ADHD STIMULANTS-S(SHC)
|
|
- Berenice Fisher
- 5 years ago
- Views:
Transcription
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
Step Therapy Criteria
Tier 5 Formulary Step Therapy 2016 Updated: 05/24/2016 Effective: 06/01/2016 What is Step Therapy? Some prescription drugs require step therapy (ST). In some cases, the plan requires you to first try certain
More informationCRITERIA 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
More information2015 Step Therapy Prior Authorization Medical Necessity Guidelines
Tufts Health Unify 2015 Step Therapy Prior Authorization Medical Necessity Guidelines Effective: 01/01/2015 Updated: 10/01/2015 Tufts Health Plan P.O. Box 9194 Watertown, MA 02471-9194 Phone: 855-393-3154
More informationAvoid paying too much for your prescriptions
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2017 Aetna Rx Step Program Medicine List Avoid paying too much for your prescriptions It s important to try to
More informationPlan Year CCHP Senior Program (HMO) Step Therapy Criteria (ST)
Plan Year 2016 CCHP Senior Program (HMO) Step Therapy Criteria (ST) Step Therapy: In some cases, CCHP Senior Program (HMO) requires you to first try certain drugs to treat your medical condition before
More informationSTEP THERAPY ALGORITHMS PUP Select Formulary
The Step Therapy drug will be dispensed if the drug has been dispensed within 120 days of current fill or if alternative (Step 1) drugs have been used first. If the member s prescription claim fails the
More informationStep Therapy Medications
Step Therapy Medications Step Therapy Group APTIOM Step-2: APTIOM 200 MG TABLET or APTIOM 400 MG TABLET or APTIOM 600 MG TABLET or APTIOM 800 MG TABLET Step 1 Drug(s): Oxcarbazepine immediate-release,
More information2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Criteria Last Updated 11/1/2015
2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Last Updated 11/1/2015 APLENZIN TAB 174MG, 348MG, 522MG Step Therapy requires trial of bupropion SR or bupropion XL in previous 180
More informationLower your costs. Save money with preferred generic and preferred brand-name drugs 2018 Aetna Rx Step Program Medicine List
Call out bold Call out light Contact information, call X-XXX-XXX-XXXX or visit www.aetna.com Call to action small copy (especially related to mobile apps). Hendani adionse rferum faceatis incte voluptassi
More informationADHD STIMULANTS - SCORE
ADHD STIMULANTS - SCORE Step Therapy Strattera Patient needs to have a paid claim for two generic formulary ADHD stimulant medications. Formulary ID# 00017034 Last Updated: 08/01/2017 1 ALPHA GLUCOSIDASE
More informationStep Therapy Medications
Step Therapy Medications Step Therapy (ST PA ) is an automated form of prior authorization. It encourages the use of therapies that should be tried first, before other treatments are covered, based on
More informationADHD STIMULANTS - SCORE
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
More informationCigna Drug and Biologic Coverage Policy
Cigna Drug and Biologic Coverage Policy Subject Step Therapy Individual and Family Plan Table of Contents Coverage Policy... 1 General Background... 5 References... 5 Effective Date... 3/15/2018 Next Review
More informationSimply Step Therapy Document September 2018 Y0114_18_33074_I_009
2018 2018 Simply Step Therapy Document September 2018 Aptiom APTIOM 200 MG TABLET APTIOM 400 MG TABLET Y0114_18_33074_I_009 APTIOM 600 MG TABLET APTIOM 800 MG TABLET Criteria If the patient has tried a
More informationRelative 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*
More informationFirstCarolinaCare Insurance Company Step Therapy Requirements
ANALGESICS, NARCOTICS KADIAN MORPHINE SULFATE ER PRIOR CLAIM FOR MORPHINE SULFATE SUSTAINED ACTION TABLET (MS CONTIN) WITHIN THE PAST 120 DAYS. ANTIBACTERIALS (EENT) BESIVANCE PRIOR CLAIM FOR CIPROFLOXACIN
More information2018 PDP Premier Step Therapy Document September 2018 Y0114_18_33144_I_009
2018 PDP Premier Step Therapy Document September 2018 Aggrenox Y0114_18_33144_I_009 aspirin 25 mg-dipyridamole 200 mg capsule,ext.release 12 hr multiphase drug may be given. Step 1 Drug(s): clopidigrel.
More informationALPHA GLUCOSIDASE INHIBITOR THERAPY
ALPHA GLUCOSIDASE INHIBITOR THERAPY GLYSET Step 1: One generic formulary product containing one of the following ingredients: glimeperide, glipizide, metformin or pioglitazone. Step 2: Glyset PAGE 1 LAST
More informationStep 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
More informationATYPICAL 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:
More informationABILIFY ABILIFY DISCMELT ACTONEL ACTOPLUS MET ACTOPLUS MET XR ACTOS ADCIRCA ADVAIR DISKUS ADVAIR HFA
Quantity Limits Paramount Medicare Formulary 2012 Formulary ID 12112, Version 22. CMS Approved 10-23-2012. ABILIFY Abilify TABS ABILIFY DISCMELT Abilify Discmelt ACTONEL Actonel TABS 150MG Actonel TABS
More informationPrescription Step Therapy Program
Prescription Step Therapy Program 04HQ3972 R11/17 Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company. HMO Louisiana, Inc. is a subsidiary of Blue Cross
More informationSmithRx Standard Formulary Step Therapy List
SmithRx Standard Formulary Step Therapy List Revised: January 27, 2017 The following medications require prior use of at least one other medication for coverage. Please note that any plan-specific customizations
More informationABILIFY 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
More information2018 Step Therapy Criteria
2018 Step Therapy Criteria ANGIOTENSIN RECEPTOR BLOCKERS... 2 ANTIDEPRESSANTS... 3 ANTIDEPRESSANTS, MISCELLANEOUS... 4 ANTIDEPRESSANTS, OTHER... 5 ANTIDIABETIC AGENTS... 6 ANTIGOUT AGENTS... 7 ANTIHYPERTENSIVE
More information2019 Simply Step Therapy Document
Aggrenox 2019 Simply Step Therapy Document AGGRENOX 25 MG-200 MG CAPSULE, EXTENDED aspirin 25 mg-dipyridamole 200 mg capsule,ext.release 12 hr multiphase drug may be given. Step 1 Drug(s): clopidigrel.
More informationSTEP 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
More informationGenerics. Lead with. Prescription Step Therapy Program
Lead with Generics Prescription Step Therapy Program WWW.BCBSLA.COM 04HQ3972 R11/10 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company GENERIC DRUGS: A
More information2015 Medicare Step Therapy Criteria. Last Modified: 12/31/2014 Last Submitted to CMS: 10/29/2014
2015 Medicare Step Therapy Criteria Last Modified: 12/31/2014 Last Submitted to CMS: 10/29/2014 1 Table of Contents AMITIZA, LINZESS... 3 ANTIDEPRESSANTS - Viibryd / Pexeva / Pristiq / Desvenlafaxine...
More information2018 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
More information2013 Step Therapy (ST) Criteria
2013 Step Therapy (ST) Criteria Some drugs require step therapy pre-approval. This means that your doctor must have you first try a different drug to treat your medical condition before we will cover a
More informationDrugs That Require Step Therapy (ST) Step Therapy Medications
Drugs That Require Step Therapy (ST) In some cases, HealthNow New York Inc. requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.
More informationStep 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
More informationAMANTADINE 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.
More informationStep 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
More informationALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Optima Tier Gold Formulary Date Effective: November 1, 2018.
ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID 18354, Version 15 1 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Trial of two of
More informationALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Health Choice Generations 1 Tier Gold Effective Date: 11/01/2018.
ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID: 18349, Ver.15 Last Updated 10/23/2018 Effective Date: 11/1/2018 1 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam
More informationSTEP 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
More information2017 Step Therapy Criteria
FRESENIUS TOTAL HEALTH 2017 Step Therapy Updated 07/01/2017. For more recent information or other questions, please contact Fresenius Total Health Customer Service at 1-855-598-6774 / TTY 1-844-209-9094.
More informationALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Farm Bureau Health Plans Date Effective: November 1, 2018.
ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID 18351, Version 15 1 ANTIDEPRESSANTS - SCORE Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Trial of two of the following
More informationSelectHealth Advantage 2018 Step Therapy Criteria Previous trial on at least ONE: Generic topical acne treatment
ACNE ADAPAL/BEN P GEL 0.1-2.5% AZELEX CRE 20% DAPSONE GEL 5% EPIDUO FORTE GEL 0.3-2.5% TRETINOIN GEL 0.04% TRETINOIN GEL 0.05% TRETINOIN GEL 0.1% ACTONEL ANTICONVULSANT ANTIDEPRESSION ANTIPSYCHOTIC ASTHMA
More informationAMANTADINE 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.
More informationAGGRENOX. Products Affected. Details. GRP B2 Last Updated: 09/01/2018. Aggrenox
GRP B2 Last Updated: 09/01/2018 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_3742 09/2014 Formulary ID: 18066: version 15 1 ANTICONVULSANTS
More informationDrug Regimen Optimization
Texas Prior Authorization Program Clinical Criteria Drug/Drug Class Clinical Criteria Information Included in this Document Excluding Valsartan / Ramipril Prior authorization criteria logic: a description
More informationStep 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
More informationANTIDEPRESSANTS. 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
More informationCost Effectiveness Recommendations For Kentucky Retirement Systems MTM Plan 2011
Medication Tier 2 options Tier 1 options Nexium- Tier 3 Aciphex Lansoprazole Omeprazole Pantoprazole Crestor- Tier 3 Lipitor Simvastatin Vytorin- Tier 3 Atacand- Tier 3 Avapro Benicar Cozaar Micardis Tevetan
More informationSelectHealth Advantage 2019 Step Therapy Criteria Previous trial on at least ONE: Generic topical acne treatment
ACNE ADAPAL/BEN P AZELEX DAPSONE TRETINOIN ACTONEL ANTICONVULSANT ANTIDEPRESSION ANTIPSYCHOTIC ASTHMA RISEDRON SOD RISEDRONATE APTIOM OXTELLAR XR SPRITAM FETZIMA KHEDEZLA TRINTELLIX ARISTADA FANAPT LATUDA
More informationSelectHealth Advantage 2018 Step Therapy Criteria. Previous trial on at least ONE: Generic topical acne treatment. Previous trial on: alendronate
ACNE ACZONE ADAPAL/BEN P AZELEX DAPSONE EPIDUO EPIDUO FORTE TRETINOIN ACTONEL RISEDRON SOD RISEDRONATE SelectHealth Advantage Previous trial on at least ONE: Generic topical acne treatment alendronate
More informationACYCLOVIR OINT (CCHP2017)
ACYCLOVIR OINT (CCHP2017) acyclovir 5 % topical ointment Step Therapy requires trial of one (1) of the following: oral generic acyclovir, oral generic famciclovir, oral generic valacyclovir. 1 ALPHAGAN
More informationStep 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
More informationA Brief Overview of Psychiatric Pharmacotherapy. Joel V. Oberstar, M.D. Chief Executive Officer
A Brief Overview of Psychiatric Pharmacotherapy Joel V. Oberstar, M.D. Chief Executive Officer Disclosures Some medications discussed are not approved by the FDA for use in the population discussed/described.
More informationACYCLOVIR OINT (CCHP2017)
ACYCLOVIR OINT (CCHP2017) acyclovir 5 % topical ointment Step Therapy requires trial of one (1) of the following: oral generic acyclovir, oral generic famciclovir, oral generic valacyclovir. 1 ALPHAGAN
More informationANGIOTENSIN RECEPTOR BLOCKERS STEP THERAPY
South Country Health Alliance 2017 Step Therapy Formulary ID: 17431 Last Updated: 10/20/2017 Effective Date: 11-01-2017 ANGIOTENSIN RECEPTOR BLOCKERS STEP THERAPY BENICAR 20 MG BENICAR 40 MG BENICAR 5
More informationThese medications will require preauthorization (PA) for HMSA Medicare Part D members.
Medicare Part D November 2014 CHANGES TO HMSA S MEDICARE FORMULARY As part of HMSA s ongoing efforts to provide our members a sustainable and affordable health plan option, it s necessary to make adjustments
More informationANTIDEPRESSANTS - BUPROPION
Step Therapy Paramount Medicare Formulary 2012 Formulary ID 12112, Version 22. CMS Approved 10-23-2012. ANTIDEPRESSANTS - BUPROPION Aplenzin may be given. Step 1 Drug(s): Budeprion Sr, Budeprion Xl, Bupropion
More informationStep 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
More informationALBUTEROL - SCORE{XE "ALBUTEROL - SCORE"}
Step Therapy ALBUTEROL - SCORE{XE "ALBUTEROL - SCORE"} Ventolin Hfa{XE "Ventolin Hfa"} Trial of ProAir Formulary ID# 00018097 Last Updated: 04/01/2018 1 ANTIDEPRESSANTS - SCORE{XE "ANTIDEPRESSANTS - SCORE"}
More informationUF Decision Report FY06-07 Beneficiary Advisory Panel 10 Jan 2008
UF Decision Report FY06-07 Beneficiary Advisory Panel 10 Jan 2008 Promoting high quality, cost effective drug therapy throughout the Military Health System UF Decisions, May 07 Class FY05 rank, total $
More informationStep Therapy Information... 4 Prior Authorization Information ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...
Step Therapy Information... 4 Prior Authorization Information... 27 ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...62 Acne Therapy Topical...64 Alcoholism Treatment Agents... 66 Analgesic
More informationDPP4 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
More informationQuantity Limits 2016 Paramount Medicare Formulary Formulary ID: Version 26 Updated: 11/1/2016
Quantity Limits 2016 Paramount Medicare Formulary Formulary ID: 16162 Version 26 Updated: 11/1/2016 ANALGESICS acetaminophen w/ codeine (300-15 mg, 300-30 mg, 300-60 mg) acetaminophen w/ codeine soln 120-12
More informationACYCLOVIR OINT (CCHP2017)
ACYCLOVIR OINT (CCHP2017) acyclovir 5 % topical ointment Step Therapy requires trial of one (1) of the following: oral generic acyclovir, oral generic famciclovir, oral generic valacyclovir. 1 ALPHAGAN
More informationBlue Medicare HMO Essential 2015 Quantity Limit List Blue Medicare Rx Standard 2015 Quantity Limit List
Blue Medicare HMO Essential 2015 Quantity Limit List Blue Medicare Rx Standard 2015 Quantity Limit List Drug Name Monthly Limit (30 days unless otherwise noted) abacavir 300 mg abacavir/lamivudine/zidovudine
More informationDPP4 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
More informationANGIOTENSIN RECEPTOR BLOCKERS
Step Therapy 2014 2 Tier-Alameda Last Updated: 10/10/2014 ANGIOTENSIN RECEPTOR BLOCKERS Benicar Benicar Hct Diovan Valsartan Step 1: First line therapy should be irbesartan, irbesartan/hctz, losartan,
More informationANTICONVULSANTS. 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
More informationJudges Reference Table for the March 2016 Psychotropic Medication Utilization Parameters for Foster Children
Judges Reference Table for the Psychotropic Medication Utilization Parameters for Foster Children Stimulants for treatment of ADHD Preschool (Ages 3-5 years) Child (Ages 6-12 years) Adolescent (Ages 13-17
More informationANTIDEPRESSANTS. 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
More informationANTICONVULSANTS. 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
More informationANTIDIABETIC 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
More informationANTIDIABETIC 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
More informationFirstCarolinaCare 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
More informationSanta 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
More information2014 Assurant Health Step Therapy Edits Created 11/04/2013; Effective 01/01/2014
2014 Assurant Health Step Therapy Edits Created 11/04/2013; Effective 01/01/2014 Drug Class Restricted Drug Pre-requisite Drugs (Try First) Acne Products Tretin-X topical tretinoin- must try Veltin AND
More informationStep Therapy Group. Atypical Antipsychotic Agents
Atypical Antipsychotic Agents Any beneficiary newly enrolled into Community Care, Inc. currently receiving aripiprazole, aripiprazole ODT, risperidone, risperidone ODT, olanzapine, olanzapine ODT, quetiapine,
More informationAMANTADINE 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
More informationANTIDIABETIC 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,
More informationALLERGIC 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
More informationHow do I request an exception to the Liberty Health Advantage s Formulary?
QUANTITY LIMITATIONS How do I request an exception to the Liberty Health Advantage s Formulary? You can ask Liberty Health Advantage to make an exception to our coverage rules. There are several types
More informationHospitality Rx Step Therapy
agents may not be a generic medication. Second line agent may not be a brand medication. Some Step Therapy category may require trial of more than one medication. CLINDAMYCIN/BENZOYL PEROX Acne Combo Antibiotic
More informationANTICONVULSANTS. Details. Step Therapy Criteria Date Effective: April 1, 2019
Step Therapy Date Effective: April 1, 2019 ANTICONVULSANTS APTIOM TABLET 200 MG ORAL APTIOM TABLET 400 MG ORAL APTIOM TABLET 600 MG ORAL APTIOM TABLET 800 MG ORAL BANZEL SUSPENSION 40 MG/ML ORAL BANZEL
More informationANTICONVULSANTS. 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
More information**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
More informationStep Therapy Program Precision Formulary
Step Therapy Program Precision Formulary Physician Guidelines Failure of previous steps in the Step Therapy Program: For most therapies, Magellan Rx Management will review the most recent 180 days of claim
More informationVNSNY 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
More information