Plan Year CCHP Senior Program (HMO) Step Therapy Criteria (ST)
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1 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 we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, CCHP Senior Program (HMO) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, CCHP Senior Program (HMO) will then cover Drug B. PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT OUR STEP THERAPY CRITERIA. CCHP Senior Program (HMO) is an HMO plan with a Medicare contract. Enrollment in CCHP Senior Program (HMO) depends on contract renewal. Last updated 10/21/2015 Formulary ID: Version: 6
2 2016 Chinese Community Health Plan Senior Program (HMO) Step Therapy Criteria Products Affected ACTONEL TAB 5MG, 30MG, 35MG, 150MG Last Updated 10/21/2015 Criteria Step Therapy requires a trial of alendronate in previous 180 days. 1
3 APLENZIN TAB 174MG, 348MG, 522MG Step Therapy requires trial of bupropion SR or bupropion Criteria XL in previous 180 days. 2
4 ARANESP ALBUMIN FREE INJ 100MCG, 150MCG, 200MCG, 300MCG, 500MCG Criteria Step Therapy requires trial of PROCRIT or EPOGEN 3
5 ARANESP ALBUMIN FREE INJ 25MCG, 40MCG, 60MCG Criteria Step Therapy requires trial of PROCRIT or EPOGEN 4
6 ARICEPT TAB 23MG Step Therapy requires trial of donepezil 10mg in previous Criteria 180 days. 5
7 ATELVIA TAB 35MG Step Therapy requires a trial of alendronate in previous 180 Criteria days. 6
8 AUVI-Q INJ 0.15MG, 0.3MG Step Therapy requires trial of EPIPEN in previous 180 days. Criteria 7
9 BECONASE AQ NASAL SPRAY 42MCG Criteria Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone and NASONEX. trial of ONE (1) of the following agents: flunisolide, fluticasone or NASONEX. BECONASE AQ requires 8
10 BESIVANCE OPHTH SUSP 0.6% Step Therapy requires trial of one of the following ciprofloxacin, levofloxacin, ofloxacin, VIGAMOX or MOXEZA in previous 180 days. Criteria 9
11 BONIVA INJ 3MG/3ML Step Therapy requires a trial of alendronate in previous 180 Criteria days. 10
12 BONIVA TAB 150MG Step Therapy requires a trial of alendronate in previous 180 Criteria days. 11
13 BRINTELLIX TAB 5MG, 10MG, 20MG Criteria Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 12
14 budesonide nasal inhaler 32mcg Criteria Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone and NASONEX. trial of ONE (1) of the following agents: flunisolide, fluticasone or NASONEX. BECONASE AQ requires 13
15 DESVENLAFAXINE ER TAB 50MG, 100MG Criteria Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 14
16 DEXILANT CAP 30MG, 60MG Step Therapy requires trial of omeprazole, lansoprazole orcriteria pantoprazole in previous 180 days. 15
17 DIFICID TAB 200MG Criteria Step Therapy requires trial of VANCOCIN. 16
18 donepezil tab 23mg Step Therapy requires trial of donepezil 10mg in previous Criteria 180 days. 17
19 ENABLEX TAB 7.5MG, 15MG Criteria Step Therapy requires trial of Vesicare OR Myrbetriq in previous 180 days. If request for bethanechol, step not required for the treatment of acute postoperative and postpartum nonobstructive (functional) urinary retention and for neurogenic atony of the urinary bladder with retention. 18
20 EPINEPHRINE INJ 0.15MG, 0.3MG Step Therapy requires trial of EPIPEN in previous 180 days. Criteria 19
21 EXTAVIA INJ Step Therapy requires trial of two of the following: AVONEX, Criteria REBIF or COPAXONE 20
22 FARXIGA TAB 5MG, 10MG Step Therapy requires trial of ONGLYZA, JANUVIA, JANUMET Criteria or KOMBIGLYZE in previous 180 days. 21
23 FETZIMA CAP TITRATION PACK Criteria Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 22
24 FETZIMA ER CAP 20MG, 40MG, 80MG, 120MG Criteria Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 23
25 fluvoxamine ER cap 100mg, 150mg Criteria Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 24
26 gatifloxacin ophth soln 0.5% Step Therapy requires trial of one of the following ciprofloxacin, levofloxacin, ofloxacin, VIGAMOX or MOXEZA in previous 180 days. Criteria 25
27 GELNIQUE GEL PUMP 3% Criteria Step Therapy requires trial of Vesicare OR Myrbetriq in previous 180 days. If request for bethanechol, step not required for the treatment of acute postoperative and postpartum nonobstructive (functional) urinary retention and for neurogenic atony of the urinary bladder with retention. 26
28 ibandronate inj 3mg/3ml Step Therapy requires a trial of alendronate in previous 180 Criteria days. 27
29 ibandronate tab 150mg Step Therapy requires a trial of alendronate in previous 180 Criteria days. 28
30 JARDIANCE TAB 10MG, 25MG Step Therapy requires trial of ONGLYZA, JANUVIA, JANUMET Criteria or KOMBIGLYZE in previous 180 days. 29
31 KHEDEZLA TAB 50MG, 100MG Criteria Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 30
32 METROGEL 1% Criteria Step Therapy requires trial of FINACEA. 31
33 NORITATE CREAM 1% Criteria Step Therapy requires trial of FINACEA. 32
34 OMNARIS NASAL SPRAY 50MCG Criteria Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone and NASONEX. trial of ONE (1) of the following agents: flunisolide, fluticasone or NASONEX. BECONASE AQ requires 33
35 OXYTROL PATCH 3.9MG Criteria Step Therapy requires trial of Vesicare OR Myrbetriq in previous 180 days. If request for bethanechol, step not required for the treatment of acute postoperative and postpartum nonobstructive (functional) urinary retention and for neurogenic atony of the urinary bladder with retention. 34
36 PANCREAZE CAP (ALL STRENGTHS) Step Therapy requires trial of CREON in previous 180 days. Criteria 35
37 PENTASA CAP 250MG, 500MG Step Therapy requires trial of one of the following ASACOL, Criteria DELZICOL or LIALDA in previous 180 days. 36
38 PERTZYE CAP (ALL STRENGTHS) Step Therapy requires trial of CREON in previous 180 days. Criteria 37
39 PEXEVA TAB 10MG, 20MG, 30MG, 40MG Criteria Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 38
40 PRISTIQ TAB 25MG, 50MG, 100MG Criteria Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 39
41 QNASL CHILDRENS NASAL SPRAY 40MCG Criteria Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone and NASONEX. trial of ONE (1) of the following agents: flunisolide, fluticasone or NASONEX. BECONASE AQ requires 40
42 QNASL NASAL SPRAY 80MCG Criteria Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone and NASONEX. trial of ONE (1) of the following agents: flunisolide, fluticasone or NASONEX. BECONASE AQ requires 41
43 RHINOCORT AQUA NASAL SPRAY 32MCG Criteria Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone and NASONEX. trial of ONE (1) of the following agents: flunisolide, fluticasone or NASONEX. BECONASE AQ requires 42
44 risedronate sodium DR tab 35mg Step Therapy requires a trial of alendronate in previous 180 Criteria days. 43
45 risedronate sodium tab 5mg, 30mg, 35mg, 150mg Step Therapy requires a trial of alendronate in previous 180 Criteria days. 44
46 TOVIAZ TAB 4MG, 8MG Criteria Step Therapy requires trial of Vesicare OR Myrbetriq in previous 180 days. If request for bethanechol, step not required for the treatment of acute postoperative and postpartum nonobstructive (functional) urinary retention and for neurogenic atony of the urinary bladder with retention. 45
47 ULORIC TAB 40MG, 80MG Step Therapy requires trial of allopurinol in previous 180 days. Criteria 46
48 ULTRESA CAP (ALL STRENGTHS) Step Therapy requires trial of CREON in previous 180 days. Criteria 47
49 URECHOLINE TAB 5MG, 10MG, 25MG, 50MG Criteria Step Therapy requires trial of Vesicare OR Myrbetriq in previous 180 days. If request for bethanechol, step not required for the treatment of acute postoperative and postpartum nonobstructive (functional) urinary retention and for neurogenic atony of the urinary bladder with retention. 48
50 VANCOCIN CAP 125MG Criteria Step Therapy requires trial of metronidazole in previous 180 days 49
51 VANCOCIN CAP 250MG Criteria Step Therapy requires trial of metronidazole in previous 180 days 50
52 vancomycin cap 125mg, 250mg Criteria Step Therapy requires trial of metronidazole in previous 180 days 51
53 VERAMYST NASAL SPRAY 27.5MCG Criteria Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone and NASONEX. trial of ONE (1) of the following agents: flunisolide, fluticasone or NASONEX. BECONASE AQ requires 52
54 VIIBRYD TAB 10MG, 20MG, 40MG Criteria Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 53
55 XIGDUO XR TAB MG Step Therapy requires trial of ONGLYZA, JANUVIA, JANUMET Criteria or KOMBIGLYZE in previous 180 days. 54
56 XIGDUO XR TAB 5-500MG, MG, MG Step Therapy requires trial of ONGLYZA, JANUVIA, JANUMET Criteria or KOMBIGLYZE in previous 180 days. 55
57 XOPENEX HFA INHALER 45MCG Step Therapy requires trial of VENTOLIN HFA in previous Criteria 180 days. 56
58 ZENPEP CAP (ALL STRENGTHS) Step Therapy requires trial of CREON in previous 180 days. Criteria 57
59 ZETONNA NASAL INHALER 37MCG Criteria Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone and NASONEX. trial of ONE (1) of the following agents: flunisolide, fluticasone or NASONEX. BECONASE AQ requires 58
60 ZIOPTAN OPHTH SOLN % Criteria Step Therapy requires trial of latanoprost. 59
61 ZYMAXID OPHTH SOLN 0.5% Step Therapy requires trial of one of the following ciprofloxacin, levofloxacin, ofloxacin, VIGAMOX or MOXEZA in previous 180 days. Criteria 60
2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Criteria Last Updated 11/1/2015
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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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