ADHD STIMULANTS-S(SHC)

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1 Step Therapy Simply Health Care 2014 Formulary ID: 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 (amphetamines, amphetamine/dextroamphetamine, dexmethylphenidate, dextroamphetamine, methylphenidate) prior to filling a Step 2 drug(daytrana, Focalin XR, Strattera). 1

2 ANTISPASMODICS-S(SHC) Detrol La Gelnique GEL 10% Oxytrol Toviaz Vesicare Patient needs to have a paid claim for one Step 1 drug (oxybutynin, tolterodine, tolterodine ER, trospium, trospium ER) prior to filling a Step 2 drug(detrol LA, Gelnique, Oxytrol, Toviaz, Vesicare). 2

3 ARB-S(SHC) Benicar Benicar Hct Edarbi Micardis Micardis Hct Patient needs to have a paid claim for one Step 1 drug (candesartan, candesartan/hctz, eprosartan 600 mg, irbesartan, irbesartan/hctz, losartan, losartan/hctz, telmisartan, telmisartan/hctz, valsartan/hctz) prior to filling a Step 2 drug (Benicar, Benicar HCT, Edarbi, Micardis, Micardis HCT). 3

4 ATOPIC DERMATITIS-S(SHC) Elidel Protopic Patient needs to have a paid claim for one Step 1 drug (topical corticosteroids) prior to filling a Step 2 drug(elidel, Protopic). 4

5 ATYPICAL ANTIPSYCHOTICS-S(SHC) Abilify ORAL SOLN Abilify TABS Abilify Discmelt Abilify Maintena INJ 300MG Fanapt Invega Latuda Saphris Patient needs to have a paid claim for one Step 1 drug (olanzapine, quetiapine, risperidone, ziprasidone) prior to filling a Step 2 drug(abilify, Fanapt, Invega, Latuda, Saphris) 5

6 BISPHOSPHONATES-S5T Actonel Atelvia Fosamax Plus D Patient needs to have a paid claim for one Step 1 drug (alendronate, ibandronate) prior to filling a Step 2 drug(actonel, Atelvia, Fosamax Plus D). 6

7 BRINTELLIX-S(SHC) Brintellix Patient needs to have a paid claim for one Step 1 drug (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) prior to filling a Step 2 drug (Brintellix). 7

8 DIFICID-S(SHC) Dificid Patient needs to have a paid claim for one Step 1 drug (vancomycin (oral) (gen)) prior to filling a Step 2 drug(dificid). 8

9 DPP4 INHIBITORS-S(SHC) Kombiglyze Xr Onglyza Patient needs to have a paid claim for one Step 1 drug (metformin or generic combination metformin products (glipizide/metformin, pioglitazone/metformin)) prior to filling a Step 2 drug (Kombiglyze, Onglyza). 9

10 FENOFIBRATES-S(SHC) Antara Fenoglide Lipofen Lofibra TABS 160MG Trilipix Patient needs to have a paid claim for one Step 1 drug (fenofibrate) prior to filling a Step 2 drug(antara, Fenoglide, Lipofen, Lofibra, Trilipix). 10

11 FETZIMA-S(SHC) Fetzima Fetzima Titration Pack Patient needs to have a paid claim for TWO Step 1 drugs (generic SSRI, generic SNRI, mirtazapine, bupropion) prior to filling a Step 2 drug (Fetzima). 11

12 GLP1 INHIBITORS-S(SHC) Bydureon Byetta Victoza Patient needs to have a paid claim for one Step 1 drug (metformin or generic combination metformin products (glipizide/metformin, pioglitazone/metformin)) prior to filling a Step 2 drug (Byetta, Bydureon, Victoza). 12

13 LONG ACTING OPIOIDS-S(SHC) Oxycontin Oxymorphone Hydrochloride Er Patient needs to have a paid claim for one Step 1 drug (morphine sulfate) prior to filling a Step 2 drug (oxymorphone ER, Oxycontin). 13

14 NASAL CORTICOSTEROIDS-S(SHC) Nasonex Rhinocort Aqua Veramyst Patient needs to have a paid claim for one Step 1 drug (flunisolide, fluticasone, triamcinolone) prior to filling a Step 2 drug (Nasonex, Rhinocort Aqua, Veramyst). 14

15 NEUPRO-S(SHC) Neupro Patient needs to have a paid claim for one Step 1 drug (ropinirole, pramipexole) prior to filling a Step 2 drug(neupro). 15

16 OPHTHALMIC PROSTAGLANDINS-S(SHC) Rescula Patient needs to have a paid claim for one Step 1 drug (latanoprost) prior to filling a Step 2 drug (Rescula) 16

17 PPI-S(SHC) Dexilant Nexium Patient needs to have a paid claim for one Step 1 drug (lansoprazole, omeprazole, omeprazole/sodium bicarbonate, pantoprazole) prior to filling a Step 2 drug (Dexilant, Nexium). 17

18 SNRI-S(SHC) Cymbalta Pristiq Patient needs to have a paid claim for one Step 1 drug (citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine) prior to filling a Step 2 drug (Cymbalta, Pristiq) OR patient requests Cymbalta and is less than 18 years or has a diagnosis of stress urinary incontinence, fibromyalgia, chronic musculoskeletal pain, diabetic neuropathy, or symptoms of suicidal ideation. 18

19 SSRI ANTIDEPRESSANTS-S(SHC) Pexeva Viibryd Patient needs to have a paid claim for one Step 1 drug (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) prior to filling a Step 2 drug (Pexeva, Viibryd). 19

20 STATINS-S(SHC) Livalo Vytorin Patient needs to have a paid claim for one Step 1 drug (atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin) prior to filling a Step 2 drug ( Livalo, Vytorin). 20

21 TRIPTANS-S(SHC) Axert Frova Relpax Zomig SOLN 2.5MG Zomig TABS Zomig Nasal Spray Zomig Zmt Patient needs to have a paid claim for one Step 1 drug (naratriptan, rizatriptan (regular tablets, MLT), sumatriptan, zolmitriptan) prior to filling a Step 2 drug (Axert, Frova, Relpax, Zomig, Zomig ZMT). 21

22 ULORIC-S(SHC) Uloric Patient needs to have a paid claim for one Step 1 drug (allopurinol) prior to filing a Step 2 drug (Uloric). 22

23 INDEX A Abilify... 5 Abilify Discmelt... 5 Abilify Maintena... 5 Actonel... 6 Adhd Stimulants-s(shc)... 1 Antara Antispasmodics-s(shc)... 2 Arb-s(shc)... 3 Atelvia... 6 Atopic Dermatitis-s(shc)... 4 Atypical Antipsychotics-s(shc)... 5 Axert B Benicar... 3 Benicar Hct... 3 Bisphosphonates-s5t... 6 Brintellix... 7 Brintellix-s(shc)... 7 Bydureon Byetta C Cymbalta D Daytrana... 1 Detrol La... 2 Dexilant Dificid... 8 Dificid-s(shc)... 8 Dpp4 Inhibitors-s(shc)... 9 E Edarbi... 3 Elidel... 4 F Fanapt... 5 Fenofibrates-s(shc) Fenoglide Fetzima Fetzima Titration Pack Fetzima-s(shc) Focalin Xr... 1 Fosamax Plus D... 6 Frova G Gelnique... 2 Glp1 Inhibitors-s(shc) I Invega... 5 K Kombiglyze Xr... 9 L Latuda... 5 Lipofen Livalo Lofibra Long Acting Opioids-s(shc) M Micardis... 3 Micardis Hct... 3 N Nasal Corticosteroids-s(shc) Nasonex Neupro Neupro-s(shc) Nexium

24 O Onglyza... 9 Ophthalmic Prostaglandins-s(shc) Oxycontin Oxymorphone Hydrochloride Er Oxytrol... 2 P Pexeva Ppi-s(shc) Pristiq Protopic... 4 R Relpax Rescula Rhinocort Aqua S Saphris... 5 Snri-s(shc) Ssri Antidepressants-s(shc) Statins-s(shc) Strattera... 1 T Toviaz... 2 Trilipix Triptans-s(shc) U Uloric Uloric-s(shc) V Veramyst Vesicare... 2 Victoza Viibryd Vytorin Z Zomig Zomig Nasal Spray Zomig Zmt

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