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 enrollee has a paid claim for at least a 1 days supply of a Latuda AND aripiprazole in the past 365 days. Otherwise, require a step therapy exception request indicating any ONE of the following: (1) History of inadequate treatment response with Latuda or aripiprazole, OR (2) history of adverse event with Latuda, OR (3)Latuda is contraindicated. 1
ANTICONVULSANTS APTIOM TABLET 200 MG APTIOM TABLET 400 MG APTIOM TABLET 600 MG APTIOM TABLET 800 MG BANZEL SUSPENSION 40 MG/ML BANZEL TABLET 200 MG BANZEL TABLET 400 MG BRIVIACT SOLUTION 10 MG/ML BRIVIACT TABLET 10 MG BRIVIACT TABLET 100 MG BRIVIACT TABLET 25 MG BRIVIACT TABLET 50 MG BRIVIACT TABLET 75 MG CELONTIN CAPSULE 300 MG FYCOMPA SUSPENSION 0.5 MG/ML FYCOMPA TABLET 10 MG FYCOMPA TABLET 12 MG FYCOMPA TABLET 2 MG FYCOMPA TABLET 4 MG FYCOMPA TABLET 6 MG FYCOMPA TABLET 8 MG ONFI SUSPENSION 2.5 MG/ML ONFI TABLET 10 MG ONFI TABLET 20 MG PEGANONE TABLET 250 MG SPRITAM TABLET DISINTEGRATING SOLUBLE 1000 MG SPRITAM TABLET DISINTEGRATING SOLUBLE 250 MG SPRITAM TABLET DISINTEGRATING SOLUBLE 500 MG SPRITAM TABLET DISINTEGRATING SOLUBLE 750 MG VIMPAT SOLUTION 10 MG/ML VIMPAT SOLUTION 200 MG/20ML INTRAVENOUS VIMPAT TABLET 150 MG VIMPAT TABLET 200 MG VIMPAT TABLET 50 MG Claim will pay automatically for Brand Anticonvulsants if enrollee has a paid claim for at least a 1 days supply of a Generic Anticonvulsant in the past 365 days. Otherwise, Brand Anticonvulsants require a step therapy exception request indicating: (1) history of inadequate treatment response with Generic Anticonvulsants, OR (2) history of adverse event with Generic Anticonvulsants, OR (3)Generic Anticonvulsants is contraindicated. 2
ANTIDEPRESSANTS amoxapine tablet 100 mg oral amoxapine tablet 150 mg oral amoxapine tablet 25 mg oral amoxapine tablet 50 mg oral citalopram hydrobromide solution 10 mg/5ml oral citalopram hydrobromide tablet 10 mg oral citalopram hydrobromide tablet 20 mg oral citalopram hydrobromide tablet 40 mg oral EMSAM PATCH 24 HOUR 12 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 6 MG/24HR TRANSDERMAL EMSAM PATCH 24 HOUR 9 MG/24HR TRANSDERMAL MARPLAN TABLET 10 MG TRINTELLIX TABLET 10 MG TRINTELLIX TABLET 20 MG TRINTELLIX TABLET 5 MG VIIBRYD STARTER PACK KIT 10 & 20 MG VIIBRYD TABLET 10 MG VIIBRYD TABLET 20 MG VIIBRYD TABLET 40 MG Claim will pay automatically for MARPLAN, EMSAM, AMOXAPINE, VIIBRYD, CITALOPRAM, OR TRINTELLIX if enrollee has a paid claim for at least a 1 days supply of MIRTAZAPINE, PHENELZINE SULFATE, TRANYLCYPROMINE SULFATE, NEFAZODONE HCL, TRAZODONE HCL, ESCITALOPRAM OXALATE, FLUOXETINE HCL, FLUVOXAMINE MALEATE, PAROXETINE HCL, PAXIL SUS, SERTRALINE HCL, DESVENLAFAXINE ER, DULOXETINE HCL, FETZIMA, FETZIMA TITRATION PACK, VENLAFAXINE HCL, VENLAFAXINE HCL ER, AMITRIPTYLINE HCL, DESIPRAMINE HCL, DOXEPIN HCL, IMIPRAMINE HCL, PROTRIPTYLINE HCL, MAPROTILINE HCL, BUPROPION HCL, BUPROPION HCL SR, or BUPROPION HCL XL in the past 365 days. Otherwise, MARPLAN, EMSAM, AMOXAPINE, VIIBRYD, CITALOPRAM OR TRINTELLIX require a step therapy exception request indicating: (1) history of inadequate treatment response with Step 1 Antidepressant, OR (2) history of adverse event with Step 1 Antidepressant, OR (3)Step 1 Antidepressant is contraindicated. 3
ATELVIA ATELVIA TABLET DELAYED RELEASE 35 MG Claim will pay automatically for Atelvia if enrollee has a paid claim for at least a 1 days supply of Alendronate, Ibandronate or Risedroante in the past 365 days. Otherwise, Atelvia requires a step therapy exception request indicating: (1) history of inadequate treatment response with Alendronate, Ibandronate or Risedroante, OR (2) history of adverse event with Alendronate, Ibandronate or Risedroante, OR (3) Alendronate, Ibandronate or Risedroante is contraindicated. 4
ATYPICALS ABILIFY MAINTENA PREFILLED SYRINGE 300 MG ABILIFY MAINTENA PREFILLED SYRINGE 400 MG ABILIFY MAINTENA SUSPENSION RECONSTITUTED ER 300 MG clozapine tablet 100 mg oral clozapine tablet 200 mg oral clozapine tablet dispersible 100 mg oral clozapine tablet dispersible 12.5 mg oral clozapine tablet dispersible 150 mg oral clozapine tablet dispersible 200 mg oral clozapine tablet dispersible 25 mg oral FANAPT TABLET 1 MG FANAPT TABLET 10 MG FANAPT TABLET 12 MG FANAPT TABLET 2 MG FANAPT TABLET 4 MG FANAPT TABLET 6 MG FANAPT TABLET 8 MG FANAPT TITRATION PACK TABLET 1 & 2 & 4 & 6 MG FAZACLO TABLET DISPERSIBLE 100 MG FAZACLO TABLET DISPERSIBLE 12.5 MG FAZACLO TABLET DISPERSIBLE 150 MG FAZACLO TABLET DISPERSIBLE 200 MG FAZACLO TABLET DISPERSIBLE 25 MG GEODON SOLUTION RECONSTITUTED 20 MG INVEGA SUSTENNA SUSPENSION 117 MG/0.75ML 5 INVEGA SUSTENNA SUSPENSION 156 MG/ML INVEGA SUSTENNA SUSPENSION 234 MG/1.5ML INVEGA SUSTENNA SUSPENSION 39 MG/0.25ML INVEGA SUSTENNA SUSPENSION 78 MG/0.5ML INVEGA TRINZA SUSPENSION 273 MG/0.875ML INVEGA TRINZA SUSPENSION 410 MG/1.315ML INVEGA TRINZA SUSPENSION 546 MG/1.75ML INVEGA TRINZA SUSPENSION 819 MG/2.625ML NUPLAZID TABLET 17 MG RISPERDAL CONSTA SUSPENSION RECONSTITUTED 12.5 MG RISPERDAL CONSTA SUSPENSION RECONSTITUTED 25 MG RISPERDAL CONSTA SUSPENSION RECONSTITUTED 37.5 MG RISPERDAL CONSTA SUSPENSION RECONSTITUTED 50 MG SAPHRIS TABLET SUBLINGUAL 10 MG SUBLINGUAL SAPHRIS TABLET SUBLINGUAL 2.5 MG SUBLINGUAL SAPHRIS TABLET SUBLINGUAL 5 MG SUBLINGUAL VERSACLOZ SUSPENSION 50 MG/ML VRAYLAR CAPSULE 1.5 MG VRAYLAR CAPSULE 3 MG
VRAYLAR CAPSULE 4.5 MG VRAYLAR CAPSULE 6 MG VRAYLAR CAPSULE THERAPY PACK 1.5 & 3 MG ZYPREXA RELPREVV SUSPENSION RECONSTITUTED 210 MG Claim will pay automatically for ABILIFY MAINTENNA, CLOZAPINE TABLET (NON-ODT), INVEGA (SUSTENNA/TRINZA), NUPLAZID, ZYPREXA RELPREVV, FANAPT, FANAPT TITRATION PACK, RISPERDAL CONSTA, VERSACLOZ, CLOZAPINE ODT, FAZACLO, SAPHRIS, NUPLAZID, GEODON,VRAYLAR if enrollee has a paid claim for at least a 1 days supply of a Latuda OR 2 GENERIC AGENTS( ARIPIPRAZOLE, CHLORPROMAZINE, COMPRO, FLUPHENAZINE, HALOPERIDOL, LOXAPINE, OLANZAPINE, PALIPERIDONE, PERPHENAZINE, PROCHLORPERAZINE, QUETIAPINE, RISPERDONE, THIORIDAZINE, THIOTHIXENE, TRIFLUOPERAZINE, or ZIPRASIDONE) in the past 365 days. Otherwise, Non-Preferred Antipsychotics require a step therapy exception request indicating any ONE of the following (1) diagnosis that is not covered by Latuda (i.e. Acute treatment of agitation for Geodon injection), OR (2)history of inadequate treatment response with Latuda, OR (3) history of adverse event with Latuda, OR (4)Latuda is contraindicated (5) diagnosis that is not covered by Nuplazid (i.e. Parkinson's disease psychosis) 6
CAPS ILARIS (150MG DELIVERED) SOLUTION RECONSTITUTED 180 MG SUBCUTANEOUS Claim will pay automatically for Ilaris if enrollee has a paid claim for at least a 1 days supply of Arcalyst in the past 365 days. Otherwise, Ilaris requires a step therapy exception request indicating: (1) diagnosis not covered by Arcalyst such as systemic juvenile idiopathic arthritis (2) history of inadequate treatment response with Arcalyst, OR (3) history of adverse event with Arcalyst OR (4) Arcalyst is contraindicated. 7
CNS STIMULANTS atomoxetine hcl capsule 10 mg oral atomoxetine hcl capsule 100 mg oral atomoxetine hcl capsule 18 mg oral atomoxetine hcl capsule 25 mg oral atomoxetine hcl capsule 40 mg oral atomoxetine hcl capsule 60 mg oral atomoxetine hcl capsule 80 mg oral Claim will pay automatically for ATOMOXETINE if enrollee has paid claims history for any one of the following formulary CNS stimulants: amphetamine salts, dexmethylphenidate, dextroamphetamine, methylphenidate OR guanfacine ER. Otherwise, ATOMOXETINE requires a step therapy exception request indicating: (1) history of inadequate treatment response with amphetamine salts, dexmethylphenidate, dextroamphetaminemethylphenidate, OR guanfacine ER OR (2) history of adverse event with amphetamine salts, dexmethylphenidate, dextroamphetamine, methylphenidate, OR guanfacine ER OR (3)amphetamine salts, dexmethylphenidate, dextroamphetamine, methylphenidate OR guanfacine ER is contraindicated. 8
ELIDEL ELIDEL CREAM 1 % EXTERNAL Claim will pay automatically for Elidel if enrollee has paid claims history for at least 2 different formulary topical steroids. 9
FENTANYL fentanyl patch 72 hour 100 mcg/hr fentanyl patch 72 hour 12 mcg/hr fentanyl patch 72 hour 25 mcg/hr fentanyl patch 72 hour 37.5 mcg/hr fentanyl patch 72 hour 50 mcg/hr fentanyl patch 72 hour 62.5 mcg/hr fentanyl patch 72 hour 75 mcg/hr fentanyl patch 72 hour 87.5 mcg/hr Claim will pay automatically for Fentanyl patches if enrollee has paid claims history of any 1 days supply in the past 365 days of Morphine ER, Methadone, morphine oral solution OR buprenorphine patches. Otherwise, the drug requires a step therapy exception request indicating any ONE of the following: (1) history of inadequate treatment response with Morphine ER, Methadone, morphine oral solution OR buprenorphine patches, OR (2) history of adverse event with Morphine ER, Methadone, morphine oral solution OR buprenorphine patches, OR (3) Morphine ER, Methadone, morphine oral solution OR buprenorphine patches are contraindicated. 10
RANEXA RANEXA TABLET EXTENDED RELEASE 12 HOUR 1000 MG RANEXA TABLET EXTENDED RELEASE 12 HOUR 500 MG Claim will pay automatically for RANEXA if enrollee has a paid claim for at least a 1 day supply of AMLODIPINE, ATENOLOL, DILTIAZEM, ISOSORBIDE DINITRATE, ISOSORBIDE MONONITRATE, METOPROLOL, NADOLOL, NICARDIPINE, NITROGLYCERIN, PROPRANOLOL in the past 365 days. Otherwise RANEXA requires a step therapy exception request indication any ONE of the following: (1) history of inadequate treatment response with step 1 agents or (2) history of adverse event with a step 1 agent or (3) step 1 agents are contraindicated. 11
ULORIC ULORIC TABLET 40 MG ULORIC TABLET 80 MG Claim will pay automatically for Uloric if enrollee has a paid claim for at least a 1 days supply of Allopurinol in the past 365 days. Otherwise, Uloric requires a step therapy exception request indicating: (1) history of inadequate treatment response with Allopurinol, OR (2) history of adverse event with Allopurinol, OR (3) Allopurinol is contraindicated. 12
Alphabetical Listing A ABILIFY MAINTENA PREFILLED SYRINGE 300 MG... 1, 5 ABILIFY MAINTENA PREFILLED SYRINGE 400 MG... 1, 5 ABILIFY MAINTENA SUSPENSION RECONSTITUTED ER 300 MG... 1, 5 amoxapine tablet 100 mg oral... 3 amoxapine tablet 150 mg oral... 3 amoxapine tablet 25 mg oral... 3 amoxapine tablet 50 mg oral... 3 APTIOM TABLET 200 MG... 2 APTIOM TABLET 400 MG... 2 APTIOM TABLET 600 MG... 2 APTIOM TABLET 800 MG... 2 ATELVIA TABLET DELAYED RELEASE 35 MG... 4 atomoxetine hcl capsule 10 mg oral... 8 atomoxetine hcl capsule 100 mg oral... 8 atomoxetine hcl capsule 18 mg oral... 8 atomoxetine hcl capsule 25 mg oral... 8 atomoxetine hcl capsule 40 mg oral... 8 atomoxetine hcl capsule 60 mg oral... 8 atomoxetine hcl capsule 80 mg oral... 8 B BANZEL SUSPENSION 40 MG/ML... 2 BANZEL TABLET 200 MG... 2 BANZEL TABLET 400 MG... 2 BRIVIACT SOLUTION 10 MG/ML... 2 BRIVIACT TABLET 10 MG... 2 BRIVIACT TABLET 100 MG... 2 BRIVIACT TABLET 25 MG... 2 BRIVIACT TABLET 50 MG... 2 BRIVIACT TABLET 75 MG... 2 C CELONTIN CAPSULE 300 MG... 2 citalopram hydrobromide solution 10 mg/5ml oral... 3 13 citalopram hydrobromide tablet 10 mg oral 3 citalopram hydrobromide tablet 20 mg oral 3 citalopram hydrobromide tablet 40 mg oral 3 clozapine tablet 100 mg oral... 5 clozapine tablet 200 mg oral... 5 clozapine tablet dispersible 100 mg oral... 5 clozapine tablet dispersible 12.5 mg oral... 5 clozapine tablet dispersible 150 mg oral... 5 clozapine tablet dispersible 200 mg oral... 5 clozapine tablet dispersible 25 mg oral... 5 E ELIDEL CREAM 1 % EXTERNAL... 9 EMSAM PATCH 24 HOUR 12 MG/24HR TRANSDERMAL... 3 EMSAM PATCH 24 HOUR 6 MG/24HR TRANSDERMAL... 3 EMSAM PATCH 24 HOUR 9 MG/24HR TRANSDERMAL... 3 F FANAPT TABLET 1 MG... 5 FANAPT TABLET 10 MG... 5 FANAPT TABLET 12 MG... 5 FANAPT TABLET 2 MG... 5 FANAPT TABLET 4 MG... 5 FANAPT TABLET 6 MG... 5 FANAPT TABLET 8 MG... 5 FANAPT TITRATION PACK TABLET 1 & 2 & 4 & 6 MG... 5 FAZACLO TABLET DISPERSIBLE 100 MG... 5 FAZACLO TABLET DISPERSIBLE 12.5 MG... 5 FAZACLO TABLET DISPERSIBLE 150 MG... 5 FAZACLO TABLET DISPERSIBLE 200 MG... 5 FAZACLO TABLET DISPERSIBLE 25 MG... 5 fentanyl patch 72 hour 100 mcg/hr... 10 fentanyl patch 72 hour 12 mcg/hr... 10
fentanyl patch 72 hour 25 mcg/hr... 10 fentanyl patch 72 hour 37.5 mcg/hr... 10 fentanyl patch 72 hour 50 mcg/hr... 10 fentanyl patch 72 hour 62.5 mcg/hr... 10 fentanyl patch 72 hour 75 mcg/hr... 10 fentanyl patch 72 hour 87.5 mcg/hr... 10 FYCOMPA SUSPENSION 0.5 MG/ML... 2 FYCOMPA TABLET 10 MG... 2 FYCOMPA TABLET 12 MG... 2 FYCOMPA TABLET 2 MG... 2 FYCOMPA TABLET 4 MG... 2 FYCOMPA TABLET 6 MG... 2 FYCOMPA TABLET 8 MG... 2 G GEODON SOLUTION RECONSTITUTED 20 MG... 5 I ILARIS (150MG DELIVERED) SOLUTION RECONSTITUTED 180 MG SUBCUTANEOUS... 7 INVEGA SUSTENNA SUSPENSION 117 MG/0.75ML... 5 INVEGA SUSTENNA SUSPENSION 156 MG/ML... 5 INVEGA SUSTENNA SUSPENSION 234 MG/1.5ML... 5 INVEGA SUSTENNA SUSPENSION 39 MG/0.25ML... 5 INVEGA SUSTENNA SUSPENSION 78 MG/0.5ML... 5 INVEGA TRINZA SUSPENSION 273 MG/0.875ML... 5 INVEGA TRINZA SUSPENSION 410 MG/1.315ML... 5 INVEGA TRINZA SUSPENSION 546 MG/1.75ML... 5 INVEGA TRINZA SUSPENSION 819 MG/2.625ML... 5 14 M MARPLAN TABLET 10 MG... 3 N NUPLAZID TABLET 17 MG... 5 O ONFI SUSPENSION 2.5 MG/ML.. 2 ONFI TABLET 10 MG... 2 ONFI TABLET 20 MG... 2 P PEGANONE TABLET 250 MG... 2 R RANEXA TABLET EXTENDED RELEASE 12 HOUR 1000 MG 11 RANEXA TABLET EXTENDED RELEASE 12 HOUR 500 MG. 11 RISPERDAL CONSTA SUSPENSION RECONSTITUTED 12.5 MG... 5 RISPERDAL CONSTA SUSPENSION RECONSTITUTED 25 MG... 5 RISPERDAL CONSTA SUSPENSION RECONSTITUTED 37.5 MG... 5 RISPERDAL CONSTA SUSPENSION RECONSTITUTED 50 MG... 5 S SAPHRIS TABLET SUBLINGUAL 10 MG SUBLINGUAL... 5 SAPHRIS TABLET SUBLINGUAL 2.5 MG SUBLINGUAL... 5 SAPHRIS TABLET SUBLINGUAL 5 MG SUBLINGUAL... 5 SPRITAM TABLET DISINTEGRATING SOLUBLE 1000 MG... 2 SPRITAM TABLET DISINTEGRATING SOLUBLE 250 MG... 2 SPRITAM TABLET DISINTEGRATING SOLUBLE 500 MG... 2 SPRITAM TABLET DISINTEGRATING SOLUBLE 750 MG... 2 T TRINTELLIX TABLET 10 MG... 3 TRINTELLIX TABLET 20 MG... 3
TRINTELLIX TABLET 5 MG... 3 U ULORIC TABLET 40 MG... 12 ULORIC TABLET 80 MG... 12 V VERSACLOZ SUSPENSION 50 MG/ML... 5 VIIBRYD STARTER PACK KIT 10 & 20 MG... 3 VIIBRYD TABLET 10 MG... 3 VIIBRYD TABLET 20 MG... 3 VIIBRYD TABLET 40 MG... 3 VIMPAT SOLUTION 10 MG/ML. 2 VIMPAT SOLUTION 200 MG/20ML INTRAVENOUS... 2 VIMPAT TABLET 150 MG... 2 VIMPAT TABLET 200 MG... 2 VIMPAT TABLET 50 MG... 2 VRAYLAR CAPSULE 1.5 MG... 5 VRAYLAR CAPSULE 3 MG... 5 VRAYLAR CAPSULE 4.5 MG... 6 VRAYLAR CAPSULE 6 MG... 6 VRAYLAR CAPSULE THERAPY PACK 1.5 & 3 MG... 6 Z ZYPREXA RELPREVV SUSPENSION RECONSTITUTED 210 MG... 6 15