2017 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements
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1 2017 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 that condition. Below is the list of drugs with step therapy requirements. H5969_501510_17 LAST UPDATED 09/01/2017
2 ALZHEIMER'S DRUGS EXELON 1.5 MG CAPSULE, EXELON 3 MG CAPSULE, EXELON 4.5 MG CAPSULE, EXELON 4.6 MG/24HR PATCH, EXELON 6 MG CAPSULE, EXELON 9.5 MG/24HR PATCH Step 1: donepezil, glanatamine Hbr, rivastigmine Step 2: Exelon patches PAGE 1 LAST UPDATED 09/01/2017
3 ANGIOTENSIN RECEPTOR ANTAGONIST (ARBS) EDARBI, EDARBYCLOR Generic ARBs and generic ARB combination products are First Line Agents. Brand ARBs and brand ARB comboination products on the formulary are Second Line Agents. PAGE 2 LAST UPDATED 09/01/2017
4 GLUCAGON-LIKE PEPTIDE-1 (GLP-1) RECEPTOR AGONISTS BYDUREON Exenatide and liraglutide are first-line agents. Exenatide ER should be used as a second line agent if first-line agents have been tried. PAGE 3 LAST UPDATED 09/01/2017
5 HIGH RISK MEDICATIONS- LONG ACTING SULFONYLUREAS CHLORPROPAMIDE, GLYBURIDE 1.25 MG TABLET, GLYBURIDE 2.5 MG TABLET, GLYBURIDE 5 MG TABLET, GLYBURIDE MICRONIZED, GLYBURIDE-METFORMIN HCL First line agents are glipizide, glipizide/metformin, glimeperide, and tolbutamide. If any of these first line agents have been tried then glyburide, glyburide micronized, glyburide/metformin, or chlorpropamide can be used as second line agents. PAGE 4 LAST UPDATED 09/01/2017
6 NON-SEDATING/LOW-SEDATING ANTIHISTAMINES (NSA/LSA) CLARINEX 0.5 MG/ML (2.5 MG/5) First-line NS/LSA drugs are OTC loratadine, prescription generic desloratadine, OTC fexofenadine, prescription generic levocetirizine, OTC cetirizine, prescription generic cetirizine, OTC cetirizine hcl/pseudoephedrine, OTC fexofenadine/pseudoephedrine, OTC loratadine/pseudoephedrine, or desloratadine/pseudoephedrine. Brand NS/LSA drugs will be covered as 2nd-line agents. PAGE 5 LAST UPDATED 09/01/2017
7 ORAL BISPHOSPHONATE AGENTS ATELVIA, FOSAMAX PLUS D, RISEDRONATE SODIUM, RISEDRONATE SODIUM DR First-line Bisphosphonates are alendronate, ibandronate (oral or injectable), or Boniva. Must have tried alendronate or Boniva in the last 180 days before using other formulary Oral Bisphosphonate agents. PAGE 6 LAST UPDATED 09/01/2017
8 PROTON PUMP INHIBITORS (PPIS) DEXILANT, ESOMEPRAZOLE MAG DR 40 MG CAP, KAPIDEX, LANSOPRAZOLE DR 15 MG CAPSULE, LANSOPRAZOLE DR 30 MG CAPSULE, PANTOPRAZOLE SOD DR 20 MG TAB, PANTOPRAZOLE SOD DR 40 MG TAB, RABEPRAZOLE SODIUM First-line PPI's are Prilosec OTC, OTC omeprazole magnesium, generic Rx/OTC omeprazole, Prevacid 24Hr(OTC), OTC lansoprazole, or esomeprazole 20mg. If Prilosec OTC, OTC omeprazole magnesium, generic Rx/OTC omeprazole, Prevacid 24Hr(OTC), OTC lansoprazole, or esomeprazole 20mg have been tried within the last 180 days then pantoprazole, lansoprazole, esomeprazole 40mg, or rabeprazole can be used as 2nd-line agents. Dexilant can be used as a 3rd-line agent if either pantoprazole, lansoprazole, esomeprazole 40mg, or rabeprazole have been tried within the last 180 days. PAGE 7 LAST UPDATED 09/01/2017
9 SGLT 2 INHIBITORS FARXIGA, INVOKAMET, INVOKANA, JARDIANCE step 1: metformin AND one DPP-4 inhibitor or DPP-4 inhibitor combination product OR one GLP-1 receptor agonist. step 2: SGLT2 inhibitor or SGLT2 inhibitor combination product PAGE 8 LAST UPDATED 09/01/2017
10 URICOSURIC AGENTS ULORIC Must have tried allopurinol first, then Uloric may be used as a 2nd line agent PAGE 9 LAST UPDATED 09/01/2017
2017 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements
2017 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
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
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
ANTIDIABETIC AGENTS - MISCELLANEOUS
ANTIDIABETIC AGENTS - MISCELLANEOUS GLYXAMBI 10 MG-5 MG GLYXAMBI 25 MG-5 MG INVOKAMET 150 MG-1,000 MG INVOKAMET 150 MG-500 MG INVOKAMET 50 MG-1,000 MG INVOKAMET 50 MG-500 MG INVOKAMET XR 150 MG-1,000 MG,
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
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.
2018 Step Therapy FID 18088
2018 Step Therapy FID 18088 Step Therapy ANTIDEPRESSANTS, SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS LEON 2018 Desvenlafaxine Er Fetzima Fetzima Titration Pack Khedezla Paxil SUSP Pristiq Trintellix
Medicare Part D Drugs that Require Step Therapy Effective 12/01/2017
Medicare Part D Drugs that Require Step Therapy Effective 12/01/2017 Providers may call the Pharmacy Help Desk at 800-641-8921 for more information or questions about criteria. The formulary may change
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
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
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
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
DPP4 INHIBITORS. Details. Step Therapy Criteria Health Alliance Plan 2019 Date Effective: 04/01/2019
DPP4 INHIBITORS Janumet 50 mg-1,000 mg tablet Januvia 50 mg tablet Janumet 50 mg-500 mg tablet Onglyza 2.5 mg tablet Januvia 100 mg tablet Onglyza 5 mg tablet Januvia 25 mg tablet Tradjenta 5 mg tablet
DPP4 INHIBITORS. Products Affected Step 2: Janumet 50 mg-1,000 mg tablet Janumet 50 mg-500 mg tablet Januvia 100 mg tablet Januvia 25 mg tablet
DPP4 INHIBITORS Janumet 50 mg-1,000 mg tablet Janumet 50 mg-500 mg tablet Januvia 100 mg tablet Januvia 25 mg tablet Januvia 50 mg tablet Onglyza 2.5 mg tablet Onglyza 5 mg tablet Tradjenta 5 mg tablet
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
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
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
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.
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:
Step Therapy Criteria (Criteria for Step Therapy-2 [ST-2] Drugs)
![Step Therapy Criteria (Criteria for Step Therapy-2 [ST-2] Drugs)](/thumbs/85/91743011.jpg "Step Therapy Criteria (Criteria for Step Therapy-2 [ST-2] Drugs)")
CareAdvantage CMC 2018 Formulary Supplement II (List of Covered Drugs) Step Therapy Criteria (Criteria for Step Therapy-2 [ST-2] Drugs) Formulary ID: 00018157 Formulary Version:11 19 CMS Approved: 08/21/2018
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
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.
ARBS MEDICATION(S) SUBJECT TO STEP THERAPY DIOVAN HCT MG TAB, DIOVAN HCT MG TABLET
ARBS DIOVAN HCT 160-12.5 MG TAB, DIOVAN HCT 80-12.5 MG TABLET 30-day trial of a Step 1 drug in the previous 120 days is required. Step 1 Drugs: Losartan, Losartan/HCTZ PAGE 1 LAST UPDATED 05/2016 BILE
WELLCARE/ OHANA HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 08/2015)
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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
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
2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements
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VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017
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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*
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