ADHD STIMULANTS - SCORE Step Therapy Strattera Patient needs to have a paid claim for two generic formulary ADHD stimulant medications. Formulary ID# 00017034 Last Updated: 08/01/2017 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# 00017034 Last Updated: 08/01/2017 2
ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er 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# 00017034 Last Updated: 08/01/2017 3
ANTIGOUT -SCORE Uloric Patient needs to have a paid claim for allopurinol Formulary ID# 00017034 Last Updated: 08/01/2017 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# 00017034 Last Updated: 08/01/2017 5
BISPHOSPHONATES -SCORE Fosamax Plus D Patient needs to have a paid claim for one generic formulary oral bisphosphonate agent Formulary ID# 00017034 Last Updated: 08/01/2017 6
DPP4 INHIBITORS - SCORE Janumet Janumet Xr Januvia Jentadueto Jentadueto Xr Kombiglyze Xr Onglyza Tradjenta Patient needs to have a paid claim for two generic formulary metformin or metformin combinations, generic sulfonylureas, or generic thiazolidinediones Formulary ID# 00017034 Last Updated: 08/01/2017 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# 00017034 Last Updated: 08/01/2017 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# 00017034 Last Updated: 08/01/2017 9
LAMA-SCORE Tudorza Pressair Patient needs to have a paid claim for Spiriva Formulary ID# 00017034 Last Updated: 08/01/2017 10
LEUKOTRIENE MODIFIERS - SCORE Zileuton Er Zyflo Zyflo Cr Trial of generic montelukast or generic zafirlukast. Formulary ID# 00017034 Last Updated: 08/01/2017 11
NASONEX BRAND-SCORE Nasonex Patient needs to have a paid claim for any one generic intranasal corticosteroid Formulary ID# 00017034 Last Updated: 08/01/2017 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# 00017034 Last Updated: 08/01/2017 13
PD AGENTS -SCORE Neupro Patient needs to have a paid claim for one generic formulary dopamine agonist agent Formulary ID# 00017034 Last Updated: 08/01/2017 14
RAYALDEE -SCORE Rayaldee Trial and failure, or intolerance to one of the following oral generics: calcitriol, doxercalciferol, paricalcitol Formulary ID# 00017034 Last Updated: 08/01/2017 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# 00017034 Last Updated: 08/01/2017 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# Formulary ID# 00017034 Last Updated: 08/01/2017 17