ALZHEIMER'S DRUGS Products Affected Step 1: donepezil 10 mg disintegrating tablet donepezil 10 mg tablet donepezil 23 mg tablet donepezil 5 mg disintegrating tablet donepezil 5 mg tablet galantamine 12 mg tablet galantamine 4 mg tablet galantamine 4 mg/ml oral solution galantamine 8 mg tablet Step 2: Exelon Patch 13.3 mg/24 hour transdermal Exelon Patch 4.6 mg/24 hr transdermal galantamine ER 16 mg 24 hr capsule,extended galantamine ER 24 mg 24 hr capsule,extended galantamine ER 8 mg 24 hr capsule,extended rivastigmine 1.5 mg capsule rivastigmine 3 mg capsule rivastigmine 4.5 mg capsule rivastigmine 6 mg capsule Exelon Patch 9.5 mg/24 hr transdermal Details Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Authorization may be given for a Step 2 drug if the patient is currently taking (or has taken in the past) the requested agent. Authorization for Exelon Patch may be given if the patient has difficulty swallowing or cannot swallow. This step therapy program applies to new utilizers only. RX_345_2015_v_01_Clinical_Criteria_Step_Therapy
ANTIDEPRESSANTS - SNRI Products Affected Step 1: citalopram 10 mg tablet citalopram 10 mg/5 ml oral solution citalopram 20 mg tablet citalopram 40 mg tablet duloxetine 20 mg capsule,delayed duloxetine 30 mg capsule,delayed duloxetine 40 mg capsule,delayed duloxetine 60 mg capsule,delayed escitalopram 10 mg tablet escitalopram 20 mg tablet escitalopram 5 mg tablet escitalopram 5 mg/5 ml oral solution fluoxetine 10 mg capsule fluoxetine 10 mg tablet fluoxetine 20 mg capsule fluoxetine 20 mg tablet fluoxetine 20 mg/5 ml oral solution fluoxetine 40 mg capsule fluoxetine 90 mg capsule,delayed fluvoxamine 100 mg tablet fluvoxamine 25 mg tablet fluvoxamine 50 mg tablet fluvoxamine ER 100 mg capsule,extended Step 2: Fetzima 120 mg capsule,extended Fetzima 20 mg (2)-40 mg (26) capsule,extended,24 hr,dose pack Fetzima 20 mg capsule,extended Fetzima 40 mg capsule,extended fluvoxamine ER 150 mg capsule,extended paroxetine 10 mg tablet paroxetine 20 mg tablet paroxetine 30 mg tablet paroxetine 40 mg tablet paroxetine ER 12.5 mg tablet,extended paroxetine ER 25 mg tablet,extended paroxetine ER 37.5 mg tablet,extended sertraline 100 mg tablet sertraline 20 mg/ml oral concentrate sertraline 25 mg tablet sertraline 50 mg tablet venlafaxine 100 mg tablet venlafaxine 25 mg tablet venlafaxine 37.5 mg tablet venlafaxine 50 mg tablet venlafaxine 75 mg tablet venlafaxine ER 150 mg capsule,extended venlafaxine ER 37.5 mg capsule,extended venlafaxine ER 75 mg capsule,extended Fetzima 80 mg capsule,extended Pristiq 100 mg tablet,extended Pristiq 25 mg tablet,extended Pristiq 50 mg tablet,extended Details 2
Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Authorization may be given for a step 2 drug without a trial of a step 1 drug, if the patient is currently taking or has taken the drug in the past. Authorization may be given for a step 2 drug, without a trial of a step 1 agent, if the patient has symptoms of suicidal ideation. RX_345_2015_v_01_Clinical_Criteria_Step_Therapy
HIGH RISK MEDICATIONS - SEDATIVE HYPNOTICS Products Affected Step 1: Rozerem 8 mg tablet trazodone 100 mg tablet trazodone 150 mg tablet Step 2: eszopiclone 1 mg tablet eszopiclone 2 mg tablet eszopiclone 3 mg tablet zaleplon 10 mg capsule zaleplon 5 mg capsule zolpidem 10 mg tablet trazodone 300 mg tablet trazodone 50 mg tablet zolpidem 5 mg tablet zolpidem ER 12.5 mg tablet,extended,multiphase zolpidem ER 6.25 mg tablet,extended,multiphase Details Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. This step therapy program applies to chronic utilizers greater than 64 years of age only. Authorization for zolpidem or zolpidem Er (brand or generic) may be given if being used for neuroleptic induced parkinsonism, dystonia, restless leg syndrome, or supranuclear paralysis. Authorization for a step 2 drug may be given in patients aged less than 65 years. 4
TOPICAL NSAIDS Products Affected Step 1: diclofenac 1.5 % topical drops diclofenac 50 mg-misoprostol 200 mcg tablet,immed.and delayed diclofenac 75 mg-misoprostol 200 mcg tablet,immediate & delayed rel diclofenac ER 100 mg tablet,extended diclofenac potassium 50 mg tablet diclofenac sodium 25 mg tablet,delayed diclofenac sodium 50 mg tablet,delayed diclofenac sodium 75 mg tablet,delayed etodolac 200 mg capsule etodolac 300 mg capsule etodolac 400 mg tablet etodolac 500 mg tablet etodolac ER 400 mg tablet,extended etodolac ER 500 mg tablet,extended etodolac ER 600 mg tablet,extended fenoprofen 600 mg tablet flurbiprofen 100 mg tablet flurbiprofen 50 mg tablet ibuprofen 100 mg/5 ml oral suspension ibuprofen 400 mg tablet ibuprofen 600 mg tablet ibuprofen 800 mg tablet ketoprofen 50 mg capsule ketoprofen 75 mg capsule ketoprofen ER 200 mg 24 hr capsule,extended meclofenamate 100 mg capsule meclofenamate 50 mg capsule mefenamic acid 250 mg capsule meloxicam 15 mg tablet meloxicam 7.5 mg tablet meloxicam 7.5 mg/5 ml oral suspension nabumetone 500 mg tablet nabumetone 750 mg tablet naproxen 125 mg/5 ml oral suspension naproxen 250 mg tablet naproxen 375 mg tablet naproxen 375 mg tablet,delayed naproxen 500 mg tablet naproxen 500 mg tablet,delayed naproxen sodium 275 mg tablet naproxen sodium 550 mg tablet naproxen sodium ER 375 mg tablet,extended 24hr mphase naproxen sodium ER 500 mg tablet,extended 24hr mphase oxaprozin 600 mg tablet piroxicam 10 mg capsule piroxicam 20 mg capsule sulindac 150 mg tablet sulindac 200 mg tablet tolmetin 200 mg tablet tolmetin 400 mg capsule tolmetin 600 mg tablet Step 2: Voltaren 1 % topical gel Details RX_345_2015_v_01_Clinical_Criteria_Step_Therapy
Criteria If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Authorization may be given for Voltaren Gel for patients with difficulty swallowing or cannot swallow. Authorization may be given for Voltaren Gel for patients with a chronic musculoskeletal pain condition (eg, osteoarthritis) in 3 or fewer joints/sites (ie, hand, wrist, elbow, knee, ankle, or foot each count as 1 joint/site) who are at risk of NSAID-associated toxicity (eg, previous gastrointestinal [GI] bleed, history of peptic ulcer disease, impaired renal function, cardiovascular disease, hypertension, heart failure, elderly patients with impaired hepatic function, or those taking concomitant anticoagulants). Authorization may be given for Voltaren Gel for patients greater than or equal to 75 years of age with hand or knee osteoarthritis. 6
ULORIC Products Affected Step 1: allopurinol 100 mg tablet Step 2: Uloric 40 mg tablet allopurinol 300 mg tablet Uloric 80 mg tablet Details Criteria If the patient has tried a Step 1 drug then authorization for a Step 2 drug may be given. Authorization may be given for Uloric if the patient has renal insufficiency or decreased renal function. Authorization may be given for Uloric if the patient is receiving concomitant medications that have significant drug-drug interactions with allopurinol, which are not noted with Uloric (eg, cyclosporine, chlorpropamide). RX_345_2015_v_01_Clinical_Criteria_Step_Therapy
Index A allopurinol 100 mg tablet... 7 allopurinol 300 mg tablet... 7 C citalopram 10 mg tablet... 2 citalopram 10 mg/5 ml oral solution... 2 citalopram 20 mg tablet... 2 citalopram 40 mg tablet... 2 D diclofenac 1.5 % topical drops... 5 diclofenac 50 mg-misoprostol 200 mcg tablet,immed.and delayed... 5 diclofenac 75 mg-misoprostol 200 mcg tablet,immediate & delayed rel... 5 diclofenac ER 100 mg tablet,extended... 5 diclofenac potassium 50 mg tablet... 5 diclofenac sodium 25 mg tablet,delayed... 5 diclofenac sodium 50 mg tablet,delayed... 5 diclofenac sodium 75 mg tablet,delayed... 5 donepezil 10 mg disintegrating tablet... 1 donepezil 10 mg tablet... 1 donepezil 23 mg tablet... 1 donepezil 5 mg disintegrating tablet... 1 donepezil 5 mg tablet... 1 duloxetine 20 mg capsule,delayed.. 2 duloxetine 30 mg capsule,delayed.. 2 duloxetine 40 mg capsule,delayed.. 2 duloxetine 60 mg capsule,delayed.. 2 E escitalopram 10 mg tablet... 2 escitalopram 20 mg tablet... 2 escitalopram 5 mg tablet... 2 escitalopram 5 mg/5 ml oral solution... 2 eszopiclone 1 mg tablet... 4 eszopiclone 2 mg tablet... 4 eszopiclone 3 mg tablet... 4 etodolac 200 mg capsule... 5 etodolac 300 mg capsule... 5 etodolac 400 mg tablet... 5 etodolac 500 mg tablet... 5 etodolac ER 400 mg tablet,extended 24 hr... 5 etodolac ER 500 mg tablet,extended 24 hr... 5 etodolac ER 600 mg tablet,extended 24 hr... 5 Exelon Patch 13.3 mg/24 hour transdermal 1 Exelon Patch 4.6 mg/24 hr transdermal... 1 Exelon Patch 9.5 mg/24 hr transdermal... 1 F fenoprofen 600 mg tablet... 5 Fetzima 120 mg capsule,extended.. 2 Fetzima 20 mg (2)-40 mg (26) capsule,extended,24 hr,dose pack 2 Fetzima 20 mg capsule,extended... 2 Fetzima 40 mg capsule,extended... 2 Fetzima 80 mg capsule,extended... 2 fluoxetine 10 mg capsule... 2 fluoxetine 10 mg tablet... 2 fluoxetine 20 mg capsule... 2 fluoxetine 20 mg tablet... 2 fluoxetine 20 mg/5 ml oral solution... 2 fluoxetine 40 mg capsule... 2 fluoxetine 90 mg capsule,delayed... 2 flurbiprofen 100 mg tablet... 5 flurbiprofen 50 mg tablet... 5 fluvoxamine 100 mg tablet... 2 fluvoxamine 25 mg tablet... 2 fluvoxamine 50 mg tablet... 2 fluvoxamine ER 100 mg capsule,extended... 2 fluvoxamine ER 150 mg capsule,extended... 2 G galantamine 12 mg tablet... 1 galantamine 4 mg tablet... 1 galantamine 4 mg/ml oral solution... 1 galantamine 8 mg tablet... 1 galantamine ER 16 mg 24 hr capsule,extended... 1 galantamine ER 24 mg 24 hr capsule,extended... 1 galantamine ER 8 mg 24 hr capsule,extended... 1 8
I ibuprofen 100 mg/5 ml oral suspension... 5 ibuprofen 400 mg tablet... 5 ibuprofen 600 mg tablet... 5 ibuprofen 800 mg tablet... 5 K ketoprofen 50 mg capsule... 5 ketoprofen 75 mg capsule... 5 ketoprofen ER 200 mg 24 hr capsule,extended... 5 M meclofenamate 100 mg capsule... 5 meclofenamate 50 mg capsule... 5 mefenamic acid 250 mg capsule... 5 meloxicam 15 mg tablet... 5 meloxicam 7.5 mg tablet... 5 meloxicam 7.5 mg/5 ml oral suspension... 5 N nabumetone 500 mg tablet... 5 nabumetone 750 mg tablet... 5 naproxen 125 mg/5 ml oral suspension... 5 naproxen 250 mg tablet... 5 naproxen 375 mg tablet... 5 naproxen 375 mg tablet,delayed... 5 naproxen 500 mg tablet... 5 naproxen 500 mg tablet,delayed... 5 naproxen sodium 275 mg tablet... 5 naproxen sodium 550 mg tablet... 5 naproxen sodium ER 375 mg tablet,extended 24hr mphase... 5 naproxen sodium ER 500 mg tablet,extended 24hr mphase... 5 O oxaprozin 600 mg tablet... 5 P paroxetine 10 mg tablet... 2 paroxetine 20 mg tablet... 2 paroxetine 30 mg tablet... 2 paroxetine 40 mg tablet... 2 paroxetine ER 12.5 mg tablet,extended... 2 paroxetine ER 25 mg tablet,extended 24 hr... 2 paroxetine ER 37.5 mg tablet,extended... 2 piroxicam 10 mg capsule... 5 piroxicam 20 mg capsule... 5 Pristiq 100 mg tablet,extended... 2 Pristiq 25 mg tablet,extended... 2 Pristiq 50 mg tablet,extended... 2 R rivastigmine 1.5 mg capsule... 1 rivastigmine 3 mg capsule... 1 rivastigmine 4.5 mg capsule... 1 rivastigmine 6 mg capsule... 1 Rozerem 8 mg tablet... 4 S sertraline 100 mg tablet... 2 sertraline 20 mg/ml oral concentrate... 2 sertraline 25 mg tablet... 2 sertraline 50 mg tablet... 2 sulindac 150 mg tablet... 5 sulindac 200 mg tablet... 5 T tolmetin 200 mg tablet... 5 tolmetin 400 mg capsule... 5 tolmetin 600 mg tablet... 5 trazodone 100 mg tablet... 4 trazodone 150 mg tablet... 4 trazodone 300 mg tablet... 4 trazodone 50 mg tablet... 4 U Uloric 40 mg tablet... 7 Uloric 80 mg tablet... 7 V venlafaxine 100 mg tablet... 2 venlafaxine 25 mg tablet... 2 venlafaxine 37.5 mg tablet... 2 venlafaxine 50 mg tablet... 2 venlafaxine 75 mg tablet... 2 venlafaxine ER 150 mg capsule,extended... 2 venlafaxine ER 37.5 mg capsule,extended... 2 venlafaxine ER 75 mg capsule,extended... 2 Voltaren 1 % topical gel... 5 Z zaleplon 10 mg capsule... 4 zaleplon 5 mg capsule... 4 zolpidem 10 mg tablet... 4 zolpidem 5 mg tablet... 4 RX_345_2015_v_01_Clinical_Criteria_Step_Therapy
zolpidem ER 12.5 mg tablet,extended,multiphase... 4 zolpidem ER 6.25 mg tablet,extended,multiphase... 4 10