 5-10 mg 5-20 mg 5-40 mg amlodipine, tablet 2.5 mg Amount: 45.0, Days: 30 Calcium Channel Blockers 5 mg atorvastatin, tablet All Amount: 30.0, Days: 30 Antilipemics Avodart, capsule 0.5 mg Amount: 30.0, Days: 30 Benign Prostatic Hyperplasia Azor, tablet 5-20 mg Amount: 30.0, Days: mg mg Benicar, tablet 5 mg Amount: 60.0, Days: 30 Angiotensin Receptor Antagonists 20 mg Amount: 30.0, Days: 30 Benicar HCT, tablet mg Amount: 30, Days: mg Celebrex, capsule All Amount: 60.0, Days: 30 NSAIDS citalopram, tablet 10 mg Amount: 45.0, Days: mg 40 mg Amount: 30.0, Days: 30 clopidogrel, tablet 75 mg Amount: 30.0, Days: 30 Platelet Aggregation Inhibitors Crestor, tablet All Amount: 30.0, Days: 30 Antilipemics Diovan, tablet 40 mg Amount: 60.0, Days: 30 Angiotensin II Receptor Antagonists 80 mg 160 mg donepezil, tablet & ODT 5 mg Amount: 30.0, Days: 30 Antidementia doxazosin, tablet 1 mg Amount: 30.0, Days: 30 Alpha Blockers 2 mg 4 mg duloxetine, capsule All Amount: 60.0, Days: 30 escitalopram, solution 5 mg/5 ml Amount: 600.0, Days: 30

4 4 Medicare Part D November 2014 Drug Name Strength Rationale/Criteria Limit Drug Class escitalopram, tablet 5 mg Amount: 45.0, Days: mg 20 mg Amount: 60.0, Days: 30 Exelon patch All Amount: 30.0, Days: 30 Antidementia Exforge, tablet mg Amount: 30.0, Days: mg mg fluoxetine, capsule 10 mg Amount: 30.0, Days: mg Amount: 120.0, Days: 30 galantamine, ER capsule 8 mg Amount: 30.0, Days: 30 Antidementia 16 mg galantamine, tablet 4 mg Amount: 180.0, Days: 30 Antidementia 8 mg Amount: 90.0, Days: 30 ibandronate, tablet 150 mg Amount: 1.0, Days: 30 Bisphosphonates Jalyn, capsule Amount: 30.0, Days: 30 Benign Prostatic Hyperplasia Latuda, tablet 20 mg Amount: 240.0, Days: 30 Antipsychotics 40 mg Amount: 30.0, Days: mg 60 mg Amount: 60.0, Days: mg losartan, tablet 25 mg Amount: 60.0, Days: 30 Angiotensin II Receptor Antagonists 50 mg losartan/hct, tablet mg Amount: 30.0, Days: mg lovastatin, tablet 10 mg Amount: 30.0, Days: 30 Antilipemics 20 mg Amount: 120.0, Days: mg Amount: 60.0, Days: 30 metoprolol, ER tablet 25 mg Amount: 60.0, Days: 30 Beta-Blockers 50 mg 100 mg Amount: 45.0, Days: 30 Namenda, XR capsule 7 mg Amount: 30.0, Days: 30 Antidementia 14 mg Niacin, ER tablet 500 mg Amount: 90.0, Days: 30 Antilipemics olanzapine, tablet 2.5 mg Amount: 30.0, Days: 30 Antipsychotics 5 mg 7.5 mg 10 mg Amount: 60.0, Days: mg 20 mg oxybutynin, ER tablet 5 mg Amount: 30.0, Days: 30 Urinary Antispasmodics 10 mg 15 mg Amount: 60.0, Days: 30

5 5 Medicare Part D November 2014 Drug Name Strength Rationale/Criteria Limit Drug Class paroxetine, tablet 10 mg Amount: 45.0, Days: mg 40 mg 30 mg Amount: 60.0, Days: 30 Paxil, susp 10 mg/5ml Amount: 900.0, Days: 30 pravastatin, tablet All Amount: 30.0, Days: 30 Antilipemics Pristiq, tablet All Amount: 30.0, Days: 30 Prolia, solution 60 mg/ml Amount: 1.0, Days: 180 Miscellaneous quetiapine, tablet All Amount: 90.0, Days: 30 Antipsychotics Restasis 0.05% Amount: 64.0, Days: 30 Miscellaneous risperidone, solution 1 mg/ml Amount: 240.0, Days: 30 Antipsychotics risperidone, tablet 0.25 mg Amount: 90.0, Days: 30 Antipsychotics 0.5 mg 1 mg Amount: 60.0, Days: 30 2 mg 3 mg 4 mg Amount: 120.0, Days: 30 Sensipar, tablet 30 mg Amount: 120.0, Days: 30 Calcium Receptor Agonists 90 mg 60 mg Amount: 60.0, Days: 30 Seroquel, XR tablet 50 mg Amount: 120, Days: 30 Antipsychotics 150 mg Amount: 30.0, Days: mg 300 mg Amount: 60.0, Days: mg sertraline, tablet 25 mg Amount: 45.0, Days: mg simvastatin, tablet All Amount: 30.0, Days: 30 Antilipemics tamsulosin, capsule 0.4 mg Amount: 60.0, Days: 30 Benign Prostatic Hyperplasia Tekturna, tablet 150 mg Amount: 30, Days: 30 Direct Renin Inhibitors/Combinations Tekturna, HCT tablet mg Amount: 30.0, Days: 30 Direct Renin Inhibitors/Combinations mg mg Amount: 60.0, Days: 30 tolterodine, ER capsule All Amount: 30.0, Days: 30 Urinary Antispasmodics valsartan/hctz, tablet mg Amount: 30.0, Days: mg mg venlafaxine, ER capsule 37.5 mg Amount: 30.0, Days: mg 150 mg Amount: 60.0, Days: 30 ziprasidone, capsule 20 mg Amount: 60.0, Days: 30 Antipsychotics 40 mg 60 mg 80 mg Amount: 90.0, Days: 30

6 6 Medicare Part D November 2014 Tier Changes Table 4 Patients on these medications will pay a higher amount than they currently pay. Consider moving your patients who use these medications to a lower-cost alternative on the HMSA Medicare Part D formulary. This is not a comprehensive list of all drugs with tier changes. It s a listing of drugs with tier changes effective January 1, 2015, that may cause the most potential impact. Table 4: Medicare Formulary Tier Changes Effective January 1, 2015 Drug Name Drug Class 2014 Tier 2015 Tier Alternatives Abilify, tablet Antipsychotics 3 5 olanzapine, quetiapine, resperidone, ziprasidone Amitriptyline 1 4 citalopram, duloxetine, escitalopram fluoxetine, sertraline, venlafaxine Celebrex NSAIDS 2 4 Celecoxib (Pending FDA approval) Diovan Angiotensin II Receptor Antagonists 2 4 Valsartan Doxepin capsule, solution 1 4 citalopram, duloxetine, escitalopram fluoxetine, sertraline, venlafaxine Dulera Steroid/Beta-Agonist Combinations 2 4 Advair, Symbicort Estradiol tablet, patch Estrogens 1 4 Imipramine 1 4 citalopram, duloxetine, escitalopram fluoxetine, sertraline, venlafaxine Latuda, tablet Antipsychotics 3 5 olanzapine, quetiapine, resperidone, ziprasidone Megestrol acetate Hormonal Antineoplastic Agents 1 4 Namenda XR Antidementia 2 4 donepezil, Namenda solution Nasonex Nasal Steroids 2 4 fluticasone, flunisolide Nitrofurantoin Anti-Infectives 1 4 ciprofloxacin, sufamethoxazole/trimethoprim, trimethoprim Phenobarbital tablet, elixir, injectionection Anticonvulsants 1 4 carbamazepine, lamotrigine, topiramate Zolpidem Hypnotics 1 4 trazodone, Silenor, temazepam We understand that some patients may need to continue the use of certain medication for clinical reasons. We encourage you to discuss formulary options with your patients; in some cases, your patients may benefit from switching to an alternative medication. If needed, your patients can get one 30-day transition supply during the first 90 days of 2015 for new PA medications, non-formulary medications, and medications with new quantity limits. Medicare Formulary Preauthorization and Exception Requests To request a PA or an exception, please call or fax CVS/Caremark, HMSA s pharmacy benefits manager. Call TTY Fax Hours of Operation 1 (855) toll-free 1 (866) toll-free 1 (855) toll-free 24 hours a day, seven days a week Mail Medicare Coverage Determination and Appeals MC 109 P.O. Box Phoenix, AZ

7 7 Medicare Part D November 2014 General information about Changes to Akamai Advantage Part D (Drug) Hydrocodone Combination Products (HCPs) How is the new formulary structure different from CY2014 to CY2015? In CY2014, Akamai Advantage (AA) plans used a four-tier expanded drug formulary. - Tier 1: Generic - Tier 2: Preferred brand - Tier 3: Non-preferred brand - Tier 4: Specialty In CY2015, AA plans will use a five-tier standard drug formulary. - Tier 1: Preferred generic - Tier 2: Non-preferred generic - Tier 3: Preferred brand - Tier 4: Non-preferred brand - Tier 5: Specialty The Akamai Advantage prescription drug benefit includes four stages. The first stage is the annual deductible. - AA Complete and AA Standard have an annual deductible of $320, except for tier 1 drugs. - AA Complete Plus and AA Standard Plus have no deductible. The first dollar the member spends goes toward the cost of the prescription drugs. The second stage is the initial coverage stage. - The member stays in the initial coverage stage until the total drug costs (what the plan, the member, and others pay for the drugs) reach $2,960. Retail (30-day supply) Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Mail Order (90-day supply) Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Complete Complete Plus Standard Standard Plus $4.50 $4.00 $4.50 $4.00 $11.00 $10.00 $11.00 $10.00 $45.00 $40.00 $45.00 $45.00 $95.00 $75.00 $95.00 $ % 33% 25% 33% Complete Complete Plus Standard Standard Plus $4.50 $4.00 $4.50 $4.00 $22.00 $20.00 $22.00 $20.00 $90.00 $80.00 $90.00 $90.00 $ $ $ $ % 33% 25% 33%

8 8 Medicare Part D November 2014 The third stage is the coverage gap. - The member stays in the coverage gap stage until the annual out-of-pocket drug costs reach $4,700. Not all plans have a coverage gap. Complete Complete Plus Standard Standard Plus No additional coverage gap Additional coverage gap for tier 1 drugs: $4.00 The fourth stage is the catastrophic stage. No additional coverage gap Member has to pay 45 percent of the drug cost for brand drugs. Member has to pay 65 percent of the drug costs for generic drugs. - The member moves to this stage after the yearly out-of-pocket drug costs reach $4,700. Additional coverage gap for tier 1 drugs: $4.00 Retail (30-day supply) All Akamai Advantage Plans Member Share The greater of 5 percent or $2.65 for generic drugs (including brand drugs treated as generic) and $6.60 for all other drugs Why do some drugs have restrictions? For certain prescription drugs, special rules restrict how and when HMSA pays for them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective way. These special rules also help control overall drug costs and keep members drug coverage more affordable. In general, these rules encourage members to get a drug that works for their medical condition and is safe and effective. Examples of rules include: - Restricting brand-name drugs when a generic version is available. - Getting the plan approval in advance. - Trying a different drug first. - Quantity limits. Why does HMSA restrict brand-name drugs when a generic version is available? Generally, a generic drug works the same as a brand-name drug and usually costs your patients less. When a generic version of a brand-name drug is available, HMSA usually won t cover the brand-name drug and network pharmacies will give the generic version. Why does HMSA require getting plan approval (prior authorization) in advance for certain drugs? The requirement for getting approval in advance helps guide appropriate use of certain drugs. For certain drugs, you or the member need to get approval from the plan before HMSA will agree to pay for the drug. This is called prior authorization. If approval isn t obtained, HMSA might not pay for the drug. Why does HMSA require trying a different drug (step therapy) first? This requirement encourages members to try less costly but just as effective drugs before HMSA covers another drug. For example, if drug A and drug B treat the same medical condition, the plan may require the member to try drug A first. If drug A doesn t work, the plan will then cover drug B. This requirement to try a different drug first is called step therapy. If you have documentation of your patient already trying the preferred drug or have clinical information that this would negatively affect the health and safety of your patient, please contact us for an exception. Why does HMSA require quantity limits? For certain drugs, HMSA limits the amount of the drug that members can have. For example, the plan might limit the number of refills, or how much of a drug can be dispensed at one time. If it s normally considered safe

9 9 Medicare Part D November 2014 to take only one pill per day of a certain drug, for example, HMSA may limit coverage to no more than one pill per day. What is HMSA s mail-order drug program? Generally, the drugs available through mail order are drugs that are taken on a regular basis for a chronic or long-term medical condition. The drugs available through HMSA s mail-order service are marked as mail-order (M) drugs in our drug list. HMSA s mail-order service requires you to order a 90-day supply. To get order forms and information about filling prescriptions by mail, members can call our mail-order pharmacy at 1 (855) This toll-free number is available 24 hours a day, seven days a week. TTY users, call 1 (866) If your patient uses a mail-order pharmacy that s not in the plan s network, the prescription won t be covered. Usually a mail-order pharmacy order will arrive in no more than 14 days. However, sometimes the mail order may be delayed. Your patient may get a temporary 30-day supply of the drug from a retail pharmacy in the event that the mail-order supply is delayed. HMSA s Akamai Advantage plans are governed by CMS rules that preempt state laws regarding mail order prescriptions. Did you know there are programs to help people pay for their drugs? Medicare provides Extra Help to pay prescription drug costs for people who have limited income and resources. Resources included in the analysis to determine eligibility for Extra Help include savings and stocks, not a member s home or car. If members qualify, they can get help paying for any Medicare drug plan s monthly premium, yearly deductible, and prescription copayments. This Extra Help also counts toward out-of-pocket costs. Members may be able to get Extra Help to pay for their prescription drug premiums and costs. To see if they qualify for Extra Help, members can call: - 1 (800) MEDICARE [1 (800) ]. TTY users, call 1 (877) , 24 hours a day, seven days a week; - The Social Security Office at 1 (800) , between 7 a.m. to 7 p.m., Monday through Friday. TTY users, call 1 (800) ; or - Med-QUEST (Hawaii s Medicaid program) at on Oahu or 1 (800) toll-free on the Neighbor Islands and U.S. Mainland. TTY users, call on Oahu or 1 (800) toll-free on the Neighbor Islands and U.S. Mainland. What is the Medicare Coverage Gap Discount Program? The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand-name drugs to Part D enrollees who have reached the coverage gap and are not currently receiving Extra Help. What is a network pharmacy? A network pharmacy is a pharmacy that has a contract with the plan to provide members with covered prescription drugs. The term covered drugs means all of the Part D prescription drugs that are covered on HMSA s drug list. To find a network pharmacy, you can look in your Provider Directory, visit our website (hmsa.com/advantage), or call Customer Relations.

Drugs That Require Step Therapy (ST) Step Therapy Medications

Drugs That Require Step Therapy (ST) Step Therapy Medications Drugs That Require Step Therapy (ST) In some cases, HealthNow New York Inc. requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.

More information

Drugs That Require Step Therapy (ST) Step Therapy Medications

Drugs That Require Step Therapy (ST) Step Therapy Medications Drugs That Require Step Therapy (ST) In some cases, BlueShield of Northeastern New York requires you to first try certain drugs to treat your medical condition before we will cover another drug for that

More information

ADHD STIMULANTS-S(SHC)

ADHD STIMULANTS-S(SHC) Step Therapy Simply Health Care 2014 Formulary ID: 14406 Version: 14 Last Updated: 08/01/2014 ADHD STIMULANTS-S(SHC) Daytrana Focalin Xr Strattera Patient needs to have a paid claim for one Step 1 drug

More information

2017 Step Therapy Criteria

2017 Step Therapy Criteria FRESENIUS TOTAL HEALTH 2017 Step Therapy Updated 07/01/2017. For more recent information or other questions, please contact Fresenius Total Health Customer Service at 1-855-598-6774 / TTY 1-844-209-9094.

More information

ATYPICAL ANTIPSYCHOTICS

ATYPICAL ANTIPSYCHOTICS Step Therapy CareOregon 2018 Last Updated: 07/27/2018 ATYPICAL ANTIPSYCHOTICS Fanapt Fanapt Titration Pack Paliperidone Er Vraylar The following criteria applies to members who newly start on the drug:

More information

Step Therapy Medications

Step Therapy Medications Step Therapy Medications Step Therapy Group APTIOM Step-2: APTIOM 200 MG TABLET or APTIOM 400 MG TABLET or APTIOM 600 MG TABLET or APTIOM 800 MG TABLET Step 1 Drug(s): Oxcarbazepine immediate-release,

More information

ANGIOTENSIN RECEPTOR BLOCKERS STEP THERAPY

ANGIOTENSIN RECEPTOR BLOCKERS STEP THERAPY South Country Health Alliance 2017 Step Therapy Formulary ID: 17431 Last Updated: 10/20/2017 Effective Date: 11-01-2017 ANGIOTENSIN RECEPTOR BLOCKERS STEP THERAPY BENICAR 20 MG BENICAR 40 MG BENICAR 5

More information

Part D Pharmacy. An Independent Licensee of the Blue Cross Blue Shield Association ( )

Part D Pharmacy. An Independent Licensee of the Blue Cross Blue Shield Association ( ) Part D Pharmacy 1 An Independent Licensee of the Blue Cross Blue Shield Association 044507 (12-21-2017) New MA pharmacy partner We ve selected CVS Caremark to manage our part D pharmacy benefits Providence

More information

FirstCarolinaCare Insurance Company Step Therapy Requirements

FirstCarolinaCare Insurance Company Step Therapy Requirements ANALGESICS, NARCOTICS KADIAN MORPHINE SULFATE ER PRIOR CLAIM FOR MORPHINE SULFATE SUSTAINED ACTION TABLET (MS CONTIN) WITHIN THE PAST 120 DAYS. ANTIBACTERIALS (EENT) BESIVANCE PRIOR CLAIM FOR CIPROFLOXACIN

More information

Step Therapy Criteria 2019

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

More information

2017 Step Therapy (ST) Criteria

2017 Step Therapy (ST) Criteria 2017 Step Therapy (ST) 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

More information

2018 Step Therapy (ST) Criteria

2018 Step Therapy (ST) Criteria 2018 Step Therapy (ST) 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

More information

CRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication.

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

More information

STEP THERAPY ALGORITHMS PUP Select Formulary

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

More information

DT Description Price Category Price change

DT Description Price Category Price change Tariff T Watch October 2014 Readers are no doubt aware of this quarter's bad news for primary care prescribing allocations: NHS England has d the remuneration mechanism for community pharmacies gaining

More information

A BULLETIN FOR PHARMACY SERVICE PROVIDERS FROM ALBERTA BLUE CROSS. Pan-Canadian Select Molecule Price Initiative for Generic Drugs

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

More information

ALLERGIC CONJUNCTIVITIS AGENTS

ALLERGIC CONJUNCTIVITIS AGENTS 2018 5 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: 18390 Last Updated: 04/2018 Effective Date: 05-01-2018 ALLERGIC CONJUNCTIVITIS AGENTS epinastine 0.05 % eye drops

More information

DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 759 M %

DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 759 M % June 2016 On 13th May, the DH announced that there would be reductions to Category M prices from June until September. http://psnc.org.uk/our-news/contractor-notice-category-m-price-reduction/ This has

More information

Drugs That Require Step Therapy (ST) Step Therapy Medications

Drugs That Require Step Therapy (ST) Step Therapy Medications Drugs That Require Step Therapy (ST) In some cases, BlueShield of Northeastern New York requires you to first try certain drugs to treat your medical condition before we will cover another drug for that

More information

ANGIOTENSIN RECEPTOR BLOCKERS

ANGIOTENSIN RECEPTOR BLOCKERS Step Therapy 2014 2 Tier-Alameda Last Updated: 10/10/2014 ANGIOTENSIN RECEPTOR BLOCKERS Benicar Benicar Hct Diovan Valsartan Step 1: First line therapy should be irbesartan, irbesartan/hctz, losartan,

More information

Step Therapy Requirements. Effective: 03/01/2015

Step Therapy Requirements. Effective: 03/01/2015 Effective: 03/01/2015 Updated 02/2015 ANTI-INFLAMMATORY AGENTS - GI DIPENTUM PRIOR CLAIM FOR BALSALAZIDE OR APRISO WITHIN THE PAST 120 DAYS. ANTICONVULSANTS APTIOM BANZEL FYCOMPA OXTELLAR XR POTIGA QUDEXY

More information

Generics. Lead with. P r e s c r i p t i o n S t e p T h e r a p y P r o g r a m

Generics. Lead with. P r e s c r i p t i o n S t e p T h e r a p y P r o g r a m Lead with Generics P r e s c r i p t i o n S t e p T h e r a p y P r o g r a m WWW.BCBSLA.COM 04HQ3972 5/09 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity

More information

Generics. Lead with. Prescription Step Therapy Program

Generics. Lead with. Prescription Step Therapy Program Lead with Generics Prescription Step Therapy Program WWW.BCBSLA.COM 04HQ3972 R11/10 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company GENERIC DRUGS: A

More information

Step Therapy Requirements

Step Therapy Requirements An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 12/01/2017 Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/2014 1 ABILIFY Abilify 10 mg tablet

More information

Drugs That Require Step Therapy (ST) Step Therapy Medications

Drugs That Require Step Therapy (ST) Step Therapy Medications Drugs That Require Step Therapy (ST) In some cases, BlueShield of Northeastern New York requires you to first try certain drugs to treat your medical condition before we will cover another drug for that

More information

Drugs That Require Step Therapy (ST) Step Therapy Medications

Drugs That Require Step Therapy (ST) Step Therapy Medications Drugs That Require Step Therapy (ST) In some cases, BlueCross BlueShield of WNY requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.

More information

VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017

VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017 Effective: 01/01/2017 Updated 11/2016 ANTI-INFLAMMATORY AGENTS - GI DIPENTUM PRIOR CLAIM FOR BALSALAZIDE OR APRISO WITHIN THE PAST 120 DAYS. ANTICONVULSANTS APTIOM BANZEL FYCOMPA GABITRIL OXTELLAR XR POTIGA

More information

ALPHA BLOCKERS. Products Affected Step 1: Details. Step 2: Rapaflo 4 mg capsule Rapaflo 8 mg capsule

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

More information

ALLERGIC RHINITIS-NASAL

ALLERGIC RHINITIS-NASAL ALLERGIC RHINITIS-NASAL FLUNISOLIDE Patient needs to have paid claims for any one of the following Step 1 drugs: NasaCort OTC, fluticasone Rx, fluticasone OTC, Budesonide OTC. Prior to filling the Step

More information

2014 Quantity Limits (QL) Criteria

2014 Quantity Limits (QL) Criteria 2014 Quantity Limits (QL) Criteria Certain drugs covered through your EmblemHealth Medicare HMO/PPO Medicare Plan are covered for only a limited quantity. We do this to ensure compliance with the US Food

More information

2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+)

2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+) 2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+) In some cases, UCare requires you to first try certain drugs to

More information

Step Therapy Criteria

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

More information

2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements

2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements 2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for

More information

2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements

2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements 2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for

More information

2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements

2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements 2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for

More information

Alaska Medicaid 90 Day** Generic Prescription Medication List

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

More information

Contents ALPHA BLOCKERS... 3 COLCRYS-PST... 4 DPP-4 INHIBITORS-PST... 5 HIGH RISK MEDICATIONS - SEDATIVE HYPNOTICS... 6

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

More information

5-ASA. Products Affected Dipentum 250 mg capsule. Details. Lialda 1.2 gram tablet,delayed release

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.

More information

2018 PDP Premier Step Therapy Document September 2018 Y0114_18_33144_I_009

2018 PDP Premier Step Therapy Document September 2018 Y0114_18_33144_I_009 2018 PDP Premier Step Therapy Document September 2018 Aggrenox Y0114_18_33144_I_009 aspirin 25 mg-dipyridamole 200 mg capsule,ext.release 12 hr multiphase drug may be given. Step 1 Drug(s): clopidigrel.

More information

Cigna Drug and Biologic Coverage Policy

Cigna Drug and Biologic Coverage Policy Cigna Drug and Biologic Coverage Policy Subject Step Therapy Individual and Family Plan Table of Contents Coverage Policy... 1 General Background... 5 References... 5 Effective Date... 3/15/2018 Next Review

More information

Relative Cost/Month. Less than $10. Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*

Relative Cost/Month. Less than $10. Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL* Allergy Chlorpheniramine Tablet* Diphenhydramine Tablet* Diphenhydramine Liquid* Loratadine Tablet* Cetirizine Tablet* Loratadine 10mg ODT* Less than $10 Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*

More information

2014 Preferred Drug List An evidence-based pharmacy program that works for you

2014 Preferred Drug List An evidence-based pharmacy program that works for you 2014 Preferred Drug List An evidence-based pharmacy program that works for you What is the Moda Health Preferred Drug Program? The Moda Health Preferred Drug Program is a pharmacy program that is designed

More information

2015 Step Therapy Prior Authorization Medical Necessity Guidelines

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

More information

Drug Regimen Optimization

Drug Regimen Optimization Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Excluding Valsartan / Ramipril Prior authorization criteria logic: a description

More information

Simply Step Therapy Document September 2018 Y0114_18_33074_I_009

Simply Step Therapy Document September 2018 Y0114_18_33074_I_009 2018 2018 Simply Step Therapy Document September 2018 Aptiom APTIOM 200 MG TABLET APTIOM 400 MG TABLET Y0114_18_33074_I_009 APTIOM 600 MG TABLET APTIOM 800 MG TABLET Criteria If the patient has tried a

More information

DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 702 M %

DT Description Price Category Price change Percentage BNF 1.2 Mebeverine 135mg tablets (100) 702 M % December 16 No Category M changes so the reductions imposed in May which were only supposed to last until September continue As in November, most changes are Category A lines with a few Category C. Significant

More information

5-ASA. Products Affected Dipentum 250 mg capsule. Details. Lialda 1.2 gram tablet,delayed release

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.

More information

Step Therapy Requirements. Effective: 11/01/2018

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

More information

2013 Step Therapy (ST) Criteria

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

More information

VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 04/01/2019

VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 04/01/2019 VNSNY CHOICE FIDA Complete Step Therapy Requirements Effective: 04/01/2019 Updated 03/2019 AMANTADINE ER OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED

More information

Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18

Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18 Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18 Granite Alliance requires step therapy for certain drugs. This means prior to receiving a drug with a step therapy

More information

2018 Step Therapy Criteria

2018 Step Therapy Criteria 2018 Step Therapy Criteria ANGIOTENSIN RECEPTOR BLOCKERS... 2 ANTIDEPRESSANTS... 3 ANTIDEPRESSANTS, MISCELLANEOUS... 4 ANTIDEPRESSANTS, OTHER... 5 ANTIDIABETIC AGENTS... 6 ANTIGOUT AGENTS... 7 ANTIHYPERTENSIVE

More information

Plan Year CCHP Senior Program (HMO) Step Therapy Criteria (ST)

Plan Year CCHP Senior Program (HMO) Step Therapy Criteria (ST) Plan Year 2016 CCHP Senior Program (HMO) Step Therapy Criteria (ST) Step Therapy: In some cases, CCHP Senior Program (HMO) requires you to first try certain drugs to treat your medical condition before

More information

5-ASA. Products Affected DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED RELEASE. Details

5-ASA. Products Affected DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED RELEASE. Details 5-ASA DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda or Dipentum. 1 ANTIEMETICS

More information

5-ASA. Products Affected. Details. Dipentum 250 mg capsule. Lialda 1.2 gram tablet,delayed release

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

More information

Step Therapy Requirements. Effective: 05/01/2018

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

More information

ANTIDEPRESSANTS. Details. dose pack Viibryd 10 mg tablet Viibryd 20 mg tablet Viibryd 40 mg tablet. Criteria

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

More information

Upper Peninsula Health Plan Advantage (HMO) (List of Covered Drugs)

Upper Peninsula Health Plan Advantage (HMO) (List of Covered Drugs) Analgesics Opioid Analgesics, Long-acting fentanyl 100 mcg/hr patch td72 morphine sulfate 30 mg tablet er Opioid Analgesics, Short-acting fentanyl citrate 200 mcg lozenge hd hydrocodone/acetaminophen 5

More information

STEP THERAPY PROGRAM

STEP THERAPY PROGRAM STEP THERAPY PROGRAM Step Therapy Program Certain prescription drugs call for a more detailed assessment to help ensure that they represent reasonable treatment. For these drugs, Great-West s Special Authorization

More information

ANTICONVULSANTS. Details

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

More information

While there is around a 3% increase shown in costs for Category M lines, I think this is due to the inclusion of more lines in Category M.

While there is around a 3% increase shown in costs for Category M lines, I think this is due to the inclusion of more lines in Category M. April 2018 The usual quarterly of Category M prices Another set of similar comments as I made in January: significant increases in many lines which have been subject to price concessions but even more

More information

Step Therapy Requirements

Step Therapy Requirements Step Therapy Requirements Denver Health Medicare Choice (HMO SNP)/Medicare Select (HMO) Effective: 09/01/2017 Updated 08/2017 ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet

More information

AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details

AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details AMANTADINE ER OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED RELEASE PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS. 1 ANTICONVULSANTS

More information

Avoid paying too much for your prescriptions

Avoid paying too much for your prescriptions Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2017 Aetna Rx Step Program Medicine List Avoid paying too much for your prescriptions It s important to try to

More information

Step Therapy Requirements. Effective: 12/01/2016

Step Therapy Requirements. Effective: 12/01/2016 Effective: 12/01/2016 H2986_PD_049 Updated 11/2016 ALPHA 1-PROTEINASE INHIBITOR GLASSIA PRIOR CLAIM FOR ARALAST NP OR ZEMAIRA WITHIN THE PAST 120 DAYS. ANALGESICS, NARCOTICS KADIAN MORPHINE SULFATE ER

More information

STEP THERAPY CRITERIA

STEP THERAPY CRITERIA STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered under your medical or prescription

More information

ANTICONVULSANTS. Details

ANTICONVULSANTS. Details ANTICONVULSANTS APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL 200 MG BANZEL 40 MG/ML ORAL SUSPENSION BANZEL 400 MG FYCOMPA 0.5 MG/ML ORAL SUSPENSION FYCOMPA 10 MG FYCOMPA 12 MG FYCOMPA

More information

VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017

VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017 VNSNY CHOICE FIDA Complete Step Therapy Requirements Effective: 01/01/2017 Updated 12/23/2016 ANTICONVULSANTS Aptiom 200 mg tablet Potiga 200 mg tablet Aptiom 400 mg tablet Potiga 300 mg tablet Aptiom

More information

PRIOR ADAP FORMULARY - RX OPTIONS

PRIOR ADAP FORMULARY - RX OPTIONS PRIOR ADAP FORMULARY - RX OPTIONS Created by Care Directions Case Manageent - 602-264-2273 MEDICATION Pharacies ALLERGY/COUGH/COLD DIPHENHYDRAMINE 50 MG FLUTICASONE $35 HYDROXYZINE 25 MG, 50 MG X LORATIDINE

More information

Step Therapy Requirements. Effective: 1/1/2019

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

More information

Table 1: Price increases for Brand Name Drugs with Generic Equivalents

Table 1: Price increases for Brand Name Drugs with Generic Equivalents Table 1: Price increases for Brand Name Drugs with Generic Equivalents Brand Name Medication and Dose Total % Change Since 10/2012 ACTOS 15 MG TABLET 6.36 11.03 73.39% ACTOS 30 MG TABLET 9.7 16.80 73.23%

More information

Introducing exciting new Rx benefits 2019

Introducing exciting new Rx benefits 2019 Introducing exciting new x benefits 2019 In 2019, the Middlesex prescription plan is aligning with best-in-class evidence-based practices. Two new tiers will be added that evaluate drugs on the basis of

More information

AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details

AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details 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.

More information

AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details

AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details 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.

More information

STEP THERAPY CRITERIA

STEP THERAPY CRITERIA STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered under your medical or prescription

More information

SmithRx Standard Formulary Step Therapy List

SmithRx Standard Formulary Step Therapy List SmithRx Standard Formulary Step Therapy List Revised: January 27, 2017 The following medications require prior use of at least one other medication for coverage. Please note that any plan-specific customizations

More information

TEST ANTICONVULSANT THERAPY. Products Affected. Step 2: Network Health Insurance Corporation NetworkCares Step Therapy Criteria Last Updated 11/2018

TEST ANTICONVULSANT THERAPY. Products Affected. Step 2: Network Health Insurance Corporation NetworkCares Step Therapy Criteria Last Updated 11/2018 TEST Network Health Insurance Corporation NetworkCares Step Therapy Last Updated 11/2018 ANTICONVULSANT THERAPY Aptiom Banzel Briviact Celontin Dilantin 30 Mg Capsule Equetro Fycompa 0.5 Mg/ml Oral Susp

More information

ANTIDIABETIC AGENTS - MISCELLANEOUS

ANTIDIABETIC AGENTS - MISCELLANEOUS ANTIDIABETIC AGENTS - MISCELLANEOUS Glyxambi 10 mg-5 mg tablet Glyxambi 25 mg-5 mg tablet Invokamet 150 mg-1,000 mg tablet Invokamet 150 mg-500 mg tablet Invokamet 50 mg-1,000 mg tablet Invokamet 50 mg-500

More information

Drug Regimen Optimization

Drug Regimen Optimization Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Clinical Criteria Information Included in this Document Excluding Valsartan / Ramipril Prior authorization criteria logic: a description

More information

FirstCarolinaCare Insurance Company. Step Therapy Requirements

FirstCarolinaCare Insurance Company. Step Therapy Requirements FirstCarolinaCare Insurance Company Step Therapy Requirements Effective: 12/01/2018 ANTICONVULSANTS APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL 200 MG BANZEL 40 MG/ML ORAL SUSPENSION

More information

Quarterly pharmacy formulary change notice

Quarterly pharmacy formulary change notice The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members. These formulary changes,

More information

Glossary of Medications

Glossary of Medications CLPNA Medications Administration Module Glossary of Medications Acetaminophen. Acetaminophen is a non-opioid analgesic used to manage mild pain and fever. Acetylsalicylic acid. Acetylsalicylic acid is

More information

Santa Clara Family Health Plan Cal MediConnect Formulary. List of Step Therapy Requirements Effective: 12/01/ E

Santa Clara Family Health Plan Cal MediConnect Formulary. List of Step Therapy Requirements Effective: 12/01/ E Santa Clara Family Health Plan Cal MediConnect Formulary List of Step Therapy Requirements Effective: 12/01/2018 13027.12E ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET

More information

DT Description Price Category Price change Percentage

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

More information

ANTICONVULSANTS. Details

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

More information

Step Therapy Requirements

Step Therapy Requirements An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 05/01/2018 Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/2014 1 BETA-BLOCKERS BYSTOLIC 10 MG

More information