TEST ANTICONVULSANT THERAPY. Products Affected. Step 2: Network Health Insurance Corporation NetworkCares Step Therapy Criteria Last Updated 11/2018

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1 TEST Network Health Insurance Corporation NetworkCares Step Therapy Last Updated 11/2018 ANTICONVULSANT THERAPY Aptiom Banzel Briviact Celontin Dilantin 30 Mg Capsule Equetro Fycompa 0.5 Mg/ml Oral Susp Fycompa 10 Mg Tablet Fycompa 12 Mg Tablet Fycompa 2 Mg Tablet Fycompa 4 Mg Tablet Fycompa 6 Mg Tablet Fycompa 8 Mg Tablet Gabitril 12 Mg Tablet Gabitril 16 Mg Tablet Lamictal (blue) Lamictal (green) Lamictal (orange) Lamictal Xr (blue) Lamictal Xr (green) Lamictal Xr (orange) Oxtellar Xr Spritam Vimpat 10 Mg/ml Solution Vimpat 100 Mg Tablet Vimpat 150 Mg Tablet Vimpat 200 Mg Tablet Vimpat 200 Mg/20 Ml Vial Vimpat 50 Mg Tablet back period is 365 days. Step 1 drugs are Carbamazepine, Divalproex Sodium, Epitol, Ethosuximide, Felbamate, Fosphenytoin, Gabapentin, Lamotrigine, Levetiracetam, Oxcarbazepine, Phenytoin, Primidone, Roweepra, Tiagabine, Topiramate, Valproate Sodium, Valproic Acid, Zonisamide. 1

2 ARICEPT THERAPY Donepezil Hcl 23 Mg Tablet back period is 180 days. Step 1 drugs are Donepezil 10mg. 2

3 ATYPICAL ANTIPSYCHOTIC THERAPY Fanapt Latuda Olanzapine 10 Mg Tablet Olanzapine 15 Mg Tablet Olanzapine 2.5 Mg Tablet Olanzapine 20 Mg Tablet Olanzapine 5 Mg Tablet Olanzapine 7.5 Mg Tablet Olanzapine Odt Olanzapine-fluoxetine Hcl Paliperidone Er Quetiapine Fumarate Er Rexulti Saphris Vraylar Must first try two step one drugs to receive a step two drug. Look back period is 365 days. Step 1 drugs are Aripiprazole (ODT, tablets, oral solution), Clozapine, Fazaclo, Fluphenazine, Haloperidol, Loxapine, Perphenazine, Pimozide, Quetiapine, Risperidone, Thioridazine, Thiothixene, Trifluoperazine, Ziprasidone. Members may request an exception and Rexulti, quetiapine XR and fluoxetine-olanzapine will be allowed as first line treatment for Major Depressive Disorder. Latuda, fluoxetine/olanzapine or quetiapine XR will be allowed as first line treatment for bipolar depression. 3

4 BALSALAZIDE THERAPY Giazo back period is 180 days. Step 1 drugs are Balsalazide. 4

5 BASAL INSULIN Levemir Levemir Flextouch Tresiba Flextouch U-100 Tresiba Flextouch U-200 back period is 180 days. Step 1 drugs are Basaglar, Lantus, Toujeo. 5

6 DPP-4 Alogliptin Alogliptin-metformin Alogliptin-pioglitazone Glyxambi Jentadueto Jentadueto Xr Kazano Nesina Oseni Tradjenta back period is 180 days. Step 1 drugs are Janumet, Januvia, Kobmiglyze, Onglyza. 6

7 GLP-1 Adlyxin Bydureon Bydureon Bcise Bydureon Pen Byetta Ozempic Tanzeum Trulicity Victoza 2-pak Victoza 3-pak back period is 180 days. Step 1 drugs are Metformin OR Metformin/Glipizide. Victoza will be approved first-line if being used to reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes and established cardiovascular disease. 7

8 HIGH RISK MEDICATIONS - SEDATIVE/HYPNOTICS Belsomra Edluar Eszopiclone Zaleplon Zolpidem Tartrate 10 Mg Tablet Zolpidem Tartrate 5 Mg Tablet Zolpidem Tartrate Er This step therapy program applies to members aged 65 years or greater. Must first try one step one drug to receive a step two drug. Look back period is 180 days. Step 1 drugs are Rozerem, Silenor, Trazodone. Authorization for Edluar may be given if the patient has difficulty swallowing or cannot swallow tablets. 8

9 INSPRA THERAPY Aldactazide Tablet Carospir Eplerenone back period is 180 days. Step 1 drugs are Spironolactone, Spironolactone/HCTZ. 9

10 NASAL CORTICOSTEROID THERAPY Beconase Aq Dymista Mometasone Furoate 50 Mcg Spry Omnaris Qnasl Qnasl Children Triamcinolone 55 Mcg Nasal Spr Zetonna back period is 365 days. Step 1 drugs are Flunisolide, Fluticasone. Members may request an exception and mometasone will be allowed as first line treatment for Prophylaxis of Seasonal Allergic Rhinitis or nasal polyps. Members may request an exception and beclomethasone dipropionate (Beconase AQ) will be allowed as first line treatment for nasal polyps 10

11 OPHTHALMIC BETA BLOCKER THERAPY Betimol Betoptic S Combigan Istalol Timoptic Ocudose back period is 180 days. Step 1 drugs are Betaxalol, Carteolol, Dorzolamide/Timolol, Levobunolol, Metipranolol, Timolol. 11

12 OPHTHALMIC PROSTAGLANDIN THERAPY Bimatoprost 0.03% Eye Drops Lumigan Rhopressa Travatan Z Vyzulta Zioptan back period is 180 days. Step 1 drugs are Latanoprost. 12

13 OSTEOPOROSIS THERAPY Binosto Forteo Fosamax Plus D Ibandronate 3 Mg/3 Ml Vial Prolia Tymlos back period is 180 days. Step 1 drugs are Alendronate, Risedronate, and Ibandronate 150mg tablets. Members may request an exception and Prolia will be allowed as first line treatment for Breast cancer - Osteopenia, In members at high risk of fracture receiving aromatase inhibitor therapy, and for Osteopenia, In members at high risk of fracture receiving androgen deprivation therapy - Prostate cancer, Nonmetastatic. 13

14 PULMONARY ANTI-INFLAMMATORY Symbicort back period is 180 days. Step 1 drugs are Fluticasone/Salmeterol, Advair, Breo Ellipta, Dulera. 14

15 RESTLESS LEG THERAPY Horizant back period is 180 days. Step 1 drugs are Gabapentin, Pramipexole, Ropinirole. 15

16 TRIPTAN THERAPY Onzetra Xsail Treximet Zembrace Symtouch Zomig 2.5 Mg Nasal Spray Zomig 5 Mg Nasal Spray Must first try two step one drugs to receive a step two drug. Look back period is 365 days. Step 1 drugs are Almotriptan, Eletriptan, Frovatriptan, Naratriptan, Rizatriptan, Sumatriptan, Sumatriptan-naproxen (generic), Zolmitriptan. 16

17 Index A Adlyxin 7 Aldactazide Tablet 9 Alogliptin 6 Alogliptin-metformin 6 Alogliptin-pioglitazone 6 Aptiom 1 B Banzel 1 Beconase Aq 10 Belsomra 8 Betimol 11 Betoptic S 11 Bimatoprost 0.03% Eye Drops 12 Binosto 13 Briviact 1 Bydureon 7 Bydureon Bcise 7 Bydureon Pen 7 Byetta 7 C Carospir 9 Celontin 1 Combigan 11 D Dilantin 30 Mg Capsule 1 Donepezil Hcl 23 Mg Tablet 2 Dymista 10 E Edluar 8 Eplerenone 9 Equetro 1 Eszopiclone 8 F Fanapt 3 Forteo 13 Fosamax Plus D 13 Fycompa 0.5 Mg/ml Oral Susp 1 Fycompa 10 Mg Tablet 1 Fycompa 12 Mg Tablet 1 Fycompa 2 Mg Tablet 1 Fycompa 4 Mg Tablet 1 Fycompa 6 Mg Tablet 1 Fycompa 8 Mg Tablet 1 G Gabitril 12 Mg Tablet 1 Gabitril 16 Mg Tablet 1 Giazo 4 Glyxambi 6 H Horizant 15 I Ibandronate 3 Mg/3 Ml Vial 13 Istalol 11 J Jentadueto 6 Jentadueto Xr 6 K Kazano 6 L Lamictal (blue) 1 Lamictal (green) 1 Lamictal (orange) 1 Lamictal Xr (blue) 1 Lamictal Xr (green) 1 Lamictal Xr (orange) 1 Latuda 3 Levemir 5 Levemir Flextouch 5 Lumigan 12 17

18 M Mometasone Furoate 50 Mcg Spry 10 N Nesina 6 O Olanzapine 10 Mg Tablet 3 Olanzapine 15 Mg Tablet 3 Olanzapine 2.5 Mg Tablet 3 Olanzapine 20 Mg Tablet 3 Olanzapine 5 Mg Tablet 3 Olanzapine 7.5 Mg Tablet 3 Olanzapine Odt 3 Olanzapine-fluoxetine Hcl 3 Omnaris 10 Onzetra Xsail 16 Oseni 6 Oxtellar Xr 1 Ozempic 7 P Paliperidone Er 3 Prolia 13 Q Qnasl 10 Qnasl Children 10 Quetiapine Fumarate Er 3 R Rexulti 3 Rhopressa 12 S Saphris 3 Spritam 1 Symbicort 14 T Tanzeum 7 Timoptic Ocudose 11 Tradjenta 6 Travatan Z 12 Tresiba Flextouch U Tresiba Flextouch U Treximet 16 Triamcinolone 55 Mcg Nasal Spr 10 Trulicity 7 Tymlos 13 V Victoza 2-pak 7 Victoza 3-pak 7 Vimpat 10 Mg/ml Solution 1 Vimpat 100 Mg Tablet 1 Vimpat 150 Mg Tablet 1 Vimpat 200 Mg Tablet 1 Vimpat 200 Mg/20 Ml Vial 1 Vimpat 50 Mg Tablet 1 Vraylar 3 Vyzulta 12 Z Zaleplon 8 Zembrace Symtouch 16 Zetonna 10 Zioptan 12 Zolpidem Tartrate 10 Mg Tablet 8 Zolpidem Tartrate 5 Mg Tablet 8 Zolpidem Tartrate Er 8 Zomig 2.5 Mg Nasal Spray 16 Zomig 5 Mg Nasal Spray 16 18