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 medication. Formulary ID 17354 Version 15 1
ALPHA GLUCOSIDASE INHIBITOR -SCORE Glyset Patient needs to have a paid claim for generic formulary metformin or metformin combinations, generic sulfonylureas, or generic thiazolidinediones Formulary ID 17354 Version 15 2
ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Khedezla Pexeva Patient needs to have a paid claim for TWO of the following formulary products: bupropion, mirtazapine, generic SSRI, or generic SNRI. Formulary ID 17354 Version 15 3
ANTIGOUT -SCORE Uloric Patient needs to have a paid claim for allopurinol Formulary ID 17354 Version 15 4
ATYPICAL ANTIPSYCHOTICS - SCORE Fanapt Fanapt Titration Pack Saphris Vraylar Patient needs to have a paid claim for two generic formulary atypical antipsychotic agents Formulary ID 17354 Version 15 5
BISPHOSPHONATES -SCORE Fosamax Plus D Patient needs to have a paid claim for one generic formulary oral bisphosphonate agent Formulary ID 17354 Version 15 6
DPP4 INHIBITORS - SCORE Janumet Janumet Xr Januvia Jentadueto Jentadueto Xr Kombiglyze Xr Onglyza Tradjenta Trial of one generic metformin containing products, generic sulfonylureas, or generic thiazolidinediones Formulary ID 17354 Version 15 7
EPINEPHRINE -SCORE Adrenaclick Epinephrine INJ 0.15MG/0.15ML, 0.3MG/0.3ML History of trial and failure, or intolerance to one of the following: EpiPen or EpiPen Jr or epinephrine (generic EpiPen or EpiPen Jr) Formulary ID 17354 Version 15 8
GLP1 AGONIST - SCORE Bydureon Bydureon Pen Byetta Trulicity Victoza Patient needs to have a paid claim for generic formulary metformin or metformin combinations, generic sulfonylureas, or generic thiazolidinediones Formulary ID 17354 Version 15 9
LAMA-SCORE Tudorza Pressair Patient needs to have a paid claim for Spiriva Formulary ID 17354 Version 15 10
LEUKOTRIENE MODIFIERS - SCORE Zileuton Er Zyflo Zyflo Cr Trial of generic montelukast or generic zafirlukast. Formulary ID 17354 Version 15 11
NASONEX BRAND-SCORE Nasonex Patient needs to have a paid claim for any one generic intranasal corticosteroid Formulary ID 17354 Version 15 12
OPHTHALMIC NSAID - SCORE Bromsite Patient must have a paid claim for one of the following: generic, single ingredient, ophthalmic NSAID solutions: diclofenac, flurbiprofen, ketorolac, or brand Nevanac or brand Ilevro Formulary ID 17354 Version 15 13
PD AGENTS -SCORE Neupro Patient needs to have a paid claim for one generic formulary dopamine agonist agent Formulary ID 17354 Version 15 14
RAYALDEE -SCORE Rayaldee Trial of one of the following oral generics: calcitriol, doxercalciferol, paricalcitol Formulary ID 17354 Version 15 15
SGLT2 - SCORE Invokamet Invokamet Xr Invokana Jardiance Synjardy Synjardy Xr Paid claim for generic formulary metformin or metformin combinations, generic sulfonylureas, or generic thiazolidinediones. Jardiance, Synjardy only: ST does not apply for patients with CV disease, defined as one of the following: h/o MI, multi-vessel CAD, left main CAD, h/o stroke, Occlusive PAD, single-vessel CAD with documentation of unstable angina or a positive stress test for ischemia. Formulary ID 17354 Version 15 16
STATINS -SCORE Altoprev TB24 20MG, 40MG, 60MG Livalo Livalo: Trial of one generic formulary HMG-CoA reductase inhibitor (statin). Altoprev: Trial of two generic formulary HMG-CoA reductase inhibitors (statin). Formulary ID 17354 Version 15 17
INDEX A Adhd Stimulants - Score... 1 Adrenaclick... 8 Alpha Glucosidase Inhibitor -score... 2 Altoprev... 17 Antidepressants - Score... 3 Antigout -score... 4 Aplenzin... 3 Atypical Antipsychotics - Score... 5 B Bisphosphonates -score... 6 Bromsite... 13 Bydureon... 9 Bydureon Pen... 9 Byetta... 9 D Desvenlafaxine Er... 3 Dpp4 Inhibitors - Score... 7 E Emsam... 3 Epinephrine... 8 Epinephrine -score... 8 F Fanapt... 5 Fanapt Titration Pack... 5 Fetzima... 3 Fetzima Titration Pack... 3 Fosamax Plus D... 6 G Glp1 Agonist - Score... 9 Glyset... 2 I Invokamet... 16 Invokamet Xr... 16 Invokana... 16 J Janumet... 7 Janumet Xr... 7 Januvia... 7 Jardiance... 16 Jentadueto... 7 Jentadueto Xr... 7 K Khedezla... 3 Kombiglyze Xr... 7 L Lama-score... 10 Leukotriene Modifiers - Score... 11 Livalo... 17 N Nasonex... 12 Nasonex Brand-score... 12 Neupro... 14 O Onglyza... 7 Ophthalmic Nsaid - Score... 13 P Pd Agents -score... 14 Pexeva... 3 R Rayaldee... 15 Rayaldee -score... 15 S Saphris... 5 Sglt2 - Score... 16 Formulary ID 17354 Version 15 18
Statins -score... 17 Strattera... 1 Synjardy... 16 Synjardy Xr... 16 T Tradjenta... 7 Trulicity... 9 Tudorza Pressair... 10 U Uloric... 4 V Victoza... 9 Vraylar... 5 Z Zileuton Er... 11 Zyflo... 11 Zyflo Cr... 11 Formulary ID 17354 Version 15 19