Step Therapy ALBUTEROL - SCORE{XE "ALBUTEROL - SCORE"} Ventolin Hfa{XE "Ventolin Hfa"} Trial of ProAir Formulary ID# 00018097 Last Updated: 04/01/2018 1
ANTIDEPRESSANTS - SCORE{XE "ANTIDEPRESSANTS - SCORE"} Aplenzin{XE "Aplenzin"} Desvenlafaxine Er{XE "Desvenlafaxine Er"} TB24 100MG, 50MG Emsam{XE "Emsam"} Fetzima{XE "Fetzima"} Fetzima Titration Pack{XE "Fetzima Titration Pack"} Trial of two of the following formulary products: bupropion, mirtazapine, generic SSRI, or generic SNRI. Formulary ID# 00018097 Last Updated: 04/01/2018 2
ANTIGOUT -SCORE{XE "ANTIGOUT -SCORE"} Uloric{XE "Uloric"} Trial of allopurinol Formulary ID# 00018097 Last Updated: 04/01/2018 3
ATYPICAL ANTIPSYCHOTICS - SCORE{XE "ATYPICAL ANTIPSYCHOTICS - SCORE"} Fanapt{XE "Fanapt"} Fanapt Titration Pack{XE "Fanapt Titration Pack"} Vraylar{XE "Vraylar"} Trial of two generic formulary atypical antipsychotic agents Formulary ID# 00018097 Last Updated: 04/01/2018 4
BISPHOSPHONATES -SCORE{XE "BISPHOSPHONATES - SCORE"} Fosamax Plus D{XE "Fosamax Plus D"} Trial of one generic formulary oral bisphosphonate agent Formulary ID# 00018097 Last Updated: 04/01/2018 5
DPP4 INHIBITORS - SCORE{XE "DPP4 INHIBITORS - SCORE"} Janumet{XE "Janumet"} Janumet Xr{XE "Janumet Xr"} Januvia{XE "Januvia"} Jentadueto{XE "Jentadueto"} Jentadueto Xr{XE "Jentadueto Xr"} Kombiglyze Xr{XE "Kombiglyze Xr"} Onglyza{XE "Onglyza"} Tradjenta{XE "Tradjenta"} Trial of one generic formulary metformin or metformin combination Formulary ID# 00018097 Last Updated: 04/01/2018 6
EPINEPHRINE -SCORE{XE "EPINEPHRINE -SCORE"} Adrenaclick{XE "Adrenaclick"} Epinephrine{XE "Epinephrine"} INJ 0.15MG/0.15ML, 0.3MG/0.3ML Trial of generic epinephrine (generic Epipen or generic EpiPen Jr, by manufacturer: Mylan, NDCs 495020101** and 495020102**) Formulary ID# 00018097 Last Updated: 04/01/2018 7
FILGRASTIM - SCORE{XE "FILGRASTIM - SCORE"} Granix{XE "Granix"} Neupogen{XE "Neupogen"} Trial of Zarxio Formulary ID# 00018097 Last Updated: 04/01/2018 8
GABAPENTIN - SCORE{XE "GABAPENTIN - SCORE"} Gralise{XE "Gralise"} Gralise Starter{XE "Gralise Starter"} Trial of generic gabapentin Formulary ID# 00018097 Last Updated: 04/01/2018 9
GLP1 AGONIST - SCORE{XE "GLP1 AGONIST - SCORE"} Bydureon{XE "Bydureon"} Bydureon Bcise{XE "Bydureon Bcise"} Bydureon Pen{XE "Bydureon Pen"} Trulicity{XE "Trulicity"} Victoza{XE "Victoza"} Trial of one generic formulary metformin or metformin combination Formulary ID# 00018097 Last Updated: 04/01/2018 10
LAMA - SCORE{XE "LAMA - SCORE"} Tudorza Pressair{XE "Tudorza Pressair"} Trial of Spiriva Formulary ID# 00018097 Last Updated: 04/01/2018 11
LEUKOTRIENE MODIFIERS - SCORE{XE "LEUKOTRIENE MODIFIERS - SCORE"} Zileuton Er{XE "Zileuton Er"} Zyflo{XE "Zyflo"} Trial of generic montelukast or generic zafirlukast Formulary ID# 00018097 Last Updated: 04/01/2018 12
LONG-ACTING OPIOID - SCORE{XE "LONG-ACTING OPIOID - SCORE"} Arymo Er{XE "Arymo Er"} Trial of Embeda Formulary ID# 00018097 Last Updated: 04/01/2018 13
OPHTHALMIC NSAID - SCORE{XE "OPHTHALMIC NSAID - SCORE"} Bromsite{XE "Bromsite"} Trial of one generic ophthalmic NSAID solution: diclofenac, flurbiprofen, ketorolac, AND one brand from: Nevanac, Prolensa, Ilevro. Formulary ID# 00018097 Last Updated: 04/01/2018 14
PD AGENTS - SCORE{XE "PD AGENTS - SCORE"} Neupro{XE "Neupro"} Trial of one generic formulary dopamine agonist agent Formulary ID# 00018097 Last Updated: 04/01/2018 15
RYTARY - SCORE{XE "RYTARY - SCORE"} Rytary{XE "Rytary"} Trial of any generic antiparkinson agent Formulary ID# 00018097 Last Updated: 04/01/2018 16
SGLT2 - SCORE{XE "SGLT2 - SCORE"} Glyxambi{XE "Glyxambi"} Invokamet{XE "Invokamet"} Invokamet Xr{XE "Invokamet Xr"} Invokana{XE "Invokana"} Jardiance{XE "Jardiance"} Synjardy{XE "Synjardy"} Synjardy Xr{XE "Synjardy Xr"} Trial of one generic formulary metformin or metformin combination Formulary ID# 00018097 Last Updated: 04/01/2018 17
STATINS - SCORE{XE "STATINS - SCORE"} Livalo{XE "Livalo"} Trial of any one generic formulary HMG-CoA reductase inhibitor (statin) Formulary ID# Formulary ID# 00018097 Last Updated: 04/01/2018 18