ACYCLOVIR OINT (CCHP2017) acyclovir 5 % topical ointment Step Therapy requires trial of one (1) of the following: oral generic acyclovir, oral generic famciclovir, oral generic valacyclovir. 1
ALPHAGAN (CCHP2017) Alphagan P 0.1 % eye drops Step Therapy requires trial of brimonidine 0.15%. 2
ANTIDEPRESSANT_NVT 2017 desvenlafaxine ER 100 mg tablet,extended release 24 hr desvenlafaxine ER 50 mg tablet,extended release 24 hr duloxetine 40 mg capsule,delayed release 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 fluvoxamine ER 100 mg capsule,extended release 24 hr fluvoxamine ER 150 mg capsule,extended release 24 hr Trintellix 10 mg tablet Trintellix 20 mg tablet Trintellix 5 mg tablet Viibryd 10 mg (7)-20 mg (23) tablets in a dose pack Viibryd 10 mg tablet Viibryd 20 mg tablet Viibryd 40 mg tablet Step Therapy requires trial of one of the following generic SSRI's in previous 120 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain. 3
ARANESP_NVT 2016 Aranesp 10 mcg/0.4 ml (in polysorbate) Aranesp 100 mcg/0.5 ml (in polysorbate) Aranesp 100 mcg/ml (in polysorbate) Injection Aranesp 150 mcg/0.3 ml (in polysorbate) Aranesp 200 mcg/0.4 ml (in polysorbate) Aranesp 200 mcg/ml (in polysorbate) Injection Aranesp 25 mcg/0.42 ml (in polysorbate) Aranesp 25 mcg/ml (in polysorbate) Injection Aranesp 300 mcg/0.6 ml (in polysorbate) Aranesp 300 mcg/ml (in polysorbate) Injection Aranesp 40 mcg/0.4 ml (in polysorbate) Aranesp 40 mcg/ml (in polysorbate) Injection Aranesp 500 mcg/ml (in polysorbate) Aranesp 60 mcg/0.3 ml (in polysorbate) Aranesp 60 mcg/ml (in polysorbate) Injection Step Therapy requires trial of PROCRIT or EPOGEN 4
ARICEPT 23_NVT 2015 donepezil 23 mg tablet Step Therapy requires trial of donepezil 10mg in previous 120 days. 5
DRY EYE OTC (CCHP 2018) Restasis 0.05 % eye drops in a dropperette Restasis MultiDose 0.05 % eye drops Step Therapy requires trial of OTC artificial tears. 6
ESTRING_NVT 2016 Estring 2 mg (7.5 mcg/24 hour) vaginal ring Step Therapy requires trial of PREMARIN VAGINAL CREAM in previous 120 days. 7
NAMZARIC_NVT Namzaric 14 mg-10 mg capsule sprinkle,extended release Namzaric 21 mg-10 mg capsule sprinkle,extended release Namzaric 28 mg-10 mg capsule sprinkle,extended release Namzaric 7 mg-10 mg capsule sprinkle,extended release Namzaric 7/14/21/28 mg-10 mg capsule,sprinkle,er 24hr,dose pack Patient has tried or was intolerant to donepezil and memantine. 8
OPHTHALMIC ANTI-INFECTIVES_NVT 2015 Besivance 0.6 % eye drops,suspension gatifloxacin 0.5 % eye drops Step Therapy requires trial of one of the following ciprofloxacin, levofloxacin, ofloxacin, VIGAMOX or MOXEZA in previous 120 days. 9
PANCREATIC ENZYMES_NVT 2015 Pancreaze 10,500 unit-35,500 unit-61,500 unit capsule,delayed release Pancreaze 16,800 unit-56,800 unit-98,400 unit capsule,delayed release Pancreaze 2,600 unit-6,200 unit-10,850 unit capsule,delayed release Pancreaze 21,000 unit-54,700 unit-83,900 unit capsule,delayed release Pancreaze 4,200 unit-14,200 unit-24,600 unit capsule,delayed release Step Therapy requires trial of CREON in previous 120 days. 10
ULORIC_NVT 2015 Uloric 40 mg tablet Uloric 80 mg tablet Step Therapy requires trial of allopurinol in previous 120 days. 11
VANCOCIN_NVT vancomycin 125 mg capsule vancomycin 250 mg capsule Step Therapy requires trial of metronidazole in previous 120 days. If for C. difficile-associate diarrhea, step therapy not required if for severe or complicated disease. 12
ZADITOR OTC (CCHP2017) olopatadine 0.1 % eye drops Step 3: olopatadine 0.2 % eye drops Pazeo 0.7 % eye drops Step Therapy requires trial of OTC zaditor/ketotifen for olopatadine ophth soln. Trial of olopatadine ophth soln required for PATADAY/PAZEO. 13
INDEX A acyclovir 5 % topical ointment... 1 Alphagan P 0.1 % eye drops... 2 Aranesp 10 mcg/0.4 ml (in polysorbate)... 4 Aranesp 100 mcg/0.5 ml (in polysorbate)... 4 Aranesp 100 mcg/ml (in polysorbate) Injection... 4 Aranesp 150 mcg/0.3 ml (in polysorbate)... 4 Aranesp 200 mcg/0.4 ml (in polysorbate)... 4 Aranesp 200 mcg/ml (in polysorbate) Injection... 4 Aranesp 25 mcg/0.42 ml (in polysorbate)... 4 Aranesp 25 mcg/ml (in polysorbate) Injection... 4 Aranesp 300 mcg/0.6 ml (in polysorbate)... 4 Aranesp 300 mcg/ml (in polysorbate) Injection... 4 Aranesp 40 mcg/0.4 ml (in polysorbate)... 4 Aranesp 40 mcg/ml (in polysorbate) Injection... 4 Aranesp 500 mcg/ml (in polysorbate)... 4 Aranesp 60 mcg/0.3 ml (in polysorbate)... 4 Aranesp 60 mcg/ml (in polysorbate) Injection... 4 B Besivance 0.6 % eye drops,suspension... 9 D desvenlafaxine ER 100 mg tablet,extended release 24 hr... 3 desvenlafaxine ER 50 mg tablet,extended release 24 hr... 3 donepezil 23 mg tablet... 5 duloxetine 40 mg capsule,delayed release.. 3 E Estring 2 mg (7.5 mcg/24 hour) vaginal ring... 7 F Fetzima 120 mg capsule,extended release.. 3 Fetzima 20 mg (2)-40 mg (26) capsule,extended release,24 hr,dose pack 3 Fetzima 20 mg capsule,extended release... 3 Fetzima 40 mg capsule,extended release... 3 Fetzima 80 mg capsule,extended release... 3 fluvoxamine ER 100 mg capsule,extended release 24 hr... 3 fluvoxamine ER 150 mg capsule,extended release 24 hr... 3 G gatifloxacin 0.5 % eye drops... 9 N Namzaric 14 mg-10 mg capsule sprinkle,extended release... 8 Namzaric 21 mg-10 mg capsule sprinkle,extended release... 8 Namzaric 28 mg-10 mg capsule sprinkle,extended release... 8 Namzaric 7 mg-10 mg capsule sprinkle,extended release... 8 Namzaric 7/14/21/28 mg-10 mg capsule,sprinkle,er 24hr,dose pack... 8 O olopatadine 0.1 % eye drops... 13 olopatadine 0.2 % eye drops... 13 P Pancreaze 10,500 unit-35,500 unit-61,500 unit capsule,delayed release... 10 Pancreaze 16,800 unit-56,800 unit-98,400 unit capsule,delayed release... 10 Pancreaze 2,600 unit-6,200 unit-10,850 unit capsule,delayed release... 10 Pancreaze 21,000 unit-54,700 unit-83,900 unit capsule,delayed release... 10 Pancreaze 4,200 unit-14,200 unit-24,600 unit capsule,delayed release... 10 Pazeo 0.7 % eye drops... 13 14
R Restasis 0.05 % eye drops in a dropperette. 6 Restasis MultiDose 0.05 % eye drops... 6 T Trintellix 10 mg tablet... 3 Trintellix 20 mg tablet... 3 Trintellix 5 mg tablet... 3 U Uloric 40 mg tablet... 11 Uloric 80 mg tablet... 11 V vancomycin 125 mg capsule... 12 vancomycin 250 mg capsule... 12 Viibryd 10 mg (7)-20 mg (23) tablets in a dose pack... 3 Viibryd 10 mg tablet... 3 Viibryd 20 mg tablet... 3 Viibryd 40 mg tablet... 3 15