Effective Date: 01/01/2018 This document contains Step Therapy Approval Criteria for the following medications: 1. Colcrys (colchicine) 2. Dovonex (calcipotriene) 3. Enbrel (etanercept) 4. Humira (adalimumab) 5. Imitrex Injection vial and STATdose (sumatriptan succinate) 6. Jardiance (empagliflozin) 7. Nexium (esomeprazole) 8. OxyContin (oxycodone extended-release) 9. Protopic (tacrolimus) 10. Relpax (eletriptan) 11. Risperdal Consta (risperidone long-acting injection) 12. Soriatane (acitretin) 13. Victoza (liraglutide) 14. Vyvanse (lisdexamfetamine) 15. Xifaxan (rifaximin)
Colcrys (colchicine) colchicine Colcrys Antigout; antiinflammatory Previous failure of one of the following in the past 365 days: o A formulary NSAID o A formulary glucocorticoid o Allopurinol o Probenecid/colchicine Quantity Limit (QL) of 60 tablets per 30 days Initial: October 2016
Dovonex (calcipotriene) calcipotriene Dovonex Antipsoriatic, Synthetic Vitamin D3 Previous failure of a formulary topical corticosteroid in the past 365 days Initial: January 2016
Enbrel (etanercept) etanercept Enbrel TNF inhibitor; immune suppressant Previous failure of one of the following in the past 365 days: o Asacol o Balsalazide o Dipentum o Methotrexate o Rowasa o Azathioprine o Cyclosporine o Hydroxychloroquine o Hydroxyurea o Leflunomide o Mercaptopurine o Soriatane o Sulfasalazine Quantity limit (QL) of 4 injections per 28 days Initial: 10/01/2013 04/01/2015, 10/01/2016
Humira (adalimumab) adalimumab Humira TNF inhibitor; monoclonal antibody; antirheumatic Previous failure of one of the following in the past 365 days: o Asacol o Balsalazide o Dipentum o Methotrexate o Rowasa o Azathioprine o Cyclosporine o Hydroxychloroquine o Hydroxyurea o Leflunomide o Mercaptopurine o Soriatane o Sulfasalazine Quantity limit (QL) of 4 injections per 28 days Initial: 10/01/2013 04/01/2015, 10/01/2016
Imitrex Injection vial and STATdose (sumatriptan succinate) sumatriptan Imitrex Injection vial and Imitrex STATdose 5HT-1 serotonin receptor agonist; antimigraine Previous failure of sumatriptan oral tablets or sumatriptan nasal spray in the past 365 days Quantity limit (QL) of 6 doses (3 ml) per 30 days Initial: 10/01/2013
Jardiance (empagliflozin) empagliflozin Jardiance SGLT2 inhibitor Previous failure of a formulary diabetes medication in the past 365 days. Initial: July 2017
Nexium (esomeprazole) esomeprazole Nexium Proton pump inhibitor Previous failure of omeprazole in the past 365 days Step 2: Previous failure of pantoprazole in the past 365 days Quantity Limit (QL) of 30 capsules per 30 days Initial: 01/01/2015 04/01/2015
OxyContin (oxycodone extended-release) oxycodone extended-release OxyContin Opioid analgesic Previous failure of one formulary long-acting opioid analgesic (i.e. morphine sulfate extended-release, fentanyl patches or methadone) in the past 365 days. Initial: January 2018
Protopic (tacrolimus) Brand names: tacrolimus Protopic Calcineurin inhibitor Previous failure of one formulary topical corticosteroid in the past 365 days Quantity Limit (QL) of 100 grams per 30 days Initial: April 2017
Relpax (eletriptan) eletriptan Relpax 5-HT1 serotonin receptor agonist; antimigraine Previous failure of a formulary triptan medication (sumatriptan tablet, sumatriptan nasal spray, sumatriptan injection, zolmitriptan tablet or zolmitriptan oral-disintegrating tablet) in the past 180 days Quantity limit (QL) of 6 tablets per 30 days Initial: 10/01/2013
Risperdal Consta (risperidone long-acting injectable) risperidone long-acting injectable Risperdal Consta Atypical antipsychotic Previous failure of risperidone tablets in the past 365 days. Initial: July 2017
Soriatane (acitretin) acitretin Soriatane Retinoid Previous failure of methotrexate in the past 365 days. Initial: October 2016
Victoza (liraglutide) liraglutide Victoza GLP-1 receptor agonist Previous failure of a formulary diabetes medication in the past 365 days. Initial: January 2018
Vyvanse (lisdexamfetamine) lisdexamfetamine Vyvanse CNS stimulant Previous failure of a formulary generic amphetamine product in the past 365 days Step 2: Previous failure of formulary generic methylphenidate product in the past 365 days Quantity Limit (QL) of 30 capsules per 30 days Initial: April 2017
Xifaxan (rifaximin) rifaximin Xifaxan Rifamycin Previous failure of lactulose, dicyclomine, ciprofloxacin or azithromycin in the past 180 days Quantity limit (QL) of 60 tablets per 30 days for the 550 mg tablets Quantity limit (QL) of 180 tablets per 30 days for the 200 mg tablets Initial: 07/01/2015 October 2017