ALLERGIC CONJUNCTIVITIS AGENTS
|
|
|
- Mary Norris
- 6 years ago
- Views:
Transcription
1 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: Last Updated: 04/2018 Effective Date: ALLERGIC CONJUNCTIVITIS AGENTS epinastine 0.05 % eye drops olopatadine 0.1 % eye drops Step 1: First line therapy should be azelastine 0.05% ophthalmic drops Second line therapy should be generic epinastine ophthalmic drops or olopatadine ophthalmic drops 1
2 ANTICONVULSANT STEP THERAPY APTIOM 200 MG TABLET APTIOM 400 MG TABLET APTIOM 600 MG TABLET APTIOM 800 MG TABLET FYCOMPA 0.5 MG/ML ORAL SUSPENSION FYCOMPA 10 MG TABLET FYCOMPA 12 MG TABLET FYCOMPA 2 MG (7)-4 MG (7) TABLETS IN A DOSE PACK FYCOMPA 2 MG TABLET FYCOMPA 4 MG TABLET FYCOMPA 6 MG TABLET FYCOMPA 8 MG TABLET SPRITAM 1,000 MG TABLET FOR ORAL SUSPENSION SPRITAM 250 MG TABLET FOR ORAL SUSPENSION SPRITAM 500 MG TABLET FOR ORAL SUSPENSION SPRITAM 750 MG TABLET FOR ORAL SUSPENSION VIMPAT 10 MG/ML ORAL SOLUTION VIMPAT 100 MG TABLET VIMPAT 150 MG TABLET VIMPAT 200 MG TABLET VIMPAT 50 MG TABLET Step 1: First line therapy should be trial of two of the following: 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, Gabitril, Phenytek or tiagabine. Once two of the medications listed in Step 1 have been tried, patients can receive therapy with Aptiom, Spritam, Fycompa, or Vimpat. 2
3 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: Last Updated: 04/2018 Effective Date: 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 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 1: First line therapy should a documented trial of two of the following: 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. 3
4 ANTIPSYCHOTIC STEP THERAPY 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 LATUDA 120 MG TABLET LATUDA 20 MG TABLET LATUDA 40 MG TABLET LATUDA 60 MG TABLET LATUDA 80 MG TABLET Step 1: First line therapy should be with two of the following medications- risperidone, olanzapine, quetiapine, ziprasidone or aripiprazole. Once two of the medications listed in step 1 have been tried, patients can receive therapy with Latuda or Fanapt. 4
5 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: Last Updated: 04/2018 Effective Date: AZOPT STEP THERAPY AZOPT 1 % EYE DROPS,SUSPENSION Step 1: First line therapy should be dorzolamide or dorzolamide/timolol. Once dorzolamide or dorzolamide/timolol has been tried, the patient can receive therapy with Azopt. 5
6 COMBIVENT STEP THERAPY COMBIVENT RESPIMAT 20 MCG- 100 MCG/ACTUATION SOLUTION FOR INHALATION Step 1: First line therapy should be Anoro Ellipta. Once Anoro Ellipta has been tried, patients can receive therapy with Combivent Respimat. 6
7 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: Last Updated: 04/2018 Effective Date: EPIPEN STEP THERAPY EPIPEN 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR EPIPEN 2-PAK 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR EPIPEN JR 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR EPIPEN JR 2-PAK 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR Step 1: First line therapy should be epinephrine auto-injector. Once epinephrine auto-injector has been tried, the patient can receive therapy with Epipen. 7
8 HYPOGLYCEMICS STEP THERAPY acarbose 100 mg tablet acarbose 25 mg tablet acarbose 50 mg tablet AVANDIA 2 MG TABLET AVANDIA 4 MG TABLET 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 MG TABLET INVOKAMET XR 150 MG-1,000 MG TABLET, EXTENDED RELEASE INVOKAMET XR 150 MG-500 MG TABLET, EXTENDED RELEASE INVOKAMET XR 50 MG-1,000 MG TABLET, EXTENDED RELEASE INVOKAMET XR 50 MG-500 MG TABLET, EXTENDED RELEASE INVOKANA 100 MG TABLET INVOKANA 300 MG TABLET JANUMET 50 MG-1,000 MG TABLET JANUMET 50 MG-500 MG TABLET JANUMET XR 100 MG-1,000 MG TABLET,EXTENDED RELEASE JANUMET XR 50 MG-1,000 MG TABLET,EXTENDED RELEASE JANUMET XR 50 MG-500 MG TABLET,EXTENDED RELEASE JANUVIA 100 MG TABLET JANUVIA 25 MG TABLET JANUVIA 50 MG TABLET JARDIANCE 10 MG TABLET JARDIANCE 25 MG TABLET JENTADUETO 2.5 MG-1,000 MG TABLET JENTADUETO 2.5 MG-500 MG TABLET JENTADUETO 2.5 MG-850 MG TABLET JENTADUETO XR 2.5 MG-1,000 MG TABLET, EXTENDED RELEASE JENTADUETO XR 5 MG-1,000 MG TABLET, EXTENDED RELEASE nateglinide 120 mg tablet nateglinide 60 mg tablet pioglitazone 15 mg tablet pioglitazone 15 mg-metformin 500 mg tablet pioglitazone 15 mg-metformin 850 mg tablet pioglitazone 30 mg tablet pioglitazone 45 mg tablet repaglinide 0.5 mg tablet repaglinide 1 mg tablet repaglinide 2 mg tablet SYNJARDY 12.5 MG-1,000 MG TABLET SYNJARDY 12.5 MG-500 MG TABLET SYNJARDY 5 MG-1,000 MG TABLET SYNJARDY 5 MG-500 MG TABLET TRADJENTA 5 MG TABLET Step 1: First line therapy should be a formulary sulfonylurea, metformin, or formulary insulin (if appropriate). Once one of these agents has been tried, patients can receive therapy with other 8
9 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: Last Updated: 04/2018 Effective Date: formulary hypoglycemics such as Avandia, Acarbose, Januvia, Janumet, Janumet XR, repaglinide, nateglinide, pioglitazone, pioglitazone/metformin, Tradjenta, Jentadueto, Jentadueto XR, Invokana, Invokamet, Invokamet XR, Jardiance, Synjardy, or Glyxambi. 9
10 KRISTALOSE STEP THERAPY KRISTALOSE 10 GRAM ORAL PACKET KRISTALOSE 20 GRAM ORAL PACKET Step 1: First line therapy should be Constulose, lactulose, and/or polyethylene glycol. Once Constulose, lactulose, and/or polyethylene glycol has been tried, the patient can receive therapy with Kristalose Packet. 10
11 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: Last Updated: 04/2018 Effective Date: NAMENDA XR STEP THERAPY memantine 14 mg capsule sprinkle,extended release 24hr memantine 21 mg capsule sprinkle,extended release 24hr memantine 28 mg capsule sprinkle,extended release 24hr memantine 7 mg capsule sprinkle,extended release 24hr NAMENDA XR 14 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMENDA XR 21 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMENDA XR 28 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMENDA XR 7 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMENDA XR 7 MG-14 MG-21 MG- 28 MG CAPSULE,SPRINKLE,ER 24HR,DOSE PACK Step 1: First line therapy should be memantine IR tablet. Once memantine IR tablet has been tried, patients can receive therapy with Namenda XR or memantine ER 11
12 PROTON PUMP INHIBITORS STEP THERAPY esomeprazole magnesium 20 mg capsule,delayed release esomeprazole magnesium 40 mg capsule,delayed release Step 1: First line therapy should be trial of two of the following: omeprazole, pantoprazole or lansoprazole. Second line should be esomeprazole magnesium. 12
13 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: Last Updated: 04/2018 Effective Date: RANEXA STEP THERAPY RANEXA 1,000 MG TABLET,EXTENDED RELEASE RANEXA 500 MG TABLET,EXTENDED RELEASE Step 1: First line therapy should be with a beta blocker or a calcium channel blocker. Once a beta blocker or a calcium channel blocker has been tried, patient may receive therapy with Ranexa 13
14 TOPICAL IMMUNOMODULATORS STEP THERAPY ELIDEL 1 % TOPICAL CREAM tacrolimus 0.03 % topical ointment tacrolimus 0.1 % topical ointment Step 1: First line therapy should be trial of 2 formulary topical corticosteroids. Once two of these agents have been tried, patients can receive therapy with Elidel or generic topical Tacrolimus. 14
15 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: Last Updated: 04/2018 Effective Date: TOPICAL TESTOSTERONE STEP THERAPY ANDROGEL 1.62 % (20.25 MG/1.25 GRAM) TRANSDERMAL GEL PACKET ANDROGEL 1.62 % (40.5 MG/2.5 GRAM) TRANSDERMAL GEL PACKET Step 1: Patient must try a formulary generic topical testosterone product. Once a formulary generic topical testosterone product has been tried, patients can receive therapy with AndroGel. 15
16 ULORIC STEP THERAPY ULORIC 40 MG TABLET ULORIC 80 MG TABLET Step 1: First line therapy should be allopurinol tablet. Once allopurinol tablet has been tried, patients can receive therapy with Uloric. 16
17 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: Last Updated: 04/2018 Effective Date: URINARY INCONTINENCE AGENTS STEP THERAPY darifenacin er 15 mg tablet,extended release 24 hr darifenacin er 7.5 mg tablet,extended release 24 hr tolterodine 1 mg tablet Step 3: MYRBETRIQ 25 MG TABLET,EXTENDED RELEASE tolterodine 2 mg tablet tolterodine er 2 mg capsule,extended release 24 hr tolterodine er 4 mg capsule,extended release 24 hr MYRBETRIQ 50 MG TABLET,EXTENDED RELEASE Step 1: First line therapy should be Oxybutynin or Oxybutynin ER. Step 2: Second line therapy should be Tolterodine, Tolterodine ER or darifenicin ER. Step 3: Once Oxybutynin or Oxybutynin ER AND Tolterodine, Tolterodine ER or darifenacin ER have been tried, patients can receive therapy with Myrbetriq. 17
18 VRAYLAR STEP THERAPY VRAYLAR 1.5 MG (1)-3 MG (6) CAPSULES IN A DOSE PACK VRAYLAR 1.5 MG CAPSULE VRAYLAR 3 MG CAPSULE VRAYLAR 4.5 MG CAPSULE VRAYLAR 6 MG CAPSULE Step 1: First line therapy should be with two of the following medicationsrisperidone, olanzapine, olanzapine ODT, ziprasidone, quetiapine or aripiprazole. Once two of the medications listed in step 1 have been tried, patients can receive therapy with Vraylar 18
19 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: Last Updated: 04/2018 Effective Date: ZAFIRLUKAST STEP THERAPY zafirlukast 10 mg tablet zafirlukast 20 mg tablet Step 1: First line therapy should be with montelukast. Step2: Once montelukast has been tried, patient may receive therapy with zafirlukast 19
20 ZIRGAN STEP THERAPY ZIRGAN 0.15 % EYE GEL Step 1: First line therapy should be generic trifluridine ophthalmic Step 2: Once generic trifluridine ophthalmic has been tried, patients can receive therapy with Zirgan. 20
21 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: Last Updated: 04/2018 Effective Date: ZORVOLEX STEP THERAPY ZORVOLEX 18 MG CAPSULE ZORVOLEX 35 MG CAPSULE Step 1: First line therapy must be trial of 1 formulary non-selective NSAID. Once one of these agents have been tried patients can receive therapy with Zorvolex. 21
22 Index A acarbose 100 mg tablet... 8 acarbose 25 mg tablet... 8 acarbose 50 mg tablet... 8 ANDROGEL 1.62 % (20.25 MG/1.25 GRAM) TRANSDERMAL GEL PACKET ANDROGEL 1.62 % (40.5 MG/2.5 GRAM) TRANSDERMAL GEL PACKET APTIOM 200 MG TABLET... 2 APTIOM 400 MG TABLET... 2 APTIOM 600 MG TABLET... 2 APTIOM 800 MG TABLET... 2 AVANDIA 2 MG TABLET... 8 AVANDIA 4 MG TABLET... 8 AZOPT 1 % EYE DROPS,SUSPENSION 5 C COMBIVENT RESPIMAT 20 MCG-100 MCG/ACTUATION SOLUTION FOR INHALATION... 6 D darifenacin er 15 mg tablet,extended release 24 hr darifenacin er 7.5 mg tablet,extended release 24 hr E ELIDEL 1 % TOPICAL CREAM epinastine 0.05 % eye drops... 1 EPIPEN 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR... 7 EPIPEN 2-PAK 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR... 7 EPIPEN JR 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR... 7 EPIPEN JR 2-PAK 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR... 7 esomeprazole magnesium 20 mg capsule,delayed release esomeprazole magnesium 40 mg capsule,delayed release F 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 FETZIMA 120 MG CAPSULE,EXTENDED RELEASE... 3 FETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED RELEASE,24 HR,DOSE PACK... 3 FETZIMA 20 MG CAPSULE,EXTENDED RELEASE... 3 FETZIMA 40 MG CAPSULE,EXTENDED RELEASE... 3 FETZIMA 80 MG CAPSULE,EXTENDED RELEASE... 3 FYCOMPA 0.5 MG/ML ORAL SUSPENSION... 2 FYCOMPA 10 MG TABLET... 2 FYCOMPA 12 MG TABLET... 2 FYCOMPA 2 MG (7)-4 MG (7) TABLETS IN A DOSE PACK... 2 FYCOMPA 2 MG TABLET... 2 FYCOMPA 4 MG TABLET... 2 FYCOMPA 6 MG TABLET... 2 FYCOMPA 8 MG TABLET... 2 G GLYXAMBI 10 MG-5 MG TABLET... 8 GLYXAMBI 25 MG-5 MG TABLET... 8 I INVOKAMET 150 MG-1,000 MG TABLET... 8 INVOKAMET 150 MG-500 MG TABLET 8 INVOKAMET 50 MG-1,000 MG TABLET... 8 INVOKAMET 50 MG-500 MG TABLET. 8 INVOKAMET XR 150 MG-1,000 MG TABLET, EXTENDED RELEASE... 8 INVOKAMET XR 150 MG-500 MG TABLET, EXTENDED RELEASE... 8 INVOKAMET XR 50 MG-1,000 MG TABLET, EXTENDED RELEASE
23 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: Last Updated: 04/2018 Effective Date: INVOKAMET XR 50 MG-500 MG TABLET, EXTENDED RELEASE... 8 INVOKANA 100 MG TABLET... 8 INVOKANA 300 MG TABLET... 8 J JANUMET 50 MG-1,000 MG TABLET... 8 JANUMET 50 MG-500 MG TABLET... 8 JANUMET XR 100 MG-1,000 MG TABLET,EXTENDED RELEASE... 8 JANUMET XR 50 MG-1,000 MG TABLET,EXTENDED RELEASE... 8 JANUMET XR 50 MG-500 MG TABLET,EXTENDED RELEASE... 8 JANUVIA 100 MG TABLET... 8 JANUVIA 25 MG TABLET... 8 JANUVIA 50 MG TABLET... 8 JARDIANCE 10 MG TABLET... 8 JARDIANCE 25 MG TABLET... 8 JENTADUETO 2.5 MG-1,000 MG TABLET... 8 JENTADUETO 2.5 MG-500 MG TABLET... 8 JENTADUETO 2.5 MG-850 MG TABLET... 8 JENTADUETO XR 2.5 MG-1,000 MG TABLET, EXTENDED RELEASE... 8 JENTADUETO XR 5 MG-1,000 MG TABLET, EXTENDED RELEASE... 8 K KRISTALOSE 10 GRAM ORAL PACKET KRISTALOSE 20 GRAM ORAL PACKET L LATUDA 120 MG TABLET... 4 LATUDA 20 MG TABLET... 4 LATUDA 40 MG TABLET... 4 LATUDA 60 MG TABLET... 4 LATUDA 80 MG TABLET... 4 M memantine 14 mg capsule sprinkle,extended release 24hr memantine 21 mg capsule sprinkle,extended release 24hr memantine 28 mg capsule sprinkle,extended release 24hr memantine 7 mg capsule sprinkle,extended release 24hr MYRBETRIQ 25 MG TABLET,EXTENDED RELEASE MYRBETRIQ 50 MG TABLET,EXTENDED RELEASE N NAMENDA XR 14 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMENDA XR 21 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMENDA XR 28 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMENDA XR 7 MG CAPSULE SPRINKLE,EXTENDED RELEASE NAMENDA XR 7 MG-14 MG-21 MG-28 MG CAPSULE,SPRINKLE,ER 24HR,DOSE PACK nateglinide 120 mg tablet... 8 nateglinide 60 mg tablet... 8 O olopatadine 0.1 % eye drops... 1 P pioglitazone 15 mg tablet... 8 pioglitazone 15 mg-metformin 500 mg tablet... 8 pioglitazone 15 mg-metformin 850 mg tablet... 8 pioglitazone 30 mg tablet... 8 pioglitazone 45 mg tablet... 8 R RANEXA 1,000 MG TABLET,EXTENDED RELEASE RANEXA 500 MG TABLET,EXTENDED RELEASE repaglinide 0.5 mg tablet... 8 repaglinide 1 mg tablet... 8 repaglinide 2 mg tablet
24 S SPRITAM 1,000 MG TABLET FOR ORAL SUSPENSION... 2 SPRITAM 250 MG TABLET FOR ORAL SUSPENSION... 2 SPRITAM 500 MG TABLET FOR ORAL SUSPENSION... 2 SPRITAM 750 MG TABLET FOR ORAL SUSPENSION... 2 SYNJARDY 12.5 MG-1,000 MG TABLET... 8 SYNJARDY 12.5 MG-500 MG TABLET. 8 SYNJARDY 5 MG-1,000 MG TABLET... 8 SYNJARDY 5 MG-500 MG TABLET... 8 T tacrolimus 0.03 % topical ointment tacrolimus 0.1 % topical ointment tolterodine 1 mg tablet tolterodine 2 mg tablet tolterodine er 2 mg capsule,extended release 24 hr tolterodine er 4 mg capsule,extended release 24 hr TRADJENTA 5 MG TABLET... 8 TRINTELLIX 10 MG TABLET... 3 TRINTELLIX 20 MG TABLET... 3 TRINTELLIX 5 MG TABLET... 3 U ULORIC 40 MG TABLET ULORIC 80 MG TABLET V VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK... 3 VIIBRYD 10 MG TABLET... 3 VIIBRYD 20 MG TABLET... 3 VIIBRYD 40 MG TABLET... 3 VIMPAT 10 MG/ML ORAL SOLUTION. 2 VIMPAT 100 MG TABLET... 2 VIMPAT 150 MG TABLET... 2 VIMPAT 200 MG TABLET... 2 VIMPAT 50 MG TABLET... 2 VRAYLAR 1.5 MG (1)-3 MG (6) CAPSULES IN A DOSE PACK VRAYLAR 1.5 MG CAPSULE VRAYLAR 3 MG CAPSULE VRAYLAR 4.5 MG CAPSULE VRAYLAR 6 MG CAPSULE Z zafirlukast 10 mg tablet zafirlukast 20 mg tablet ZIRGAN 0.15 % EYE GEL ZORVOLEX 18 MG CAPSULE ZORVOLEX 35 MG CAPSULE
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.
ANTICONVULSANT STEP THERAPY
2019 First Choice VIP Care Plus Formulary Document: 2019 Step Therapy Formulary ID: 19391 Last Updated: 2/2019 Effective Date: 03-01-2019 ANTICONVULSANT STEP THERAPY APTIOM 200 MG APTIOM 400 MG APTIOM
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
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
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
Step Therapy Requirements Denver Health Medicare Choice (HMO SNP)/Medicare Select (HMO) Effective: 09/01/2017 Updated 08/2017 ANTICONVULSANTS Aptiom 200 mg tablet Aptiom 400 mg tablet Aptiom 600 mg tablet
VNSNY CHOICE FIDA Complete Step Therapy Requirements. Effective: 01/01/2017
VNSNY CHOICE FIDA Complete Step Therapy Requirements Effective: 01/01/2017 Updated 12/23/2016 ANTICONVULSANTS Aptiom 200 mg tablet Potiga 200 mg tablet Aptiom 400 mg tablet Potiga 300 mg tablet Aptiom
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
ANTICONVULSANTS. Details
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
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
FirstCarolinaCare Insurance Company. Step Therapy Requirements
FirstCarolinaCare Insurance Company Step Therapy Requirements Effective: 12/01/2018 ANTICONVULSANTS APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL 200 MG BANZEL 40 MG/ML ORAL SUSPENSION
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
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.
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
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
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
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
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
Simply Step Therapy Document September 2018 Y0114_18_33074_I_009
2018 2018 Simply Step Therapy Document September 2018 Aptiom APTIOM 200 MG TABLET APTIOM 400 MG TABLET Y0114_18_33074_I_009 APTIOM 600 MG TABLET APTIOM 800 MG TABLET Criteria If the patient has tried a
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
2019 Simply Step Therapy Document
Aggrenox 2019 Simply 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.
2019 PDP Basic Step Therapy Document
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.
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
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.
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,
Step Therapy Medications
Step Therapy Medications Step Therapy Group APTIOM Step-2: APTIOM 200 MG TABLET or APTIOM 400 MG TABLET or APTIOM 600 MG TABLET or APTIOM 800 MG TABLET Step 1 Drug(s): Oxcarbazepine immediate-release,
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
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
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.
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
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
2018 PDP Premier Step Therapy Document September 2018 Y0114_18_33144_I_009
2018 PDP Premier Step Therapy Document September 2018 Aggrenox Y0114_18_33144_I_009 aspirin 25 mg-dipyridamole 200 mg capsule,ext.release 12 hr multiphase drug may be given. Step 1 Drug(s): clopidigrel.
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
Medicare Part D Drugs that Require Step Therapy Effective 12/01/2017
Medicare Part D Drugs that Require Step Therapy Effective 12/01/2017 Providers may call the Pharmacy Help Desk at 800-641-8921 for more information or questions about criteria. The formulary may change
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
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
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
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,
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
ADHD STIMULANTS - SCORE
ADHD STIMULANTS - SCORE Step Therapy Strattera Patient needs to have a paid claim for two generic formulary ADHD stimulant medications. Formulary ID# 00017034 Last Updated: 08/01/2017 1 ALPHA GLUCOSIDASE
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
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
2018 Step Therapy FID 18088
2018 Step Therapy FID 18088 Step Therapy ANTIDEPRESSANTS, SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS LEON 2018 Desvenlafaxine Er Fetzima Fetzima Titration Pack Khedezla Paxil SUSP Pristiq Trintellix
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
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,
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
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
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
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"}
2019 STEP THERAPY CRITERIA UCare Individual & Family Plans UCare Individual & Family Plans with Fairview
2019 STEP THERAPY CRITERIA UCare Individual & Family Plans UCare Individual & Family Plans with Fairview In some cases, UCare requires you to first try certain drugs to treat your medical condition before
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
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:
5-ASA. Products Affected DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED RELEASE. Details
5-ASA DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED You are required to have previous therapy with balsalazide, Delzicol, Apriso, or Asacol HD before we will cover Lialda or Dipentum. 1 ANTIEMETICS
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
ALPHA BLOCKERS. Products Affected. Details. Step 2: RAPAFLO 4 MG CAPSULE. Step 1: alfuzosin extended release tablet doxazosin tablet
ALPHA BLOCKERS RAPAFLO 4 MG CAPSULE RAPAFLO 8 MG CAPSULE drug may be given. alfuzosin extended release tablet doxazosin tablet tamsulosin capsule terazosin capsule 1 ANTIDEPRESSANTS - SNRI FETZIMA 10 MG
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.
2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+)
2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+) In some cases, UCare requires you to first try certain drugs to
**CRITERIA UNDER CMS REVIEW**
**CRITERIA UNDER CMS REVIEW** ANTICONVULSANTS APTIOM TABLET 200 MG APTIOM TABLET 400 MG APTIOM TABLET 600 MG APTIOM TABLET 800 MG BANZEL SUSPENSION 40 MG/ML BANZEL TABLET 200 MG BANZEL TABLET 400 MG BRIVIACT
ALZHEIMER'S DRUGS. Details. Step 2: Exelon Patch 13.3 mg/24 hour transdermal Exelon Patch 4.6 mg/24 hr transdermal
ALZHEIMER'S DRUGS Products Affected Step 1: donepezil 10 mg disintegrating tablet donepezil 10 mg tablet donepezil 23 mg tablet donepezil 5 mg disintegrating tablet donepezil 5 mg tablet galantamine 12
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
STEP THERAPY CRITERIA
STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered under your medical or prescription
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
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*
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-
HEALTH SHARE/PROVIDENCE (OHP)
HEALTH SHARE/PROVIDENCE (OHP) STEP THERAPY This is a complete list of drugs that have written coverage determination policies. Drugs on this list do not indicate that this particular drug will be covered
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
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
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
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
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
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.