GLP1-INSULIN XULTOPHY SOLUTION PEN- INJECTOR 100-3.6 UNIT-MG/ML Claim will pay automatically for Xultophy if enrollee has a paid claim for at least a one day supply for step level 1 agent (LANTUS, LEVEMIR, OZEMPIC, TOUJEO, TRESIBA, OR VICTOZA). Otherwise, Xultophy requires a step therapy exception request indicating: (1) history of inadequate treatment response with step 1 agent, OR (2) history of adverse event with step 1 agent, OR (3) step 1 agent is contraindicated. Effective 11/01/2018 1
PPI DEXILANT CAPSULE DELAYED RELEASE 30 MG ORAL DEXILANT CAPSULE DELAYED RELEASE 60 MG ORAL Claim will pay automatically for Dexilant if enrollee has a paid claim for at least a 1 days supply of lansoprazole, omeprazole, pantoprazole, or rabeprazole in the past. Otherwise, Dexilant requires a step therapy exception request indicating: (1) history of inadequate treatment response with lansoprazole, omeprazole, pantoprazole, or rabeprazole, OR (2) history of adverse event with lansoprazole, omeprazole, pantoprazole, or rabeprazole, OR (3) lansoprazole, omeprazole, pantoprazole, or rabeprazole is contraindicated. Effective 11/01/2018 2
RHEUMATOID ARTHRITIS ACTEMRA SOLUTION 200 MG/10ML INTRAVENOUS ACTEMRA SOLUTION 400 MG/20ML INTRAVENOUS ACTEMRA SOLUTION 80 MG/4ML INTRAVENOUS ACTEMRA SOLUTION PREFILLED SYRINGE 162 MG/0.9ML CIMZIA KIT 2 X 200 MG CIMZIA PREFILLED KIT 2 X 200 MG/ML COSENTYX 300 DOSE SOLUTION PREFILLED SYRINGE 150 MG/ML COSENTYX SENSOREADY 300 DOSE SOLUTION AUTO-INJECTOR 150 MG/ML KINERET SOLUTION PREFILLED SYRINGE 100 MG/0.67ML ORENCIA CLICKJECT SOLUTION AUTO-INJECTOR 125 MG/ML ORENCIA SOLUTION PREFILLED SYRINGE 125 MG/ML ORENCIA SOLUTION PREFILLED SYRINGE 50 MG/0.4ML ORENCIA SOLUTION PREFILLED SYRINGE 87.5 MG/0.7ML ORENCIA SOLUTION RECONSTITUTED 250 MG INTRAVENOUS SIMPONI ARIA SOLUTION 50 MG/4ML INTRAVENOUS SIMPONI SOLUTION AUTO- INJECTOR 100 MG/ML SIMPONI SOLUTION AUTO- INJECTOR 50 MG/0.5ML SIMPONI SOLUTION PREFILLED SYRINGE 100 MG/ML SIMPONI SOLUTION PREFILLED SYRINGE 50 MG/0.5ML STELARA SOLUTION 130 MG/26ML INTRAVENOUS STELARA SOLUTION 45 MG/0.5ML STELARA SOLUTION PREFILLED SYRINGE 45 MG/0.5ML STELARA SOLUTION PREFILLED SYRINGE 90 MG/ML TYSABRI CONCENTRATE 300 MG/15ML INTRAVENOUS XELJANZ TABLET 10 MG ORAL XELJANZ TABLET 5 MG ORAL Effective 11/01/2018 3
Claim will pay automatically for Actrema, Cimzia, Cosentyx, Kineret, Orencia, Simponi, Stelara, Tysabri, or Xeljanz if enrollee has a paid claim for at least a 1 days supply of Enbrel AND Humira in the past. Enrollee does NOT need history of Humira prior to Actrema, Cimzia, Cosentyx, Kineret, Orencia, Simponi, Stelara, Tysabri, or Xeljanz if diagnosed with Polyarticular Juvenile Idiopathic Arthritis (PJIA). Enrollee does NOT need history of Enbrel prior to Actrema, Cimzia, Cosentyx, Kineret, Orencia, Simponi, Stelara, Tysabri, or Xeljanz if diagnosed with Crohns Disease (CD), Ulcerative Colitis (UC), Juvenile Idiopathic Arthritis (JIA), or Systemic Juvenile Idiopathic arthritis (SJIA). Otherwise, Actrema, Cimzia, Cosentyx, Kineret, Orencia, Simponi, Stelara, Tysabri, or Xeljanz requires a step therapy exception request indicating: (1) history of inadequate treatment response with Enbrel AND Humira, OR (2) history of adverse event with Enbrel AND Humira, OR (3) Enbrel AND Humira is contraindicated, OR (4) For diagnosis cryopyrin-associated periodic syndromes, Kineret will be approved, OR (5) For diagnosis of relapsing Multiple sclerosis, Tysabri will be approved, OR (6) For diagnosis of Giant Cell Arteritis, Actemra will be approved. Effective 11/01/2018 4
TRINTELLIX TRINTELLIX TABLET 10 MG ORAL TRINTELLIX TABLET 20 MG ORAL TRINTELLIX TABLET 5 MG ORAL Claim will pay automatically for trintellix if enrollee has a paid claim for at least a 1 days supply of any 2 generic formulary antidepressants in the past. Otherwise, trintellix requires a step therapy exception request indicating: (1) history of inadequate treatment response with any 2 generic formulary antidepressants, OR (2) history of adverse event with any 2 generic formulary antidepressantss, OR (3) any 2 generic formulary antidepressants are contraindicated. This criteria applies to New Starts only. Effective 11/01/2018 5
UCERIS UCERIS FOAM 2 MG/ACT RECTAL UCERIS TABLET EXTENDED RELEASE 24 HOUR 9 MG ORAL Claim will pay automatically for Uceris if enrollee has a paid claim for at least a 1 days supply of any formulary corticosteroid used to treat ulcerative colitis in the past. Otherwise, Uceris requires a step therapy exception request indicating: (1) history of inadequate treatment response with formulary corticosteroid used to treat ulcerative colitis, OR (2) history of adverse event with formulary corticosteroid used to treat ulcerative colitis, OR (3) formulary corticosteroid used to treat ulcerative colitis is contraindicated. Effective 11/01/2018 6
ULORIC ULORIC TABLET 40 MG ORAL ULORIC TABLET 80 MG ORAL Claim will pay automatically for Uloric if enrollee has a paid claim for at least a 1 days supply of Allopurinol in the past. 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. Effective 11/01/2018 7
VRAYLAR VRAYLAR CAPSULE 1.5 MG ORAL VRAYLAR CAPSULE 3 MG ORAL VRAYLAR CAPSULE 4.5 MG ORAL VRAYLAR CAPSULE 6 MG ORAL VRAYLAR CAPSULE THERAPY PACK 1.5 & 3 MG ORAL Claim will pay automatically for VRAYLAR if enrollee has a paid claim for at least a 1 days supply of ARIPIPRAZOLE, OLANZAPINE, QUETIAPINE, QUITIAPINE ER, RISPERIDONE, ZIPRASIDONE OR LATUDA in the past. Otherwise, Vraylar requires a step therapy exception request indicating any ONE of criteria 1,2,3, OR 4: (1) history of inadequate treatment response with ARIPIPRAZOLE, OLANZAPINE, QUETIAPINE, QUITIAPINE ER, RISPERIDONE, ZIPRASIDONE, or LATUDA OR (2) history of adverse event with ARIPIPRAZOLE, OLANZAPINE, QUETIAPINE, QUITIAPINE ER, RISPERIDONE, ZIPRASIDONE, or LATUDA OR (3) ARIPIPRAZOLE, OLANZAPINE, QUETIAPINE, QUITIAPINE ER, RISPERIDONE, ZIPRASIDONE or LATUDA are contraindicated. OR (4) FOR Diagnosis OF MANIC EPISODES ASSOCIATED WTIH BIPOLAR DISORDER, THE COVERAGE DETERMINATION WILL BE APPROVED WITHOUT REQUIREMENT OF CONTRAINDICATION TO LATUDA. This criteria applies to New Starts only. Effective 11/01/2018 8
XTANDI XTANDI CAPSULE 40 MG ORAL Claim will pay automatically for Xtandi if enrollee has a paid claim for at least a 1 days supply of Zytiga in the past. Otherwise, Xtandi requires a step therapy exception request indicating: (1) history of inadequate treatment response with Zytiga, OR (2) history of adverse event with Zytiga, OR (3) Zytiga is contraindicated. This criteria applies to New Starts only. Effective 11/01/2018 9
Alphabetical Listing A ACTEMRA SOLUTION 200 MG/10ML ACTEMRA SOLUTION 400 MG/20ML ACTEMRA SOLUTION 80 MG/4ML ACTEMRA SOLUTION PREFILLED SYRINGE 162 MG/0.9ML... 3, 4 C CIMZIA KIT 2 X 200 MG... 3, 4 CIMZIA PREFILLED KIT 2 X 200 MG/ML... 3, 4 COSENTYX 300 DOSE SOLUTION PREFILLED SYRINGE 150 MG/ML... 3, 4 COSENTYX SENSOREADY 300 DOSE SOLUTION AUTO-INJECTOR 150 MG/ML... 3, 4 D DEXILANT CAPSULE DELAYED RELEASE 30 MG ORAL... 2 DEXILANT CAPSULE DELAYED RELEASE 60 MG ORAL... 2 K KINERET SOLUTION PREFILLED SYRINGE 100 MG/0.67ML... 3, 4 O ORENCIA CLICKJECT SOLUTION AUTO-INJECTOR 125 MG/ML... 3, 4 ORENCIA SOLUTION PREFILLED SYRINGE 125 MG/ML... 3, 4 ORENCIA SOLUTION PREFILLED SYRINGE 50 MG/0.4ML... 3, 4 ORENCIA SOLUTION PREFILLED SYRINGE 87.5 MG/0.7ML... 3, 4 ORENCIA SOLUTION RECONSTITUTED 250 MG S SIMPONI ARIA SOLUTION 50 MG/4ML SIMPONI SOLUTION AUTO-INJECTOR 100 MG/ML... 3, 4 SIMPONI SOLUTION AUTO-INJECTOR 50 MG/0.5ML... 3, 4 SIMPONI SOLUTION PREFILLED SYRINGE 100 MG/ML... 3, 4 SIMPONI SOLUTION PREFILLED SYRINGE 50 MG/0.5ML... 3, 4 STELARA SOLUTION 130 MG/26ML STELARA SOLUTION 45 MG/0.5ML... 3, 4 STELARA SOLUTION PREFILLED SYRINGE 45 MG/0.5ML... 3, 4 STELARA SOLUTION PREFILLED SYRINGE 90 MG/ML... 3, 4 T TRINTELLIX TABLET 10 MG ORAL... 5 TRINTELLIX TABLET 20 MG ORAL... 5 TRINTELLIX TABLET 5 MG ORAL... 5 TYSABRI CONCENTRATE 300 MG/15ML INTRAVENOUS... 3, 4 U UCERIS FOAM 2 MG/ACT RECTAL... 6 UCERIS TABLET EXTENDED RELEASE 24 HOUR 9 MG ORAL... 6 ULORIC TABLET 40 MG ORAL... 7 ULORIC TABLET 80 MG ORAL... 7 V VRAYLAR CAPSULE 1.5 MG ORAL... 8 VRAYLAR CAPSULE 3 MG ORAL... 8 VRAYLAR CAPSULE 4.5 MG ORAL... 8 VRAYLAR CAPSULE 6 MG ORAL... 8 10
VRAYLAR CAPSULE THERAPY PACK 1.5 & 3 MG ORAL... 8 X XELJANZ TABLET 10 MG ORAL... 3, 4 XELJANZ TABLET 5 MG ORAL... 3, 4 XTANDI CAPSULE 40 MG ORAL... 9 XULTOPHY SOLUTION PEN-INJECTOR 100-3.6 UNIT-MG/ML... 1 11