BYSTOLIC. Products Affected Step 2: BYSTOLIC 10 MG TABLET BYSTOLIC 2.5 MG TABLET. Details BYSTOLIC 20 MG TABLET BYSTOLIC 5 MG TABLET
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- Jasmin Hudson
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1 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, Sorine. Step 2 Drug(s): Bystolic. 1
2 CNS STIMULANTS DAYTRANA 10 MG/9 HR DAILY PATCH DAYTRANA 15 MG/9 HR DAILY PATCH DAYTRANA 20 MG/9 HR DAILY PATCH DAYTRANA 30 MG/9 HR DAILY PATCH STRATTERA 10 MG CAPSULE STRATTERA 100 MG CAPSULE STRATTERA 18 MG CAPSULE STRATTERA 25 MG CAPSULE STRATTERA 40 MG CAPSULE STRATTERA 60 MG CAPSULE STRATTERA 80 MG CAPSULE authorization for a Step 2 drug may be given. Step 1 Drug(s): generic from either the amphetamines or ADHD class. Step 2 Drug(s): Daytrana, Strattera. 2
3 DIFICID DIFICID 200 MG TABLET authorization for a Step 2 drug may be given. Step 1 Drug(s): metronidazole, vancomycin. Step 2 Drug(s): Dificid 3
4 DPP-4 ALOGLIPTIN 12.5 MG TABLET ALOGLIPTIN 12.5 MG-METFORMIN 1,000 MG TABLET ALOGLIPTIN 12.5 MG-METFORMIN 500 MG TABLET ALOGLIPTIN 25 MG TABLET ALOGLIPTIN 6.25 MG TABLET KAZANO 12.5 MG-1,000 MG TABLET KAZANO 12.5 MG-500 MG TABLET KOMBIGLYZE XR 2.5 MG-1,000 MG TABLET,EXTENDED RELEASE KOMBIGLYZE XR 5 MG-1,000 MG TABLET,EXTENDED RELEASE KOMBIGLYZE XR 5 MG-500 MG TABLET,EXTENDED RELEASE NESINA 12.5 MG TABLET NESINA 25 MG TABLET NESINA 6.25 MG TABLET ONGLYZA 2.5 MG TABLET ONGLYZA 5 MG TABLET authorization for a Step 2 drug may be given. Step 1 Drug(s): Januvia, Janumet, Janumet XR, Tradjenta, Jentadueto, Jentadueto XR. Step 2 Drug(s): Onglyza, Kombiglyze, Nesina, Kazano, Alogliptin, and Alogliptin/metformin. 4
5 MIGRAINE THERAPY MIGERGOT 2 MG-100 MG RECTAL SUPPOSITORY RELPAX 20 MG TABLET RELPAX 40 MG TABLET ZOMIG 2.5 MG NASAL SPRAY ZOMIG 5 MG NASAL SPRAY authorization for a Step 2 drug may be given. Step 1 Drug(s): generic from serotonin agonists or migraine combination. Step 2 Drug(s): Migerot, Relpax, Zomig. 5
6 NASAL STEROIDS BECONASE AQ 42 MCG (0.042 %) NASAL SPRAY DYMISTA 137 MCG-50 MCG/SPRAY NASAL SPRAY OMNARIS 50 MCG NASAL SPRAY QNASL 80 MCG/ACTUATION NASAL AEROSOL SPRAY ZETONNA 37 MCG/ACTUATION NASAL HFA INHALER authorization for a Step 2 drug may be given. Step 1 Drug(s): generic nasal steroid. Step 2 Drug(s): Beconase AQ, Dymista, Omnaris, Qnasl, Zetonna. Beconase AQ will be approved first line for a diagnosis of nasal polyps. 6
7 OPHTHALMIC PROSTAGLANDINS BIMATOPROST 0.03 % EYE DROPS LUMIGAN 0.01 % EYE DROPS TRAVATAN Z % EYE DROPS ZIOPTAN (PF) % EYE DROPS IN A DROPPERETTE authorization for a Step 2 drug may be given. Step 1 Drug(s): latanoprost. Step 2 Drug(s): Lumigan, Travatan Z, Zioptan, Bimatoprost. 7
8 OSTEOPOROSIS AGENT BINOSTO 70 MG EFFERVESCENT TABLET FORTEO 20 MCG/DOSE (600 MCG/2.4 ML) SUBCUTANEOUS PEN INJECTOR FOSAMAX PLUS D 70 MG-2,800 UNIT TABLET FOSAMAX PLUS D 70 MG-5,600 UNIT TABLET authorization for a Step 2 drug may be given. Step 1 Drug(s): alendronate, etidronate, ibandronate, pamidronate, risedronate, zoledronic acid, salmon calcitonin. Step 2 Drug(s): Binosto, Forteo, Fosamax + D. 8
9 ULORIC ULORIC 40 MG TABLET ULORIC 80 MG TABLET authorization for a Step 2 drug may be given. Step 1 Drug(s): allopurinol. Step 2 Drug(s): Uloric. 9
10 Index A ALOGLIPTIN 12.5 MG TABLET... 4 ALOGLIPTIN 12.5 MG-METFORMIN 1,000 MG TABLET... 4 ALOGLIPTIN 12.5 MG-METFORMIN 500 MG TABLET... 4 ALOGLIPTIN 25 MG TABLET... 4 ALOGLIPTIN 6.25 MG TABLET... 4 B BECONASE AQ 42 MCG (0.042 %) NASAL SPRAY... 6 BIMATOPROST 0.03 % EYE DROPS... 7 BINOSTO 70 MG EFFERVESCENT TABLET... 8 BYSTOLIC 10 MG TABLET... 1 BYSTOLIC 2.5 MG TABLET... 1 BYSTOLIC 20 MG TABLET... 1 BYSTOLIC 5 MG TABLET... 1 D DAYTRANA 10 MG/9 HR DAILY PATCH... 2 DAYTRANA 15 MG/9 HR DAILY PATCH... 2 DAYTRANA 20 MG/9 HR DAILY PATCH... 2 DAYTRANA 30 MG/9 HR DAILY PATCH... 2 DIFICID 200 MG TABLET... 3 DYMISTA 137 MCG-50 MCG/SPRAY NASAL SPRAY... 6 F FORTEO 20 MCG/DOSE (600 MCG/2.4 ML) SUBCUTANEOUS PEN INJECTOR... 8 FOSAMAX PLUS D 70 MG-2,800 UNIT TABLET... 8 FOSAMAX PLUS D 70 MG-5,600 UNIT TABLET... 8 K KAZANO 12.5 MG-1,000 MG TABLET.. 4 KAZANO 12.5 MG-500 MG TABLET... 4 KOMBIGLYZE XR 2.5 MG-1,000 MG TABLET,EXTENDED RELEASE... 4 KOMBIGLYZE XR 5 MG-1,000 MG TABLET,EXTENDED RELEASE... 4 KOMBIGLYZE XR 5 MG-500 MG TABLET,EXTENDED RELEASE... 4 L LUMIGAN 0.01 % EYE DROPS... 7 M MIGERGOT 2 MG-100 MG RECTAL SUPPOSITORY... 5 N NESINA 12.5 MG TABLET... 4 NESINA 25 MG TABLET... 4 NESINA 6.25 MG TABLET... 4 O OMNARIS 50 MCG NASAL SPRAY... 6 ONGLYZA 2.5 MG TABLET... 4 ONGLYZA 5 MG TABLET... 4 Q QNASL 80 MCG/ACTUATION NASAL AEROSOL SPRAY... 6 R RELPAX 20 MG TABLET... 5 RELPAX 40 MG TABLET... 5 S STRATTERA 10 MG CAPSULE... 2 STRATTERA 100 MG CAPSULE... 2 STRATTERA 18 MG CAPSULE... 2 STRATTERA 25 MG CAPSULE... 2 STRATTERA 40 MG CAPSULE... 2 STRATTERA 60 MG CAPSULE... 2 STRATTERA 80 MG CAPSULE... 2 T TRAVATAN Z % EYE DROPS... 7 U ULORIC 40 MG TABLET... 9 ULORIC 80 MG TABLET... 9 Z ZETONNA 37 MCG/ACTUATION NASAL HFA INHALER... 6 ZIOPTAN (PF) % EYE DROPS IN A DROPPERETTE... 7 ZOMIG 2.5 MG NASAL SPRAY... 5 ZOMIG 5 MG NASAL SPRAY
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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
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