Step Therapy Approval Criteria
|
|
|
- Kory Hutchinson
- 5 years ago
- Views:
Transcription
1 Effective Date: 01/01/2019 This document contains for the following medications: 1. Colcrys (colchicine) 2. Dovonex (calcipotriene) 3. Enbrel (etanercept) 4. Humira (adalimumab) 5. Imitrex Injection vial and STATdose (sumatriptan succinate) 6. Jardiance (empagliflozin) 7. Levitra (vardenafil) 8. Lyrica (pregabalin) 9. Nexium (esomeprazole) 10. OxyContin (oxycodone extended-release) 11. Protopic (tacrolimus) 12. Relpax (eletriptan) 13. Risperdal Consta (risperidone long-acting injection) 14. Soriatane (acitretin) 15. Victoza (liraglutide) 16. Vyvanse (lisdexamfetamine) 17. Xifaxan (rifaximin)
2 Colcrys (colchicine) colchicine Colcrys Antigout; antiinflammatory Previous failure of one of the following in the past 365 days: o A formulary NSAID o A formulary glucocorticoid o Allopurinol o Probenecid/colchicine Quantity Limit (QL) of 60 tablets per 30 days Initial: October 2016
3 Dovonex (calcipotriene) calcipotriene Dovonex Antipsoriatic, Synthetic Vitamin D3 Previous failure of a formulary topical corticosteroid in the past 365 days Initial: January 2016
4 Enbrel (etanercept) etanercept Enbrel TNF inhibitor; immune suppressant Previous failure of one of the following in the past 365 days: o Asacol o Balsalazide o Dipentum o Methotrexate o Rowasa o Azathioprine o Cyclosporine o Hydroxychloroquine o Hydroxyurea o Leflunomide o Mercaptopurine o Soriatane o Sulfasalazine Quantity limit (QL) of 4 injections per 28 days Initial: 10/01/ /01/2015, 10/01/2016
5 Humira (adalimumab) adalimumab Humira TNF inhibitor; monoclonal antibody; antirheumatic Previous failure of one of the following in the past 365 days: o Asacol o Balsalazide o Dipentum o Methotrexate o Rowasa o Azathioprine o Cyclosporine o Hydroxychloroquine o Hydroxyurea o Leflunomide o Mercaptopurine o Soriatane o Sulfasalazine Quantity limit (QL) of 4 injections per 28 days Initial: 10/01/ /01/2015, 10/01/2016
6 Imitrex Injection vial and STATdose (sumatriptan succinate) sumatriptan Imitrex Injection vial and Imitrex STATdose 5HT-1 serotonin receptor agonist; antimigraine Previous failure of sumatriptan oral tablets or sumatriptan nasal spray in the past 365 days Quantity limit (QL) of 6 doses (3 ml) per 30 days Initial: 10/01/2013
7 Jardiance (empagliflozin) empagliflozin Jardiance SGLT2 inhibitor Previous failure of a formulary diabetes medication in the past 365 days. Initial: July 2017
8 Levitra (vardenafil) Brand names: vardenafil Levitra Phosphodiesterase-5 (PDE-5) inhibitor Previous failure of sildenafil citrate (generic for Viagra) in the past 365 days Quantity Limit (QL) of 6 tablets per 30 days Initial: July 2018
9 Lyrica (pregabalin) pregabalin Lyrica GABA analog; anticonvulsant Previous failure of gabapentin or duloxetine in the past 365 days Initial: January 2019
10 Nexium (esomeprazole) esomeprazole Nexium Proton pump inhibitor Previous failure of omeprazole or pantoprazole in the past 365 days Quantity Limit (QL) of 30 capsules per 30 days Initial: 01/01/ /01/2015, 04/01/2018
11 OxyContin (oxycodone extended-release) oxycodone extended-release OxyContin Opioid analgesic Previous failure of one formulary long-acting opioid analgesic (i.e. morphine sulfate extended-release, fentanyl patches or methadone) in the past 365 days. Initial: January 2018
12 Protopic (tacrolimus) Brand names: tacrolimus Protopic Calcineurin inhibitor Previous failure of one formulary topical corticosteroid in the past 365 days Quantity Limit (QL) of 100 grams per 30 days Initial: April 2017
13 Relpax (eletriptan) eletriptan Relpax 5-HT1 serotonin receptor agonist; antimigraine Previous failure of a formulary triptan medication (sumatriptan tablet, sumatriptan nasal spray, sumatriptan injection, zolmitriptan tablet or zolmitriptan oral-disintegrating tablet) in the past 180 days Quantity limit (QL) of 6 tablets per 30 days Initial: 10/01/2013
14 Risperdal Consta (risperidone long-acting injectable) risperidone long-acting injectable Risperdal Consta Atypical antipsychotic Previous failure of risperidone tablets in the past 365 days. Initial: July 2017
15 Soriatane (acitretin) acitretin Soriatane Retinoid Previous failure of methotrexate in the past 365 days. Initial: October 2016
16 Victoza (liraglutide) liraglutide Victoza GLP-1 receptor agonist Previous failure of a formulary diabetes medication in the past 365 days. Initial: January 2018
17 Vyvanse (lisdexamfetamine) lisdexamfetamine Vyvanse CNS stimulant Previous failure of a formulary generic amphetamine product in the past 365 days Step 2: Previous failure of formulary generic methylphenidate product in the past 365 days Quantity Limit (QL) of 30 capsules per 30 days Initial: April 2017
18 Xifaxan (rifaximin) rifaximin Xifaxan Rifamycin Previous failure of lactulose, dicyclomine, ciprofloxacin or azithromycin in the past 180 days Quantity limit (QL) of 60 tablets per 30 days for the 550 mg tablets Quantity limit (QL) of 180 tablets per 30 days for the 200 mg tablets Initial: 07/01/2015 October 2017
Step Therapy Approval Criteria
Effective Date: 01/01/2018 This document contains Step Therapy Approval Criteria for the following medications: 1. Colcrys (colchicine) 2. Dovonex (calcipotriene) 3. Enbrel (etanercept) 4. Humira (adalimumab)
Step Therapy Approval Criteria
Effective Date: 10/01/2016 This document contains Step Therapy Approval Criteria for the following medications: 1. Colcrys (colchicine) 2. Cymbalta (duloxetine) 3. Dovonex (calcipotriene) 4. Enbrel (etanercept)
Step Therapy Approval Criteria
Effective Date: 07/01/2015 This document contains for the following medications: 1. Ambien CR (zolpidem ER) 2. Chantix Continuing Month (varenicline) 3. Chantix Starting Month (varenicline) 4. Cymbalta
FORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS
FORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS DHMC/CHP+ may add or remove drugs from the formulary or make changes to restrictions on formulary drugs
FORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS
FORMULARY UPDATES TO DENVER HEALTH MEDICAID CHOICE (DHMC) AND CHILD HEALTH PLAN PLUS (CHP+) PLANS DHMC/CHP+ may add or remove drugs from the formulary or make changes to restrictions on formulary drugs
NB Drug Plans Formulary Update
Bulletin #980 August 23, 2018 NB Drug Plans Formulary Update This update to the New Brunswick Drug Plans Formulary is effective August 23, 2018. Included in this bulletin: Regular Benefit Additions Special
INFLIXIMAB Remicade (infliximab), Inflectra (infliximab-dyyb), Ixifi* (infliximabqbtx), Renflexis (infliximab-abda)
Pre - PA Allowance None Prior-Approval Requirements Diagnoses Patient must have ONE of the following: 6 years of age or older 1. Moderate to severe Crohn s disease (CD) a. Patient has fistulizing disease
HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES
Generic Brand HICL GCN Exception/Other CERTOLIZUMAB PEGOL CIMZIA 35554 GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Is the request for a patient with a diagnosis of moderate
Pharmacy Updates Summary
All of the following changes were reviewed and approved by the SFHP Pharmacy & Therapeutics (P&T) Committee on 4/16/2014 Effective date: 5/15/2014 Therapeutic Classes reviewed: ADHD Ophthalmic antihistamines
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
Alprazolam 0.25mg, 0.5mg, 1mg tablets
Presbyterian Senior Care (HMO) / Presbyterian MediCare PPO Quantity Limits Effective November 1, 2014 For the most recent list of drugs or other questions, please contact the Presbyterian Customer Service
1 P a g e. Systemic Juvenile Idiopathic Arthritis (SJIA) (1.3) Patients 2 years of age and older with active systemic juvenile idiopathic arthritis.
LENGTH OF AUTHORIZATION: Initial: 3 months for Crohn s or Ulcerative Colitis; 1 year for all other indications. Renewal: 1 year dependent upon medical records supporting response to therapy and review
ADHD STIMULANTS-S(SHC)
Step Therapy Simply Health Care 2014 Formulary ID: 14406 Version: 14 Last Updated: 08/01/2014 ADHD STIMULANTS-S(SHC) Daytrana Focalin Xr Strattera Patient needs to have a paid claim for one Step 1 drug
Immune Modulating Drugs Prior Authorization Request Form
Patient: HPHC member ID #: Requesting provider: Phone: Servicing provider: Diagnosis: Contact for questions (name and phone #): Projected start and end date for requested Requesting provider NPI: Fax:
Michigan Department of Community Health Quantity Limitations
Abstral (fentanyl) sl tab all strength Acetaminophen Actonel Actonel 35mg Adderall XR 5mg, 10mg, 15mg 240 per 34 days 3 gm/day 2 every 28 days 4 every 28 days Advair Diskus. No more than 180 every 30 days
ETANERCEPT Generic Brand HICL GCN Exception/Other ETANERCEPT ENBREL GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW)
Generic Brand HICL GCN Exception/Other ETANERCEPT ENBREL 18830 GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Does the patient have a diagnosis of moderate to severe rheumatoid
Otezla. Otezla (apremilast) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 Subject: Otezla Page: 1 of 5 Last Review Date: March 16, 2018 Otezla Description Otezla (apremilast) Background
Step Therapy Criteria
ADCIRCA ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 ) ELIDEL 76-F ELIDEL Coverage will be provided if the member
Medical Policy An independent licensee of the Blue Cross Blue Shield Association
Otezla (apremilast) Page 1 of 7 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Otezla (apremilast) Prime Therapeutics will review Prior Authorization requests Prior
**CRITERIA UNDER CMS REVIEW**
**CRITERIA UNDER CMS REVIEW** ANTICONVULSANTS APTIOM TABLET 200 MG APTIOM TABLET 400 MG APTIOM TABLET 600 MG APTIOM TABLET 800 MG BANZEL SUSPENSION 40 MG/ML BANZEL TABLET 200 MG BANZEL TABLET 400 MG BRIVIACT
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,
Upper Peninsula Health Plan Advantage (HMO) (List of Covered Drugs)
Analgesics Opioid Analgesics, Long-acting fentanyl 100 mcg/hr patch td72 morphine sulfate 30 mg tablet er Opioid Analgesics, Short-acting fentanyl citrate 200 mcg lozenge hd hydrocodone/acetaminophen 5
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*
Regulatory Status FDA-approved indications: Entyvio is an α4β7integrin receptor antagonist indicated for: (1)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.50.12 Subject: Entyvio Page: 1 of 7 Last Review Date: September 20, 2018 Entyvio Description Entyvio
USTEKINUMAB Generic Brand HICL GCN Exception/Other USTEKINUMAB STELARA GUIDELINES FOR USE
Generic Brand HICL GCN Exception/Other USTEKINUMAB STELARA 36187 GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Does the patient have a diagnosis of psoriatic arthritis (PsA)
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
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
ANTIDEPRESSANTS. Details. Step Therapy 2018 Last Updated: 8/21/2018
ANTIDEPRESSANTS EMSAM PATCH 24 HOUR 12 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 6 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 9 MG/24HR TRANSDERMAL FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL FETZIMA
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.
2. Has the patient had a response to treatment? Y N. 3. Does the patient have a diagnosis of rheumatoid arthritis (RA)? Y N
12/21/2016 Prior Authorization Aetna Better Health of West Virginia Humira (WV88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and
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.
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
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
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
HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES HUMIRA PEDIATRIC
Generic Brand HICL GCN Exception/Other ADALIMUMAB HUMIRA 24800 HUMIRA PEDIATRIC GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Is the patient currently taking Humira? If
Index. Note: Page numbers of article titles are in boldface type.
Index Note: Page numbers of article titles are in boldface type. A Abatacept, for rheumatoid arthritis, 789 Acetaminophen, for low back pain, 735 Acupuncture for fibromyalgia, 753 for low back pain, 738
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
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 04/01/2019
VNSNY CHOICE FIDA Complete Step Therapy Requirements Effective: 04/01/2019 Updated 03/2019 AMANTADINE ER OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED
HARVARD PILGRIM HEALTH CARE RECOMMENDED MEDICATION REQUEST GUIDELINES
Generic Brand HICL GCN Exception/Other GOLIMUMAB SIMPONI 22533, 22536, 34697, 35001 ROUTE = SUBCUTANE. GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Is the request for a
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
Formulary Updates to DHMP Commercial Plans (POS/DMC/DMC-E/CSA/DERP/DPPA & DHMO:CSA/DERP/DPPA)
1 Formulary Updates to DHMP Commercial Plans (POS/DMC/DMC-E/CSA/DERP/DPPA & DHMO:CSA/DERP/DPPA) Denver Health Medical Plan (DHMP) may add or remove drugs from the formulary or make changes to restrictions
CMI Marketplace 2015 (List of Covered Drugs)
Analgesics Opioid Analgesics, Long-acting fentanyl 100 mcg/hr patch td72 fentanyl citrate 200 mcg lozenge hd morphine sulfate 30 mg tablet er oxymorphone hcl 7.5 mg tab er 12h Opioid Analgesics, Short-acting
WELLCARE/ OHANA HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 08/2015)
WELLCARE/ OHANA HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 08/2015) **To get updated information about the drugs covered by WellCare/ Ohana, please visit our website (https://www.wellcare.com
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
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
ANTIDEPRESSANTS. Details. Step Therapy 2017 Last Updated: 5/23/2017
ANTIDEPRESSANTS EMSAM PATCH 24 HOUR 12 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 6 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 9 MG/24HR TRANSDERMAL FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR 120 MG FETZIMA CAPSULE
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
Exclusion Criteria. Required Medical Documentation
Partnership HealthPlan of California: New and Revised, th Quarter P & T 2016 Effective //2016 Generic substitution required when there is an FDA approved generic equivalent; additional criteria apply for
Step Therapy Criteria
Step Therapy Group ADCIRCA 1772-D ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 Step Therapy Group ANTIPSYCHOTICS
Fml Limits. Azathioprine (Imuran) 50mg, 75mg, 100mg - $26.85 Cyclosporine, 25mg, 100mg. $ Leflunomide (Arava) 10mg Tablet - $144.
MEDICATION COVERAGE POLICY PHARMACY AND THERAPEUTICS ADVISORY COMMITTEE POLICY: Rheumatoid Arthritis (RA) P&T DATE: 2/15/2017 CLASS: Rheumatology/Anti-inflammatory Disorders REVIEW HISTORY 2/16, 5/15,
CIMZIA (certolizumab pegol)
Pre - PA Allowance None Prior-Approval Requirements Age Diagnoses 18 years of age or older Patient must have ONE of the following: 1. Moderate to severe Crohn s Disease (CD) a. Inadequate response, intolerance
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
Leitner Christian. Best Selling Drugs
Leitner Christian Best Selling Drugs 17.02.2014 Outline - Introduction - Drugs against:. Depression. Cardiovascular disease. Gastrointestinal disorders. Erectile dysfunction. Cancer. Infections. Pain -
Drug Class Prior Authorization Criteria Therapeutic Agents in Rheumatic and Inflammatory Diseases
Drug Class Prior Authorization Criteria Therapeutic Agents in Rheumatic and Inflammatory Diseases Line of Business: Medicaid P & T Approval Date: August 16, 2017 Effective Date: August 16, 2017 This policy
A. Correct! Nociceptors are pain receptors stimulated by harmful stimuli, resulting in the sensation of pain.
Pharmacology - Problem Drill 19: Anti-Inflammatory and Analgesic Drugs No. 1 of 10 1. are pain receptors stimulated by harmful stimuli, resulting in the sensation of pain. #01 (A) Nociceptors (B) Histamines
Michigan Department of Community Health Co-pay and Quantity Limitations
Michigan Department of Community Health Co-pay and Quantity Limitations Benefit Plan Co-pay Information Group ID Coverage Co-pay INCARCE Incarcerated Medicaid No coverage No coverage patients SHPDUAL CSHCSCAID
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
Step Therapy Requirements
Step Therapy Requirements Denver Health Medicare Choice (HMO SNP)/Medicare Select (HMO) Effective: 09/01/2017 Updated 08/2017 ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet
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
SASKATCHEWAN FORMULARY COMMITTEE BULLETIN 55th EDITION
Saskatchewan Health Drug Plan and Extended Benefits Branch July 2005 Bulletin #103 ISSN 0708-3246 SASKATCHEWAN FORMULARY COMMITTEE BULLETIN 55th EDITION All listings are effective July 1, 2005 NEW FULL
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
BIOANALYTICAL ASSAY LIST
GLP Bioanalytical Validated Methods (April 2010) Biological Analytical Matrix Technique 25-hydroxyvitamin D3 Monkey Serum 10 ng/ml 25-hydroxyvitamin D3 Rat Serum 2 ng/ml Acyclovir / Valacyclovir 20 ng/ml
Clinical Policy: Certolizumab (Cimzia) Reference Number: CP.PHAR.247 Effective Date: Last Review Date: Line of Business: HIM, Medicaid
Clinical Policy: (Cimzia) Reference Number: CP.PHAR.247 Effective Date: 08.16 Last Review Date: 05.18 Line of Business: HIM, Medicaid Coding Implications Revision Log See Important Reminder at the end
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
Approximate Cost for Patients
Insurance Coverage for Prescriptions Medications that enhance control of pain and symptoms may be costly if patients do not have insurance. In Ontario, the Ontario Drug Benefit (ODB) Program covers prescriptions
Your prescription benefit updates Formulary Updates - Effective January 1, 2019
Your prescription benefit updates Formulary Updates - Effective January 1, 2019 Medications are grouped by the conditions they treat. Each medication is placed in a tier that shows the amount you will
STEP THERAPY CRITERIA
STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered under your medical or prescription
First Name. Specialty: Fax. First Name DOB: Duration:
Prescriber Information Last ame: First ame DEA/PI: Specialty: Phone - - Fax - - Member Information Last ame: First ame Member ID umber DOB: - - Medication Information: Drug ame and Strength: Diagnosis:
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
Palliative Care Drug Plan (Plan P) Formulary List of drugs PharmaCare covers
Palliative Care Drug Plan (Plan P) Formulary List of drugs PharmaCare covers This formulary is current as of February 11, 2010. Important Notes: Pharmacists must submit a claim on PharmaNet at the time
Santa Clara Family Health Plan Cal MediConnect Formulary. List of Step Therapy Requirements Effective: 12/01/ E
Santa Clara Family Health Plan Cal MediConnect Formulary List of Step Therapy Requirements Effective: 12/01/2018 13027.12E ANTICONVULSANTS APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET
ABILIFY INJ. Products Affected Step 2: ABILIFY MAINTENA PREFILLED SYRINGE 300 MG INTRAMUSCULAR ABILIFY MAINTENA PREFILLED SYRINGE 400 MG INTRAMUSCULAR
ABILIFY INJ ABILIFY MAINTENA PREFILLED SYRINGE 300 MG ABILIFY MAINTENA PREFILLED SYRINGE 400 MG ABILIFY MAINTENA SUSPENSION RECONSTITUTED ER 300 MG Claim will pay automatically for ABILIFY MAINTENA if
WellCare Signature (PDP) and WellCare Classic (PDP) Formulary Addendum
WellCare Signature (PDP) and WellCare Classic (PDP) Formulary Addendum This is a listing of the changes that have occurred in our formulary. Please carefully review these changes and call WellCare if you
ADALIMUMAB Generic Brand HICL GCN Exception/Other ADALIMUMAB HUMIRA GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW)
Generic Brand HICL GCN Exception/Other ADALIMUMAB HUMIRA 24800 GUIDELINES FOR USE INITIAL CRITERIA (NOTE: FOR RENEWAL CRITERIA SEE BELOW) 1. Does the patient have a diagnosis of moderate to severe rheumatoid
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
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
Garrick Brown, MD. Digestive Health Specialists Tacoma Gig Harbor
Garrick Brown, MD Digestive Health Specialists Tacoma Gig Harbor Today s Objectives Define IBD, its potential causes and diagnosis Discuss management and treatment Discuss complementary and alternative
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
Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
Medications that require Step Therapy (ST) require trial and failure of preferred formulary agents prior to their authorization. If the prerequisite medications have been filled within the specified time
Circle Yes or No Y N. [If no, skip to question 7.] 2. Does the patient have a diagnosis of ulcerative colitis? Y N. [If no, skip to question 4.
![Circle Yes or No Y N. [If no, skip to question 7.] 2. Does the patient have a diagnosis of ulcerative colitis? Y N. [If no, skip to question 4.](/thumbs/85/91758188.jpg "Circle Yes or No Y N. [If no, skip to question 7.] 2. Does the patient have a diagnosis of ulcerative colitis? Y N. [If no, skip to question 4.")
06/01/2016 Prior Authorization AETA BETTER HEALTH OF MICHIGA (MEDICAID) Humira (MI88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign
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
Regulatory Status FDA- approved indication: Simponi and Simponi ARIA are tumor necrosis factor (TNF) blockers indicated for the treatment of: (2-3)
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.51 Subject: Simponi / Simponi ARIA Page: 1 of 9 Last Review Date: March 16, 2018 Simponi / Simponi
1. Background: Infliximab is administered parenterally; therefore, it is not covered under retail pharmacy benefits.
Subject: Infliximab (Remicade ) Original Original Committee Approval: October 13, 2006 Revised Last Committee Approval: December 3, 2008 Last Review: October 19, 2007 1. Background: Infliximab is a genetically
Follow-up to Previous Reviews. Foster Children Prescribers (Nurse Practitioner Practice Sites)
15 January 2015 1 Follow-up to Previous Reviews Foster Children Prescribers (Nurse Practitioner Practice Sites) 2 Foster Children Prescribers (Nurse Practitioner Practice Sites) 3 Ongoing Reviews Buprenorphine
Clinical Policy: Apremilast (Otezla) Reference Number: CP.PHAR.245 Effective Date: Last Review Date: Line of Business: HIM, Medicaid
Clinical Policy: (Otezla) Reference Number: CP.PHAR.245 Effective Date: 08.16 Last Review Date: 11.18 Line of Business: HIM, Medicaid Revision Log See Important Reminder at the end of this policy for important
ALLERGIC CONJUNCTIVITIS AGENTS
2018 5 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: 18390 Last Updated: 04/2018 Effective Date: 05-01-2018 ALLERGIC CONJUNCTIVITIS AGENTS epinastine 0.05 % eye drops
Helpline No:
ARTHRITIS FOUNDATION Registered Nonprofit Organisation - No. 002-847 NPO Helpline No: 0861 30 30 30 DRUGS AND ARTHRITIS This information leaflet is published by the Arthritis Foundation as part of our
Xeljanz. Xeljanz, Xeljanz XR (tofacitinib) Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.24 Subject: Xeljanz Page: 1 of 6 Last Review Date: March 16, 2018 Xeljanz Description Xeljanz, Xeljanz
Buckeye Health Plan Medicaid Criteria Updates Q1 2017
Effective date: 4/24/17 Buckeye Health Plan Medicaid Criteria Updates Q1 2017 B uckeye Health Plan (BHP) routinely reviews their Prior Authorization (PA) and Medical Necessity (MN) criteria. Decisions
WR Fentanyl Symposium. Opioids, Overdose, and Fentanyls
Opioids, Overdose, and Fentanyls Outline: What are opioids? Why are we experiencing and opioid crisis? Potency, purity, and product How do opioids cause overdose and overdose deaths? What is naloxone and