ALPHA BLOCKERS. Products Affected. Details. Step 2: RAPAFLO 4 MG CAPSULE. Step 1: alfuzosin extended release tablet doxazosin tablet
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1 ALPHA BLOCKERS RAPAFLO 4 MG CAPSULE RAPAFLO 8 MG CAPSULE drug may be given. alfuzosin extended release tablet doxazosin tablet tamsulosin capsule terazosin capsule 1
2 ANTIDEPRESSANTS - SNRI FETZIMA 10 MG FETZIMA 0 MG ()-40 MG (6) CAPSULE,EXTENDED RELEASE,4 HR,DOSE PACK FETZIMA 0 MG FETZIMA 40 MG FETZIMA 80 MG drug may be given. Authorization may be given for a step drug that does not have a generic equivalent included in step 1, without trial of a step 1 drug, if the patient is currently taking or has taken the drug in the past. Authorization may be given for a step drug that does not have a generic equivalent included in step 1, without a trial of a step 1 drug, if the patient has symptoms of suicidal ideation. citalopram tablet citalopram oral solution desvenlafaxine succinate extended release tablet duloxetine capsule escitalopram tablet escitalopram oral solution fluoxetine capsule fluoxetine oral solution fluvoxamine tablet fluvoxamine extended release capsule paroxetine tablet paroxetine extended release tablet sertraline tablet sertraline oral solution venlafaxine tablet venlafaxine extended release capsule
3 COLCRYS-PST COLCRYS 0.6 MG TABLET Criteria If the patient has tried one Step 1 product, authorization for a Step product may be given. Exceptions can be made for a step drug (without a trial of a step 1 drug) for the treatment of Familial Mediterranean Fever and for the treatment of gout flares (i.e, prophylaxis of gout flares requires a trial of a step 1 drug). MITIGARE CAPSULE 3
4 OPHTHALMIC PROSTAGLANDINS-PST ZIOPTAN (PF) % EYE DROPS IN A DROPPERETTE drug may be given. Authorization for Zioptan may be given if the patient has a known benzalkonium chloride (BAK) sensitivity or a known sensitivity to other ophthalmic preservatives. bimatoprost eye drops latanoprost eye drops LUMIGAN EYE DROPS TRAVATAN Z EYE DROPS 4
5 TOPICAL ACTINIC KERATOSIS FLUOROURACIL 0. % TOPICAL CREAM ZYCLARA. % TOPICAL CREAM PUMP ZYCLARA 3.7 % TOPICAL CREAM PACKET drug may be given. CARAC TOPICAL CREAM diclofenac 3% topical gel fluorouracil % topical solution fluorouracil % topical solution fluorouracil % topical cream imiquimod topical cream packet
6 ULORIC ULORIC 40 MG TABLET ULORIC 80 MG TABLET drug may be given. Authorization may be given for Uloric if the patient has renal insufficiency or decreased renal function. Authorization may be given for Uloric if the patient is receiving concomitant medications that have significant drug-drug interactions with allopurinol, which are not noted with Uloric (eg, cyclosporine, chlorpropamide). allopurinol tablet 6
7 Index C COLCRYS 0.6 MG TABLET... 3 F FETZIMA 10 MG... FETZIMA 0 MG ()-40 MG (6),4 HR,DOSE PACK... FETZIMA 0 MG... FETZIMA 40 MG... FETZIMA 80 MG... FLUOROURACIL 0. % TOPICAL CREAM... R RAPAFLO 4 MG CAPSULE... RAPAFLO 8 MG CAPSULE... U ULORIC 40 MG TABLET... ULORIC 80 MG TABLET... Z ZIOPTAN (PF) % EYE DROPS IN A DROPPERETTE... ZYCLARA. % TOPICAL CREAM PUMP... ZYCLARA 3.7 % TOPICAL CREAM PACKET
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2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements
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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
ALPHA BLOCKERS. Products Affected Step 1: Details. Step 2: Rapaflo 4 mg capsule Rapaflo 8 mg capsule
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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
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.
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