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 restriction, a similar drug must be tried first. This document contains a list of the drugs that require step therapy and their covered alternatives. Step therapy criteria is based on current medical and prescribing practices, and the clinical recommendations of the physicians and pharmacists on the Granite Alliance Pharmacy and Therapeutics Committee. If you have any questions please contact us, Granite Alliance, at 1-855-586-2573 (TTY users call 711), or visit www.mygraniterx.com. We are available 24 hours a day, seven days a week. Our preferred hours are Monday through Friday 7 a.m. to 7 p.m., Mountain Time. Formulary ID: 00018386 Version: 14 Granite Alliance Insurance Company is a Medicare-approved Prescription Drug Plan. S3875_FORM18_410L
APTIOM APTIOM STEP 1: Patient has a history of filling a 60 day supply of: 2 generic adjunctive AEDs (lamotrigine, topiramate, oxcarbazepine, levetiracetam, zonisamide, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Aptiom. PAGE 2 LAST UPDATED 11/2018
ATYPICAL ANTIPSYCHOTICS FANAPT, INVEGA SUSTENNA, LATUDA 120 MG TABLET, LATUDA 20 MG TABLET, LATUDA 40 MG TABLET, LATUDA 80 MG TABLET, REXULTI, SAPHRIS, VRAYLAR STEP 1: Patient has a history of filling a 30 day supply of: aripiprazole, risperidone, olanzapine, olanzapine/fluoxetine quetiapine, or ziprasidone within the last 180 days. STEP 2: Once Step one is met the patient may fill Fanapt, Latuda, Invega, Rexulti, Vraylar or Saphris. PAGE 3 LAST UPDATED 11/2018
AUBAGIO AUBAGIO STEP 1: Patient has a history of filling a 30 day supply of one of the following within the past 180 days: peginterferon beta-1a (Plegridy), interferon beta-1a (Avonex), dimethyl fumarate (Tecfidera) or glatiramer (Copaxone). STEP 2: Once step one is met the patient may fill Aubagio. PAGE 4 LAST UPDATED 11/2018
BRIVIACT BRIVIACT STEP 1: Patient has a history of filling a 30 day supply of: 2 generic adjunctive AEDs (lamotrigine, topiramate, oxcarbazepine, levetiracetam, zonisamide, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Briviact. PAGE 5 LAST UPDATED 11/2018
CHENODAL CHENODAL STEP 1: Patient has a history of filling a 30 day supply of: generic ursodial within the past 180 days. STEP 2: Once step one is met the member may fill Chenodal. PAGE 6 LAST UPDATED 11/2018
CIMZIA CIMZIA 200 MG VIAL KIT, CIMZIA 200 MG/ML SYRINGE KIT STEP 1: Patient has a history of filling a 30 day supply of: Humira (adalimumab) or Enbrel (etanercept) within the past 180 days. STEP 2: Once step one is met the patient may fill Cimzia. PAGE 7 LAST UPDATED 11/2018
CORLANOR CORLANOR Step 1: Patient has a history of filling a 30 day supply of generic carvedilol, metoprolol succinate, or bisoprolol. Step 2: Once Step One has been met the patient may fill Corlanor. PAGE 8 LAST UPDATED 11/2018
COSENTYX COSENTYX (2 SYRINGES), COSENTYX PEN, COSENTYX PEN (2 PENS), COSENTYX SYRINGE STEP 1: Patient has a history of filling a 30 day supply of: Humira (adalimumab) or Enbrel (etanercept) within the past 180 days. STEP 2: Once step one is met the patient may fill Cosentyx. PAGE 9 LAST UPDATED 11/2018
DALIRESP DALIRESP STEP 1: Patient has a history of filling a 30 day supply of: 2 agents used in the treatment of COPD (Serevent, Advair, Symbicort, Spiriva, Anoro Ellipta, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Daliresp. PAGE 10 LAST UPDATED 11/2018
ELIDEL ELIDEL STEP 1: Patient has a history of filling a 30 day supply of: 2 generic topical steroids (clobetasol, betamethasone, mometasone, hydrocortisone, triamcinolone, nystatin/triamcinolone, betamethasone/clotrimazole) within the past 180 days. STEP 2: Once step one is met the patient may fill Elidel. PAGE 11 LAST UPDATED 11/2018
EMSAM EMSAM STEP 1: Patient has a history of filling a 60 day supply of: 2 generic antidepressants (such as citalopram, venlafaxine, bupropion, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Emsam. PAGE 12 LAST UPDATED 11/2018
FETZIMA FETZIMA STEP 1: Patient has a history of filling a 60 day supply of: 2 generic antidepressants (such as citalopram, venlafaxine, bupropion, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Fetzima. PAGE 13 LAST UPDATED 11/2018
FYCOMPA FYCOMPA 0.5 MG/ML ORAL SUSP, FYCOMPA 10 MG TABLET, FYCOMPA 12 MG TABLET, FYCOMPA 2 MG TABLET, FYCOMPA 4 MG TABLET, FYCOMPA 6 MG TABLET, FYCOMPA 8 MG TABLET STEP 1: Patient has a history of filling a 30 day supply of: 2 generic adjunctive AEDs (lamotrigine, topiramate, oxcarbazepine, levetiracetam, zonisamide, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Fycompa. PAGE 14 LAST UPDATED 11/2018
GILENYA GILENYA 0.5 MG CAPSULE STEP 1: Patient has a history of filling a 30 day supply of one of the following within the past 180 days: interferon beta-1a (Avonex), peginterferon beta-1a (Plegridy), dimethyl fumarate (Tecfidera) or glatiramer (Copaxone). STEP 2: Once step one is met the patient may fill Gilenya. PAGE 15 LAST UPDATED 11/2018
GLP-1/LA INSULIN COMBO SOLIQUA 100-33 STEP 1: Patient has a history of filling a 30 day supply of: a long acting insulin (Lantus, Toujeo, Levemir etc.) Or a GLP-1 (Victoza, Trulicity, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Soliqua. PAGE 16 LAST UPDATED 11/2018
NEUPRO NEUPRO STEP 1: Patient has a history of filling a 30 day supply of: pramipexole or ropinirole within the past 180 days. STEP 2: Once step one is met the patient may fill Neupro. PAGE 17 LAST UPDATED 11/2018
OTREXUP OTREXUP 10 MG/0.4 ML AUTO-INJ, OTREXUP 12.5 MG/0.4 ML AUTOINJ, OTREXUP 15 MG/0.4 ML AUTO-INJ, OTREXUP 17.5 MG/0.4 ML AUTOINJ, OTREXUP 20 MG/0.4 ML AUTO-INJ, OTREXUP 22.5 MG/0.4 ML AUTOINJ, OTREXUP 25 MG/0.4 ML AUTO-INJ STEP 1: Patient has a history of filling a 30 day supply of: generic methotrexate within the past 180 days. STEP 2: Once step one is met the patient may fill Otrexup. PAGE 18 LAST UPDATED 11/2018
RANEXA RANEXA STEP 1: Patient has a history of filling a 30 day supply of at least 2 of the following: generic isosorbide, metoprolol, atenolol, diltiazem, verapamil, amlodipine or felodipine within the last 180 days. STEP 2: Once Step one is met the patient may fill Ranexa. PAGE 19 LAST UPDATED 11/2018
TEKTURNA TEKTURNA, TEKTURNA HCT STEP 1: Patient has a history of filling a 30 day supply of: 1 generic ACE inhibitor (such as lisinopril, enalapril, ramipril, etc.) OR Angiotensin Receptor Blocker (such as losartan, irbesartan, etc.) within the last 180 days. STEP 2: Once Step one is met the patient may fill Tekturna or Tekturna HCT. PAGE 20 LAST UPDATED 11/2018
TRINTELLIX TRINTELLIX STEP 1: Patient has a history of filling a 30 day supply of: 2 generic antidepressants (such as citalopram, venlafaxine, bupropion, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Trintellix. PAGE 21 LAST UPDATED 11/2018
TROKENDI TROKENDI XR STEP 1: Patient has a history of filling a 30 day supply of: 2 generic adjunctive AEDs (lamotrigine, topiramate, oxcarbazepine, levetiracetam, zonisamide, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Trokendi. PAGE 22 LAST UPDATED 11/2018
ULORIC ULORIC STEP 1: Patient has a history of filling a 30 day supply of: allopurinol within the past 180 days. STEP 2: Once step one is met the patient may fill Uloric. PAGE 23 LAST UPDATED 11/2018
VIIBRYD VIIBRYD STEP 1: Patient has a history of filling a 60 day supply of: trazodone within the past 180 days. STEP 2: Once step one is met the patient may fill Viibryd. PAGE 24 LAST UPDATED 11/2018
VIMPAT VIMPAT 10 MG/ML SOLUTION, VIMPAT 100 MG TABLET, VIMPAT 150 MG TABLET, VIMPAT 200 MG TABLET, VIMPAT 200 MG/20 ML VIAL, VIMPAT 50 MG TABLET STEP 1: Patient has a history of filling a 30 day supply of: 2 generic adjunctive AEDs (lamotrigine, topiramate, oxcarbazepine, levetiracetam, zonisamide, etc.) within the past 180 days. STEP 2: Once step one is met the patient may fill Vimpat. PAGE 25 LAST UPDATED 11/2018
XELJANZ XELJANZ, XELJANZ XR STEP 1: Patient has a history of filling a 30 day supply of: Humira (adalimumab) or Enbrel (etanercept) within the past 180 days. STEP 2: Once step one is met the patient may fill Xeljanz. PAGE 26 LAST UPDATED 11/2018
ZONTIVITY ZONTIVITY STEP 1: Patient has a history of filling a 1 day supply of generic clopidogrel within the past 180 days. STEP 2: Once step one is met the patient may fill Zontivity. PAGE 27 LAST UPDATED 11/2018
ZYCLARA ZYCLARA STEP 1: Patient has a history of filling a 1 day supply of: 1 generic topical 5-FU, imiquimod, or branded Picato within the past 180 days. STEP 2: Once step one is met the patient may fill Zyclara.