2019 PDP Basic Step Therapy Document
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- Dominick Reynolds
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1 Aggrenox 2019 PDP Basic 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. Step 2 Drug(s): Aggrenox (aspirin/extended-release dipyridamole). Applies to New Starts Only. 1
2 Aptiom - B APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET APTIOM 800 MG TABLET drug may be given. Step 1 Drug(s): Lamotrigine IR, Levetiracetam IR\XR, Oxcarbazepine IR, Topiramate, Zonisamide. Step 2 Drug(s): Aptiom (eslicarbazepine). Applies to New Starts Only. 2
3 Bystolic BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET Criteria If the patient has tried TWO Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): any TWO formulary Beta-blocker. Step 2 Drug(s): Bystolic (nebivolol) 3
4 Fanapt FANAPT 1 MG TABLET FANAPT 10 MG TABLET FANAPT 12 MG TABLET FANAPT 1MG(2)-2 MG(2)-4MG(2)-6 MG(2) TABLETS IN A DOSE PACK FANAPT 2 MG TABLET FANAPT 4 MG TABLET FANAPT 6 MG TABLET FANAPT 8 MG TABLET drug may be given. Step 1 Drug(s): olanzapine, paliperidone, quetiapine fumarate, risperidone, ziprasidone. Step 2 Drug(s): Fanapt (iloperidone), Fanapt Titration Pack (iloperidone). Applies to New Starts Only. 4
5 PERT Agents - B ZENPEP 10,000 UNIT-32,000 UNIT- 42,000 UNIT CAPSULE,DELAYED ZENPEP 10,000 UNIT-34,000 UNIT- 55,000 UNIT CAPSULE,DELAYED ZENPEP 15,000 UNIT-47,000 UNIT- 63,000 UNIT CAPSULE,DELAYED ZENPEP 15,000 UNIT-51,000 UNIT- 82,000 UNIT CAPSULE,DELAYED ZENPEP 20,000 UNIT-63,000 UNIT- 84,000 UNIT CAPSULE,DELAYED ZENPEP 20,000 UNIT-68,000 UNIT- 109,000 UNIT CAPSULE,DELAYED ZENPEP 25,000 UNIT-79,000 UNIT- 105,000 UNIT CAPSULE,DELAYED ZENPEP 25,000 UNIT-85,000 UNIT- 136,000 UNIT CAPSULE,DELAYED ZENPEP 3,000 UNIT-10,000 UNIT- 14,000 UNIT CAPSULE,DELAYED ZENPEP 3,000 UNIT-10,000 UNIT- 16,000 UNIT CAPSULE,DELAYED ZENPEP 40,000 UNIT-126,000 UNIT- 168,000 UNIT CAPSULE,DELAYED ZENPEP 40,000 UNIT-136,000 UNIT- 218,000 UNIT CAPSULE,DELAYED ZENPEP 5,000 UNIT-17,000 UNIT- 24,000 UNIT CAPSULE,DELAYED ZENPEP 5,000 UNIT-17,000 UNIT- 27,000 UNIT CAPSULE,DELAYED drug may be given. Step 1 Drug(s): Creon. Step 2 Drug(s): Zenpep. New Starts Only 5
6 Ranexa RANEXA 1,000 MG TABLET,EXTENDED RANEXA 500 MG TABLET,EXTENDED drug may be given. Step 1 Drug(s): any formulary Beta-blocker, Calcium-channel blocker, or Long-acting nitrate. Step 2 Drug(s): Ranexa (ranolazine) 6
7 Thioridazine HRM thioridazine 10 mg tablet thioridazine 100 mg tablet thioridazine 25 mg tablet thioridazine 50 mg tablet Criteria If the patient has tried TWO Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s):aripiprazole, Fanapt (iloperidone), Latuda, Olanzapine, paliperidone, Quetiapine, Risperidone, Ziprasidone. Step 2 Drug(s): Thioridazine. New Starts Only 7
8 Trintellix - C BRINTELLIX 10 MG TABLET BRINTELLIX 20 MG TABLET BRINTELLIX 5 MG TABLET TRINTELLIX 10 MG TABLET TRINTELLIX 20 MG TABLET TRINTELLIX 5 MG TABLET Criteria If the patient has tried TWO Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine IR/ER. Step 2 Drug(s): Trintellix. Applies to New Starts Only. 8
9 Uloric ULORIC 40 MG TABLET ULORIC 80 MG TABLET drug may be given. Step 1 Drug(s): allopurinol. Step 2 Drug(s): Uloric. Approve without trial of step 1 drug if Patient has contraindication to allopurinol use. 9
10 Viibryd - C VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK VIIBRYD 10 MG (7)-20 MG (7)-40 MG(16) TABLETS IN A DOSE PACK VIIBRYD 10 MG TABLET VIIBRYD 20 MG TABLET VIIBRYD 40 MG TABLET Criteria If the patient has tried TWO Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine IR/ER. Step 2 Drug(s): Viibryd, Viibryd Titration Pack. Applies to New Starts Only. 10
11 Index AGGRENOX 25 MG-200 MG CAPSULE, EXTENDED...1 APTIOM 200 MG TABLET... 2 APTIOM 400 MG TABLET... 2 APTIOM 600 MG TABLET... 2 APTIOM 800 MG TABLET... 2 aspirin 25 mg-dipyridamole 200 mg capsule,ext.release 12 hr multiphase... 1 BRINTELLIX 10 MG TABLET...8 BRINTELLIX 20 MG TABLET...8 BRINTELLIX 5 MG TABLET...8 BYSTOLIC 10 MG TABLET... 3 BYSTOLIC 2.5 MG TABLET... 3 BYSTOLIC 20 MG TABLET... 3 BYSTOLIC 5 MG TABLET... 3 FANAPT 1 MG TABLET... 4 FANAPT 10 MG TABLET... 4 FANAPT 12 MG TABLET... 4 FANAPT 1MG(2)-2 MG(2)-4MG(2)-6 MG(2) TABLETS IN A DOSE PACK... 4 FANAPT 2 MG TABLET... 4 FANAPT 4 MG TABLET... 4 FANAPT 6 MG TABLET... 4 FANAPT 8 MG TABLET... 4 RANEXA 1,000 MG TABLET,EXTENDED...6 RANEXA 500 MG TABLET,EXTENDED...6 thioridazine 10 mg tablet... 7 thioridazine 100 mg tablet... 7 thioridazine 25 mg tablet... 7 thioridazine 50 mg tablet... 7 TRINTELLIX 10 MG TABLET...8 TRINTELLIX 20 MG TABLET...8 TRINTELLIX 5 MG TABLET...8 ULORIC 40 MG TABLET...9 ULORIC 80 MG TABLET...9 VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK...10 VIIBRYD 10 MG (7)-20 MG (7)-40 MG(16) TABLETS IN A DOSE PACK VIIBRYD 10 MG TABLET...10 VIIBRYD 20 MG TABLET...10 VIIBRYD 40 MG TABLET...10 ZENPEP 10,000 UNIT-32,000 UNIT- 42,000 UNIT CAPSULE,DELAYED... 5 ZENPEP 10,000 UNIT-34,000 UNIT- 55,000 UNIT CAPSULE,DELAYED... 5 ZENPEP 15,000 UNIT-47,000 UNIT- 63,000 UNIT CAPSULE,DELAYED... 5 ZENPEP 15,000 UNIT-51,000 UNIT- 82,000 UNIT CAPSULE,DELAYED... 5 ZENPEP 20,000 UNIT-63,000 UNIT- 84,000 UNIT CAPSULE,DELAYED... 5 ZENPEP 20,000 UNIT-68,000 UNIT- 109,000 UNIT CAPSULE,DELAYED... 5 ZENPEP 25,000 UNIT-79,000 UNIT- 105,000 UNIT CAPSULE,DELAYED... 5 ZENPEP 25,000 UNIT-85,000 UNIT- 136,000 UNIT CAPSULE,DELAYED... 5 ZENPEP 3,000 UNIT-10,000 UNIT- 14,000 UNIT CAPSULE,DELAYED... 5 ZENPEP 3,000 UNIT-10,000 UNIT- 16,000 UNIT CAPSULE,DELAYED... 5 ZENPEP 40,000 UNIT-126,000 UNIT- 168,000 UNIT CAPSULE,DELAYED... 5 ZENPEP 40,000 UNIT-136,000 UNIT- 218,000 UNIT CAPSULE,DELAYED... 5 ZENPEP 5,000 UNIT-17,000 UNIT- 24,000 UNIT CAPSULE,DELAYED... 5 ZENPEP 5,000 UNIT-17,000 UNIT- 27,000 UNIT CAPSULE,DELAYED
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ARISTADA ARISTADA PREFILLED SYRINGE 1064 MG/3.9ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 441 MG/1.6ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 662 MG/2.4ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 882
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PPI DEXILANT CAPSULE DELAYED RELEASE 30 MG ORAL DEXILANT CAPSULE DELAYED RELEASE 60 MG ORAL Claim will pay automatically for Dexilant if enrollee has a paid claim for at least a 1 days supply of lansoprazole,
ARISTADA. Products Affected Step 2: ARISTADA PREFILLED SYRINGE 1064 MG/3.9ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 441 MG/1.
ARISTADA ARISTADA PREFILLED SYRINGE 1064 MG/3.9ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 441 MG/1.6ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 662 MG/2.4ML INTRAMUSCULAR ARISTADA PREFILLED SYRINGE 882
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ARISTADA Aristada Prefilled Syringe 441 MG/1.6ML Intramuscular Aristada Prefilled Syringe 662 MG/2.4ML Intramuscular Aristada Prefilled Syringe 882 MG/3.2ML Intramuscular Claim will pay automatically for
5-ASA. Products Affected DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED RELEASE. Details
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