ARISTADA - ARISTADA INJ 441MG/1.6 ARISTADA INJ 662MG/2.4 ARISTADA INJ 882MG/3.2 CLAIM WILL PAY AUTOMATICALLY FOR ARISTADA IF ENROLLEE HAS A PAID CLAIM FOR AT LEAST A 1 DAYS SUPPLY OF ABILIFY MAINTENA AND LATUDA IN THE PAST. OTHERWISE, ARISTADA REQUIRES A STEP THERAPY EXCEPTION REQUEST INDICATING: (1) HISTORY OF INADEQUATE TREATMENT RESPONSE WITH ABILIFY MAINTENA AND LATUDA, OR (2) HISTORY OF ADVERSE EVENT WITH ABILIFY MAINTENA AND LATUDA, OR (3) ABILIFY MAINTENA AND LATUDA ARE CONTRAINDICATED. Effective 01/01/2017 1
MYRBETRIQ - MYRBETRIQ TAB 25MG MYRBETRIQ TAB 50MG CLAIM WILL PAY AUTOMATICALLY FOR MYRBETRIQ IF ENROLLEE HAS A PAID CLAIM FOR AT LEAST A 1 DAYS SUPPLY OF ANY FORMULARY URINARY ANTICHOLINERGIC IN THE PAST. OTHERWISE, MYRBETRIQ REQUIRES A STEP THERAPY EXCEPTION REQUEST INDICATING: (1) HISTORY OF INADEQUATE TREATMENT RESPONSE WITH FORMULARY URINARY ANTICHOLINERGIC, OR (2) HISTORY OF ADVERSE EVENT WITH FORMULARY URINARY ANTICHOLINERGIC, OR (3) FORMULARY URINARY ANTICHOLINERGIC IS CONTRAINDICATED. Effective 01/01/2017 2
PANCREATIC ENZYMES - CREON CAP 12000UNT CREON CAP 24000UNT CREON CAP 3000UNIT CREON CAP 36000UNT CREON CAP 6000UNIT PERTZYE CAP 16000-57500-60500 UNIT PERTZYE CAP 8000-28750-30250 UNIT 1. THE PATIENT IS CURRENTLY STABILIZED ON CREON OR PERTZYE, OR 2. THE PATIENT HAS HAD A TRIAL OF ZENPEP OR PANCREAZE OR 3. THE PATIENT HAS HAD AN INADEQUATE RESPONSE AFTER A TRIAL OF ZENPEP OR PANCREAZE OR 4. THE PATIENT IS INTOLERANT TO OR HAD AN ADVERSE REACTION WITH ZENPEP OR PANCREAZE. Effective 01/01/2017 3
PPI - DEXILANT CAP 30MG DR DEXILANT CAP 60MG DR 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 01/01/2017 4
RHEUMATOID ARTHRITIS - ACTEMRA INJ 162/0.9 ACTEMRA INJ 200/10ML ACTEMRA INJ 400/20ML ACTEMRA INJ 80MG/4ML CIMZIA KIT CIMZIA PREFL KIT 200MG/ML COSENTYX INJ 150MG/ML COSENTYX PEN INJ 150MG/ML KINERET INJ ORENCIA INJ 125MG/ML ORENCIA INJ 250MG SIMPONI ARIA SOL 50MG/4ML SIMPONI AUTO-INJ 100MG/ML SIMPONI AUTO-INJ 50/0.5ML SIMPONI PFS INJ 100MG/ML SIMPONI PFS INJ 50/0.5ML STELARA INJ 45MG/0.5 STELARA INJ 90MG/ML XELJANZ TAB 5MG CLAIM WILL PAY AUTOMATICALLY FOR ACTREMA, CIMZIA, COSENTYX, KINERET, ORENCIA, SIMPONI, STELARA, OR XELJANZ IF ENROLLEE HAS A PAID CLAIM FOR AT LEAST A 1 DAYS SUPPLY OF ENBREL OR HUMIRA IN THE PAST. OTHERWISE, ACTREMA, CIMZIA, KINERET, ORENCIA, SIMPONI, STELARA, OR XELJANZ REQUIRES A STEP THERAPY EXCEPTION REQUEST INDICATING: (1) HISTORY OF INADEQUATE TREATMENT RESPONSE WITH ENBREL OR HUMIRA, OR (2) HISTORY OF ADVERSE EVENT WITH ENBREL OR HUMIRA, OR (3) ENBREL OR HUMIRA IS CONTRAINDICATED, OR (4) FOR DIAGNOSIS CRYOPYRIN-ASSOCIATED PERIODIC SYNDROMES, KINERET WILL BE APPROVED, OR (5) FOR DIAGNOSIS PEDIATRIC ULCERATIVE COLITIS, REMICADE WILL BE APPROVED. Effective 01/01/2017 5
TRINTELLIX - TRINTELLIX TAB 10MG TRINTELLIX TAB 20MG TRINTELLIX TAB 5MG 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. Effective 01/01/2017 6
UCERIS - UCERIS AER 2MG/ACT UCERIS TAB 9MG 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 01/01/2017 7
VRAYLAR - VRAYLAR CAP 1.5-3MG VRAYLAR CAP 1.5MG VRAYLAR CAP 3MG VRAYLAR CAP 4.5MG VRAYLAR CAP 6MG CLAIM WILL PAY AUTOMATICALLY FOR VRAYLAR IF ENROLLEE HAS A PAID CLAIM FOR AT LEAST A 1 DAYS SUPPLY OF ARIPIPRAZOLE, OLANZAPINE, QUETIAPINE, RISPERIDONE, SEROQUEL XR, ZIPRASIDONE OR LATUDA IN THE PAST. OTHERWISE, VRAYLAR REQUIRES A STEP THERAPY EXCEPTION REQUEST INDICATING ANY ONE OF 1,2,3, OR 4: (1) HISTORY OF INADEQUATE TREATMENT RESPONSE WITH ARIPIPRAZOLE, OLANZAPINE, QUETIAPINE, RISPERIDONE, SEROQUEL XR, ZIPRASIDONE, OR LATUDA OR (2) HISTORY OF ADVERSE EVENT WITH ARIPIPRAZOLE, OLANZAPINE, QUETIAPINE, RISPERIDONE, SEROQUEL XR, ZIPRASIDONE, OR LATUDA OR (3) ARIPIPRAZOLE, OLANZAPINE, QUETIAPINE, RISPERIDONE, SEROQUEL XR, ZIPRASIDONE OR LATUDA ARE CONTRAINDICATED. OR (4) FOR DIAGNOSIS OF MANIC EPIPISODES ASSOCIATED WTIH BIPOLAR DISORDER, THE COVERAGE DETERMINATION WILL BE APPROVED WITHOUT REQUIREMENT OF TRIAL AND FAILURE OR CONTRAINDICATION TO LATUDA. Effective 01/01/2017 8
XTANDI - XTANDI CAP 40MG 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. Effective 01/01/2017 9