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, Lamotrigine immediate-release, Zonisamide, Levetiracetam, Levetiracetam XR, Topiramate. Step 2 Drug(s): Aptiom (eslicarbazepine). Applies to New Starts Only. Number of days for claims review for step 1 drugs: 180 days COREG CR Step-2: COREG CR 10 MG CAPSULE, EXTENDED RELEASE or COREG CR 20 MG CAPSULE, EXTENDED RELEASE or COREG CR 40 MG CAPSULE, EXTENDED RELEASE or COREG CR 80 MG CAPSULE, EXTENDED RELEASE Step 1 Drug(s): cavedilol regular release. Step 2 Drug(s): Coreg CR. Applies to New Starts Only CYCLOSET DEXILANT Step-2: CYCLOSET 0.8 MG TABLET Step-2: DEXILANT 30 MG CAPSULE, DELAYED RELEASE or DEXILANT 60 MG CAPSULE, DELAYED RELEASE Step 1 Drug(s): metformin. Step 2 Drug(s): Cycloset (bromocriptine mesylate) If the patient has tried a Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): omeprazole, pantoprazole, or lansoprazole. Step 2 Drug(s): Dexilant Y0114_17_29357_010 10/4/2017 1 Updated 10/2017

DOXEPIN HRM - B Step-2: doxepin 10 mg capsule or doxepin 10 mg/ml oral concentrate or doxepin 100 mg capsule or doxepin 150 mg capsule or doxepin 25 mg capsule or doxepin 50 mg capsule or doxepin 75 mg capsule given. Step 1 Drug(s): bupropion, buspirone, citalopram, desipramine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nortriptyline, paroxetine CR, paroxetine, Pristiq, sertraline, trazodone, venlafaxine IR/ER, Viibryd. Step 2 Drug(s): Doxepin. Applies to New Starts Only. Number of days for claims review for step 1 drugs: 180 days FANAPT Step-2: FANAPT 1 MG TABLET or FANAPT 10 MG TABLET or FANAPT 12 MG TABLET or FANAPT 1MG(2)-2 MG(2)- 4MG(2)-6 MG(2) TABLETS IN A DOSE PACK or FANAPT 2 MG TABLET or FANAPT 4 MG TABLET or FANAPT 6 MG TABLET or FANAPT 8 MG TABLET Step 1 Drug(s): risperidone, olanzapine, quetiapine fumarate, ziprasidone, paliperidone. Step 2 Drug(s): Fanapt (iloperidone), Fanapt Titration Pack (iloperidone). Applies to New Starts Only. Number of days for claims review for step 1 drugs: 180 days Y0114_17_29357_010 10/4/2017 2 Updated 10/2017

FENTANYL PATCH-E Step-2: fentanyl 100 mcg/hr 12 mcg/hr transdermal patch or fentanyl 25 mcg/hr 37.5 mcg/hour transdermal patch or fentanyl 50 mcg/hr 62.5 mcg/hour transdermal patch or fentanyl 75 mcg/hr 87.5 mcg/hour transdermal patch Step 1 Drug(s): hydromorphone er, methadone, morphine sulfate ER/CR, tramadol ER. Step 2 Drug(s): fentanyl td patch. New starts Only. Look back 180 days GELNIQUE Step-2: GELNIQUE 10 % (100 MG/GRAM) TRANSDERMAL GEL PACKET If the patient has tried Toviaz/VESIcare/Myrbetriq and one of the following: oxybutynin, oxybutynin solution, oxybutynin ER, tolterodine IR/ER, OR trospium IR/ER. Then Gelnique (oxybutynin) may be authorized. KHEDEZLA Step-2: KHEDEZLA 100 MG TABLET,EXTENDED RELEASE or KHEDEZLA 50 MG TABLET,EXTENDED RELEASE given. Step 1 Drug(s): Bupropion, Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Mirtazapine, Paroxetine, Sertraline, Venlafaxine (immediate or extended-release products). Step 2 Drug(s): Khedezla. Applies to New Starts Only. Number of days for claims review for step 1 drugs: 180 days NASAL STEROID - B Step-2: budesonide 32 mcg/actuation nasal spray Step 1 Drug(s): fluticasone propionate or flunisolide nasal. Step 2 Drug(s): budesonide nasal may be authorized. Look back 180 days. Y0114_17_29357_010 10/4/2017 3 Updated 10/2017

NP BISPHOSPHONAT ES - B Step-2: FOSAMAX PLUS D 70 MG-2,800 UNIT TABLET or FOSAMAX PLUS D 70 MG-5,600 UNIT TABLET or risedronate 150 mg tablet or risedronate 30 mg tablet or risedronate 35 mg tablet or risedronate 35 mg tablet (12 pack) or risedronate 35 mg tablet (4 pack) or risedronate 5 mg tablet Step 1 Drug(s): Alendronate, ibandronate tablets. Step 2 Drug(s): Risedronate, Fosamax plus D. Look back 180 days. NP RAPID INSULIN Step-2: APIDRA 100 UNIT/ML SUBCUTANEOUS SOLUTION or APIDRA SOLOSTAR 100 UNIT/ML SUBCUTANEOUS INSULIN PEN Step 1 Drug(s): Novolog, Humalog. Step 2 Drug(s): Apidra. New starts Only. Y0114_17_29357_010 10/4/2017 4 Updated 10/2017

OXYCONTIN - B Step-2: oxycodone er 10 mg hr or oxycodone er 15 mg hr or oxycodone er 20 mg hr or oxycodone er 30 mg hr or oxycodone er 40 mg hr or oxycodone er 60 mg hr or OXYCODONE ER 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR or OXYCONTIN 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE or OXYCONTIN 15 MG TABLET,CRUSH RESISTANT,EXTENDED Step 1 Drug(s): Fentanyl Patch, methadone, morphine sulfate ER/CR. Step 2 Drug(s): OxyContin (oxycodone controlled-release). New Starts. Look back 180 days. Y0114_17_29357_010 10/4/2017 5 Updated 10/2017

RANEXA Step-2: RANEXA 1,000 MG TABLET,EXTENDED RELEASE or RANEXA 500 MG TABLET,EXTENDED RELEASE Step 1 Drug(s): any formulary Beta-blocker, Calcium-channel blocker, or Long-acting nitrate. Step 2 Drug(s): Ranexa (ranolazine) THIORIDAZINE HRM Step-2: thioridazine 10 mg tablet or thioridazine 100 mg tablet or thioridazine 25 mg tablet or thioridazine 50 mg tablet given. Step 1 Drug(s): Fanapt (iloperidone), paliperidone, Risperidone, aripiprazole, Latuda, Olanzapine, Quetiapine, Ziprasidone. Step 2 Drug(s): Thioridazine. New Starts Only TRINTELLIX Step-2: TRINTELLIX 10 MG TABLET or TRINTELLIX 20 MG TABLET or TRINTELLIX 5 MG TABLET given. Step 1 Drug(s): citalopram, fluoxetine, paroxetine, paroxetine CR, sertraline, venlafaxine, venlafaxine er, escitalopram, fluvoxamine. Step 2 Drug(s): Trintellix (Vortioxetine). Applies to New Starts Only. Number of days for claims review for step 1 drugs: 180 days ULORIC Step-2: ULORIC 40 MG TABLET or ULORIC 80 MG TABLET Step 1 Drug(s): allopurinol. Step 2 Drug(s): Uloric. Approve without trial of step 1 drug if Patient has contraindication to allopurinol use. VIIBRYD Step-2: VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK or VIIBRYD 10 MG TABLET or VIIBRYD 20 MG TABLET or VIIBRYD 40 MG TABLET given. Step 1 Drug(s): citalopram, fluoxetine, fluvoxamine, paroxetine, paroxetine CR, sertraline, venlafaxine IR/ER, escitalopram. Step 2 Drug(s): Viibryd, Viibryd Titration Pack. Applies to New Starts Only. Number of days for claims review for step 1 drugs: 180 days Y0114_17_29357_010 10/4/2017 6 Updated 10/2017