JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET BYDUREON BCISE 2 MG/0.
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1 ANTI DIABETICS BYDUREON 2 MG SUBCUTANEOUS JANUVIA 25 MG TABLET EXTENDED RELEASE SUSPENSION JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET BYDUREON BCISE 2 MG/0.85 ML JENTADUETO 2.5 MG-1,000 MG TAB SUBCUTANEOUS AUTO-INJECTOR JENTADUETO 2.5 MG-500 MG TAB BYETTA 10 MCG/DOSE(250 MCG/ML)2.4 JENTADUETO 2.5 MG-850 MG TAB ML SUBCUTANEOUS PEN JENTADUETO XR 2.5 MG-1,000 MG TAB BYETTA 5 MCG/DOSE (250 MCG/ML)1.2 ML JENTADUETO XR 5 MG-1,000 MG TAB SUBCUTANEOUS PEN SYNJARDY 12.5 MG-1,000 MG TAB INVOKAMET 150 MG-1,000 MG TAB SYNJARDY 12.5 MG-500 MG TAB INVOKAMET 150 MG-500 MG TABLET SYNJARDY 5 MG-1,000 MG TAB INVOKAMET 50 MG-1,000 MG TABLET SYNJARDY 5 MG-500 MG TAB INVOKAMET 50 MG-500 MG TABLET SYNJARDY XR 10 MG-1,000 MG TABLET, INVOKAMET XR 150 MG-1,000 MG TAB EXTENDED RELEASE INVOKAMET XR 150 MG-500 MG TAB SYNJARDY XR 12.5 MG-1,000 MG INVOKAMET XR 50 MG-1,000 MG TAB TABLET, EXTENDED RELEASE INVOKAMET XR 50 MG-500 MG TAB SYNJARDY XR 25 MG-1,000 MG TABLET, INVOKANA 100 MG TABLET EXTENDED RELEASE INVOKANA 300 MG TABLET SYNJARDY XR 5 MG-1,000 MG TABLET, JANUMET 50 MG-1,000 MG TABLET EXTENDED RELEASE JANUMET 50 MG-500 MG TABLET TRADJENTA 5 MG TABLET JANUMET XR 100 MG-1,000 MG TAB TRULICITY 0.75 MG/0.5 ML JANUMET XR 50 MG-1,000 MG TAB SUBCUTANEOUS PEN INJECTOR JANUMET XR 50 MG-500 MG TAB TRULICITY 1.5 MG/0.5 ML JANUVIA 100 MG TABLET SUBCUTANEOUS PEN INJECTOR Step 1: Trial of one generic formulary metformin or generic metformin combinations or sulfonylurea or thiazolidinedione. Janumet, Janumet XR, Januvia, Jentadueto, Jentadueto XR, Tradjenta, Formulary GLP1 agonist, Invokana, Invokamet, Invokamet XR, Jardiance, Synjardy. 1
2 ANTIDEPRESSANT THERAPY APLENZIN 174 MG TABLET,EXTENDED RELEASE APLENZIN 348 MG TABLET,EXTENDED RELEASE APLENZIN 522 MG TABLET,EXTENDED RELEASE DESVENLAFAXINE ER 100 MG TABLET,EXTENDED RELEASE 24 HR DESVENLAFAXINE ER 50 MG TABLET,EXTENDED RELEASE 24 HR DESVENLAFAXINE FUMARATE ER 100 MG TABLET, EXTENDED RELEASE 24 HR DESVENLAFAXINE FUMARATE ER 50 MG TABLET, EXTENDED RELEASE 24 HR EMSAM 12 MG/24 HR TRANSDERMAL 24 HOUR PATCH EMSAM 6 MG/24 HR TRANSDERMAL 24 HOUR PATCH EMSAM 9 MG/24 HR TRANSDERMAL 24 HOUR PATCH Step 1: Trial of TWO of the following formulary products: bupropion, mirtazapine, generic SSRI, or generic SNRI. Emsam or Aplenzin or Desvenlafaxine ER 50mg, 100mg 2
3 ATYPICAL ANTIPSYCHOTICS 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 SAPHRIS 10 MG SUBLINGUAL TABLET SAPHRIS 2.5 MG SUBLINGUAL TABLET SAPHRIS 5 MG SUBLINGUAL TABLET Step 1: Trial of two oral, single-ingredient, generic formulary atypical antipsychotic agents. Fanapt or Saphris 3
4 FETZIMA 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 Step 1: Generic venlafaxine immediate release tablets or extended release capsules. Fetzima 4
5 FILGRASTIM GRANIX 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE GRANIX 300 MCG/ML SUBCUTANEOUS SOLUTION GRANIX 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE GRANIX 480 MCG/1.6 ML SUBCUTANEOUS SOLUTION NEUPOGEN 300 MCG/0.5 ML INJECTION SYRINGE NEUPOGEN 300 MCG/ML INJECTION SOLUTION NEUPOGEN 480 MCG/0.8 ML INJECTION SYRINGE NEUPOGEN 480 MCG/1.6 ML INJECTION SOLUTION NIVESTYM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE NIVESTYM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE Step 1: Trial of Zarxio. Granix, Neupogen, or Nivestym 5
6 INVEGA TRINZA THERAPY INVEGA TRINZA 273 MG/0.875 ML INTRAMUSCULAR SYRINGE INVEGA TRINZA 410 MG/1.315 ML INTRAMUSCULAR SYRINGE INVEGA TRINZA 546 MG/1.75 ML INTRAMUSCULAR SYRINGE INVEGA TRINZA 819 MG/2.625 ML INTRAMUSCULAR SYRINGE Step 1: Invega Sustenna Invega Trinza 6
7 LEUKOTRIENE MODIFIER ASTHMA THERAPY zileuton er 600 mg tablet,extended release 12hr mphase ZYFLO 600 MG TABLET Step 1: Trial of generic formulary montelukast or generic zafirlukast. Step 2: Zyflo or Zileuton ER 7
8 NEUPRO THERAPY NEUPRO 1 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH NEUPRO 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH NEUPRO 3 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH NEUPRO 4 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH NEUPRO 6 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH NEUPRO 8 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH Step 1: Trial of one generic formulary dopamine agonist agent. Neupro. 8
9 OZEMPIC 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 Step 1: Byetta or Bydureon AND Trulicity, Ozempic. 9
10 QTERN QTERN 10 MG-5 MG TABLET Step 1: Trial of Glyxambi. Qtern. 10
11 RHOFADE RHOFADE 1 % TOPICAL CREAM Step 1: Trial of Finacea and Mirvaso. Rhofade 11
12 RHOPRESSA RHOPRESSA 0.02 % EYE DROPS Step 1: Trial of any two formulary prostaglandin or prostamide analogs or dorzolamide, dorzolamide-timolol, betaxolol, Simbrinza, Alphagan P, Azopt, timolol maleate, brimonidine, carteolol, Cosopt, or levobunolol. Rhopressa. 12
13 RYTARY RYTARY MG-95 MG CAPSULE,EXTENDED RELEASE RYTARY MG-145 MG CAPSULE,EXTENDED RELEASE RYTARY MG-195 MG CAPSULE,EXTENDED RELEASE RYTARY MG-245 MG CAPSULE,EXTENDED RELEASE Step 1: Trial of any generic antiparkinson agent. Rytary 13
14 TOPICAL IMMUNOMODULATOR THERAPY ELIDEL 1 % TOPICAL CREAM pimecrolimus 1 % topical cream ST : Pending CMS Approval 14
15 TRELEGY TRELEGY ELLIPTA 100 MCG-62.5 MCG-25 MCG POWDER FOR INHALATION Step 1: Any two of the following: Advair, Breo, Symbicort, generic fluticasone-salmeterol combination. Trelegy 15
16 TRESIBA FLEXTOUCH THERAPY TRESIBA FLEXTOUCH U-100 INSULIN 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN TRESIBA FLEXTOUCH U-200 INSULIN 200 UNIT/ML (3 ML) SUBCUTANEOUS PEN TRESIBA U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS SOLUTION Step 1: Any one of the following: Lantus, Lantus Solostar, Toujeo, Toujeo Max. Tresiba Flextouch 16
17 UCERIS ORAL THERAPY budesonide dr-er 9 mg tablet,delayed and extended release Step 1: Both mesalamine 1200 mg delayed release and oral generic sulfasalazine. Uceris Tablet 17
18 ULORIC THERAPY ULORIC 40 MG TABLET ULORIC 80 MG TABLET Step 1: Trial of oral generic allopurinol. Uloric 18
19 VYZULTA VYZULTA % EYE DROPS Step 1: Trial of any two formulary prostaglandin or prostamide analogs. Vyzulta. 19
20 INDEX A APLENZIN 174 MG TABLET,EXTENDED RELEASE... 2 APLENZIN 348 MG TABLET,EXTENDED RELEASE... 2 APLENZIN 522 MG TABLET,EXTENDED RELEASE... 2 B budesonide dr-er 9 mg tablet,delayed and extended release BYDUREON 2 MG SUBCUTANEOUS EXTENDED RELEASE SUSPENSION 1 BYDUREON 2 MG/0.65 ML SUBCUTANEOUS PEN INJECTOR... 1 BYDUREON BCISE 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR 1 BYETTA 10 MCG/DOSE(250 MCG/ML)2.4 ML SUBCUTANEOUS PEN INJECTOR... 1 BYETTA 5 MCG/DOSE (250 MCG/ML)1.2 ML SUBCUTANEOUS PEN INJECTOR... 1 D DESVENLAFAXINE ER 100 MG TABLET,EXTENDED RELEASE 24 HR... 2 DESVENLAFAXINE ER 50 MG TABLET,EXTENDED RELEASE 24 HR... 2 DESVENLAFAXINE FUMARATE ER 100 MG TABLET, EXTENDED RELEASE 24 HR... 2 DESVENLAFAXINE FUMARATE ER 50 MG TABLET, EXTENDED RELEASE 24 HR... 2 E ELIDEL 1 % TOPICAL CREAM EMSAM 12 MG/24 HR TRANSDERMAL 24 HOUR PATCH... 2 EMSAM 6 MG/24 HR TRANSDERMAL 24 HOUR PATCH... 2 EMSAM 9 MG/24 HR TRANSDERMAL 24 HOUR PATCH... 2 F FANAPT 1 MG TABLET... 3 FANAPT 10 MG TABLET... 3 FANAPT 12 MG TABLET... 3 FANAPT 1MG(2)-2 MG(2)-4MG(2)-6 MG(2) TABLETS IN A DOSE PACK... 3 FANAPT 2 MG TABLET... 3 FANAPT 4 MG TABLET... 3 FANAPT 6 MG TABLET... 3 FANAPT 8 MG TABLET... 3 FETZIMA 120 MG CAPSULE,EXTENDED RELEASE... 4 FETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED RELEASE,24 HR,DOSE PACK... 4 FETZIMA 20 MG CAPSULE,EXTENDED RELEASE... 4 FETZIMA 40 MG CAPSULE,EXTENDED RELEASE... 4 FETZIMA 80 MG CAPSULE,EXTENDED RELEASE... 4 G GRANIX 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE... 5 GRANIX 300 MCG/ML SUBCUTANEOUS SOLUTION... 5 GRANIX 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE... 5 GRANIX 480 MCG/1.6 ML SUBCUTANEOUS SOLUTION... 5 I INVEGA TRINZA 273 MG/0.875 ML INTRAMUSCULAR SYRINGE... 6 INVEGA TRINZA 410 MG/1.315 ML INTRAMUSCULAR SYRINGE... 6 INVEGA TRINZA 546 MG/1.75 ML INTRAMUSCULAR SYRINGE... 6 INVEGA TRINZA 819 MG/2.625 ML INTRAMUSCULAR SYRINGE... 6 INVOKAMET 150 MG-1,000 MG TABLET... 1 INVOKAMET 150 MG-500 MG TABLET 1 20
21 INVOKAMET 50 MG-1,000 MG TABLET... 1 INVOKAMET 50 MG-500 MG TABLET. 1 INVOKAMET XR 150 MG-1,000 MG TABLET, EXTENDED RELEASE... 1 INVOKAMET XR 150 MG-500 MG TABLET, EXTENDED RELEASE... 1 INVOKAMET XR 50 MG-1,000 MG TABLET, EXTENDED RELEASE... 1 INVOKAMET XR 50 MG-500 MG TABLET, EXTENDED RELEASE... 1 INVOKANA 100 MG TABLET... 1 INVOKANA 300 MG TABLET... 1 J JANUMET 50 MG-1,000 MG TABLET... 1 JANUMET 50 MG-500 MG TABLET... 1 JANUMET XR 100 MG-1,000 MG TABLET,EXTENDED RELEASE... 1 JANUMET XR 50 MG-1,000 MG TABLET,EXTENDED RELEASE... 1 JANUMET XR 50 MG-500 MG TABLET,EXTENDED RELEASE... 1 JANUVIA 100 MG TABLET... 1 JANUVIA 25 MG TABLET... 1 JANUVIA 50 MG TABLET... 1 JARDIANCE 10 MG TABLET... 1 JARDIANCE 25 MG TABLET... 1 JENTADUETO 2.5 MG-1,000 MG TABLET... 1 JENTADUETO 2.5 MG-500 MG TABLET... 1 JENTADUETO 2.5 MG-850 MG TABLET... 1 JENTADUETO XR 2.5 MG-1,000 MG TABLET, EXTENDED RELEASE... 1 JENTADUETO XR 5 MG-1,000 MG TABLET, EXTENDED RELEASE... 1 N NEUPOGEN 300 MCG/0.5 ML INJECTION SYRINGE... 5 NEUPOGEN 300 MCG/ML INJECTION SOLUTION... 5 NEUPOGEN 480 MCG/0.8 ML INJECTION SYRINGE... 5 NEUPOGEN 480 MCG/1.6 ML INJECTION SOLUTION... 5 NEUPRO 1 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH... 8 NEUPRO 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH... 8 NEUPRO 3 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH... 8 NEUPRO 4 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH... 8 NEUPRO 6 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH... 8 NEUPRO 8 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH... 8 NIVESTYM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE... 5 NIVESTYM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE... 5 O OZEMPIC 0.25 MG OR 0.5 MG (2 MG/1.5 ML) SUBCUTANEOUS PEN INJECTOR... 9 OZEMPIC 1 MG/DOSE (2 MG/1.5 ML) SUBCUTANEOUS PEN INJECTOR... 9 P pimecrolimus 1 % topical cream Q QTERN 10 MG-5 MG TABLET R RHOFADE 1 % TOPICAL CREAM RHOPRESSA 0.02 % EYE DROPS RYTARY MG-95 MG CAPSULE,EXTENDED RELEASE RYTARY MG-145 MG CAPSULE,EXTENDED RELEASE RYTARY MG-195 MG CAPSULE,EXTENDED RELEASE RYTARY MG-245 MG CAPSULE,EXTENDED RELEASE S SAPHRIS 10 MG SUBLINGUAL TABLET... 3 SAPHRIS 2.5 MG SUBLINGUAL TABLET... 3 SAPHRIS 5 MG SUBLINGUAL TABLET 3 21
22 SYNJARDY 12.5 MG-1,000 MG TABLET... 1 SYNJARDY 12.5 MG-500 MG TABLET. 1 SYNJARDY 5 MG-1,000 MG TABLET... 1 SYNJARDY 5 MG-500 MG TABLET... 1 SYNJARDY XR 10 MG-1,000 MG TABLET, EXTENDED RELEASE... 1 SYNJARDY XR 12.5 MG-1,000 MG TABLET, EXTENDED RELEASE... 1 SYNJARDY XR 25 MG-1,000 MG TABLET, EXTENDED RELEASE... 1 SYNJARDY XR 5 MG-1,000 MG TABLET, EXTENDED RELEASE... 1 T TRADJENTA 5 MG TABLET... 1 TRELEGY ELLIPTA 100 MCG-62.5 MCG-25 MCG POWDER FOR INHALATION TRESIBA FLEXTOUCH U-100 INSULIN 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN TRESIBA FLEXTOUCH U-200 INSULIN 200 UNIT/ML (3 ML) SUBCUTANEOUS PEN TRESIBA U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS SOLUTION TRULICITY 0.75 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR... 1 TRULICITY 1.5 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR... 1 U ULORIC 40 MG TABLET ULORIC 80 MG TABLET V VYZULTA % EYE DROPS Z zileuton er 600 mg tablet,extended release 12hr mphase... 7 ZYFLO 600 MG TABLET
Y0133_StepTherapyCriteria _C 10/18/18 Y0133_StepTherapyCriteria _C es 10/18/18
Step Therapy Grid Certain cost-effective drugs must be used before other more expensive drugs are covered. For example, certain brand-name medications will only be covered if a generic alternative has
ALBUTEROL - 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
ALBUTEROL - 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
ALBUTEROL - 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
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
ALBUTEROL - 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"}
ADHD STIMULANTS - SCORE
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ADHD 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
DPP4 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
DPP4 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
ALBUTEROL - SCORE. Products Affected. Details. Step Therapy Criteria Golden State Medicare Health Plan, Golden (HMO) Last Updated: 09/01/2018
Step Therapy Golden State Medicare Health Plan, Golden (HMO) Last Updated: 09/01/2018 ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir 1 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG
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
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
Step Therapy Requirements. Effective: 11/01/2018
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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
ANTICONVULSANTS. 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
Step Therapy Requirements. Effective: 05/01/2018
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ANTICONVULSANTS. 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
Santa 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
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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.
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
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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.
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ANTICONVULSANTS APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL 200 MG BANZEL 40 MG/ML ORAL SUSPENSION BANZEL 400 MG FYCOMPA 0.5 MG/ML ORAL SUSPENSION FYCOMPA 10 MG FYCOMPA 12 MG FYCOMPA
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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
Step 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
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017
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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, 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
Step Therapy Criteria
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5-ASA. Products Affected DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED RELEASE. Details
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5-ASA. Products Affected. Details. Dipentum 250 mg capsule. Lialda 1.2 gram tablet,delayed release
Updated 11/1/17 5-ASA Dipentum 250 mg capsule Lialda 1.2 gram tablet,delayed release You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda
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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
Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Value Rx (HMO) and Stride SM Value Rx Plus (HMO) Step Therapy Requirements
Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Value Rx (HMO) and Stride SM Value Rx Plus (HMO) Step Therapy Requirements Effective 7/1/2018 Updated 6/2018 BRAND NAME ANTIDEPRESSANTS APLENZIN
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 04/01/2019
VNSNY CHOICE FIDA Complete Step Therapy Requirements Effective: 04/01/2019 Updated 03/2019 AMANTADINE ER OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED
Step Therapy Requirements
An Independent Licensee of the Blue Cross and Blue Shield Association Step Therapy Requirements Effective: 05/01/2018 Updated 4/2018 H0302_2_2014 CMS Accepted 05/05/2014 1 BETA-BLOCKERS BYSTOLIC 10 MG
ANTIEMETICS STEP. Step Therapy Requirements Effective April 1, 2019
Step Therapy Requirements Effective April 1, 2019 ANTIEMETICS STEP Sancuso 3.1 mg/24 hour transdermal patch Zuplenz 4 mg oral soluble film Zuplenz 8 mg oral soluble film COVERAGE OF CERTAIN BRAND NAME
ACYCLOVIR 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
ACYCLOVIR 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
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.
2018 Step Therapy Criteria (List of Step Therapy Criteria)
Criteria Last Updated: October 05, 2017 Effective Date: January 1, 2018 2018 Step Therapy Criteria (List of Step Therapy Criteria) PLEASE READ CAREFULLY: IEHP DUALCHOICE CAL MEDICONNECT PLAN (MEDICARE-
Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Value Rx (HMO), Stride SM Value Rx Plus (HMO) and Stride SM Gain Rx (HMO)
Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Value Rx (HMO), Stride SM Value Rx Plus (HMO) and Stride SM Gain Rx (HMO) Step Therapy Requirements Effective 4/1/2019 Updated 3/2019 BRAND
ACYCLOVIR 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
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
ANTICONVULSANTS. 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
ANTICONVULSANT THERAPY
Network Health Insurance Corporation NetworkCares Step Therapy Last Updated: 7/2017 ANTICONVULSANT THERAPY Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet Aptiom 800 mg tablet Banzel 200
ALOGLIPTIN STEP. Step Therapy Requirements Effective April 1, 2018
Step Therapy Requirements Effective April 1, 2018 ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone
ALOGLIPTIN STEP. Step Therapy Requirements Effective June 1, 2018
Step Therapy Requirements Effective June 1, 2018 ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone
ACYCLOVIR 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
Mercy Care ALBENDAZOLE. Products Affected. ALBENZA TABLET 200 MG ORAL Details. Criteria. Refer to PA Guideline for approval criteria
ALBENDAZOLE Mercy Care ALBENZA TABLET 200 MG ORAL Refer to PA Guideline for approval criteria 1 BRIMONIDINE-TIMOLOL COMBIGAN SOLUTION 0.2-0.5 % OPHTHALMIC Requires use of separate ingredients for at least
TEST ANTICONVULSANT THERAPY. Products Affected. Step 2: Network Health Insurance Corporation NetworkCares Step Therapy Criteria Last Updated 11/2018
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
ANTIDEPRESSANTS. 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
2018 Step Therapy Criteria (List of Step Therapy Criteria)
Step Therapy Criteria Last Updated: March 20, 2018 Effective Date: April 1, 2018 2018 Step Therapy Criteria (List of Step Therapy Criteria) PLEASE READ CAREFULLY: IEHP DUALCHOICE CAL MEDICONNECT PLAN (MEDICARE-MEDICAID
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.
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
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
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
2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements
2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for
2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements
2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for
Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
Medications that require Step Therapy (ST) require trial and failure of preferred formulary agents prior to their authorization. If the prerequisite medications have been filled within the specified time
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
2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements
2018 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for
ABILIFY 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
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
Quarterly pharmacy formulary change notice
Quarterly pharmacy formulary change notice Provider update Summary: Effective August 1, 2018, the preferred formulary changes detailed in the table below will apply to District of Columbia Healthy Families
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.
ALPHA BLOCKERS. Products Affected Step 1: Details. Step 2: Rapaflo 4 mg capsule Rapaflo 8 mg capsule
CHRISTUS Health Plan Generations (HMO) CHRISTUS Health Plan Generations Plus (HMO) 2018 Premier Performance Standard Step Therapy PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS
ANTIDEPRESSANTS. Details. Step Therapy 2017 Last Updated: 5/23/2017
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 FETZIMA CAPSULE
2018 Step Therapy (ST) Criteria
2018 Step Therapy (ST) 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 drug that
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017
Effective: 01/01/2017 Updated 11/2016 ANTI-INFLAMMATORY AGENTS - GI DIPENTUM PRIOR CLAIM FOR BALSALAZIDE OR APRISO WITHIN THE PAST 120 DAYS. ANTICONVULSANTS APTIOM BANZEL FYCOMPA GABITRIL OXTELLAR XR POTIGA
BYSTOLIC. Products Affected Step 2: BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET. Details BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET
BYSTOLIC BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET authorization for a Step 2 drug may be given. Step 1 Drug(s): generic beta-blockers and/or combinations,
ALOGLIPTIN STEP. Details. Step Therapy Requirements Effective November 1, 2017
ALOGLIPTIN STEP alogliptin 12.5 mg tablet alogliptin 12.5 mg-metformin 1,000 mg tablet alogliptin 12.5 mg-metformin 500 mg tablet alogliptin 12.5 mg-pioglitazone 15 mg tablet alogliptin 12.5 mg-pioglitazone
Step 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,
2017 Step Therapy (ST) Criteria
2017 Step Therapy (ST) 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 drug that
Contents ALPHA BLOCKERS... 3 COLCRYS-PST... 4 DPP-4 INHIBITORS-PST... 5 HIGH RISK MEDICATIONS - SEDATIVE HYPNOTICS... 6
CHRISTUS Health Plan Generations (HMO) 2017 Step Therapy Criteria H1189_PC57 Accepted 11/17/2016 1 Contents ALPHA BLOCKERS... 3 COLCRYS-PST... 4 DPP-4 INHIBITORS-PST... 5 HIGH RISK MEDICATIONS - SEDATIVE
5-ASA. Products Affected Dipentum 250 mg capsule. Details. Lialda 1.2 gram tablet,delayed release
5-ASA Dipentum 250 mg capsule Lialda 1.2 gram tablet,delayed release You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda or Dipentum.
Formulary Medical Necessity Program
BENEFIT APPLICATION Formulary Medical Necessity Program DRUG POLICY Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations
Quarterly pharmacy formulary change notice
Provider update Quarterly pharmacy formulary change notice Summary: The formulary changes listed in the table below were reviewed and approved at our first-quarter 2018, Pharmacy and Therapeutics Committee