ACYCLOVIR OINT (CCHP2017)
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1 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
2 ALPHAGAN (CCHP2017) ALPHAGAN P 0.1 % EYE DROPS Step Therapy requires trial of brimonidine 0.15%. 2
3 ANTIDEPRESSANT_NVT 2017 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 duloxetine 40 mg capsule,delayed release 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 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 fluvoxamine er 100 mg capsule,extended release 24 hr fluvoxamine er 150 mg capsule,extended release 24 hr MARPLAN 10 MG TABLET 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 requires trial of one of the following generic SSRI's in previous 120 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine, Paxil oral solution, or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 3
4 ARICEPT 23_NVT 2015 donepezil 10 mg disintegrating tablet donepezil 5 mg disintegrating tablet Step Therapy requires trial of regular donepezil 5 mg or 10mg oral tablets in previous 120 days. 4
5 DEXILANT_2019 DEXILANT 30 MG CAPSULE, DELAYED RELEASE DEXILANT 60 MG CAPSULE, DELAYED RELEASE Step therapy requires trial of lansoprazole in the previous 120 days. 5
6 DRY EYE OTC (CCHP 2018) RESTASIS 0.05 % EYE DROPS IN A DROPPERETTE Step Therapy requires trial of OTC artificial tears. 6
7 OPHTHALMIC ANTI-INFECTIVES_NVT 2015 BESIVANCE 0.6 % EYE DROPS,SUSPENSION gatifloxacin 0.5 % eye drops Step Therapy requires trial of one of the following ciprofloxacin, levofloxacin, or ofloxacinin previous 120 days. 7
8 PANCREATIC ENZYMES_NVT 2015 PANCREAZE 10,500 UNIT-35,500 UNIT-61,500 UNIT CAPSULE,DELAYED RELEASE PANCREAZE 16,800 UNIT-56,800 UNIT-98,400 UNIT CAPSULE,DELAYED RELEASE PANCREAZE 2,600 UNIT-6,200 UNIT- 10,850 UNIT CAPSULE,DELAYED RELEASE PANCREAZE 21,000 UNIT-54,700 UNIT-83,900 UNIT CAPSULE,DELAYED RELEASE PANCREAZE 4,200 UNIT-14,200 UNIT- 24,600 UNIT CAPSULE,DELAYED RELEASE Step Therapy requires trial of CREON in previous 120 days. 8
9 PENTASA_NVT 2015 APRISO GRAM CAPSULE,EXTENDED RELEASE DELZICOL 400 MG CAPSULE (DR TABLETS INSIDE) LIALDA 1.2 GRAM TABLET,DELAYED RELEASE Step Therapy requires trial of one of the following: mesalamine delayedrelease 1.2gm, or mesalamine DR 800 mg in previous 120 days. 9
10 ST_RIVASTIGMINE_2019 rivastigmine 13.3 mg/24 hour transdermal patch rivastigmine 4.6 mg/24 hour transdermal patch rivastigmine 9.5 mg/24 hour transdermal patch Step Therapy requires trial of rivastigmine tablets in past 120 days. 10
11 ST_SMOKINGCESS_2019 ZYBAN 150 MG TABLET,EXTENDED RELEASE Step therapy requires trial of Nicoderm patches in previous 120 days. 11
12 ULORIC_NVT 2015 ULORIC 40 MG TABLET ULORIC 80 MG TABLET Step Therapy requires trial of allopurinol in previous 120 days. 12
13 ZADITOR OTC (CCHP2017) olopatadine 0.1 % eye drops Step 3: olopatadine 0.2 % eye drops PAZEO 0.7 % EYE DROPS Step Therapy requires trial of OTC zaditor/ketotifen for olopatadine ophth soln. Trial of olopatadine 1 mg/ml ophth soln required for olopatadine 2 mg/ml and PAZEO 13
14 INDEX A acyclovir 5 % topical ointment... 1 ALPHAGAN P 0.1 % EYE DROPS... 2 APRISO GRAM CAPSULE,EXTENDED RELEASE... 9 B BESIVANCE 0.6 % EYE DROPS,SUSPENSION... 7 D DELZICOL 400 MG CAPSULE (DR TABLETS INSIDE)... 9 DESVENLAFAXINE ER 100 MG TABLET,EXTENDED RELEASE 24 HR... 3 DESVENLAFAXINE ER 50 MG TABLET,EXTENDED RELEASE 24 HR... 3 DESVENLAFAXINE FUMARATE ER 100 MG TABLET, EXTENDED RELEASE 24 HR... 3 DESVENLAFAXINE FUMARATE ER 50 MG TABLET, EXTENDED RELEASE 24 HR... 3 DEXILANT 30 MG CAPSULE, DELAYED RELEASE... 5 DEXILANT 60 MG CAPSULE, DELAYED RELEASE... 5 donepezil 10 mg disintegrating tablet... 4 donepezil 5 mg disintegrating tablet... 4 duloxetine 40 mg capsule,delayed release.. 3 E EMSAM 12 MG/24 HR TRANSDERMAL 24 HOUR PATCH... 3 EMSAM 6 MG/24 HR TRANSDERMAL 24 HOUR PATCH... 3 EMSAM 9 MG/24 HR TRANSDERMAL 24 HOUR PATCH... 3 F 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 fluvoxamine er 100 mg capsule,extended release 24 hr... 3 fluvoxamine er 150 mg capsule,extended release 24 hr... 3 G gatifloxacin 0.5 % eye drops... 7 L LIALDA 1.2 GRAM TABLET,DELAYED RELEASE... 9 M MARPLAN 10 MG TABLET... 3 O olopatadine 0.1 % eye drops olopatadine 0.2 % eye drops P PANCREAZE 10,500 UNIT-35,500 UNIT- 61,500 UNIT CAPSULE,DELAYED RELEASE... 8 PANCREAZE 16,800 UNIT-56,800 UNIT- 98,400 UNIT CAPSULE,DELAYED RELEASE... 8 PANCREAZE 2,600 UNIT-6,200 UNIT- 10,850 UNIT CAPSULE,DELAYED RELEASE... 8 PANCREAZE 21,000 UNIT-54,700 UNIT- 83,900 UNIT CAPSULE,DELAYED RELEASE... 8 PANCREAZE 4,200 UNIT-14,200 UNIT- 24,600 UNIT CAPSULE,DELAYED RELEASE... 8 PAZEO 0.7 % EYE DROPS
15 R RESTASIS 0.05 % EYE DROPS IN A DROPPERETTE... 6 rivastigmine 13.3 mg/24 hour transdermal patch rivastigmine 4.6 mg/24 hour transdermal patch rivastigmine 9.5 mg/24 hour transdermal patch T 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 Z ZYBAN 150 MG TABLET,EXTENDED 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
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
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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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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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