FirstCarolinaCare Insurance Company Step Therapy Requirements
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- Berniece Marlene Sherman
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1 ANALGESICS, NARCOTICS KADIAN MORPHINE SULFATE ER PRIOR CLAIM FOR MORPHINE SULFATE SUSTAINED ACTION TABLET (MS CONTIN) WITHIN THE PAST 120 DAYS.
2 ANTIBACTERIALS (EENT) BESIVANCE PRIOR CLAIM FOR CIPROFLOXACIN OPHTHALMIC DROPS, CIPROFLOXACIN OPHTHALMIC OINTMENT, OR OFLOXACIN OPHTHALMIC DROPS WITHIN THE LAST 120 DAYS.
3 ANTIDIABETIC AGENTS - INSULINS LEVEMIR LEVEMIR FLEXPEN PRIOR CLAIM FOR INSULIN GLARGINE (LANTUS OR LANTUS SOLOSTAR) WITHIN THE PAST 120 DAYS.
4 ANTIDIABETIC AGENTS - MISCELLANEOUS INVOKANA PRIOR CLAIM FOR METFORMIN, METFORMIN ER, A SULFONYLUREA, A COMBINATION OF SULFONYLUREA AND METFORMIN, PIOGLITAZONE, OR COMBINATION PIOGLITAZONE AND METFORMIN WITHIN THE PAST 120 DAYS.
5 ANTIPSYCHOTIC AGENTS FANAPT FAZACLO INVEGA LATUDA SAPHRIS PRIOR CLAIM FOR A GENERIC ANTIPSYCHOITIC SUCH AS RISPERIDONE TABLET, RISPERIDONE DISINTEGRATING TABLET, CLOZAPINE TABLET, CLOZAPINE ORAL DISINTEGRATING TABLET, OLANZAPINE TABLET, OLANZAPINE ORAL DISINTEGRATING TABLET, IMMEDIATE RELEASE QUETIAPINE FUMARATE, OR ZIPRASIDONE, AND ABILIFY WITHIN THE PAST 365 DAYS.
6 ANTIULCER AGENTS LANSOPRAZOLE PRIOR CLAIM FOR GENERIC FEDERAL LEGEND OMEPRAZOLE OR PANTOPRAZOLE WITHIN THE PAST 120 DAYS.
7 ARIPIPRAZOLE ABILIFY ABILIFY DISCMELT PRIOR CLAIM FOR A GENERIC ATYPICAL ANTIPSYCHOTIC SUCH AS RISPERIDONE TABLET, RISPERIDONE DISINTEGRATING TABLET, CLOZAPINE TABLET, CLOZAPINE ORAL DISINTEGRATING TABLET, OLANZAPINE TABLET, OLANZAPINE ORAL DISINTEGRATING TABLET, IMMEDIATE RELEASE QUETIAPINE FUMARATE, OR ZIPRASIDONE OR AN SSRI OR SNRI SUCH AS CITALOPRAM, FLUOXETINE, PAROXETINE, SERTRALINE, OR VENLAFAXINE WITHIN THE PAST 120 DAYS.
8 B VERSUS D ADMINISTRATIVE STEP CYCLOPHOSPHAMIDE METHOTREXATE TREXALL PRIOR CLAIM FOR A RHEUMATOID ARTHRITIS DRUG WITHIN THE PAST 120 DAYS.
9 BUDESONIDE-FORMOTEROL FUMERATE SYMBICORT PRIOR CLAIM FOR ADVAIR OR DULERA WITHIN THE PAST 120 DAYS.
10 COPD DALIRESP PRIOR CLAIM FOR ONE COPD AGENT (LAMA, LABA, SAMA, SAMA/SABA) SUCH AS ATROVENT, COMBIVENT, SPIRIVA, ARCAPTA, SEREVENT, OR FORADIL WITHIN THE LAST 120 DAYS.
11 GLP-1 ANALOGS BYDUREON BYETTA PRIOR CLAIM FOR EITHER METFORMIN, METFORMIN ER, A SULFONYLUREA AGENT (E.G. GLYBURIDE, GLIPIZIDE), COMBINATION OF A SULFONYLUREA AND METFORMIN, A THIAZOLIDINEDIONE (E.G. PIOGLITAZONE, ROSIGLITAZONE), OR A COMBINATION THIAZOLIDINEDIONE AND METFORMIN WITHIN THE PAST 120 DAYS.
12 HYPERURICEMIC AGENTS ULORIC PRIOR CLAIM FOR ALLOPURINOL OR COLCHICINE WITHIN THE PAST 120 DAYS
13 KETOLIDES KETEK PRIOR CLAIM FOR A MACROLIDE WITHIN THE PAST 120 DAYS.
14 MULTIPLE SCLEROSIS AGENTS AVONEX AVONEX ADMINISTRATION PACK BETASERON EXTAVIA PRIOR CLAIM FOR REBIF (INTERFERON BETA-1A) OR COPAXONE (GLATIRAMIR ACETATE) WITHIN THE PAST 120 DAYS.
15 NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPE CELEBREX PRIOR CLAIM FOR ONE (1) NON-STEROIDAL ANTI-INFLAMMATORY AGENTS WITHIN THE PAST 120 DAYS.
16 OPHTHALMIC ANTIHISTAMINES BEPREVE PATADAY PATANOL PRIOR CLAIM FOR LEVOCETIRIZINE OR CROMOLYN SODIUM EYE DROPS WITHIN THE PAST 120 DAYS.
17 QUETIAPINE FUMARATE EXTENDED RELEASE SEROQUEL XR PRIOR CLAIM FOR A GENERIC ATYPICAL ANTIPSYCHOTIC SUCH AS RISPERIDONE TABLET, RISPERIDONE DISINTEGRATING TABLET, CLOZAPINE TABLET, CLOZAPINE ORAL DISINTEGRATING TABLET, OLANZAPINE TABLET, OLANZAPINE ORAL DISINTEGRATING TABLET, IMMEDIATE RELEASE QUETIAPINE FUMARATE, OR ZIPRASIDONE OR AN SSRI OR SNRI SUCH AS CITALOPRAM, FLUOXETINE, PAROXETINE, SERTRALINE, OR VENLAFAXINE AND ABILIFY WITHIN THE PAST 365 DAYS.
18 RENIN ANGIOTENSION SYSTEM INHIBITORS AMTURNIDE AZOR BENICAR BENICAR HCT DIOVAN EXFORGE EXFORGE HCT MICARDIS MICARDIS HCT TEKAMLO TEKTURNA TEKTURNA HCT TEVETEN TEVETEN HCT TRIBENZOR PRIOR CLAIM FOR AN ANGIOTENSIN CONVERTING ENZYME INHIBITOR (ACE INHIBITOR), OR ACE INHIBITOR COMBINATION OR A GENERIC ANGIOTENSIN RECEPTOR BLOCKER (ARB), OR GENERIC ARB COMBINATION WITHIN THE PAST 120 DAYS.
19 ROTIGOTINE NEUPRO PRIOR CLAIM FOR IMMEDIATE RELEASE PRAMIPEXOLE OR IMMEDIATE RELEASE ROPINIROLE WITHIN THE PAST 120 DAYS.
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
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
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ANTIDIABETIC AGENTS - MISCELLANEOUS
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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
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 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.
Medicare Part D Drugs that Require Step Therapy Effective 12/01/2017
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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
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
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
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
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
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
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
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
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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
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
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 04/01/2019
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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
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