ADHD STIMULANTS - SCORE

Transcription

1 Step Therapy Trillium 5 Tier Effective Date: 12/01/2017 Approval Date: 10/24/2017 ADHD STIMULANTS - SCORE Strattera Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication. Formulary ID Version 15 1

2 ALPHA GLUCOSIDASE INHIBITOR -SCORE Glyset Patient needs to have a paid claim for generic formulary metformin or metformin combinations, generic sulfonylureas, or generic thiazolidinediones Formulary ID Version 15 2

3 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Khedezla Pexeva Patient needs to have a paid claim for TWO of the following formulary products: bupropion, mirtazapine, generic SSRI, or generic SNRI. Formulary ID Version 15 3

4 ANTIGOUT -SCORE Uloric Patient needs to have a paid claim for allopurinol Formulary ID Version 15 4

5 ATYPICAL ANTIPSYCHOTICS - SCORE Fanapt Fanapt Titration Pack Saphris Vraylar Patient needs to have a paid claim for two generic formulary atypical antipsychotic agents Formulary ID Version 15 5

6 BISPHOSPHONATES -SCORE Fosamax Plus D Patient needs to have a paid claim for one generic formulary oral bisphosphonate agent Formulary ID Version 15 6

7 DPP4 INHIBITORS - SCORE Janumet Janumet Xr Januvia Jentadueto Jentadueto Xr Kombiglyze Xr Onglyza Tradjenta Trial of one generic metformin containing products, generic sulfonylureas, or generic thiazolidinediones Formulary ID Version 15 7

8 EPINEPHRINE -SCORE Adrenaclick Epinephrine INJ 0.15MG/0.15ML, 0.3MG/0.3ML History of trial and failure, or intolerance to one of the following: EpiPen or EpiPen Jr or epinephrine (generic EpiPen or EpiPen Jr) Formulary ID Version 15 8

9 GLP1 AGONIST - SCORE Bydureon Bydureon Pen Byetta Trulicity Victoza Patient needs to have a paid claim for generic formulary metformin or metformin combinations, generic sulfonylureas, or generic thiazolidinediones Formulary ID Version 15 9

10 LAMA-SCORE Tudorza Pressair Patient needs to have a paid claim for Spiriva Formulary ID Version 15 10

11 LEUKOTRIENE MODIFIERS - SCORE Zileuton Er Zyflo Zyflo Cr Trial of generic montelukast or generic zafirlukast. Formulary ID Version 15 11

12 NASONEX BRAND-SCORE Nasonex Patient needs to have a paid claim for any one generic intranasal corticosteroid Formulary ID Version 15 12

13 OPHTHALMIC NSAID - SCORE Bromsite Patient must have a paid claim for one of the following: generic, single ingredient, ophthalmic NSAID solutions: diclofenac, flurbiprofen, ketorolac, or brand Nevanac or brand Ilevro Formulary ID Version 15 13

14 PD AGENTS -SCORE Neupro Patient needs to have a paid claim for one generic formulary dopamine agonist agent Formulary ID Version 15 14

15 RAYALDEE -SCORE Rayaldee Trial of one of the following oral generics: calcitriol, doxercalciferol, paricalcitol Formulary ID Version 15 15

16 SGLT2 - SCORE Invokamet Invokamet Xr Invokana Jardiance Synjardy Synjardy Xr Paid claim for generic formulary metformin or metformin combinations, generic sulfonylureas, or generic thiazolidinediones. Jardiance, Synjardy only: ST does not apply for patients with CV disease, defined as one of the following: h/o MI, multi-vessel CAD, left main CAD, h/o stroke, Occlusive PAD, single-vessel CAD with documentation of unstable angina or a positive stress test for ischemia. Formulary ID Version 15 16

17 STATINS -SCORE Altoprev TB24 20MG, 40MG, 60MG Livalo Livalo: Trial of one generic formulary HMG-CoA reductase inhibitor (statin). Altoprev: Trial of two generic formulary HMG-CoA reductase inhibitors (statin). Formulary ID Version 15 17

18 INDEX A Adhd Stimulants - Score... 1 Adrenaclick... 8 Alpha Glucosidase Inhibitor -score... 2 Altoprev Antidepressants - Score... 3 Antigout -score... 4 Aplenzin... 3 Atypical Antipsychotics - Score... 5 B Bisphosphonates -score... 6 Bromsite Bydureon... 9 Bydureon Pen... 9 Byetta... 9 D Desvenlafaxine Er... 3 Dpp4 Inhibitors - Score... 7 E Emsam... 3 Epinephrine... 8 Epinephrine -score... 8 F Fanapt... 5 Fanapt Titration Pack... 5 Fetzima... 3 Fetzima Titration Pack... 3 Fosamax Plus D... 6 G Glp1 Agonist - Score... 9 Glyset... 2 I Invokamet Invokamet Xr Invokana J Janumet... 7 Janumet Xr... 7 Januvia... 7 Jardiance Jentadueto... 7 Jentadueto Xr... 7 K Khedezla... 3 Kombiglyze Xr... 7 L Lama-score Leukotriene Modifiers - Score Livalo N Nasonex Nasonex Brand-score Neupro O Onglyza... 7 Ophthalmic Nsaid - Score P Pd Agents -score Pexeva... 3 R Rayaldee Rayaldee -score S Saphris... 5 Sglt2 - Score Formulary ID Version 15 18

19 Statins -score Strattera... 1 Synjardy Synjardy Xr T Tradjenta... 7 Trulicity... 9 Tudorza Pressair U Uloric... 4 V Victoza... 9 Vraylar... 5 Z Zileuton Er Zyflo Zyflo Cr Formulary ID Version 15 19