Step Therapy Information... 4 Prior Authorization Information... 27 ACE Inhibitors and ACE Inhibitor Combinations...60 Acne Therapy...62 Acne Therapy Topical...64 Alcoholism Treatment Agents... 66 Analgesic Narcotic Agonist Combinations... 66 Analgesic Narcotic Agonists and Combinations... 67 Analgesic, Anti-inflammatory or Antipyretic... 68 Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic... 68 Analgesics - Narcotic... 69 Androgen-Anabolic... 73 Anesthetics... 74 Angina Therapy...74 Angiotensin II Receptor Blocker (ARBs) and ARB Cominations...75 Anorectal Preparations... 77 Anti-Infective Agents...78 Antiarrhythmics... 79 Antibacterial Agents...80 Anticoagulants... 82 Anticonvulsants...85 Antidepressant Combinations... 86 Antidepressants... 86 Antidiarrheals...86 Antidotes and other Reversal Agents... 87 Antiemetic - Antihistamines and Antihistamine Combinations... 88 Antiemetics... 88 Antifungals... 88 Antihyperlipidemic Agents Other...88 Antihyperlipidemic Combinations...89 Antihyperlipidemics... 89 Antihypertensive Therapy Agents... 89 Antihypertensive Therapy Combinations... 90 Antimycobacterial Agents... 91 Antineoplastic - Antimetabolites...92 Antineoplastic - Protein-Tyrosine Kinase Inhibitors... 92 Antineoplastic - Systemic Enzyme Inhibitors... 92 Antineoplastic - Topoisomerase Inhibitors... 92 Antineoplastics...93 Antiparasitics...97 Antiparkinson Therapy...97 Antiparkinson s Adjuvants...100 Antiprotozoal...100 Antiprotozoal-Antibacterial Agents...101 Antipsychotic - Atypical Agents, General... 101 Antipsychotic - Dopamine Antagonists... 108 Antipsychotics (Neuroleptics)...109 Antiretroviral - Entry Inhibitors...110 Antiretrovirals...110 Antiseptics and Disinfectants... 112 Antithyroid Agents...112 Antitussive-Antihistamine Combinations...112 Antitussive-Antihistamine-Decongestant Combinations, All... 112 Antivirals... 112 Asthma/COPD Therapy Agents... 114 Beta Adrenergic Blockers... 116 BetaLactam Antibiotics... 117 Bone Resorption Inhibitors...119 Bone Resorption Inhibitors - Bisphosphonates and Combinations...120 Calcium and Bone Metabolism Regulators...120 Calcium Channel Blockers...120 Calcium Channel Blockers and Combinations...120 Cardiovascular Sympathomimetics and Combinations...122 Cardiovascular Therapy Agents...122 Central Nervous System Agents...127 Chemical Dependency, Agents to Treat... 147 Chemicals-Pharmaceutical Adjuvants... 147 CNS Stimulants...147 Cognitive Disorder Therapy... 148 1
Contraceptives...149 Contraceptives Intravaginal... 149 Contraceptives Oral... 149 Contraceptives Transdermal...155 Corticosteroids...155 Cough and Cold or Allergy Combinations...156 Cystic Fibrosis Therapy Agents... 157 Dental-Periodontal Products... 157 Dermatological...157 Dermatological - Anti-infective Combinations... 163 Dermatological - Anti-infectives... 164 Dermatological - Antiparasitics and Combinations... 165 Dermatological - Antipsoriatic Agents Systemic... 166 Dermatological - Antipsoriatics... 166 Dermatological - Dermatitis or Eczema Agents... 166 Dermatological - Glucocorticoids and Combinations... 166 Dermatological - Topical Local Anesthetics and Combinations... 167 Diabetic Therapy...167 Diagnostic Agents...170 Digestive Aids... 170 Disease Modifying Anti-Rheumatoid Drugs (DMARD)...171 Diuretic - Potassium Sparing (Single Agent), All...171 Diuretic - Potassium Sparing Diuretics and Combinations... 171 Diuretics...172 Drugs to treat Erectile Dysfunction... 173 Eating Disorder Therapy... 173 Electrolyte Balance-Nutritional Products...173 Endocrine...174 Estrogen Combinations...177 Estrogens and Combinations...177 Fertility Enhancers... 178 Folate Antagonist Antibiotics...178 Gastrointestinal Antispasmodics...179 Gastrointestinal Therapy Agents...179 Genitourinary Therapy... 182 GI Antispasmodic Combinations...184 Gout and Hyperuricemia Therapy...184 Hematological Agents...185 Hematopoietic Agents...186 Hematopoietic Agents - Hematopoietic Growth Factors... 186 Hemostatics... 187 Hepatitis Agents...187 Hepatitis C Treatment Agents...188 Immunosuppressive Agents...188 Influenza Agents... 189 Insulin - Human and Analogs, Single Agent... 189 Insulin - Human and Analogs, Single Agents, and Combinations...190 Laxative Combinations...190 Laxatives...191 Locomotor System...191 Medical Supplies and DME - Diabetic Supplies...191 Medical Supplies and Durable Medical Equipment (DME)... 192 Menopausal Symptoms Suppressant... 197 Metabolic Disease Enzyme Replacement Agents... 197 Metabolic Modifiers... 198 Migraine Therapy...198 Minerals and Electrolytes...199 Minerals and Electrolytes - Potassium and Combinations...200 Mouth-Throat-Dental - Preparations... 201 Multiple Sclerosis Agents...202 Musculoskeletal Therapy Agents... 203 Narcolepsy and Cataplexy Therapy Agents...204 Nasal Preparations... 204 Neuromuscular Therapy Agents... 204 NSAID Analgesics...205 NSAID Analgesics and NSAID Combinations...205 Ophthalmic - Anti-infectives... 207 Ophthalmic - Intraocular Pressure Reducing Agents...207 Ophthalmic Agents...208 2
Ophthalmic Combinations...210 Oral Antidiabetic Agents... 211 Otic...215 Otic - Anti-infectives... 215 Oxytocics... 216 Passive Immunizing Agents...216 Penicillin Antibiotic Combinations... 216 Peptic Ulcer - H. Pylori Agents...217 Peptic Ulcer Therapy... 217 Pharmaceutical Adjuvants... 220 Prolactin Inhibitors... 220 Prostatic Hypertrophy Agents... 220 Pulmonary Antihypertensive Agents... 221 Quinolone Antibiotics... 221 Renin-Angiotensin-Aldosterone System (RAAS) Blocking Agents... 221 Respiratory Therapy Agents... 223 Salicylate Analgesic and Salicylate Combinations...227 Sedative-Hypnotics...227 Skeletal Muscle Relaxant Combinations...229 Smoking Deterrents and Combinations... 229 Smoking Deterrents, Systemic...229 Thyroid Therapy...229 Urinary Anti-infective Combinations...232 Urinary Anti-infectives... 232 Urinary Antispasmodics... 233 Urinary ph Modifiers... 233 Vaccine Viral - Hepatitis...234 Vaccines... 234 Vaccines - Bacterial... 235 Vaccines - Viral...235 Vaginal Anti-infectives...237 Vaginal Antibacterials... 237 Vaginal Antifungals... 237 Vaginal Products...237 Vitamin Combinations... 237 Vitamins... 238 Vitamins - Water Soluble... 238 Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic... 239 Antacids and Combinations... 239 Contraceptives...239 Contraceptives Intravaginal... 240 Gastrointestinal Therapy Agents...240 Hematological Agents...242 Insulin - Human and Analogs, Single Agent... 243 Insulin - Human and Analogs, Single Agents, and Combinations...243 Medical Supplies and DME - Contraceptives...243 Medical Supplies and DME - Diabetic Supplies...244 Medical Supplies and DME-Glucose Monitoring and Insulin Admin Supplies... 274 Medical Supplies and Durable Medical Equipment (DME)... 274 Minerals and Electrolytes...290 Smoking Deterrents and Combinations... 293 Vitamins... 295 Vitamins - Water Soluble... 296 3
Step Therapy Information Gastrointestinal Therapy Agents SANCUSO 3.1 MG/24 HR PATCH SANCUSO PA,QL,ST See Prior Authorization Criteria, Requires trial and failure of ondansetron or granisetron ZUPLENZ 4 MG SOLUBLE FILM ZUPLENZ PA,ST See Prior Authorization Criteria, Requires trial and failure of ondansetron or granisetron ZUPLENZ 8 MG SOLUBLE FILM ZUPLENZ PA,ST See Prior Authorization Criteria, Requires trial and failure of ondansetron or granisetron ANZEMET 100 MG TABLET ANZEMET PA,QL,ST,SP PA Required, Requires trial and failure of ondansetron or granisetron ANZEMET 50 MG TABLET ANZEMET PA,QL,ST,SP PA Required, Requires trial and failure of ondansetron or granisetron Genitourinary Therapy GELNIQUE 10% GEL PUMP GELNIQUE QL,ST Requires trial and failure of oxybutynin, tolterodine or trospium GELNIQUE 10% GEL SACHETS GELNIQUE QL,ST Requires trial and failure of oxybutynin, tolterodine or trospium OXYTROL 3.9 MG/24HR PATCH OXYTROL QL,ST Requires trial and failure of oxybutynin, tolterodine or trospium RAPAFLO 4 MG CAPSULE RAPAFLO QL,ST Requires trial and failure of finasteride, tamsulosin or alfuzosin RAPAFLO 8 MG CAPSULE RAPAFLO QL,ST Requires trial and failure of finasteride, tamsulosin or alfuzosin Gout and Hyperuricemia Therapy ULORIC 40 MG TABLET ULORIC QL,ST Requires treatment failure, intolerance or contraindication with generic allopurinol (Zyloprim). ULORIC 80 MG TABLET ULORIC QL,ST Requires treatment failure, intolerance or contraindication with generic allopurinol (Zyloprim). Menopausal Symptoms Suppressant PAROXETINE MESYLATE 7.5 MG CAP PAROXETINE MESYLATE QL,ST Requires trial/failure of generic paroxetine (Paxil) and generic venlafaxine (Effexor, Effexor XR or venlafaxine ER). BRISDELLE 7.5 MG CAPSULE BRISDELLE QL,ST Requires trial/failure of generic paroxetine (Paxil) and generic venlafaxine (Effexor, Effexor XR or venlafaxine ER). 4
Step Therapy Information Migraine Therapy SUMAVEL DOSEPRO 4 MG/0.5 ML SUMAVEL DOSEPRO QL,ST Requires trial and failure of both options generic sumatriptan injection (Imitrex) and generic rizatriptan (Maxalt MLT). SUMAVEL DOSEPRO 6 MG/0.5 ML SUMAVEL DOSEPRO QL,ST Requires trial and failure of both options generic sumatriptan injection (Imitrex) and generic rizatriptan (Maxalt MLT). Musculoskeletal Therapy Agents AMRIX ER 15 MG CAPSULE AMRIX ST Approval requires previous trial and failure of generic immediaterelease cyclobenzaprine (Flexeril). AMRIX ER 30 MG CAPSULE AMRIX ST Approval requires previous trial and failure of generic immediaterelease cyclobenzaprine (Flexeril). Nasal Preparations DYMISTA NASAL SPRAY DYMISTA PA,ST See Prior Authorization Criteria, Requires trial and failure/ intolerance of 2 of the following intranasal steroids: 1. Generic fluticasone (Flonase). 2. Generic flunisolide (Nasarel). 3. Generic triamcinolone (Nasacort AQ). Ophthalmic Agents ALOCRIL 2% EYE DROPS ALOCRIL ST Requires trial and failure of ketotifen or another generic agent ALOMIDE 0.1% EYE DROPS ALOMIDE ST Requires trial and failure of ketotifen or another generic agent LUMIGAN 0.01% EYE DROPS LUMIGAN ST Requires trial and failure of latanoprost or travoprost TRAVATAN Z 0.004% EYE DROP TRAVATAN Z ST Requires trial and failure of latanoprost or travoprost BEPREVE 1.5% EYE DROPS BEPREVE ST Requires trial and failure of ketotifen or another generic agent EMADINE 0.05% EYE DROPS EMADINE ST Requires trial and failure of ketotifen or another generic agent LASTACAFT 0.25% EYE DROPS LASTACAFT ST Requires trial and failure of ketotifen or another generic agent ZIOPTAN 0.0015% EYE DROPS ZIOPTAN ST Requires trial and failure of latanoprost or travoprost Oral Antidiabetic Agents ALOGLIPTIN-METFORMIN 12.5-1000 ALOGLIPTIN-METFORMIN QL,ST Requires trial and failure of Januvia and Onglyza ALOGLIPTIN-METFORMIN 12.5-500 ALOGLIPTIN-METFORMIN QL,ST Requires trial and failure of Januvia and Onglyza 5
Step Therapy Information Oral Antidiabetic Agents ALOGLIPTIN-PIOGLIT 12.5-15 MG ALOGLIPTIN-PIOGLITAZONE QL,ST Requires trial and failure of Januvia and Onglyza ALOGLIPTIN-PIOGLIT 12.5-30 MG ALOGLIPTIN-PIOGLITAZONE QL,ST Requires trial and failure of Januvia and Onglyza ALOGLIPTIN-PIOGLIT 12.5-45 MG ALOGLIPTIN-PIOGLITAZONE QL,ST Requires trial and failure of Januvia and Onglyza ALOGLIPTIN-PIOGLIT 25-15 MG TB ALOGLIPTIN-PIOGLITAZONE QL,ST Requires trial and failure of Januvia and Onglyza ALOGLIPTIN-PIOGLIT 25-30 MG TB ALOGLIPTIN-PIOGLITAZONE QL,ST Requires trial and failure of Januvia and Onglyza ALOGLIPTIN-PIOGLIT 25-45 MG TB ALOGLIPTIN-PIOGLITAZONE QL,ST Requires trial and failure of Januvia and Onglyza INVOKAMET 150-1,000 MG TABLET INVOKAMET PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent INVOKAMET 150-500 MG TABLET INVOKAMET PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent INVOKAMET 50-1,000 MG TABLET INVOKAMET PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent INVOKAMET 50-500 MG TABLET INVOKAMET PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent INVOKAMET XR 150-1,000 MG TAB INVOKAMET XR ST Requires trial and failure of metformin or a metformin combination agent INVOKAMET XR 150-500 MG TABLET INVOKAMET XR ST Requires trial and failure of metformin or a metformin combination agent INVOKAMET XR 50-1,000 MG TAB INVOKAMET XR ST Requires trial and failure of metformin or a metformin combination agent INVOKAMET XR 50-500 MG TABLET INVOKAMET XR ST Requires trial and failure of metformin or a metformin combination agent JANUMET 50-1,000 MG TABLET JANUMET ST Requires trial and failure of metformin or a metformin combination agent JANUMET 50-500 MG TABLET JANUMET ST Requires trial and failure of metformin or a metformin combination agent JANUMET XR 100-1,000 MG TABLET JANUMET XR QL,ST Requires trial and failure of metformin or a metformin combination agent JANUMET XR 50-1,000 MG TABLET JANUMET XR QL,ST Requires trial and failure of metformin or a metformin combination agent 6
Step Therapy Information Oral Antidiabetic Agents JANUMET XR 50-500 MG TABLET JANUMET XR QL,ST Requires trial and failure of metformin or a metformin combination agent JENTADUETO 2.5 MG-1,000 MG TAB JENTADUETO QL,ST Requires trial and failure of metformin or a metformin combination agent JENTADUETO 2.5 MG-500 MG TAB JENTADUETO QL,ST Requires trial and failure of metformin or a metformin combination agent JENTADUETO 2.5 MG-850 MG TAB JENTADUETO QL,ST Requires trial and failure of metformin or a metformin combination agent JENTADUETO XR 2.5 MG-1,000 MG JENTADUETO XR ST Requires trial and failure of metformin or a metformin combination agent JENTADUETO XR 5 MG-1,000 MG TB JENTADUETO XR ST Requires trial and failure of metformin or a metformin combination agent KOMBIGLYZE XR 2.5-1,000 MG TAB KOMBIGLYZE XR ST Requires trial and failure of metformin or a metformin combination agent KOMBIGLYZE XR 5-1,000 MG TAB KOMBIGLYZE XR ST Requires trial and failure of metformin or a metformin combination agent KOMBIGLYZE XR 5-500 MG TABLET KOMBIGLYZE XR ST Requires trial and failure of metformin or a metformin combination agent SYNJARDY 12.5-1,000 MG TABLET SYNJARDY PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent SYNJARDY 12.5-500 MG TABLET SYNJARDY PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent SYNJARDY 5-1,000 MG TABLET SYNJARDY PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent SYNJARDY 5-500 MG TABLET SYNJARDY PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent SYNJARDY XR 10-1,000 MG TABLET SYNJARDY XR ST Requires trial and failure of metformin or a metformin combination agent SYNJARDY XR 12.5-1,000 MG TAB SYNJARDY XR ST Requires trial and failure of metformin or a metformin combination agent SYNJARDY XR 25-1,000 MG TABLET SYNJARDY XR ST Requires trial and failure of metformin or a metformin combination agent 7
Step Therapy Information Oral Antidiabetic Agents SYNJARDY XR 5-1,000 MG TABLET SYNJARDY XR ST Requires trial and failure of metformin or a metformin combination agent XIGDUO XR 10 MG-1,000 MG TAB XIGDUO XR PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent XIGDUO XR 10 MG-500 MG TABLET XIGDUO XR PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent XIGDUO XR 5 MG-1,000 MG TABLET XIGDUO XR PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent XIGDUO XR 5 MG-500 MG TABLET XIGDUO XR PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent Angiotensin II Receptor Blocker (ARBs) and ARB Cominations EDARBYCLOR 40-12.5 MG TABLET EDARBYCLOR QL,ST Requires documentation that the member has experienced failure of or intolerance to a generic Angiotensin II Receptor Blocker (ARB) and Benicar/HCT. EDARBYCLOR 40-25 MG TABLET EDARBYCLOR QL,ST Requires documentation that the member has experienced failure of or intolerance to a generic Angiotensin II Receptor Blocker (ARB) and Benicar/HCT. Peptic Ulcer Therapy ESOMEPRAZOLE MAG DR 20 MG CAP ESOMEPRAZOLE MAGNESIUM ST Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). ESOMEPRAZOLE MAG DR 40 MG CAP ESOMEPRAZOLE MAGNESIUM ST Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). 8
Step Therapy Information Peptic Ulcer Therapy OMEPRAZOLE-BICARB 40-1,680 PKT OMEPRAZOLE-BICARB 20-1,100 CAP OMEPRAZOLE-BICARB 20-1,680 PKT OMEPRAZOLE-BICARB 40-1,100 CAP OMEPRAZOLE-SODIUM BICARBONATE OMEPRAZOLE-SODIUM BICARBONATE OMEPRAZOLE-SODIUM BICARBONATE OMEPRAZOLE-SODIUM BICARBONATE ST QL,ST ST QL,ST Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). ACIPHEX SPRINKLE DR 10 MG CAP ACIPHEX SPRINKLE QL,ST Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). ACIPHEX SPRINKLE DR 5 MG CAP ACIPHEX SPRINKLE QL,ST Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). DEXILANT DR 30 MG CAPSULE DEXILANT ST Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). DEXILANT DR 60 MG CAPSULE DEXILANT ST Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). 9
Step Therapy Information Peptic Ulcer Therapy ESOMEPRAZOLE DR 24.65 MG CAP ESOMEPRAZOLE STRONTIUM ST Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). ESOMEPRAZOLE DR 49.3 MG CAP ESOMEPRAZOLE STRONTIUM ST Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). NEXIUM DR 10 MG PACKET NEXIUM ST Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). NEXIUM DR 2.5 MG PACKET NEXIUM ST Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). NEXIUM DR 20 MG PACKET NEXIUM ST Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). NEXIUM DR 40 MG PACKET NEXIUM ST Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). NEXIUM DR 5 MG PACKET NEXIUM ST Requires failure of or intolerance to all generic alternatives: generic omeprazole (Prilosec) and generic pantoprazole (Protonix) and generic lansoprazole (Prevacid/ Prevacid Solutab) and generic rabeprazole (Aciphex). Renin-Angiotensin-Aldosterone System (RAAS) Blocking Agents 10
Step Therapy Information Renin-Angiotensin-Aldosterone System (RAAS) Blocking Agents EDARBI 40 MG TABLET EDARBI QL,ST Requires documentation that the member has experienced failure of or intolerance to a generic Angiotensin II Receptor Blocker (ARB) and Benicar/HCT. EDARBI 80 MG TABLET EDARBI QL,ST Requires documentation that the member has experienced failure of or intolerance to a generic Angiotensin II Receptor Blocker (ARB) and Benicar/HCT. Respiratory Therapy Agents BUDESONIDE 32 MCG NASAL SPRAY BUDESONIDE QL,ST Requires trial and failure/ intolerance of 2 of the following intranasal steroids: 1. Generic fluticasone (Flonase). 2. Generic flunisolide (Nasarel). 3. Generic triamcinolone (Nasacort AQ). MOMETASONE FUROATE 50 MCG SPRY MOMETASONE FUROATE QL,ST Requires trial and failure/ intolerance of 2 of the following intranasal steroids: 1. Generic fluticasone (Flonase). 2. Generic flunisolide (Nasarel). 3. Generic triamcinolone (Nasacort AQ). BECONASE AQ 0.042% SPRAY BECONASE AQ QL,ST Requires trial and failure/ intolerance of 2 of the following intranasal steroids: 1. Generic fluticasone (Flonase). 2. Generic flunisolide (Nasarel). 3. Generic triamcinolone (Nasacort AQ). OMNARIS 50 MCG NASAL SPRAY OMNARIS QL,ST Requires trial and failure/ intolerance of 2 of the following intranasal steroids: 1. Generic fluticasone (Flonase). 2. Generic flunisolide (Nasarel). 3. Generic triamcinolone (Nasacort AQ). QNASL 80 MCG NASAL SPRAY QNASL QL,ST Requires trial and failure/ intolerance of 2 of the following intranasal steroids: 1. Generic fluticasone (Flonase). 2. Generic flunisolide (Nasarel). 3. Generic triamcinolone (Nasacort AQ). QNASL CHILDREN S 40 MCG SPRAY QNASL CHILDREN QL,ST Requires trial and failure/ intolerance of 2 of the following intranasal steroids: 1. Generic fluticasone (Flonase). 2. Generic flunisolide (Nasarel). 3. Generic triamcinolone (Nasacort AQ). VERAMYST 27.5 MCG NASAL SPRAY VERAMYST QL,ST Requires trial and failure/ intolerance of 2 of the following intranasal steroids: 1. Generic fluticasone (Flonase). 2. Generic flunisolide (Nasarel). 3. Generic triamcinolone (Nasacort AQ). 11
Step Therapy Information Respiratory Therapy Agents ZETONNA 37 MCG NASAL SPRAY ZETONNA QL,ST Requires trial and failure/ intolerance of 2 of the following intranasal steroids: 1. Generic fluticasone (Flonase). 2. Generic flunisolide (Nasarel). 3. Generic triamcinolone (Nasacort AQ). Sedative-Hypnotics ZOLPIDEM TART 1.75 MG TAB SL ZOLPIDEM TARTRATE QL,ST Requires trial and failure, or intolerance to generic zolpidem extended release (Ambien CR) and generic zaleplon (Sonata). Also, coverage will not be approved for combination therapy with other sedative hypnotics. ZOLPIDEM TART 3.5 MG TABLET SL ZOLPIDEM TARTRATE QL,ST Requires trial and failure, or intolerance to generic zolpidem extended release (Ambien CR) and generic zaleplon (Sonata). Also, coverage will not be approved for combination therapy with other sedative hypnotics. SILENOR 6 MG TABLET SILENOR QL,ST Requires treatment failure of 3 out of 4 of the following: immediaterelease zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata), or trazodone (Desyrel). ZOLPIMIST 5 MG ORAL SPRAY ZOLPIMIST ST Requires treatment failure of 3 out of 4 of the following: immediaterelease zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata), or trazodone (Desyrel). BELSOMRA 10 MG TABLET BELSOMRA QL,ST Requires treatment failure of 3 out of 4 of the following: immediaterelease zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata), or trazodone (Desyrel). BELSOMRA 15 MG TABLET BELSOMRA QL,ST Requires treatment failure of 3 out of 4 of the following: immediaterelease zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata), or trazodone (Desyrel). BELSOMRA 20 MG TABLET BELSOMRA QL,ST Requires treatment failure of 3 out of 4 of the following: immediaterelease zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata), or trazodone (Desyrel). BELSOMRA 5 MG TABLET BELSOMRA QL,ST Requires treatment failure of 3 out of 4 of the following: immediaterelease zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata), or trazodone (Desyrel). 12
Step Therapy Information Sedative-Hypnotics EDLUAR 10 MG SL TABLET EDLUAR QL,ST Requires treatment failure of 3 out of 4 of the following: immediaterelease zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata), or trazodone (Desyrel). EDLUAR 5 MG SL TABLET EDLUAR QL,ST Requires treatment failure of 3 out of 4 of the following: immediaterelease zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata), or trazodone (Desyrel). SILENOR 3 MG TABLET SILENOR QL,ST Requires treatment failure of 3 out of 4 of the following: immediaterelease zolpidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata), or trazodone (Desyrel). ACE Inhibitors and ACE Inhibitor Combinations PRESTALIA 14 MG-10 MG TABLET PRESTALIA QL,ST Coverage requires the following: 1. Trial and failure of a preferred ACE inhibitor and calcium channel blocker combination (example: generic Lotrel (amlodipine/ benazepril)). 2. Trial and failure of the individual agents, perindopril and amlodipine used in combination at doses similar to the combination product. PRESTALIA 3.5 MG-2.5 MG TABLET PRESTALIA QL,ST Coverage requires the following: 1. Trial and failure of a preferred ACE inhibitor and calcium channel blocker combination (example: generic Lotrel (amlodipine/ benazepril)). 2. Trial and failure of the individual agents, perindopril and amlodipine used in combination at doses similar to the combination product. PRESTALIA 7 MG-5 MG TABLET PRESTALIA QL,ST Coverage requires the following: 1. Trial and failure of a preferred ACE inhibitor and calcium channel blocker combination (example: generic Lotrel (amlodipine/ benazepril)). 2. Trial and failure of the individual agents, perindopril and amlodipine used in combination at doses similar to the combination product. Acne Therapy FABIOR 0.1% FOAM FABIOR QL,ST Requires trial and failure with the preferred alternatives generic adapalene (Differin) and generic tretinoin (Retin-A, Avita). 13
Step Therapy Information Acne Therapy Topical ONEXTON GEL PUMP ONEXTON QL,ST Coverage requires trial of all of the following: 1. The individuals agents in combination (topical clindamycin plus benzoyl peroxide) 2. Duac(g) and 3. Benzaclin(g) Antiparkinson Therapy RYTARY ER 23.75 MG-95 MG CAP RYTARY QL,ST Coverage requires a trial and failure of generic Sinemet immediate release or Sinemet CR. RYTARY ER 36.25 MG-145 MG CAP RYTARY QL,ST Coverage requires a trial and failure of generic Sinemet immediate release or Sinemet CR. RYTARY ER 48.75 MG-195 MG CAP RYTARY QL,ST Coverage requires a trial and failure of generic Sinemet immediate release or Sinemet CR. RYTARY ER 61.25 MG-245 MG CAP RYTARY QL,ST Coverage requires a trial and failure of generic Sinemet immediate release or Sinemet CR. Antipsychotic - Atypical Agents, General FANAPT 1 MG TABLET FANAPT ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). FANAPT 10 MG TABLET FANAPT ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). FANAPT 12 MG TABLET FANAPT ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). FANAPT 2 MG TABLET FANAPT ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). FANAPT 4 MG TABLET FANAPT ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). FANAPT 6 MG TABLET FANAPT ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). FANAPT 8 MG TABLET FANAPT ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). 14
Step Therapy Information Antipsychotic - Atypical Agents, General FANAPT TITRATION PACK FANAPT ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). LATUDA 120 MG TABLET LATUDA QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). LATUDA 20 MG TABLET LATUDA QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). LATUDA 40 MG TABLET LATUDA QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). LATUDA 60 MG TABLET LATUDA QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). LATUDA 80 MG TABLET LATUDA QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). REXULTI 0.25 MG TABLET REXULTI QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone), one of which must be generic aripiprazole (Abilify). Or For a diagnosis of Major Depressive Disorder, requires a trial of an antidepressant in combination with a generic aripiprazole (Abilify), and documentation that Rexulti will be used adjunctively with an antidepressant. REXULTI 0.5 MG TABLET REXULTI QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone), one of which must be generic aripiprazole (Abilify). Or For a diagnosis of Major Depressive Disorder, requires a trial of an antidepressant in combination with a generic aripiprazole (Abilify), and documentation that Rexulti will be used adjunctively with an antidepressant. 15
Step Therapy Information Antipsychotic - Atypical Agents, General REXULTI 1 MG TABLET REXULTI QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone), one of which must be generic aripiprazole (Abilify). Or For a diagnosis of Major Depressive Disorder, requires a trial of an antidepressant in combination with a generic aripiprazole (Abilify), and documentation that Rexulti will be used adjunctively with an antidepressant. REXULTI 2 MG TABLET REXULTI QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone), one of which must be generic aripiprazole (Abilify). Or For a diagnosis of Major Depressive Disorder, requires a trial of an antidepressant in combination with a generic aripiprazole (Abilify), and documentation that Rexulti will be used adjunctively with an antidepressant. REXULTI 3 MG TABLET REXULTI QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone), one of which must be generic aripiprazole (Abilify). Or For a diagnosis of Major Depressive Disorder, requires a trial of an antidepressant in combination with a generic aripiprazole (Abilify), and documentation that Rexulti will be used adjunctively with an antidepressant. REXULTI 4 MG TABLET REXULTI QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone), one of which must be generic aripiprazole (Abilify). Or For a diagnosis of Major Depressive Disorder, requires a trial of an antidepressant in combination with a generic aripiprazole (Abilify), and documentation that Rexulti will be used adjunctively with an antidepressant. SAPHRIS 10 MG TAB SUBLINGUAL BLACK CHERRY SAPHRIS PA,QL,ST PA Required, Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). 16
Step Therapy Information Antipsychotic - Atypical Agents, General SAPHRIS 5 MG TAB SUBLINGUAL BLACK CHERRY SAPHRIS PA,QL,ST PA Required, Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). SEROQUEL XR 150 MG TABLET SEROQUEL XR QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone), one of which must be generic aripiprazole (Abilify). Or For a diagnosis of Major Depressive Disorder, requires a trial of an antidepressant in combination with a generic aripiprazole (Abilify), and documentation that Rexulti will be used adjunctively with an antidepressant. SEROQUEL XR 200 MG TABLET SEROQUEL XR QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone), one of which must be generic aripiprazole (Abilify). Or For a diagnosis of Major Depressive Disorder, requires a trial of an antidepressant in combination with a generic aripiprazole (Abilify), and documentation that Rexulti will be used adjunctively with an antidepressant. SEROQUEL XR 300 MG TABLET SEROQUEL XR QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone), one of which must be generic aripiprazole (Abilify). Or For a diagnosis of Major Depressive Disorder, requires a trial of an antidepressant in combination with a generic aripiprazole (Abilify), and documentation that Rexulti will be used adjunctively with an antidepressant. SEROQUEL XR 400 MG TABLET SEROQUEL XR QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone), one of which must be generic aripiprazole (Abilify). Or For a diagnosis of Major Depressive Disorder, requires a trial of an antidepressant in combination with a generic aripiprazole (Abilify), and documentation that Rexulti will be used adjunctively with an antidepressant. 17
Step Therapy Information Antipsychotic - Atypical Agents, General SEROQUEL XR 50 MG TABLET SEROQUEL XR QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone), one of which must be generic aripiprazole (Abilify). Or For a diagnosis of Major Depressive Disorder, requires a trial of an antidepressant in combination with a generic aripiprazole (Abilify), and documentation that Rexulti will be used adjunctively with an antidepressant. VERSACLOZ 50 MG/ML SUSPENSION VERSACLOZ ST Requires treatment failure or intolerance to clozapine tablets and clozapine ODT unless the member is unable to take both formulations VRAYLAR 1.5 MG CAPSULE VRAYLAR QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). VRAYLAR 1.5 MG-3 MG PACK VRAYLAR QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). VRAYLAR 3 MG CAPSULE VRAYLAR QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). VRAYLAR 4.5 MG CAPSULE VRAYLAR QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). VRAYLAR 6 MG CAPSULE VRAYLAR QL,ST Requires a trial of two generic antipsychotics (aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone). Antivirals SITAVIG 50 MG BUCCAL TABLET SITAVIG PA,ST See Prior Authorization Criteria, Coverage requires trial and failure of generic oral acyclovir (Zovirax) and generic valacyclovir (Valtrex). Beta Adrenergic Blockers BYSTOLIC 10 MG TABLET BYSTOLIC ST Requires trial and failure of a generic beta blocker BYSTOLIC 2.5 MG TABLET BYSTOLIC ST Requires trial and failure of a generic beta blocker BYSTOLIC 20 MG TABLET BYSTOLIC ST Requires trial and failure of a generic beta blocker 18
Step Therapy Information Beta Adrenergic Blockers BYSTOLIC 5 MG TABLET BYSTOLIC ST Requires trial and failure of a generic beta blocker Bone Resorption Inhibitors RISEDRONATE SOD DR 35 MG TAB RISEDRONATE SODIUM DR QL,ST Requires documentation that the member has tried and failed or not tolerated treatment with generic alendronate (Fosamax), or generic ibandronate (Boniva). RISEDRONATE SODIUM 30 MG TAB RISEDRONATE SODIUM QL,ST Requires documentation that the member has tried and failed or not tolerated treatment with generic alendronate (Fosamax), or generic ibandronate (Boniva). RISEDRONATE SODIUM 30 MG TABLET RISEDRONATE SODIUM QL,ST Requires documentation that the member has tried and failed or not tolerated treatment with generic alendronate (Fosamax), or generic ibandronate (Boniva). RISEDRONATE SODIUM 35 MG TAB RISEDRONATE SODIUM QL,ST Requires documentation that the member has tried and failed or not tolerated treatment with generic alendronate (Fosamax), or generic ibandronate (Boniva). RISEDRONATE SODIUM 35 MG TABLET RISEDRONATE SODIUM QL,ST Requires documentation that the member has tried and failed or not tolerated treatment with generic alendronate (Fosamax), or generic ibandronate (Boniva). RISEDRONATE SODIUM 5 MG TABLET RISEDRONATE SODIUM QL,ST Requires documentation that the member has tried and failed or not tolerated treatment with generic alendronate (Fosamax), or generic ibandronate (Boniva). BINOSTO 70 MG TABLET EFF BINOSTO QL,ST Requires documentation that the member has tried and failed or not tolerated treatment with generic alendronate (Fosamax), or generic ibandronate (Boniva). Bone Resorption Inhibitors - Bisphosphonates and Combinations FOSAMAX PLUS D 70 MG-2,800 UNITS FOSAMAX PLUS D QL,ST Requires documentation that the member has tried and failed or not tolerated treatment with generic alendronate (Fosamax), or generic ibandronate (Boniva). FOSAMAX PLUS D 70 MG-5,600 UNITS FOSAMAX PLUS D QL,ST Requires documentation that the member has tried and failed or not tolerated treatment with generic alendronate (Fosamax), or generic ibandronate (Boniva). 19
Step Therapy Information Cardiovascular Therapy Agents CARDURA XL 4 MG TABLET CARDURA XL ST Requires trial and failure of finasteride, tamsulosin or alfuzosin CARDURA XL 8 MG TABLET CARDURA XL ST Requires trial and failure of finasteride, tamsulosin or alfuzosin Central Nervous System Agents DESVENLAFAXINE ER 50 MG TABLET DESVENLAFAXINE ER QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. APLENZIN ER 174 MG TABLET APLENZIN ST Requires trial and failure of generic bupropion APLENZIN ER 348 MG TABLET APLENZIN ST Requires trial and failure of generic bupropion APLENZIN ER 522 MG TABLET APLENZIN ST Requires trial and failure of generic bupropion APTIOM 200 MG TABLET APTIOM PA,QL,ST PA Required, Coverage of the requested drug is provided when all of the following are met: 1. Member is >= 18 years of age. 2. Adjunctive therapy in partial-onset epilepsy. 3. Member has experienced treatment failure or intolerance to at least 3 generic alternatives for the treatment of partial-onset seizures or 4. Member is stable on Aptiom APTIOM 400 MG TABLET APTIOM PA,QL,ST PA Required, Coverage of the requested drug is provided when all of the following are met: 1. Member is >= 18 years of age. 2. Adjunctive therapy in partial-onset epilepsy. 3. Member has experienced treatment failure or intolerance to at least 3 generic alternatives for the treatment of partial-onset seizures or 4. Member is stable on Aptiom APTIOM 600 MG TABLET APTIOM PA,QL,ST PA Required, Coverage of the requested drug is provided when all of the following are met: 1. Member is >= 18 years of age. 2. Adjunctive therapy in partial-onset epilepsy. 3. Member has experienced treatment failure or intolerance to at least 3 generic alternatives for the treatment of partial-onset seizures or 4. Member is stable on Aptiom 20
Step Therapy Information Central Nervous System Agents APTIOM 800 MG TABLET APTIOM PA,QL,ST PA Required, Coverage of the requested drug is provided when all of the following are met: 1. Member is >= 18 years of age. 2. Adjunctive therapy in partial-onset epilepsy. 3. Member has experienced treatment failure or intolerance to at least 3 generic alternatives for the treatment of partial-onset seizures or 4. Member is stable on Aptiom DAYTRANA 10 MG/9 HR PATCH DAYTRANA ST Coverage will be provided when the following have been met: 1. Diagnosis of ADHD. 2.? 6 years of age 3. Treatment failure or intolerance to one generic methylphenidate product and one generic amphetamine product (one of which must be a longacting formulation). DAYTRANA 15 MG/9 HR PATCH DAYTRANA ST Coverage will be provided when the following have been met: 1. Diagnosis of ADHD. 2.? 6 years of age 3. Treatment failure or intolerance to one generic methylphenidate product and one generic amphetamine product (one of which must be a longacting formulation). DAYTRANA 20 MG/9 HOUR PATCH DAYTRANA ST Coverage will be provided when the following have been met: 1. Diagnosis of ADHD. 2.? 6 years of age 3. Treatment failure or intolerance to one generic methylphenidate product and one generic amphetamine product (one of which must be a longacting formulation). DAYTRANA 30 MG/9 HOUR PATCH DAYTRANA ST Coverage will be provided when the following have been met: 1. Diagnosis of ADHD. 2.? 6 years of age 3. Treatment failure or intolerance to one generic methylphenidate product and one generic amphetamine product (one of which must be a longacting formulation). DESVENLAFAXINE ER 100 MG TAB DESVENLAFAXINE ER QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. DESVENLAFAXINE ER 50 MG TAB DESVENLAFAXINE ER QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. DESVENLAFAXINE FUM ER 100 MG DESVENLAFAXINE FUMARATE ER QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. 21
Step Therapy Information Central Nervous System Agents DESVENLAFAXINE FUM ER 50 MG DESVENLAFAXINE FUMARATE ER QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. FETZIMA 20-40 MG TITRATION PAK FETZIMA QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. FETZIMA ER 120 MG CAPSULE FETZIMA QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. FETZIMA ER 20 MG CAPSULE FETZIMA QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. FETZIMA ER 40 MG CAPSULE FETZIMA QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. FETZIMA ER 80 MG CAPSULE FETZIMA QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. FORFIVO XL 450 MG TABLET FORFIVO XL QL,ST Requires trial and failure of generic bupropion KHEDEZLA ER 100 MG TABLET KHEDEZLA QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. KHEDEZLA ER 50 MG TABLET KHEDEZLA QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. PRISTIQ ER 100 MG TABLET PRISTIQ ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. PRISTIQ ER 25 MG TABLET PRISTIQ ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. PRISTIQ ER 50 MG TABLET PRISTIQ ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. QUILLIVANT XR 25 MG/5 ML SUSP QUILLIVANT XR PA,ST See Prior Authorization Criteria, Coverage will be provided when the following have been met: 1. Diagnosis of ADHD. 2.? 6 years of age 3. Treatment failure or intolerance to one generic methylphenidate product and one generic amphetamine product (one of which must be a longacting formulation). TRINTELLIX 10 MG TABLET TRINTELLIX QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. TRINTELLIX 20 MG TABLET TRINTELLIX QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. 22
Step Therapy Information Central Nervous System Agents TRINTELLIX 5 MG TABLET TRINTELLIX QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. VIIBRYD 10 MG TABLET VIIBRYD QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. VIIBRYD 20 MG TABLET VIIBRYD QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. VIIBRYD 40 MG TABLET VIIBRYD QL,ST Requires trial and failure of at least 2 generic or preferred antidepressant agents. Dermatological ELIDEL 1% CREAM ELIDEL ST Requires trial and failure of a topical corticosteroid or calcipotriene SORILUX 0.005% FOAM SORILUX PA,ST PA Required, Requires trial and failure of a topical corticosteroid or calcipotriene SOOLANTRA 1% CREAM SOOLANTRA QL,ST Coverage will be provided when all of the following have been met: Trial and failure of all of the following: 1. Generic topical metronidazole. 2. Generic topical sulfacetamide 10%-sulfur 5%. 3. Generic oral tetracycline, generic doxycycline or generic minocycline. FINACEA 15% FOAM FINACEA QL,ST Coverage will be provided when all of the following have been met: Trial and failure of all of the following: 1. Generic topical metronidazole. 2. Generic topical sulfacetamide 10%-sulfur 5%. 3. Generic oral tetracycline, generic doxycycline or generic minocycline. MIRVASO 0.33% GEL MIRVASO ST Coverage will be provided when all of the following have been met: Trial and failure of all of the following: 1. Generic topical metronidazole. 2. Generic topical sulfacetamide 10%-sulfur 5%. 3. Generic oral tetracycline, generic doxycycline or generic minocycline. 23
Step Therapy Information Dermatological MIRVASO 0.33% GEL PUMP MIRVASO ST Coverage will be provided when all of the following have been met: Trial and failure of all of the following: 1. Generic topical metronidazole. 2. Generic topical sulfacetamide 10%-sulfur 5%. 3. Generic oral tetracycline, generic doxycycline or generic minocycline. ZITHRANOL 1% SHAMPOO ZITHRANOL PA,ST PA Required, Requires trial and failure of a topical corticosteroid or calcipotriene Dermatological - Anti-infectives ECOZA 1% FOAM ECOZA PA,ST See Prior Authorization Criteria, Requires two 30-day trials of a generic topical antifungal ERTACZO 2% CREAM ERTACZO ST Requires two 30-day trials of a generic topical antifungal EXELDERM 1% CREAM EXELDERM ST Requires two 30-day trials of a generic topical antifungal EXELDERM 1% SOLUTION EXELDERM ST Requires two 30-day trials of a generic topical antifungal JUBLIA 10% TOPICAL SOLUTION JUBLIA PA,ST See Prior Authorization Criteria, Requires two 30-day trials of a generic topical antifungal KERYDIN 5% TOPICAL SOLUTION KERYDIN PA,ST See Prior Authorization Criteria, Requires two 30-day trials of a generic topical antifungal LUZU 1% CREAM LUZU PA,ST See Prior Authorization Criteria, Requires two 30-day trials of a generic topical antifungal VUSION OINTMENT VUSION ST Requires two 30-day trials of a generic topical antifungal XOLEGEL 2% GEL XOLEGEL PA,ST See Prior Authorization Criteria, Requires two 30-day trials of a generic topical antifungal Dermatological - Antipsoriatics ENSTILAR 0.005%-0.064% FOAM ENSTILAR PA,QL,ST PA Required, Requires trial and failure of a topical corticosteroid or calcipotriene TACLONEX 0.005%-0.064% SUSPENSION TACLONEX PA,ST PA Required, Requires trial and failure of a topical corticosteroid or calcipotriene Diabetic Therapy ALOGLIPTIN 12.5 MG TABLET ALOGLIPTIN QL,ST Requires trial and failure of Januvia and Onglyza 24
Step Therapy Information Diabetic Therapy ALOGLIPTIN 25 MG TABLET ALOGLIPTIN QL,ST Requires trial and failure of Januvia and Onglyza BYDUREON 2 MG VIAL BYDUREON PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent FARXIGA 10 MG TABLET FARXIGA PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent FARXIGA 5 MG TABLET FARXIGA PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent JANUVIA 100 MG TABLET JANUVIA QL,ST Requires trial and failure of metformin or a metformin combination agent ADLYXIN 10-20 MCG STARTER PACK ADLYXIN ST Requires trial and failure of metformin or a metformin combination agent ADLYXIN 20 MCG MAINTENANCE PK ADLYXIN ST Requires trial and failure of metformin or a metformin combination agent ALOGLIPTIN 6.25 MG TABLET ALOGLIPTIN QL,ST Requires trial and failure of Januvia and Onglyza BYDUREON 2 MG PEN INJECT BYDUREON PEN PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent BYETTA 10 MCG DOSE PEN INJ BYETTA PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent BYETTA 5 MCG DOSE PEN INJ BYETTA PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent INVOKANA 100 MG TABLET INVOKANA PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent INVOKANA 300 MG TABLET INVOKANA PA,ST See Prior Authorization Criteria, Requires trial and failure of metformin or a metformin combination agent JANUVIA 25 MG TABLET JANUVIA QL,ST Requires trial and failure of metformin or a metformin combination agent JANUVIA 50 MG TABLET JANUVIA QL,ST Requires trial and failure of metformin or a metformin combination agent 25