Before a Step 2 medication is covered You get a prescription
|
|
|
- Angelica Perkins
- 5 years ago
- Views:
Transcription
1 Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment you need, usually at a lower cost. Here s how it works: Before a Step 2 medication is covered You get a prescription Try a Step 1 medication first With this program, you need to try a Step 1 medication first, before a Step 2 medication may be covered. When you bring a prescription to the pharmacy, our system will automatically screen the medication for step therapy requirements. If your prior pharmacy claims show you have tried a Step 1 medication in the recent past, the Step 2 medication may be processed. If not, the pharmacist will contact your doctor for further explanation. There are some drugs that require three steps before a medication is covered. You must try Step 1 and Step 2 medications before receiving benefit coverage for a Step 3 medication. We encourage you to discuss your treatment and medication options with your doctor. If you have questions about the Step Therapy program, call the toll-free member phone number on the back of your ID card.
2 Step Therapy Program Step Therapy Medications (2 steps)* If you have a prescription for any of the following Step 2 medications, you will be required to first try a Step 1 medication(s) for benefit coverage. Attention Deficit Disorder Dextroamphetamine, Amphetaminedextroamphetamine, Methylphenidate, Dexmethylphenidate, Vyvanse Procentra/Dextroamphetamine, Desoxyn/Methamphetamine, Adderall XR/Amphetamine ER, Kapvay/Clonidine ER, Focalin XR/ Dexmethylphenidate ER, Metadate CD/Methylphenidate ER, Ritalin SR/Concerta/ Methylphenidate ER, Methylin/ Methylphenidate Solution, Ritalin LA/Methylphenidate ER, Daytrana, Methylin, Quillivant Antibiotics Doxycycline Acticlate, Adoxa, Doryx Bethkis Tobi Neb/Tobramycin Neb Antipsychotics Olanzapine, Risperidone, Geodon/Ziprasidone, Fanapt, Invega, Latuda Risperidone ODT, Quetiapine, Seroquel XR, Saphris, Abilify Asthma/COPD Striverdi Symbicort, Advair Diskus, Foradil, Serevent Dulera Advair Diskus, Advair HFA, Symbicort Anoro Ellipta Symbicort, Advair Diskus, Foradil, Serevent, Spiriva, Breo Ellipta Montelukast and any one of the following: Methylprednisolone, Prednisolone, Prednisone, Ventolin HFA,Proair HFA, Foradil, Serevent, Qvar, Pulmicort, Flovent Diskus, Flovent HFA, Asmanex, Advair Diskus, Advair HFA, Symbicort Zyflo, Zyflo CR OptumRx optumrx.com
3 Step Therapy Medications (2 steps)* Continued Cardiovascular Carvedilol Coreg CR Cholesterol Lowering Agents Depression Benazepril, Candesartan, Captopril, Enalopril, Fosinopril, Irbesartan, Lisinopril, Moexipril, Perindopril, Quinapril, Ramipril, Telmisartan, Trandolapril, Benazepril-amlodipine, Trandolapril-verapamil, Benazepril-HCTZ, Captopril-HCTZ, Enalapril-HCTZ, Fosinopril-HCTZ, Irbesartan-HCTZ, Lisinopril-HCTZ, Moexipril-HCTZ, Quinapril-HCTZ, Losartan, Losartan-HCTZ Amlodipine and any one of the following: Atorvastatin, Lovastatin, Pravastatin, Simvastatin, Crestor, Vytorin Lipofen and any one of the following: Fenofibric Acid, Fenofibrate Atorvastatin, Lovastatin, Pravastatin, Simvastatin, Crestor Atorvastatin, Lovastatin, Pravastatin, Simvastatin, Crestor, Vytorin Citalopram, Escitalopram, Fluoxetine, Paroxetine, Paroxetine ER, Sertraline, Venlafaxine, Venlafaxine ER, Bupropion SR, Mirtazapine, Mirtazapine ODT, Duloxetine, Pristiq Paroxetine or Sertraline Venlafaxine, Venlafaxine ER, Duloxetine, Pristiq Bupropion SR Edarbi, Edarbyclor, Azor, Exforge, Exforge HCT, Tribenzor Caduet/Amlodipine-atorvastatin Fibricor, Fenoglide, Triglide Lipitor, Lescol/Fluvastatin, Lescol XL, Mevacor, Altroprev, Livalo, Pravachol, Zocor Liptruzet Viibryd, Brintellix Luvox CR/Fluvoxamine ER Fetzima Aplenzin 3
4 Step Therapy Program Step Therapy Medications (2 steps)* Continued Diabetes Humalog or Novolog Apidra Metformin or Metformin ER Metformin, Metformin ER Metformin-glipizide, Metformin-glyburide, Metformin-pioglitazone, Chlorpropamide, Glimepiride, Glipizide, Glipizide ER, Glyburide, Tolazamide, Tolbutamide, Pioglitazone, Pioglitazone-glimepiride, Novolog, Lantus, Humalog, Levemir, Humulin, Novolin, Byetta Metformin-glipizide, Metformin-glyburide, Metformin-pioglitazone, Chlorpropamide, Glimepiride, Glipizide, Glipizide ER, Glyburide, Tolazamide, Tolbutamide, Pioglitazone, Pioglitazone-glimepiride, Novolog, Lantus, Humalog, Levemir, Humulin, Novolin, Byetta Amaryl, Diabeta, Duetact, Glucotrol, Glucotrol XR, Glucovance, Glynase, Metaglip, Prandimet, Prandin, Precose, Starlix Actoplus Met XR, Actos Glyset Riomet Ear Condition Ofloxacin Cetraxal/Ciprofloxacin Gastrointestinal Creon and Zenpep Viokace, Pancreaze, Pertzye, Ultresa (Miscellaneous) Polyethylene Glycol or Lactulose Amitiza, Linzess Gout Allopurinol Uloric Insomnia Zolpidem or Zolpidem CR Intermezzo, Edluar, Zolpimist OptumRx optumrx.com
5 Step Therapy Medications (2 steps)* Continued Migraine Rizatriptan (tablet)/rizatriptan RDT, Treximet Sumatriptan (tablet), Zolmitriptan (tablet)/zolmitriptan ODT Skin Conditions (Miscellaneous) Any one of the following topical corticosteroids: Alclometasone, Betamethasone Dipropionate (augmented), Betamethasone Dipropionate, Clobetasol, Desonide, Desoximetasone, Diflorasone, Fluocinolone, Fluocinonide, Fluticasone, Hydrocortisone, Mometasone, Triamcinolone, Pramosone Elidel, Protopic Narcotic Analgesics Nausea/ Vomiting Neurologic Non-Narcotic Analgesics Morphine Sulfate CR, Morphine Sulfate SR, Oxycontin Tramadol or Tramadol-acetaminophen Metoclopramide Amitriptyline, Cyclobenzaprine, Duloxetine, Lyrica Gabapentin Diclofenac, Etodolac, Fenoprofen, Flurbiprofen, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac, Meloxicam, Nabumetone, Naproxen, Oxaprozin, Piroxicam, Sulindac, Tolmetin Exalgo Tramadol ER Metozolv ODT Savella Gralise Duexis Oncology Fluorouracil or Imiquimod Picato Opthalamic Bepreve, Lastacaft Agents Azelastine, Patanol, Pataday Osteoporosis Alendronate Atelvia 5
6 Step Therapy Program Step Therapy Medications (2 steps)* Continued Overactive Bladder Parkinson's Disease Prostatic Hypertrophy Severe Allergic Reaction Ulcer/Acid Reflux Oxybutynin, Vesicare, Oxytrol, Gelnique Ropinorole or Pramipexole Alfuzosin, Doxazosin, Terazosin, Tamsulosin, Rapaflo Epipen, Epipen Jr Omeprazole, Lansoprazole (capsule), Pantoprazole, Nexium, Dexilant Omeclamox or Pylera Detrol/Tolterodine, Sanctura/Trospium, Sanctura XR/Trospium ER, Detrol LA/ Tolterodine SR, Myrbetriq Requip XL/Ropinirole ER, Mirapex ER Cardura XL Epinephrine, Auvi-Q, Adrenaclick Esomeprazole Strontium, Lansoprazole Suspension, Prevacid, Prevacid ODT/Lanosprazole ODT, First-Omeprazole Suspension, Aciphex/Rabeprazole, Zegerid/ Omeprazole-sodium Bicarbonate, Prilosec, Protonix Prevpac/Lansoprazole-amoxicillinclarithromycin, Helidac Step Therapy Medications (3 steps)* If you have a prescription for any of the following Step 3 medications, you must first try Step 1 and Step 2 medications for benefit coverage. Step 3 Asthma /COPD Theophylline, Qvar, Pulmicort, Flovent Diskus, Flovent HFA, Asmanex, Tudorza, Atrovent HFA, Spiriva, Advair Diskus, Advair HFA, Symbicort, Theo-24 Foradil and Serevent Arcapta OptumRx optumrx.com
7 Step Therapy Medications (3 steps)* Continued Step 3 Cardiovascular Diabetes Benazepril, Candesartan, Captopril, Enalopril, Fosinopril, Irbesartan, Lisinopril, Moexipril, Perindopril, Quinapril, Ramipril, Telmisartan, Trandolapril, Benazepril-amlodipine, Trandolaprilverapamil, Benazepril-HCTZ, Captopril- HCTZ, Enalapril-HCTZ, Fosinopril-HCTZ, Irbesartan-HCTZ, Lisinopril-HCTZ, Moexipril-HCTZ, Quinapril-HCTZ, Losartan, Losartan-HCTZ Benazepril, Candesartan, Captopril, Enalopril, Fosinopril, Irbesartan, Irbesartan HCTZ, Lisinopril, Moexipril, Perindopril, Quinapril, Ramipril, Trandolapril, Benazepril-amlodipine, Trandolaprilverapamil, Telmisartan, Benazepril- HCTZ, Captopril-HCTZ, Enalapril-HCTZ, Fosinopril-HCTZ, Lisinopril-HCTZ, Moexipril-HCTZ, Quinapril-HCTZ, Losartan, Losartan-HCTZ Metformin-glipizide, Metformin-glyburide, Metformin-pioglitazone, Chlorpropamide, Glimepiride, Glipizide, Glipizide ER, Glyburide, Tolazamide, Tolbutamide, Pioglitazone, Pioglitazone-glimepiride, Novolog, Lantus, Humalog, Levemir, Humulin, Novolin, Byetta Any one of the following: Azor, Exforge, Exforge HCT Tekturna or Tekturna HCT Any two of the following: Benicar, Benicar HCT, Diovan, Micardis HCT Any one of the following: Tradjenta, Onglyza, Januvia, Jentadueto, Kombiglyze, Janumet Twynsta/ Telmisartanamlopidine Tekamlo, Amturnide Atacand, Atacand HCT/ Candesartan- HCTZ, Teveten/ Eprosartan, Teveten HCT, Avapro, Avalide, Cozaar, Hyzaar, Diovan HCT, Micardis Nesina, Kazano, Oseni 7
8 Step Therapy Medications (3 steps)* Continued Step 3 Diabetes Continued Metformin-glipizide, Metformin-glyburide, Metformin-pioglitazone, Chlorpropamide, Glimepiride, Glipizide, Glipizide ER, Glyburide, Tolazamide, Tolbutamide, Pioglitazone, Pioglitazone-glimepiride, Novolog, Lantus, Humalog, Levemir, Humulin, Novolin, Byetta Metformin-glipizide, Metformin-glyburide, Metformin-pioglitazone, Chlorpropamide, Glimepiride, Glipizide, Glipizide ER, Glyburide, Tolazamide, Tolbutamide, Pioglitazone, Pioglitazone-glimepiride, Novolog, Lantus, Humalog, Levemir, Humulin, Novolin Metformin, Metformin ER, Metformin-glipizide, Metformin-glyburide, Metforminpioglitazone, Chlorpropamide, Glimepiride, Glipizide, Glipizide ER, Glyburide, Tolazamide, Tolbutamide, Pioglitazone, Pioglitazone-glimepiride, Novolog, Lantus, Humalog, Levemir, Humulin, Novolin, Byetta Janumet Byetta, Victoza Invokamet, Invokana Janumet XR Bydureon, Tanzeum Fargixa, Jardiance * Step therapy requirements are effective as of January 1, The list of step therapy medications is subject to change without notice. Step therapy requirements may vary by benefit plan. Additional clinical programs, including quantity limits and prior authorization, may exist for the above medications which may affect your prescription drug coverage. optumrx.com OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum TM company a leading provider of integrated health services. Learn more at optum.com. All Optum TM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners OptumRx, Inc. A09934 ORX0785_150101
Step Therapy. Here s how it works:
Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment
SmithRx 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
Premium Step Therapy. Here s how it works:
Premium Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment
Select Step Therapy Programs January 2016
Anti-infectives Oral Brand Tetracyclines Acticlate, Adoxa, Doryx, Targadox doxycycline Otic Agents Cetraxal Cardiovascular ofloxacin Beta Blockers Coreg CR Calcium Channel Blockers Prestalia Renin-Angiotensin
STEP 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
Select Step Therapy. Here s how it works:
Select Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment
Step therapy Premium. Utilization management updates - January 1, Here s how it works:
Utilization management updates - January 1, 2019 Step therapy Premium Most medical conditions have many medication options. Although their clinical effectiveness may be the same, the cost can be very different.
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
Premium step therapy. Here s how it works:
Premium step therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment
Step 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
Try a Step 1 medication first
Premium step therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment
Generics. 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
Avoid 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
Step 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
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*
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
ClearScript Step Therapy Drug List
ClearScript Step Therapy Drug List The ClearScript Step Therapy Program requires a trial of one or more first step drugs before a second step or target drug is covered. For example, if two drugs are used
Select Step Therapy. Here s how it works:
Select Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment
Step Therapy Group Algorithm Steps
Step Therapy Group Algorithm Steps ACTONEL AMITIZA ANTICONVULSANT ANTIDEPRESSION Previous trial on alendronate Step 1: ALENDRONATE SODIUM Step 2: RISEDRONATE SODIUM, RISEDRONATE SODIUM DR Previous trial
FirstCarolinaCare 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
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
2015 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
Core and Select Step Therapy
Core and Select Step Therapy Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get
2013 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
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
Cigna 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
ANTICHOLINERGIC BRONCHODILATORS ANTICHOLINERGIC BETA-AGONIST COMBO'S CORTICOSTEROID / BRONCHODILATOR COMBO'S NASAL STEROIDS LEUKOTRIENE MODIFIERS
1 of 5 ALLERGY / ASTHMA THERAPIES ANTIHISTAMINES, MINIMALLY SEDATING cetirizine fexofenadine loratadine ANTIHISTAMINE/DECONGESTANT COMBINATIONS cetirizine/pseudoephedrine fexofenadine/pseudoephedrine loratadine/pseudoephedrine
SelectHealth 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
RxBlue 2010 ST Criteria
RxBlue 2010 ST Criteria ANTIDEPRESSANTS - SARAFEM... 10 FLUOXETINE HCL... 10 SARAFEM... 10 SELFEMRA... 10 ANTIDEPRESSANTS- SSRI, SNRI... 11 CELEXA... 11 CITALOPRAM... 11 CYMBALTA... 11 EFFEXOR XR... 11
Save on your drugs with HealthyRx
Save on your drugs with HealthyRx HealthyRx is a savings program offered through the UVa Hoo s Well program. It helps lower your costs on drugs for certain health conditions. Effective 4/1/17, you are
Lower 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
Generics. Lead with. P r e s c r i p t i o n S t e p T h e r a p y P r o g r a m
Lead with Generics P r e s c r i p t i o n S t e p T h e r a p y P r o g r a m WWW.BCBSLA.COM 04HQ3972 5/09 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity
2015 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...
2019 Step Therapy (ST) Criteria
2019 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
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
Step Therapy. Here s how it works: Move on to a Step 2 drug if necessary
Step Therapy Most medical conditions can be treated with several different drug options. There are many drugs that cost much less than others despite working the same way and being just as effective. The
ALLERGIC RHINITIS-NASAL
ALLERGIC RHINITIS-NASAL FLUNISOLIDE Patient needs to have paid claims for any one of the following Step 1 drugs: NasaCort OTC, fluticasone Rx, fluticasone OTC, Budesonide OTC. Prior to filling the Step
2018 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
THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM
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
SelectHealth 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
These 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
SelectHealth 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
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
Prescription 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
Drugs 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.
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
2014 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
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
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
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
Cost 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
Drug 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
High-Cost Drug Exclusions
PHARMACY SERVICES High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at
PDF created with pdffactory trial version
We are using more prescription drugs than ever before to manage health conditions and prevent problems. And those drugs are more expensive than ever before. In 2003, prescription drug costs in the United
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:
2014 Medicare Step Therapy Criteria. Last Modified: Last Submitted to CMS:
2014 Medicare Step Therapy Criteria Last Modified: 09.30.2014 Last Submitted to CMS: 09.02.2014 1 Table of Contents AMITIZA, LINZESS... 3 ANTIDEPRESSANTS - Viibryd / Pexeva / Pristiq / Desvenlafaxine...
Drugs That Have Quantitiy Limits (QL)
Drugs That Have Quantitiy Limits (QL) There are Quantity Limits set by your UA Medicare Group Part D Prescription Drug Plan for the drugs listed below. The UA Medicare Group Part D Prescription Drug Plan
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
If you have questions about the Step Therapy Program, contact ClearScript Member Services at the number on the back of your ID Card.
Step Therapy The ClearScript Step Therapy program promotes the cost-effective use of clinically appropriate medications when more than one drug is available to treat a medical condition. What is Step Therapy?
ALPHA 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
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
THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM
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
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,
Hospitality 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
If you have questions about the Step Therapy Program, contact ClearScript Member Services at the number on the back of your ID Card.
Step Therapy The ClearScript Step Therapy program promotes the cost-effective use of clinically appropriate medications when more than one drug is available to treat a medical condition. What is Step Therapy?
High-Cost Drug Exclusions
Pharmacy Services High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at
Amitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
School Corp Formulary Antiviral Acyclovir 400mg Zovirax Asthma Advair Diskus Diskus 250/50 Fluticasone/Salmeterol Asthma Albuterol Sulfate 2.5 mg/3 ml Proventil Arthritis and Pain Allendronate Sodium 70
Drugs That Require Step Therapy (ST) Step Therapy Medications
Drugs That Require Step Therapy (ST) In some cases, BlueShield of Northeastern New York requires you to first try certain drugs to treat your medical condition before we will cover another drug for that
ANGIOTENSIN 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
Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18
Granite Alliance Insurance Company (PDP) 2018 Step Therapy Criteria Last Updated: 10/23/18 Granite Alliance requires step therapy for certain drugs. This means prior to receiving a drug with a step therapy
Value-Based Drug List for ABCs of Diabetes
Effective January 1, 2019 Value-Based Drug List for ABCs of Diabetes PCPS provides a Value-Based Benefit Design (VBD) to qualified participants in the ABCs of Diabetes. This means you will have lower out-of-pocket
Amitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil
Antiviral Acyclovir 400mg Zovirax Asthma Advair Diskus Diskus 250/50 Fluticasone/Salmeterol Asthma Albuterol Sulfate 2.5 mg/3 ml Proventil Arthritis and Pain Allendronate Sodium 70 mg Fosamax Arthritis
Medications Requiring Prior Authorization for Medical Necessity
Medications Requiring Prior Medical Necessity January 2016 Below is a list of medicines by drug class that will not be covered without a prior authorization for medical necessity. If you continue using
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
ANTIDEPRESSANTS - 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
Blue 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
ABILIFY 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
PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION. for the KENT COUNTY EMPLOYEE AND RETIREE BENEFITS PLAN (PRESCRIPTION PLAN EXTRACT
PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION for the KENT COUNTY EMPLOYEE AND RETIREE BENEFITS PLAN (PRESCRIPTION PLAN EXTRACT PRESRIPTION DRUG BENEFIT The prescription drug benefit is administered through
Step Therapy Requirements
An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 12/01/2017 Updated 11/2017 H0302_2_2014 CMS Accepted 05/05/2014 1 ABILIFY Abilify 10 mg tablet
2014 Preferred Drug List An evidence-based pharmacy program that works for you
2014 Preferred Drug List An evidence-based pharmacy program that works for you What is the Moda Health Preferred Drug Program? The Moda Health Preferred Drug Program is a pharmacy program that is designed
Alaska Medicaid 90 Day** Generic Prescription Medication List
1 ACYCLOVIR 200 MG CAPSULE BUPROPION HCL 150 MG TAB ER 24H ACYCLOVIR 200 MG/5ML BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 400 MG TABLET BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 800 MG TABLET BUPROPION HCL
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
Medications Requiring Prior Authorization for Medical Necessity
Medications Requiring Prior Medical Necessity January 2016 Below is a list of medicines by drug class that will not be covered without a prior authorization for medical necessity, effective January 1,
Mercy Care Plan. Acyclovir Ointment. Products Affected. acyclovir ointment 5 % external Details. Criteria. Requires use of oral Acyclovir
Acyclovir Ointment Mercy Care Plan acyclovir ointment 5 % external Requires use of oral Acyclovir 1 Adcirca ADCIRCA TABLET 20 MG ORAL Requires use of Sildenafil 2 Albenza ALBENZA TABLET 200 MG ORAL Requires
AGGRENOX. Products Affected. Details. Open 1 Last Updated: 10/01/2018. Aggrenox
Open 1 Last Updated: 10/01/2018 AGGRENOX Aggrenox A documented trial of one month of formulary generic aspirin/dipyridamole capsules. NR_0009_3742 09/2014 Formulary ID: 19076: version 7 1 ANTIDEPRESSANTS
Oregon Health Plan prescription benefit updates
Oregon Health Plan prescription benefit updates EOCCO s prescription program is a pharmacy benefit that offers members a choice of safe and effective medication treatments. The program also helps you save
ANGIOTENSIN 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,
Drug Regimen Optimization
Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Excluding Valsartan / Ramipril Prior authorization criteria logic: a description
Primary/Preferred Drug List
April 2012 Primary/Preferred Drug List The CVS Caremark Primary/Preferred Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should
Blue Cross KeyRx TK Preventive RX Pack Drug List Large Group Effective January 1, 2019
Blue Cross KeyRx TK Preventive RX Pack Drug List Large Group Effective January 1, 2019 Your employer may have elected to include the KeyRx Turn-Key Preventive Pack Drug List in your benefit plan. Below
2017 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.
How 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
Plan 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
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.