2018 Step Therapy Criteria (List of Step Therapy Criteria)
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1 Criteria Last Updated: October 05, 2017 Effective Date: January 1, Step Therapy Criteria (List of Step Therapy Criteria) PLEASE READ CAREFULLY: IEHP DUALCHOICE CAL MEDICONNECT PLAN (MEDICARE- MEDICAID PLAN) REQUIRES YOU TO FIRST TRY CERTAIN DRUGS TO TREAT YOUR MEDICAL CONDITION BEFORE WE WILL COVER ANOTHER DRUG FOR THAT CONDITION. THIS DOCUMENT CONTAINS INFORMATION ABOUT THE STEP THERAPY CRITERIA THAT WE COVER IN THIS PLAN. Note to existing members: Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, List of Covered Drugs, pharmacy and provider networks and copayments may change from time to time throughout the year and on January 1 of each year. IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a Health Plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. You can get this information for free in other languages. Call IEHP (4347), 8am 8pm (PST) 7 days a week, including holidays.tty/tdd users should call The call is free. Usted puede obtener esta información gratis en otros idiomas. Llame al IEHP (4347), 8 am-8pm (Hora del Pacífico), los 7 días de la semana, incluidos días festivos. Los usuarios de TTY/TDD deben llamar al La llamada es gratuita. H5355_CMC_18_701350
2 celecoxib Must try one of the formulary alternatives: diclofenac, diclofenac ER, diclofenac DR, ibuprofen, meloxicam, naproxen Step 1: diclofenac er 100 mg tablet,extended release 24 hr, diclofenac potassium 50 mg tablet, diclofenac sodium 25 mg tablet,delayed release, diclofenac sodium 50 mg tablet,delayed release, diclofenac sodium 75 mg tablet,delayed release, ibuprofen 100 mg/5 ml oral suspension, ibuprofen 400 mg tablet, ibuprofen 600 mg tablet, ibuprofen 800 mg tablet, meloxicam 15 mg tablet, meloxicam 7.5 mg tablet, naproxen 250 mg tablet, naproxen 375 mg tablet, naproxen 500 mg tablet Step 2: celecoxib 100 mg capsule, celecoxib 200 mg capsule, celecoxib 400 mg capsule, celecoxib 50 mg capsule 2
3 diabetes Must try one of the formulary alternatives: Basaglar, Step 1: BASAGLAR KWIKPEN 100 UNIT/ML (3 ML) glimepiride, glimepiride-pioglitazone, glipizide, glipizide ER, SUBCUTANEOUS, glimepiride 1 mg tablet, glimepiride 2 glipizide-metformin, glyburide, glyburide-metformin, Humalog, mg tablet, glimepiride 4 mg tablet, glipizide 10 mg tablet, Humalog Mix, Humulin, Humulin N, Humulin R, Lantus, glipizide 2.5 mg-metformin 250 mg tablet, glipizide 2.5 mgmetformin, metformin ER, Novolin, Novolin N, Novolin R metformin 500 mg tablet, glipizide 5 mg tablet, glipizide 5 mgmetformin 500 mg tablet, glipizide er 10 mg tablet, extended release 24 hr, glipizide er 2.5 mg tablet, extended release 24 hr, glipizide er 5 mg tablet, extended release 24 hr, glyburide 1.25 mg tablet, glyburide 1.25 mg-metformin 250 mg tablet, glyburide 2.5 mg tablet, glyburide 2.5 mg-metformin 500 mg tablet, glyburide 5 mg tablet, glyburide 5 mg-metformin 500 mg tablet, glyburide micronized 1.5 mg tablet, glyburide micronized 3 mg tablet, glyburide micronized 6 mg tablet, HUMALOG 100 UNIT/ML SUBCUTANEOUS SOLUTION, HUMALOG MIX UNIT/ML SUBCUTANEOUS SUSPENSION, HUMALOG MIX UNIT/ML SUBCUTANEOUS SUSPENSION, HUMULIN 70/ UNIT/ML SUBCUTANEOUS SUSPENSION, HUMULIN N 100 UNIT/ML SUBCUTANEOUS SUSPENSION, HUMULIN R U UNIT/ML INJECTION SOLUTION, HUMULIN R U-500 (CONCENTRATED) INSULIN 500 UNIT/ML SUBCUTANEOUS SOLN, LANTUS 100 UNIT/ML SUBCUTANEOUS SOLUTION, LANTUS SOLOSTAR 100 UNIT/ML (3 ML) SUBCUTANEOUS INSULIN PEN, metformin 1,000 mg tablet, metformin 500 mg tablet, metformin 850 mg tablet, metformin er 500 mg tablet,extended release 24 hr, metformin er 750 mg tablet,extended release 24 hr, NOVOLIN 70/ UNIT/ML SUBCUTANEOUS SUSPENSION, NOVOLIN N 100 UNIT/ML SUBCUTANEOUS SUSPENSION, NOVOLIN R 100 UNIT/ML INJECTION SOLUTION, pioglitazone 30 mgglimepiride 2 mg tablet, pioglitazone 30 mg-glimepiride 4 mg tablet 3
4 Step 2: alogliptin 12.5 mg tablet, alogliptin 12.5 mgmetformin 1,000 mg tablet, alogliptin 12.5 mg-metformin 500 mg tablet, alogliptin 25 mg tablet, alogliptin 6.25 mg tablet, BYETTA 10 MCG/DOSE(250 MCG/ML)2.4 ML SUBCUTANEOUS PEN INJECTOR, BYETTA 5 MCG/DOSE (250 MCG/ML)1.2 ML SUBCUTANEOUS PEN INJECTOR, INVOKAMET 150 MG-1,000 MG TABLET, INVOKAMET 150 MG-500 MG TABLET, INVOKAMET 50 MG-1,000 MG TABLET, INVOKAMET 50 MG-500 MG TABLET, INVOKANA 100 MG TABLET, INVOKANA 300 MG TABLET, JANUMET 50 MG-1,000 MG TABLET, JANUMET 50 MG-500 MG TABLET, JANUMET XR 100 MG-1,000 MG TABLET,EXTENDED RELEASE, JANUMET XR 50 MG-1,000 MG TABLET,EXTENDED RELEASE, JANUMET XR 50 MG-500 MG TABLET,EXTENDED RELEASE, JANUVIA 100 MG TABLET, JANUVIA 25 MG TABLET, JANUVIA 50 MG TABLET, TANZEUM 30 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR, TANZEUM 50 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR 4
5 memantine Must try one of the formulary alternatives: memantine Step 1: memantine 10 mg tablet, memantine 2 mg/ml oral solution, memantine 5 mg tablet, memantine 5 mg-10 mg tablets in a dose pack Step 2: NAMENDA XR 14 MG CAPSULE SPRINKLE,EXTENDED RELEASE, NAMENDA XR 21 MG CAPSULE SPRINKLE,EXTENDED RELEASE, NAMENDA XR 28 MG CAPSULE SPRINKLE,EXTENDED RELEASE, NAMENDA XR 7 MG CAPSULE SPRINKLE,EXTENDED RELEASE, NAMENDA XR 7 MG-14 MG-21 MG-28 MG CAPSULE,SPRINKLE,ER 24HR,DOSE PACK 5
6 Index alogliptin 12.5 mg tablet... 4 alogliptin 12.5 mg-metformin 1,000 mg tablet... 4 alogliptin 12.5 mg-metformin 500 mg tablet... 4 alogliptin 25 mg tablet... 4 alogliptin 6.25 mg tablet... 4 BASAGLAR KWIKPEN 100 UNIT/ML (3 ML) SUBCUTANEOUS... 3 BYETTA 10 MCG/DOSE(250 MCG/ML)2.4 ML SUBCUTANEOUS PEN INJECTOR... 4 BYETTA 5 MCG/DOSE (250 MCG/ML)1.2 ML SUBCUTANEOUS PEN INJECTOR... 4 celecoxib 100 mg capsule... 2 celecoxib 200 mg capsule... 2 celecoxib 400 mg capsule... 2 celecoxib 50 mg capsule... 2 diclofenac er 100 mg tablet,extended release 24 hr... 2 diclofenac potassium 50 mg tablet... 2 diclofenac sodium 25 mg tablet,delayed release...2 diclofenac sodium 50 mg tablet,delayed release...2 diclofenac sodium 75 mg tablet,delayed release...2 glimepiride 1 mg tablet...3 glimepiride 2 mg tablet...3 glimepiride 4 mg tablet...3 glipizide 10 mg tablet... 3 glipizide 2.5 mg-metformin 250 mg tablet...3 glipizide 2.5 mg-metformin 500 mg tablet...3 glipizide 5 mg tablet... 3 glipizide 5 mg-metformin 500 mg tablet...3 glipizide er 10 mg tablet, extended release 24 hr... 3 glipizide er 2.5 mg tablet, extended release 24 hr... 3 glipizide er 5 mg tablet, extended release 24 hr... 3 glyburide 1.25 mg tablet...3 glyburide 1.25 mg-metformin 250 mg tablet... 3 glyburide 2.5 mg tablet...3 glyburide 2.5 mg-metformin 500 mg tablet... 3 glyburide 5 mg tablet...3 glyburide 5 mg-metformin 500 mg tablet... 3 glyburide micronized 1.5 mg tablet... 3 glyburide micronized 3 mg tablet... 3 glyburide micronized 6 mg tablet... 3 HUMALOG 100 UNIT/ML SUBCUTANEOUS SOLUTION... 3 HUMALOG MIX UNIT/ML HUMALOG MIX UNIT/ML HUMULIN 70/ UNIT/ML HUMULIN N 100 UNIT/ML HUMULIN R U UNIT/ML INJECTION SOLUTION...3 HUMULIN R U-500 (CONCENTRATED) INSULIN 500 UNIT/ML SUBCUTANEOUS SOLN... 3 ibuprofen 100 mg/5 ml oral suspension... 2 ibuprofen 400 mg tablet... 2 ibuprofen 600 mg tablet... 2 ibuprofen 800 mg tablet... 2 INVOKAMET 150 MG-1,000 MG TABLET... 4 INVOKAMET 150 MG-500 MG TABLET INVOKAMET 50 MG-1,000 MG TABLET... 3 INVOKAMET 50 MG-500 MG TABLET... 4 INVOKANA 100 MG TABLET...4 INVOKANA 300 MG TABLET...4 JANUMET 50 MG-1,000 MG TABLET... 4 JANUMET 50 MG-500 MG TABLET... 4 JANUMET XR 100 MG-1,000 MG TABLET,EXTENDED RELEASE... 4 JANUMET XR 50 MG-1,000 MG TABLET,EXTENDED RELEASE... 4 JANUMET XR 50 MG-500 MG TABLET,EXTENDED RELEASE... 4 JANUVIA 100 MG TABLET... 4 JANUVIA 25 MG TABLET... 4 JANUVIA 50 MG TABLET... 4 LANTUS 100 UNIT/ML SUBCUTANEOUS SOLUTION... 3 LANTUS SOLOSTAR 100 UNIT/ML (3 ML) SUBCUTANEOUS INSULIN PEN...3 meloxicam 15 mg tablet...3 meloxicam 7.5 mg tablet...3 memantine 10 mg tablet...5 memantine 2 mg/ml oral solution... 5 memantine 5 mg tablet...5 memantine 5 mg-10 mg tablets in a dose pack...5 metformin 1,000 mg tablet...3 metformin 500 mg tablet...3 metformin 850 mg tablet...3 metformin er 500 mg tablet,extended release 24 hr... 3 metformin er 750 mg tablet,extended release 24 hr... 3 NAMENDA XR 14 MG CAPSULE
7 NAMENDA XR 21 MG CAPSULE NAMENDA XR 28 MG CAPSULE NAMENDA XR 7 MG CAPSULE NAMENDA XR 7 MG-14 MG-21 MG-28 MG CAPSULE,SPRINKLE,ER 24HR,DOSE PACK... 5 naproxen 250 mg tablet... 2 naproxen 375 mg tablet... 2 naproxen 500 mg tablet... 2 NOVOLIN 70/ UNIT/ML NOVOLIN N 100 UNIT/ML NOVOLIN R 100 UNIT/ML INJECTION SOLUTION... 3 pioglitazone 30 mg-glimepiride 2 mg tablet...3 pioglitazone 30 mg-glimepiride 4 mg tablet...3 TANZEUM 30 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR... 4 TANZEUM 50 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR
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Value Based Tier Drugs are selected for the management of Asthma, Diabetes, Hypertension and Hyperlipidemia. These drugs are covered at no charge or at a reduced cost share. Medications are under continual
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ALZHEIMER'S DRUGS. Details. Step 2: Exelon Patch 13.3 mg/24 hour transdermal Exelon Patch 4.6 mg/24 hr transdermal
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