Step Therapy Criteria
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- Horatio Manning
- 5 years ago
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1 ADCIRCA 1772-D ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 AMYLIN ANALOG 676-D SYMLINPEN 120, SYMLINPEN 60 rapid-acting insulin or short-acting insulin, or pre-mixed insulin within the past 120 days ANTIPSYCHOTICS 657-D LATUDA, REXULTI, SAPHRIS aripiprazole, olanzapine, risperidone, quetiapine regular release, or ziprasidone within the past 180 days DESVENLAFAXINE/FETZIMA 1888-D DESVENLAFAXINE ER, FETZIMA, FETZIMA TITRATION PACK Coverage will be provided if the patient has filled a prescription for a 30 day supply of a generic serotonin-norepinephrine reuptake inhibitor (SNRI) OR generic mirtazapine, generic bupropion, or a generic selective serotonin reuptake inhibitor (SSRI) within the past 120 days. DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS 1009-D JANUMET, JANUMET XR, JANUVIA, JENTADUETO XR, TRADJENTA metformin within the past 180 days DOXEPIN 1496-E DOXEPIN HYDROCHLORIDE Coverage will be provided if the member has filled a prescription for at least a 7 day supply of a generic topical corticosteroid AND at least a 7 day supply of topical tacrolimus (Protopic) or Elidel (pimecrolimus) within the past 120 days. EXELDERM 1380-D EXELDERM Coverage will be provided if the patient has filled a prescription for a 7 day supply of a generic topical antifungal agent within the past 120 days Updated 01/01/2019 1
2 GLP- 1 AGONIST 676-D OZEMPIC, TRULICITY, VICTOZA metformin within the past 180 days GLP-1 AGONIST/LONG ACTING INSULIN COMBO 676-D SOLIQUA 100/33, XULTOPHY 100/3.6 metformin and long acting insulin or a GLP-1 receptor agonist within the past 180 days INTUNIV 781-D GUANFACINE ER Coverage will be provided if the member has filled a prescription for an amphetamine-dextroamphetamine, dextroamphetamine, methamphetamine, lisdexamfetamine, methylphenidate or dexmethylphenidate product (at least a 30 day supply within the past 180 LIVALO/ROSUVASTATIN 2530-F LIVALO, ROSUVASTATIN CALCIUM Coverage will be provided if the member is less than 10 years of age (rosuvastatin only) or has filled a prescription for at least a 30 day supply of atorvastatin or simvastatin within the past 180 days. LYRICA 656-D LYRICA Coverage will be provided if the member has filled a prescription for regular release generic gabapentin (at least a 30 day supply within the past 120 NASAL STEROID 380-D OMNARIS Coverage will be provided if the member has filled a prescription for at least a 30 day supply of a generic nasal steroid within the past 180 days. NY OTC ALTABAX/CENTANY 1076-D ALTABAX, CENTANY AT Coverage will be provided if the member has filled a prescription for generic mupirocin (at least a 5 day supply within the past 180 NY OTC ANTI-LICE 1080-D SKLICE, ULESFIA permethrin (at least a 14 day supply within the past 60 Updated 01/01/2019 2
3 NY OTC ANTIFUNGALS TOPICAL 1079-D CICLOPIROX, CICLOPIROX OLAMINE, CLOTRIMAZOLE, ECONAZOLE NITRATE, KETOCONAZOLE, NAFTIFINE HCL, NAFTIFINE HYDROCHLORIDE, OXICONAZOLE NITRATE, OXISTAT Coverage will be provided if the member has filled a prescription for a generic OTC clotrimazole 1% topical cream OR OTC miconazole 2% topical cream/lotion/oint/soln OR OTC butenafine 1% topical cream OR OTC tolnaftate 1% topical cream/powder/spray/soln (at least a 14 day supply within the past 180 NY OTC ANTIFUNGALS TOPICAL KETOCONAZOLE 1079-D KETOCONAZOLE Coverage will be provided if the member has tried a generic OTC clotrimazole 1% topical cream OR OTC miconazole 2% topical cream/lotion/oint/soln OR OTC butenafine 1% topical cream (14 days within the past 180 NY OTC ANTIFUNGALS TOPICAL NYSTATIN 1079-D NYAMYC, NYSTATIN, NYSTOP Coverage will be provided if the member has tried a generic OTC clotrimazole 1% topical cream OR OTC miconazole 2% topical cream/lotion/oint/soln (14 days within the past 180 NY OTC ANTIHISTAMINES NON-SEDATING 1081-D CLARINEX, DESLORATADINE, DESLORATADINE ODT loratadine, fexofenadine, or cetirizine (at least a 14 day supply within the past 180 NY OTC ANTIVIRALS - TOPICAL 1075-D DENAVIR Coverage will be provided if the member has filled a prescription for oral acyclovir, valacyclovir, famciclovir OR OTC Abreva (at least a 1 day supply within the past 180 NY OTC CORTISPORIN 1076-D CORTISPORIN NEOMYCIN-BACITRACIN-POLYMYXIN OINTMENT (at least a 5 day supply within the past 180 Updated 01/01/2019 3
4 NY OTC OPHTHALMICS ANTIHISTAMINE 1082-D AZELASTINE HCL, BEPREVE, EMADINE, EPINASTINE HCL, LASTACAFT, OLOPATADINE HCL, OLOPATADINE HYDROCHLORIDE Zaditor (at least a 14 day supply within the past 180 NY OTC PROTON PUMP INHIBITORS 1078-D DEXILANT, ESOMEPRAZOLE MAGNESIUM, LANSOPRAZOLE, OMEPRAZOLE, PANTOPRAZOLE SODIUM, RABEPRAZOLE SODIUM Coverage will be provided if the member has filled a prescription for an OTC generic Proton Pump Inhibitor or Nexium OTC (at least a 30 day supply within the past 180 NY OTC TOPICAL ACNE 1077-D ADAPALENE/BENZOYL PEROXID, BENZIQ, BENZIQ LS, BP FOAMING WASH, BP WASH, CLEARPLEX X, EPIDUO FORTE Coverage will be provided if the member has filled a prescription for an OTC benzoyl peroxide product (at least a 30 day supply within the past 180 OPIOID ER 2219-M BELBUCA, EMBEDA, FENTANYL, HYDROMORPHONE HCL ER, HYSINGLA ER, METHADONE HCL, METHADONE HCL INTENSOL, MORPHINE SULFATE ER, NUCYNTA ER, OXYCODONE HCL ER, OXYCONTIN, OXYMORPHONE HYDROCHLORIDE, TRAMADOL HCL ER Coverage will be provided if the member has filled a cumulative 7-day or greater supply of an immediate-release opioid agent within the past 90 days OR has been receiving an extended-release opioid agent for a cumulative 30 days or greater within the past 90 days. OPIOID IR 2221-M CODEINE SULFATE, HYDROMORPHONE HCL, MORPHINE SULFATE, NUCYNTA, OXYCODONE HCL, OXYMORPHONE HYDROCHLORIDE, TRAMADOL HCL Coverage will be provided to the member for up to a 7-day supply of immediate-release opioids if the member does not have at least a cumulative 7-day supply of an opioid agent (immediate- or extended-release) within the past 90 days. Updated 01/01/2019 4
5 OPIOID IR COMBO PRODUCTS 1358-E ACETAMINOPHEN/CODEINE, CAPITAL/CODEINE, ENDOCET, HYDROCODONE BITARTRATE/AC, HYDROCODONE/ACETAMINOPHEN, LORTAB, OXYCODONE/ACETAMINOPHEN, OXYCODONE/ASPIRIN, OXYCODONE/IBUPROFEN, XYLON Coverage will be provided to the member for up to a 7-day supply of immediate-release opioids if the member does not have at least a cumulative 7-day supply of an opioid agent (immediate- or extended-release) within the past 90 days. PDPD AUTOIMMUNE ACTEMRA For Rheumatoid Arthritis, try Enbrel, Humira, Kevzara, Xeljanz 5mg, or Xeljanz XR. For Ankylosing Spondylitis, try Cosentyx, Enbrel, or Humira. For Psoriatic Arthritis, try Cosentyx, Enbrel, Humira, or Otezla. For Crohn's, try Humira or Stelara (after failure of Humira). For Ulcerative Colitis, try Humira or Simponi (after failure of Humira). For Psoriasis, try Humira, Otezla, Stelara, or Taltz. PDPD HEP C SOVALDI, ZEPATIER Must try Epclusa or Harvoni PDPD MS AVONEX, AVONEX PEN, PLEGRIDY, PLEGRIDY STARTER PACK Must try Betaseron, Rebif, Glatiramer 40mg, Glatopa 20mg, Copaxone 20mg, Copaxone 40mg, Gilenya, Tecfidera or Aubagio RANEXA 658-D RANEXA Coverage will be provided if the member has filled a prescription for a nitrate plus a beta blocker or a calcium channel blocker (at least a 30 day supply within the past 365 SAVELLA 2557-D SAVELLA, SAVELLA TITRATION PACK Coverage will be provided if the member has filled a prescription for at least a 30 day supply of immediate-release gabapentin, immediate-release pregabalin, duloxetine, or amitriptyline within the past 120 days. SIMVA 80MG 981-D SIMVASTATIN Coverage will be provided if the member has filled a prescription for 80mg strength of simvastatin (Zocor) (at least a 290 day supply within the past 365 Updated 01/01/2019 5
6 SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR (SGLT2) AND SGLT2 COMBINATIONS 676-D FARXIGA, GLYXAMBI, JARDIANCE, QTERN, SYNJARDY, SYNJARDY XR, XIGDUO XR metformin within the past 180 days TGST ACNE 771-D AZELEX Coverage will be provided if the member has filled a prescription for a generic acne product (at least a 30 day supply within the past 180 TGST ARB/RI 376-D EDARBI, TEKTURNA Coverage will be provided if the member has filled a prescription for a generic ACE, ACE/HCTZ combination, ARB, or ARB/HCTZ combination (at least a 30 day supply within the past 365 TGST BISPHOSPHONATES 377-D FOSAMAX PLUS D Coverage will be provided if the member has filled a prescription for a generic bisphosphonate product (at least a 28 day supply within the past 365 TGST BPH-ALPHA1 BLCK 606-D CARDURA XL, RAPAFLO Coverage will be provided if the member has filled a prescription for a generic Benign Prostatic Hyperplasia (BPH) agent (e.g., alfuzosin ext-rel, doxazosin, tamsulosin, terazosin) (at least a 30 day supply within the past 365 TGST PROSTAGL ANALOG 613-D LUMIGAN, TRAVATAN Z, ZIOPTAN Coverage will be provided if the member has filled a prescription for a generic prostaglandin analogue (at least a 30 day supply within the past 365 TGST SLEEP AGENTS 382-D BELSOMRA, ROZEREM, SILENOR Coverage will be provided if the member has filled a prescription for a generic nonbenzodiazepine hypnotic (at least a 30 day supply within the past 180 TGST SSRI 384-D TRINTELLIX, VIIBRYD, VIIBRYD STARTER PACK Coverage will be provided if the member has filled a prescription for a generic SSRI product (at least a 30 day supply within the past 365 Updated 01/01/2019 6
7 TGST URINARY ANTISPASMODICS 385-D MYRBETRIQ, VESICARE Coverage will be provided if the member has filled a prescription for a generic urinary antispasmodic (at least a 30 day supply within the past 180 TRUVADA 2664-D TRUVADA Truvada will be covered for pre-exposure (PrEP) and post-exposure (PEP) prophylaxis only. The formulary alternative for treatment is Cimduo. Coverage will be provided if the request is less than a 30 day supply OR the member has not filled Truvada in the previous 120 days OR the member has filled Truvada previously but has not filled any other antiretroviral medication in the past 120 days. ULORIC 540-D ULORIC Coverage will be provided if the member has filled a prescription for allopurinol (at least a 30 day supply within the past 180 Updated 01/01/2019 7
Step Therapy Criteria
Step Therapy Group ADCIRCA 1772-D ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 Step Therapy Group ANTIPSYCHOTICS
Step Therapy Criteria
ADCIRCA ADCIRCA Coverage will be provided if the member has filled a prescription for sildenafil (at least a 30 day supply within the past 365 ) ELIDEL 76-F ELIDEL Coverage will be provided if the member
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.
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.
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
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
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
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
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 Criteria
Tier 5 Formulary Step Therapy 2016 Updated: 05/24/2016 Effective: 06/01/2016 What is Step Therapy? Some prescription drugs require step therapy (ST). In some cases, the plan requires you to first try certain
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
ADHD STIMULANTS-S(SHC)
Step Therapy Simply Health Care 2014 Formulary ID: 14406 Version: 14 Last Updated: 08/01/2014 ADHD STIMULANTS-S(SHC) Daytrana Focalin Xr Strattera Patient needs to have a paid claim for one Step 1 drug
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
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
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
HEALTHTEAM ADVANTAGE 2018 Step Therapy Criteria
GLP1-INSULIN XULTOPHY SOLUTION PEN- INJECTOR 100-3.6 UNIT-MG/ML Claim will pay automatically for Xultophy if enrollee has a paid claim for at least a one day supply for step level 1 agent (LANTUS, LEVEMIR,
DIFICID. Products Affected Step 2: DIFICID TABLET 200 MG ORAL. Details
DIFICID DIFICID TABLET 200 MG ORAL Claim will pay automatically for Dificid if enrollee has a paid claim for at least a 1 days supply of vancomycin in the past. Otherwise, Dificid requires a step therapy
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
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
Cigna Drug and Biologic Coverage Policy
Cigna Drug and Biologic Coverage Policy Subject Step Therapy Individual and Family Plan Table of Contents Coverage Policy... 1 General Background... 5 References... 5 Effective Date... 3/15/2018 Next Review
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
HEALTHTEAM ADVANTAGE 2018 Step Therapy Criteria
GLP1-INSULIN XULTOPHY SOLUTION PEN- INJECTOR 100-3.6 UNIT-MG/ML HEALTHTEAM ADVANTAGE Claim will pay automatically for Xultophy if enrollee has a paid claim for at least a one day supply for step level
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
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
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
Medicare Part D Drugs that Require Step Therapy Effective 12/01/2017
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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
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
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
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,
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
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
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
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,
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
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
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.
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
2017 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements
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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
SmithRx Standard Formulary Step Therapy List
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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
CARE N CARE HEALTH PLAN
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
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
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
STEP THERAPY ALGORITHMS PUP Select Formulary
The Step Therapy drug will be dispensed if the drug has been dispensed within 120 days of current fill or if alternative (Step 1) drugs have been used first. If the member s prescription claim fails the
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
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
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
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.
CARE N CARE HEALTH PLAN
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
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. 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
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
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"}
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Effective Date: 01/01/2019 This document contains for the following medications: 1. Colcrys (colchicine) 2. Dovonex (calcipotriene) 3. Enbrel (etanercept) 4. Humira (adalimumab) 5. Imitrex Injection vial
CARE N CARE HEALTH PLAN
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
PPHP 2017 Formulary 2017 Step Therapy Criteria
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
HEALTHTEAM ADVANTAGE PLAN 2017 Step Therapy Criteria Pending CMS Approval
ARISTADA - ARISTADA INJ 441MG/1.6 ARISTADA INJ 662MG/2.4 ARISTADA INJ 882MG/3.2 CLAIM WILL PAY AUTOMATICALLY FOR ARISTADA IF ENROLLEE HAS A PAID CLAIM FOR AT LEAST A 1 DAYS SUPPLY OF ABILIFY MAINTENA AND
2019 PacificSource Health Plans Step Therapy Criteria. Last Modified: 02/22/2019 (All criteria reviewed at least once per year)
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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
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ALPHA BLOCKERS. Products Affected Step 1: Details. Step 2: Rapaflo 4 mg capsule Rapaflo 8 mg capsule
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Contents ALPHA BLOCKERS... 3 COLCRYS-PST... 4 DPP-4 INHIBITORS-PST... 5 HIGH RISK MEDICATIONS - SEDATIVE HYPNOTICS... 6
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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
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 Approval Criteria
Effective Date: 01/01/2018 This document contains Step Therapy Approval Criteria for the following medications: 1. Colcrys (colchicine) 2. Dovonex (calcipotriene) 3. Enbrel (etanercept) 4. Humira (adalimumab)
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.