ANTICONVULSANT STEP THERAPY

Transcription

1 2019 First Choice VIP Care Plus Formulary Document: 2019 Step Therapy Formulary ID: Last Updated: 2/2019 Effective Date: ANTICONVULSANT STEP THERAPY APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BRIVIACT 10 MG BRIVIACT 10 MG/ML ORAL SOLUTION BRIVIACT 100 MG BRIVIACT 25 MG BRIVIACT 50 MG BRIVIACT 75 MG FYCOMPA 0.5 MG/ML ORAL SUSPENSION FYCOMPA 10 MG FYCOMPA 12 MG FYCOMPA 2 MG FYCOMPA 4 MG FYCOMPA 6 MG FYCOMPA 8 MG SPRITAM 1,000 MG FOR ORAL SUSPENSION SPRITAM 250 MG FOR ORAL SUSPENSION SPRITAM 500 MG FOR ORAL SUSPENSION SPRITAM 750 MG FOR ORAL SUSPENSION VIMPAT 10 MG/ML ORAL SOLUTION VIMPAT 100 MG VIMPAT 150 MG VIMPAT 200 MG VIMPAT 50 MG Step 1: First line therapy should be a documented trial of two of the following formulary medications: carbamazepine, carbamazepine ER, divalproex sodium, divalproex sodium ER, gabapentin, lamotrigine, lamotrigine ER, levetiracetam, levetiracetam ER, oxcarbazepine, valproic acid, zonisamide, phenytoin, phenytoin ER, felbamate, ethosuxamide, topiramate, primidone, Dilantin, phenobarbital, Phenytek or tiagabine. Once two of the medications listed in Step 1 have been tried, patients can receive therapy with Aptiom, Spritam, Fycompa, Briviact or Vimpat. 1

2 ANTIDEPRESSANT STEP THERAPY FETZIMA 120 MG CAPSULE,EXTENDED RELEASE FETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED RELEASE,24 HR,DOSE PACK FETZIMA 20 MG CAPSULE,EXTENDED RELEASE FETZIMA 40 MG CAPSULE,EXTENDED RELEASE FETZIMA 80 MG CAPSULE,EXTENDED RELEASE TRINTELLIX 10 MG TRINTELLIX 20 MG TRINTELLIX 5 MG VIIBRYD 10 MG (7)-20 MG (23) S IN A DOSE PACK VIIBRYD 10 MG VIIBRYD 20 MG VIIBRYD 40 MG Step 1: First line therapy should be a documented trial of two of the following formulary medications: citalopram, duloxetine, escitalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER or desvenlafaxine. Once two of the medications listed in step 1 have been tried, patient can receive therapy with Trintellix, Fetzima or Viibryd. 2

3 2019 First Choice VIP Care Plus Formulary Document: 2019 Step Therapy Formulary ID: Last Updated: 2/2019 Effective Date: AZOPT STEP THERAPY AZOPT 1 % EYE DROPS,SUSPENSION Step 1: First line therapy should be a documented trial of formulary dorzolamide or dorzolamide/timolol. Once dorzolamide or dorzolamide/timolol has been tried, the patient can receive therapy with Azopt. 3

4 COMBIVENT STEP THERAPY COMBIVENT RESPIMAT 20 MCG- 100 MCG/ACTUATION SOLUTION FOR INHALATION Step 1: First line therapy should be a documented trial of formulary Anoro Ellipta. Once Anoro Ellipta has been tried, patients can receive therapy with Combivent Respimat. 4

5 2019 First Choice VIP Care Plus Formulary Document: 2019 Step Therapy Formulary ID: Last Updated: 2/2019 Effective Date: GLP-1 AGONIST STEP THERAPY OZEMPIC 0.25 MG OR 0.5 MG (2 MG/1.5 ML) SUBCUTANEOUS PEN INJECTOR OZEMPIC 1 MG/DOSE (2 MG/1.5 ML) SUBCUTANEOUS PEN INJECTOR TRULICITY 0.75 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR TRULICITY 1.5 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR VICTOZA 2-PAK 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR VICTOZA 3-PAK 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR Step 1: First line therapy should be a documented trial of a formulary metformin or metformin ER. Once metformin or metformin ER has been tried, patients can receive therapy with Victoza, Trulicity, or Ozempic. 5

6 HYPOGLYCEMICS STEP THERAPY acarbose 100 mg acarbose 25 mg acarbose 50 mg alogliptin 12.5 mg alogliptin 12.5 mg-metformin 1,000 mg alogliptin 12.5 mg-metformin 500 mg alogliptin 12.5 mg-pioglitazone 15 mg alogliptin 12.5 mg-pioglitazone 30 mg alogliptin 12.5 mg-pioglitazone 45 mg alogliptin 25 mg alogliptin 25 mg-pioglitazone 15 mg alogliptin 25 mg-pioglitazone 30 mg alogliptin 25 mg-pioglitazone 45 mg alogliptin 6.25 mg AVANDIA 2 MG AVANDIA 4 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, EXTENDED RELEASE INVOKAMET XR 150 MG-500 MG, EXTENDED RELEASE INVOKAMET XR 50 MG-1,000 MG, EXTENDED RELEASE INVOKAMET XR 50 MG-500 MG, EXTENDED RELEASE INVOKANA 100 MG INVOKANA 300 MG JANUMET 50 MG-1,000 MG JANUMET 50 MG-500 MG JANUMET XR 100 MG-1,000 MG,EXTENDED RELEASE JANUMET XR 50 MG-1,000 MG,EXTENDED RELEASE JANUMET XR 50 MG-500 MG,EXTENDED RELEASE JANUVIA 100 MG JANUVIA 25 MG JANUVIA 50 MG JENTADUETO 2.5 MG-1,000 MG JENTADUETO 2.5 MG-500 MG JENTADUETO 2.5 MG-850 MG JENTADUETO XR 2.5 MG-1,000 MG, EXTENDED RELEASE JENTADUETO XR 5 MG-1,000 MG, EXTENDED RELEASE nateglinide 120 mg nateglinide 60 mg pioglitazone 15 mg pioglitazone 15 mg-metformin 500 mg pioglitazone 15 mg-metformin 850 mg pioglitazone 30 mg pioglitazone 45 mg repaglinide 0.5 mg repaglinide 1 mg repaglinide 2 mg SEGLUROMET 2.5 MG-1,000 MG SEGLUROMET 2.5 MG-500 MG 6

7 2019 First Choice VIP Care Plus Formulary Document: 2019 Step Therapy Formulary ID: Last Updated: 2/2019 Effective Date: SEGLUROMET 7.5 MG-1,000 MG SEGLUROMET 7.5 MG-500 MG STEGLATRO 15 MG STEGLATRO 5 MG STEGLUJAN 15 MG-100 MG STEGLUJAN 5 MG-100 MG TRADJENTA 5 MG Step 1: First line therapy should be a documented trial with a formulary sulfonylurea, metformin or formulary insulin (if appropriate). Once one of these agents has been tried, patients can receive therapy with other formulary hypoglycemics such as Avandia, acarbose, Januvia, Janumet, Janumet XR, repaglinide, nateglinide, pioglitazone, pioglitazone/metformin, alogliptin, alogliptin/metformin, alogliptin/pioglitazone, Tradjenta, Jentadueto, Jentadueto XR, Invokana, Invokamet, Invokamet XR, Steglatro, Segluromet or Steglujan 7

8 KRISTALOSE STEP THERAPY KRISTALOSE 20 GRAM ORAL PACKET lactulose 10 gram oral packet Step 1: First line therapy should be a documented trial of formulary Constulose, lactulose, or polyethylene glycol. Once Constulose, lactulose, or polyethylene glycol has been tried, patients can receive therapy with Kristalose packet. 8

9 2019 First Choice VIP Care Plus Formulary Document: 2019 Step Therapy Formulary ID: Last Updated: 2/2019 Effective Date: RANEXA STEP THERAPY RANEXA 1,000 MG,EXTENDED RELEASE RANEXA 500 MG,EXTENDED RELEASE Step 1: First line therapy should be a documented trial of a formulary beta blocker or a calcium channel blocker. Once a beta blocker or a calcium channel blocker has been tried, patients may receive therapy with Ranolazine (Ranexa). 9

10 TOPICAL IMMUNOMODULATORS STEP THERAPY ELIDEL 1 % TOPICAL CREAM pimecrolimus 1 % topical cream tacrolimus 0.03 % topical ointment tacrolimus 0.1 % topical ointment Step 1: First line therapy should be a documented trial of two formulary topical corticosteroids. Once two of these agents have been tried, patients can receive therapy with Elidel or generic topical tacrolimus. 10

11 2019 First Choice VIP Care Plus Formulary Document: 2019 Step Therapy Formulary ID: Last Updated: 2/2019 Effective Date: TREXALL STEP THERAPY TREXALL 10 MG TREXALL 15 MG TREXALL 5 MG TREXALL 7.5 MG Step 1: First line therapy should be a documented trial with formulary generic methotrexate. Once generic methotrexate has been tried, patients can receive Trexall. 11

12 ULORIC STEP THERAPY ULORIC 40 MG ULORIC 80 MG Step 1: First line therapy should be a documented trial of formulary allopurinol. Once allopurinol has been tried, patients can receive therapy with Uloric. 12

13 2019 First Choice VIP Care Plus Formulary Document: 2019 Step Therapy Formulary ID: Last Updated: 2/2019 Effective Date: URINARY INCONTINENCE AGENTS STEP THERAPY darifenacin er 15 mg,extended release 24 hr Step 3: MYRBETRIQ 25 MG,EXTENDED RELEASE darifenacin er 7.5 mg,extended release 24 hr MYRBETRIQ 50 MG,EXTENDED RELEASE Step 1: First line therapy should be a documented trial of formulary oxybutynin, oxybutynin ER, tolterodine or tolterodine ER. Second line therapy should be formulary darifenicin ER. Step 3: Once oxybutynin, oxybutynin ER, tolterodine or tolterodine ER AND darifenacin ER have been tried, patients can receive therapy with Myrbetriq. 13

14 ZAFIRLUKAST STEP THERAPY zafirlukast 10 mg zafirlukast 20 mg Step 1: First line therapy should be a documented trial of formulary montelukast. Once montelukast has been tried, patients may receive therapy with zafirlukast. 14

15 2019 First Choice VIP Care Plus Formulary Document: 2019 Step Therapy Formulary ID: Last Updated: 2/2019 Effective Date: ZIRGAN STEP THERAPY ZIRGAN 0.15 % EYE GEL Step 1: First line therapy should be a documented trial of formulary generic trifluridine ophthalmic. Once generic trifluridine ophthalmic has been tried, patients can receive therapy with Zirgan. 15

16 Index A acarbose 100 mg... 6 acarbose 25 mg... 6 acarbose 50 mg... 6 alogliptin 12.5 mg... 6 alogliptin 12.5 mg-metformin 1,000 mg... 6 alogliptin 12.5 mg-metformin 500 mg... 6 alogliptin 12.5 mg-pioglitazone 15 mg... 6 alogliptin 12.5 mg-pioglitazone 30 mg... 6 alogliptin 12.5 mg-pioglitazone 45 mg... 6 alogliptin 25 mg... 6 alogliptin 25 mg-pioglitazone 15 mg 6 alogliptin 25 mg-pioglitazone 30 mg 6 alogliptin 25 mg-pioglitazone 45 mg 6 alogliptin 6.25 mg... 6 APTIOM 200 MG... 1 APTIOM 400 MG... 1 APTIOM 600 MG... 1 APTIOM 800 MG... 1 AVANDIA 2 MG... 6 AVANDIA 4 MG... 6 AZOPT 1 % EYE DROPS,SUSPENSION 3 B BRIVIACT 10 MG... 1 BRIVIACT 10 MG/ML ORAL SOLUTION... 1 BRIVIACT 100 MG... 1 BRIVIACT 25 MG... 1 BRIVIACT 50 MG... 1 BRIVIACT 75 MG... 1 C COMBIVENT RESPIMAT 20 MCG-100 MCG/ACTUATION SOLUTION FOR INHALATION... 4 D darifenacin er 15 mg,extended release 24 hr darifenacin er 7.5 mg,extended release 24 hr E ELIDEL 1 % TOPICAL CREAM F FETZIMA 120 MG CAPSULE,EXTENDED RELEASE... 2 FETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED RELEASE,24 HR,DOSE PACK... 2 FETZIMA 20 MG CAPSULE,EXTENDED RELEASE... 2 FETZIMA 40 MG CAPSULE,EXTENDED RELEASE... 2 FETZIMA 80 MG CAPSULE,EXTENDED RELEASE... 2 FYCOMPA 0.5 MG/ML ORAL SUSPENSION... 1 FYCOMPA 10 MG... 1 FYCOMPA 12 MG... 1 FYCOMPA 2 MG... 1 FYCOMPA 4 MG... 1 FYCOMPA 6 MG... 1 FYCOMPA 8 MG... 1 I INVOKAMET 150 MG-1,000 MG... 6 INVOKAMET 150 MG-500 MG 6 INVOKAMET 50 MG-1,000 MG... 6 INVOKAMET 50 MG-500 MG. 6 INVOKAMET XR 150 MG-1,000 MG, EXTENDED RELEASE... 6 INVOKAMET XR 150 MG-500 MG, EXTENDED RELEASE... 6 INVOKAMET XR 50 MG-1,000 MG, EXTENDED RELEASE... 6 INVOKAMET XR 50 MG-500 MG, EXTENDED RELEASE... 6 INVOKANA 100 MG... 6 INVOKANA 300 MG... 6 J JANUMET 50 MG-1,000 MG... 6 JANUMET 50 MG-500 MG... 6 JANUMET XR 100 MG-1,000 MG,EXTENDED RELEASE

17 2019 First Choice VIP Care Plus Formulary Document: 2019 Step Therapy Formulary ID: Last Updated: 2/2019 Effective Date: JANUMET XR 50 MG-1,000 MG,EXTENDED RELEASE... 6 JANUMET XR 50 MG-500 MG,EXTENDED RELEASE... 6 JANUVIA 100 MG... 6 JANUVIA 25 MG... 6 JANUVIA 50 MG... 6 JENTADUETO 2.5 MG-1,000 MG... 6 JENTADUETO 2.5 MG-500 MG... 6 JENTADUETO 2.5 MG-850 MG... 6 JENTADUETO XR 2.5 MG-1,000 MG, EXTENDED RELEASE... 6 JENTADUETO XR 5 MG-1,000 MG, EXTENDED RELEASE... 6 K KRISTALOSE 20 GRAM ORAL PACKET... 8 L lactulose 10 gram oral packet... 8 M MYRBETRIQ 25 MG,EXTENDED RELEASE MYRBETRIQ 50 MG,EXTENDED RELEASE N nateglinide 120 mg... 6 nateglinide 60 mg... 6 O OZEMPIC 0.25 MG OR 0.5 MG (2 MG/1.5 ML) SUBCUTANEOUS PEN INJECTOR... 5 OZEMPIC 1 MG/DOSE (2 MG/1.5 ML) SUBCUTANEOUS PEN INJECTOR... 5 P pimecrolimus 1 % topical cream pioglitazone 15 mg... 6 pioglitazone 15 mg-metformin 500 mg... 6 pioglitazone 15 mg-metformin 850 mg... 6 pioglitazone 30 mg... 6 pioglitazone 45 mg... 6 R RANEXA 1,000 MG,EXTENDED RELEASE... 9 RANEXA 500 MG,EXTENDED RELEASE... 9 repaglinide 0.5 mg... 6 repaglinide 1 mg... 6 repaglinide 2 mg... 6 S SEGLUROMET 2.5 MG-1,000 MG... 6 SEGLUROMET 2.5 MG-500 MG... 6 SEGLUROMET 7.5 MG-1,000 MG... 7 SEGLUROMET 7.5 MG-500 MG... 7 SPRITAM 1,000 MG FOR ORAL SUSPENSION... 1 SPRITAM 250 MG FOR ORAL SUSPENSION... 1 SPRITAM 500 MG FOR ORAL SUSPENSION... 1 SPRITAM 750 MG FOR ORAL SUSPENSION... 1 STEGLATRO 15 MG... 7 STEGLATRO 5 MG... 7 STEGLUJAN 15 MG-100 MG.. 7 STEGLUJAN 5 MG-100 MG... 7 T tacrolimus 0.03 % topical ointment tacrolimus 0.1 % topical ointment TRADJENTA 5 MG... 7 TREXALL 10 MG TREXALL 15 MG TREXALL 5 MG TREXALL 7.5 MG TRINTELLIX 10 MG... 2 TRINTELLIX 20 MG... 2 TRINTELLIX 5 MG

18 TRULICITY 0.75 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR... 5 TRULICITY 1.5 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR... 5 U ULORIC 40 MG ULORIC 80 MG V VICTOZA 2-PAK 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR... 5 VICTOZA 3-PAK 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR... 5 VIIBRYD 10 MG (7)-20 MG (23) S IN A DOSE PACK... 2 VIIBRYD 10 MG... 2 VIIBRYD 20 MG... 2 VIIBRYD 40 MG... 2 VIMPAT 10 MG/ML ORAL SOLUTION. 1 VIMPAT 100 MG... 1 VIMPAT 150 MG... 1 VIMPAT 200 MG... 1 VIMPAT 50 MG... 1 Z zafirlukast 10 mg zafirlukast 20 mg ZIRGAN 0.15 % EYE GEL