Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Value Rx (HMO) and Stride SM Value Rx Plus (HMO) Step Therapy Requirements Effective 7/1/2018 Updated 6/2018
BRAND NAME ANTIDEPRESSANTS APLENZIN 174 MG TABLET,EXTENDED APLENZIN 348 MG TABLET,EXTENDED APLENZIN 522 MG TABLET,EXTENDED 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 FETZIMA 80 MG CAPSULE,EXTENDED FORFIVO XL 450 MG TABLET,EXTENDED PAXIL 10 MG/5 ML ORAL SUSPENSION PEXEVA 10 MG TABLET PEXEVA 20 MG TABLET PEXEVA 30 MG TABLET PEXEVA 40 MG TABLET PRISTIQ 100 MG TABLET,EXTENDED PRISTIQ 25 MG TABLET,EXTENDED PRISTIQ 50 MG TABLET,EXTENDED SARAFEM 10 MG TABLET SARAFEM 20 MG TABLET 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 USE OF A FIRST LINE GENERIC ANTIDEPRESSANT IN SSRI/SNRI CLASS OR GENERIC BUPROPION HYDROCHLORIDE 1
BRAND NAME ATYPICAL ANTIPSYCHOTICS FANAPT 1 MG TABLET FANAPT 10 MG TABLET FANAPT 12 MG TABLET FANAPT 1MG(2)-2 MG(2)-4MG(2)-6 MG(2) TABLETS IN A DOSE PACK FANAPT 2 MG TABLET FANAPT 4 MG TABLET FANAPT 6 MG TABLET FANAPT 8 MG TABLET LATUDA 120 MG TABLET LATUDA 20 MG TABLET LATUDA 40 MG TABLET LATUDA 60 MG TABLET LATUDA 80 MG TABLET REXULTI 0.25 MG TABLET REXULTI 0.5 MG TABLET REXULTI 1 MG TABLET REXULTI 2 MG TABLET REXULTI 3 MG TABLET REXULTI 4 MG TABLET SAPHRIS (BLACK CHERRY) 10 MG SUBLINGUAL TABLET SAPHRIS (BLACK CHERRY) 2.5 MG SUBLINGUAL TABLET SAPHRIS (BLACK CHERRY) 5 MG SUBLINGUAL TABLET VRAYLAR 1.5 MG CAPSULE VRAYLAR 3 MG CAPSULE VRAYLAR 4.5 MG CAPSULE VRAYLAR 6 MG CAPSULE PRIOR HISTORY OR USE OF ONE FIRST LINE GENERIC ATYPICAL ANTIPSYCHOTIC AGENT 2
BRAND NAME SEDATIVE HYPNOTICS BELSOMRA 10 MG TABLET BELSOMRA 15 MG TABLET BELSOMRA 20 MG TABLET BELSOMRA 5 MG TABLET EDLUAR 10 MG SUBLINGUAL TABLET EDLUAR 5 MG SUBLINGUAL TABLET ROZEREM 8 MG TABLET ZOLPIMIST 5 MG/SPRAY (0.1 ML) ORAL SPRAY USE OF A FIRST LINE GENERIC SEDATIVE HYPNOTIC AGENT 3
JUXTAPID JUXTAPID 10 MG CAPSULE JUXTAPID 20 MG CAPSULE JUXTAPID 30 MG CAPSULE JUXTAPID 40 MG CAPSULE JUXTAPID 5 MG CAPSULE JUXTAPID 60 MG CAPSULE FIRST LINE USE OF REPATHA 4
LEVETIRACETAM SPRITAM 1,000 MG TABLET FOR ORAL SUSPENSION SPRITAM 250 MG TABLET FOR ORAL SUSPENSION SPRITAM 500 MG TABLET FOR ORAL SUSPENSION SPRITAM 750 MG TABLET FOR ORAL SUSPENSION USE OF FIRST-LINE GENERIC LEVETIRACETAM 5
OPHTHALMIC BETA BLOCKERS betaxolol 0.5 % eye drops timolol maleate 0.25 % eye gel forming solution timolol maleate 0.5 % eye gel forming solution FIRST-LINE USE OF GENERIC TIMOLOL MALEATE 0.25% OR 0.5% EYE DROPS 6
ULORIC ULORIC 40 MG TABLET ULORIC 80 MG TABLET FIRST LINE USE OF ALLOPURINOL 7
8
INDEX APLENZIN 174 MG TABLET,EXTENDED... 1 APLENZIN 348 MG TABLET,EXTENDED... 1 APLENZIN 522 MG TABLET,EXTENDED... 1 BELSOMRA 10 MG TABLET...3 BELSOMRA 15 MG TABLET...3 BELSOMRA 20 MG TABLET...3 BELSOMRA 5 MG TABLET... 3 betaxolol 0.5 % eye drops... 6 EDLUAR 10 MG SUBLINGUAL TABLET... 3 EDLUAR 5 MG SUBLINGUAL TABLET... 3 FANAPT 1 MG TABLET... 2 FANAPT 10 MG TABLET... 2 FANAPT 12 MG TABLET... 2 FANAPT 1MG(2)-2 MG(2)-4MG(2)-6 MG(2) TABLETS IN A DOSE PACK... 2 FANAPT 2 MG TABLET... 2 FANAPT 4 MG TABLET... 2 FANAPT 6 MG TABLET... 2 FANAPT 8 MG TABLET... 2 FETZIMA 120 MG CAPSULE,EXTENDED... 1 FETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED,24 HR,DOSE PACK...1 FETZIMA 20 MG CAPSULE,EXTENDED... 1 FETZIMA 40 MG CAPSULE,EXTENDED... 1 FETZIMA 80 MG CAPSULE,EXTENDED... 1 FORFIVO XL 450 MG TABLET,EXTENDED... 1 JUXTAPID 10 MG CAPSULE... 4 JUXTAPID 20 MG CAPSULE... 4 JUXTAPID 30 MG CAPSULE... 4 JUXTAPID 40 MG CAPSULE... 4 JUXTAPID 5 MG CAPSULE...4 JUXTAPID 60 MG CAPSULE... 4 LATUDA 120 MG TABLET...2 LATUDA 20 MG TABLET... 2 LATUDA 40 MG TABLET... 2 LATUDA 60 MG TABLET... 2 LATUDA 80 MG TABLET... 2 PAXIL 10 MG/5 ML ORAL SUSPENSION... 1 PEXEVA 10 MG TABLET...1 PEXEVA 20 MG TABLET...1 PEXEVA 30 MG TABLET...1 PEXEVA 40 MG TABLET...1 PRISTIQ 100 MG TABLET,EXTENDED... 1 PRISTIQ 25 MG TABLET,EXTENDED... 1 PRISTIQ 50 MG TABLET,EXTENDED... 1 REXULTI 0.25 MG TABLET...2 REXULTI 0.5 MG TABLET...2 REXULTI 1 MG TABLET... 2 REXULTI 2 MG TABLET... 2 REXULTI 3 MG TABLET... 2 REXULTI 4 MG TABLET... 2 ROZEREM 8 MG TABLET... 3 SAPHRIS (BLACK CHERRY) 10 MG SUBLINGUAL TABLET...2 SAPHRIS (BLACK CHERRY) 2.5 MG SUBLINGUAL TABLET...2 SAPHRIS (BLACK CHERRY) 5 MG SUBLINGUAL TABLET...2 SARAFEM 10 MG TABLET... 1 SARAFEM 20 MG TABLET... 1 SPRITAM 1,000 MG TABLET FOR ORAL SUSPENSION... 5 SPRITAM 250 MG TABLET FOR ORAL SUSPENSION... 5 SPRITAM 500 MG TABLET FOR ORAL SUSPENSION... 5 SPRITAM 750 MG TABLET FOR ORAL SUSPENSION... 5 timolol maleate 0.25 % eye gel forming solution... 6 timolol maleate 0.5 % eye gel forming solution... 6 TRINTELLIX 10 MG TABLET... 1 9
TRINTELLIX 20 MG TABLET... 1 TRINTELLIX 5 MG TABLET... 1 ULORIC 40 MG TABLET...7 ULORIC 80 MG TABLET...7 VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK... 1 VIIBRYD 10 MG TABLET... 1 VIIBRYD 20 MG TABLET... 1 VIIBRYD 40 MG TABLET... 1 VRAYLAR 1.5 MG CAPSULE... 2 VRAYLAR 3 MG CAPSULE... 2 VRAYLAR 4.5 MG CAPSULE... 2 VRAYLAR 6 MG CAPSULE... 2 ZOLPIMIST 5 MG/SPRAY (0.1 ML) ORAL SPRAY...3 10