ANTI DIABETICS BYDUREON 2 MG SUBCUTANEOUS JANUVIA 25 MG TABLET EXTENDED RELEASE SUSPENSION JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET BYDUREON BCISE 2 MG/0.85 ML JENTADUETO 2.5 MG-1,000 MG TAB SUBCUTANEOUS AUTO-INJECTOR JENTADUETO 2.5 MG-500 MG TAB BYETTA 10 MCG/DOSE(250 MCG/ML)2.4 JENTADUETO 2.5 MG-850 MG TAB ML SUBCUTANEOUS PEN JENTADUETO XR 2.5 MG-1,000 MG TAB BYETTA 5 MCG/DOSE (250 MCG/ML)1.2 ML JENTADUETO XR 5 MG-1,000 MG TAB SUBCUTANEOUS PEN SYNJARDY 12.5 MG-1,000 MG TAB INVOKAMET 150 MG-1,000 MG TAB SYNJARDY 12.5 MG-500 MG TAB INVOKAMET 150 MG-500 MG TABLET SYNJARDY 5 MG-1,000 MG TAB INVOKAMET 50 MG-1,000 MG TABLET SYNJARDY 5 MG-500 MG TAB INVOKAMET 50 MG-500 MG TABLET SYNJARDY XR 10 MG-1,000 MG TABLET, INVOKAMET XR 150 MG-1,000 MG TAB EXTENDED RELEASE INVOKAMET XR 150 MG-500 MG TAB SYNJARDY XR 12.5 MG-1,000 MG INVOKAMET XR 50 MG-1,000 MG TAB TABLET, EXTENDED RELEASE INVOKAMET XR 50 MG-500 MG TAB SYNJARDY XR 25 MG-1,000 MG TABLET, INVOKANA 100 MG TABLET EXTENDED RELEASE INVOKANA 300 MG TABLET SYNJARDY XR 5 MG-1,000 MG TABLET, JANUMET 50 MG-1,000 MG TABLET EXTENDED RELEASE JANUMET 50 MG-500 MG TABLET TRADJENTA 5 MG TABLET JANUMET XR 100 MG-1,000 MG TAB TRULICITY 0.75 MG/0.5 ML JANUMET XR 50 MG-1,000 MG TAB SUBCUTANEOUS PEN INJECTOR JANUMET XR 50 MG-500 MG TAB TRULICITY 1.5 MG/0.5 ML JANUVIA 100 MG TABLET SUBCUTANEOUS PEN INJECTOR Step 1: Trial of one generic formulary metformin or generic metformin combinations or sulfonylurea or thiazolidinedione. Janumet, Janumet XR, Januvia, Jentadueto, Jentadueto XR, Tradjenta, Formulary GLP1 agonist, Invokana, Invokamet, Invokamet XR, Jardiance, Synjardy. 1
ANTIDEPRESSANT THERAPY APLENZIN 174 MG TABLET,EXTENDED RELEASE APLENZIN 348 MG TABLET,EXTENDED RELEASE APLENZIN 522 MG TABLET,EXTENDED RELEASE DESVENLAFAXINE ER 100 MG TABLET,EXTENDED RELEASE 24 HR DESVENLAFAXINE ER 50 MG TABLET,EXTENDED RELEASE 24 HR DESVENLAFAXINE FUMARATE ER 100 MG TABLET, EXTENDED RELEASE 24 HR DESVENLAFAXINE FUMARATE ER 50 MG TABLET, EXTENDED RELEASE 24 HR EMSAM 12 MG/24 HR TRANSDERMAL 24 HOUR PATCH EMSAM 6 MG/24 HR TRANSDERMAL 24 HOUR PATCH EMSAM 9 MG/24 HR TRANSDERMAL 24 HOUR PATCH Step 1: Trial of TWO of the following formulary products: bupropion, mirtazapine, generic SSRI, or generic SNRI. Emsam or Aplenzin or Desvenlafaxine ER 50mg, 100mg 2
ATYPICAL ANTIPSYCHOTICS FANAPT 1 MG TABLET FANAPT 10 MG TABLET FANAPT 12 MG TABLET FANAPT 1MG(2)-2 MG(2)-4MG(2)-6 MG(2) TABLETS IN A DOSE PACK FANAPT 2 MG TABLET FANAPT 4 MG TABLET FANAPT 6 MG TABLET FANAPT 8 MG TABLET SAPHRIS 10 MG SUBLINGUAL TABLET SAPHRIS 2.5 MG SUBLINGUAL TABLET SAPHRIS 5 MG SUBLINGUAL TABLET Step 1: Trial of two oral, single-ingredient, generic formulary atypical antipsychotic agents. Fanapt or Saphris 3
FETZIMA THERAPY FETZIMA 120 MG CAPSULE,EXTENDED RELEASE FETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED RELEASE,24 HR,DOSE PACK FETZIMA 20 MG CAPSULE,EXTENDED RELEASE FETZIMA 40 MG CAPSULE,EXTENDED RELEASE FETZIMA 80 MG CAPSULE,EXTENDED RELEASE Step 1: Generic venlafaxine immediate release tablets or extended release capsules. Fetzima 4
FILGRASTIM GRANIX 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE GRANIX 300 MCG/ML SUBCUTANEOUS SOLUTION GRANIX 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE GRANIX 480 MCG/1.6 ML SUBCUTANEOUS SOLUTION NEUPOGEN 300 MCG/0.5 ML INJECTION SYRINGE NEUPOGEN 300 MCG/ML INJECTION SOLUTION NEUPOGEN 480 MCG/0.8 ML INJECTION SYRINGE NEUPOGEN 480 MCG/1.6 ML INJECTION SOLUTION NIVESTYM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE NIVESTYM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE Step 1: Trial of Zarxio. Granix, Neupogen, or Nivestym 5
INVEGA TRINZA THERAPY INVEGA TRINZA 273 MG/0.875 ML INTRAMUSCULAR SYRINGE INVEGA TRINZA 410 MG/1.315 ML INTRAMUSCULAR SYRINGE INVEGA TRINZA 546 MG/1.75 ML INTRAMUSCULAR SYRINGE INVEGA TRINZA 819 MG/2.625 ML INTRAMUSCULAR SYRINGE Step 1: Invega Sustenna Invega Trinza 6
LEUKOTRIENE MODIFIER ASTHMA THERAPY zileuton er 600 mg tablet,extended release 12hr mphase ZYFLO 600 MG TABLET Step 1: Trial of generic formulary montelukast or generic zafirlukast. Step 2: Zyflo or Zileuton ER 7
NEUPRO THERAPY NEUPRO 1 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH NEUPRO 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH NEUPRO 3 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH NEUPRO 4 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH NEUPRO 6 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH NEUPRO 8 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH Step 1: Trial of one generic formulary dopamine agonist agent. Neupro. 8
OZEMPIC OZEMPIC 0.25 MG OR 0.5 MG (2 MG/1.5 ML) SUBCUTANEOUS PEN INJECTOR OZEMPIC 1 MG/DOSE (2 MG/1.5 ML) SUBCUTANEOUS PEN INJECTOR Step 1: Byetta or Bydureon AND Trulicity, Ozempic. 9
QTERN QTERN 10 MG-5 MG TABLET Step 1: Trial of Glyxambi. Qtern. 10
RHOFADE RHOFADE 1 % TOPICAL CREAM Step 1: Trial of Finacea and Mirvaso. Rhofade 11
RHOPRESSA RHOPRESSA 0.02 % EYE DROPS Step 1: Trial of any two formulary prostaglandin or prostamide analogs or dorzolamide, dorzolamide-timolol, betaxolol, Simbrinza, Alphagan P, Azopt, timolol maleate, brimonidine, carteolol, Cosopt, or levobunolol. Rhopressa. 12
RYTARY RYTARY 23.75 MG-95 MG CAPSULE,EXTENDED RELEASE RYTARY 36.25 MG-145 MG CAPSULE,EXTENDED RELEASE RYTARY 48.75 MG-195 MG CAPSULE,EXTENDED RELEASE RYTARY 61.25 MG-245 MG CAPSULE,EXTENDED RELEASE Step 1: Trial of any generic antiparkinson agent. Rytary 13
TOPICAL IMMUNOMODULATOR THERAPY ELIDEL 1 % TOPICAL CREAM pimecrolimus 1 % topical cream ST : Pending CMS Approval 14
TRELEGY TRELEGY ELLIPTA 100 MCG-62.5 MCG-25 MCG POWDER FOR INHALATION Step 1: Any two of the following: Advair, Breo, Symbicort, generic fluticasone-salmeterol combination. Trelegy 15
TRESIBA FLEXTOUCH THERAPY TRESIBA FLEXTOUCH U-100 INSULIN 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN TRESIBA FLEXTOUCH U-200 INSULIN 200 UNIT/ML (3 ML) SUBCUTANEOUS PEN TRESIBA U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS SOLUTION Step 1: Any one of the following: Lantus, Lantus Solostar, Toujeo, Toujeo Max. Tresiba Flextouch 16
UCERIS ORAL THERAPY budesonide dr-er 9 mg tablet,delayed and extended release Step 1: Both mesalamine 1200 mg delayed release and oral generic sulfasalazine. Uceris Tablet 17
ULORIC THERAPY ULORIC 40 MG TABLET ULORIC 80 MG TABLET Step 1: Trial of oral generic allopurinol. Uloric 18
VYZULTA VYZULTA 0.024 % EYE DROPS Step 1: Trial of any two formulary prostaglandin or prostamide analogs. Vyzulta. 19
INDEX A APLENZIN 174 MG TABLET,EXTENDED RELEASE... 2 APLENZIN 348 MG TABLET,EXTENDED RELEASE... 2 APLENZIN 522 MG TABLET,EXTENDED RELEASE... 2 B budesonide dr-er 9 mg tablet,delayed and extended release... 17 BYDUREON 2 MG SUBCUTANEOUS EXTENDED RELEASE SUSPENSION 1 BYDUREON 2 MG/0.65 ML SUBCUTANEOUS PEN INJECTOR... 1 BYDUREON BCISE 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR 1 BYETTA 10 MCG/DOSE(250 MCG/ML)2.4 ML SUBCUTANEOUS PEN INJECTOR... 1 BYETTA 5 MCG/DOSE (250 MCG/ML)1.2 ML SUBCUTANEOUS PEN INJECTOR... 1 D DESVENLAFAXINE ER 100 MG TABLET,EXTENDED RELEASE 24 HR... 2 DESVENLAFAXINE ER 50 MG TABLET,EXTENDED RELEASE 24 HR... 2 DESVENLAFAXINE FUMARATE ER 100 MG TABLET, EXTENDED RELEASE 24 HR... 2 DESVENLAFAXINE FUMARATE ER 50 MG TABLET, EXTENDED RELEASE 24 HR... 2 E ELIDEL 1 % TOPICAL CREAM... 14 EMSAM 12 MG/24 HR TRANSDERMAL 24 HOUR PATCH... 2 EMSAM 6 MG/24 HR TRANSDERMAL 24 HOUR PATCH... 2 EMSAM 9 MG/24 HR TRANSDERMAL 24 HOUR PATCH... 2 F FANAPT 1 MG TABLET... 3 FANAPT 10 MG TABLET... 3 FANAPT 12 MG TABLET... 3 FANAPT 1MG(2)-2 MG(2)-4MG(2)-6 MG(2) TABLETS IN A DOSE PACK... 3 FANAPT 2 MG TABLET... 3 FANAPT 4 MG TABLET... 3 FANAPT 6 MG TABLET... 3 FANAPT 8 MG TABLET... 3 FETZIMA 120 MG CAPSULE,EXTENDED RELEASE... 4 FETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED RELEASE,24 HR,DOSE PACK... 4 FETZIMA 20 MG CAPSULE,EXTENDED RELEASE... 4 FETZIMA 40 MG CAPSULE,EXTENDED RELEASE... 4 FETZIMA 80 MG CAPSULE,EXTENDED RELEASE... 4 G GRANIX 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE... 5 GRANIX 300 MCG/ML SUBCUTANEOUS SOLUTION... 5 GRANIX 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE... 5 GRANIX 480 MCG/1.6 ML SUBCUTANEOUS SOLUTION... 5 I INVEGA TRINZA 273 MG/0.875 ML INTRAMUSCULAR SYRINGE... 6 INVEGA TRINZA 410 MG/1.315 ML INTRAMUSCULAR SYRINGE... 6 INVEGA TRINZA 546 MG/1.75 ML INTRAMUSCULAR SYRINGE... 6 INVEGA TRINZA 819 MG/2.625 ML INTRAMUSCULAR SYRINGE... 6 INVOKAMET 150 MG-1,000 MG TABLET... 1 INVOKAMET 150 MG-500 MG TABLET 1 20
INVOKAMET 50 MG-1,000 MG TABLET... 1 INVOKAMET 50 MG-500 MG TABLET. 1 INVOKAMET XR 150 MG-1,000 MG TABLET, EXTENDED RELEASE... 1 INVOKAMET XR 150 MG-500 MG TABLET, EXTENDED RELEASE... 1 INVOKAMET XR 50 MG-1,000 MG TABLET, EXTENDED RELEASE... 1 INVOKAMET XR 50 MG-500 MG TABLET, EXTENDED RELEASE... 1 INVOKANA 100 MG TABLET... 1 INVOKANA 300 MG TABLET... 1 J JANUMET 50 MG-1,000 MG TABLET... 1 JANUMET 50 MG-500 MG TABLET... 1 JANUMET XR 100 MG-1,000 MG TABLET,EXTENDED RELEASE... 1 JANUMET XR 50 MG-1,000 MG TABLET,EXTENDED RELEASE... 1 JANUMET XR 50 MG-500 MG TABLET,EXTENDED RELEASE... 1 JANUVIA 100 MG TABLET... 1 JANUVIA 25 MG TABLET... 1 JANUVIA 50 MG TABLET... 1 JARDIANCE 10 MG TABLET... 1 JARDIANCE 25 MG TABLET... 1 JENTADUETO 2.5 MG-1,000 MG TABLET... 1 JENTADUETO 2.5 MG-500 MG TABLET... 1 JENTADUETO 2.5 MG-850 MG TABLET... 1 JENTADUETO XR 2.5 MG-1,000 MG TABLET, EXTENDED RELEASE... 1 JENTADUETO XR 5 MG-1,000 MG TABLET, EXTENDED RELEASE... 1 N NEUPOGEN 300 MCG/0.5 ML INJECTION SYRINGE... 5 NEUPOGEN 300 MCG/ML INJECTION SOLUTION... 5 NEUPOGEN 480 MCG/0.8 ML INJECTION SYRINGE... 5 NEUPOGEN 480 MCG/1.6 ML INJECTION SOLUTION... 5 NEUPRO 1 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH... 8 NEUPRO 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH... 8 NEUPRO 3 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH... 8 NEUPRO 4 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH... 8 NEUPRO 6 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH... 8 NEUPRO 8 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH... 8 NIVESTYM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE... 5 NIVESTYM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE... 5 O OZEMPIC 0.25 MG OR 0.5 MG (2 MG/1.5 ML) SUBCUTANEOUS PEN INJECTOR... 9 OZEMPIC 1 MG/DOSE (2 MG/1.5 ML) SUBCUTANEOUS PEN INJECTOR... 9 P pimecrolimus 1 % topical cream... 14 Q QTERN 10 MG-5 MG TABLET... 10 R RHOFADE 1 % TOPICAL CREAM... 11 RHOPRESSA 0.02 % EYE DROPS... 12 RYTARY 23.75 MG-95 MG CAPSULE,EXTENDED RELEASE... 13 RYTARY 36.25 MG-145 MG CAPSULE,EXTENDED RELEASE... 13 RYTARY 48.75 MG-195 MG CAPSULE,EXTENDED RELEASE... 13 RYTARY 61.25 MG-245 MG CAPSULE,EXTENDED RELEASE... 13 S SAPHRIS 10 MG SUBLINGUAL TABLET... 3 SAPHRIS 2.5 MG SUBLINGUAL TABLET... 3 SAPHRIS 5 MG SUBLINGUAL TABLET 3 21
SYNJARDY 12.5 MG-1,000 MG TABLET... 1 SYNJARDY 12.5 MG-500 MG TABLET. 1 SYNJARDY 5 MG-1,000 MG TABLET... 1 SYNJARDY 5 MG-500 MG TABLET... 1 SYNJARDY XR 10 MG-1,000 MG TABLET, EXTENDED RELEASE... 1 SYNJARDY XR 12.5 MG-1,000 MG TABLET, EXTENDED RELEASE... 1 SYNJARDY XR 25 MG-1,000 MG TABLET, EXTENDED RELEASE... 1 SYNJARDY XR 5 MG-1,000 MG TABLET, EXTENDED RELEASE... 1 T TRADJENTA 5 MG TABLET... 1 TRELEGY ELLIPTA 100 MCG-62.5 MCG-25 MCG POWDER FOR INHALATION... 15 TRESIBA FLEXTOUCH U-100 INSULIN 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN... 16 TRESIBA FLEXTOUCH U-200 INSULIN 200 UNIT/ML (3 ML) SUBCUTANEOUS PEN... 16 TRESIBA U-100 INSULIN 100 UNIT/ML SUBCUTANEOUS SOLUTION... 16 TRULICITY 0.75 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR... 1 TRULICITY 1.5 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR... 1 U ULORIC 40 MG TABLET... 18 ULORIC 80 MG TABLET... 18 V VYZULTA 0.024 % EYE DROPS... 19 Z zileuton er 600 mg tablet,extended release 12hr mphase... 7 ZYFLO 600 MG TABLET... 7 22