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
ANAPHYLAXIS_NVT 2015 epinephrine 0.15 mg/0.15 ml injection,auto-injector epinephrine 0.3 mg/0.3 ml injection, injector-auto Step Therapy requires trial of EPIPEN or EPINEPHRINE 0.15MG/0.3ML AUTO-INJECTOR in previous 120 days. 3
ANTIDEPRESSANT_NVT 2017 DESVENLAFAXINE ER 100 MG TABLET,EXTENDED 24 HR DESVENLAFAXINE ER 50 MG TABLET,EXTENDED 24 HR duloxetine 40 mg capsule,delayed release 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 fluvoxamine er 100 mg capsule,extended release 24 hr fluvoxamine er 150 mg capsule,extended release 24 hr PEXEVA 10 MG TABLET PEXEVA 20 MG TABLET PEXEVA 30 MG TABLET PEXEVA 40 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 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. 4
APLENZIN_NVT 2015 APLENZIN 174 MG TABLET,EXTENDED APLENZIN 348 MG TABLET,EXTENDED APLENZIN 522 MG TABLET,EXTENDED Step Therapy requires trial of bupropion SR or bupropion XL in previous 120 days. 5
ARANESP_NVT 2016 ARANESP 10 MCG/0.4 ML (IN SYRINGE ARANESP 100 MCG/0.5 ML (IN SYRINGE ARANESP 100 MCG/ML (IN ARANESP 150 MCG/0.3 ML (IN SYRINGE ARANESP 200 MCG/0.4 ML (IN SYRINGE ARANESP 200 MCG/ML (IN ARANESP 25 MCG/0.42 ML (IN SYRINGE ARANESP 25 MCG/ML (IN ARANESP 300 MCG/0.6 ML (IN SYRINGE ARANESP 300 MCG/ML (IN ARANESP 40 MCG/0.4 ML (IN SYRINGE ARANESP 40 MCG/ML (IN ARANESP 500 MCG/ML (IN SYRINGE ARANESP 60 MCG/0.3 ML (IN SYRINGE ARANESP 60 MCG/ML (IN Step Therapy requires trial of PROCRIT or EPOGEN 6
ARICEPT 23_NVT 2015 donepezil 23 mg tablet Step Therapy requires trial of donepezil 10mg in previous 120 days. 7
DEXILANT_NVT 2017 DEXILANT 30 MG CAPSULE, DELAYED DEXILANT 60 MG CAPSULE, DELAYED Step Therapy requires trial of rabeprazole, omeprazole, lansoprazole or pantoprazole in previous 120 days. 8
DIFICID_NVT DIFICID 200 MG TABLET Step Therapy requires trial of vancomycin. 9
DRY EYE OTC (CCHP 2018) RESTASIS 0.05 % EYE DROPS IN A DROPPERETTE Step Therapy requires trial of OTC artificial tears. 10
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. 11
METROGEL_NAVITUS NORITATE 1 % TOPICAL CREAM Step Therapy requires trial of FINACEA. 12
NAMZARIC_NVT NAMZARIC 14 MG-10 MG CAPSULE SPRINKLE,EXTENDED NAMZARIC 21 MG-10 MG CAPSULE SPRINKLE,EXTENDED NAMZARIC 28 MG-10 MG CAPSULE SPRINKLE,EXTENDED NAMZARIC 7 MG-10 MG CAPSULE SPRINKLE,EXTENDED NAMZARIC 7/14/21/28 MG-10 MG CAPSULE,SPRINKLE,ER 24HR,DOSE PACK Patient has tried or was intolerant to donepezil and memantine. 13
NASAL CORTICOSTEROIDS_NVT 2017 BECONASE AQ 42 MCG (0.042 %) NASAL SPRAY budesonide 32 mcg/actuation nasal spray mometasone 50 mcg/actuation nasal spray OMNARIS 50 MCG NASAL SPRAY QNASL 40 MCG/ACTUATION NASAL AEROSOL SPRAY QNASL 80 MCG/ACTUATION NASAL AEROSOL SPRAY ZETONNA 37 MCG/ACTUATION NASAL HFA INHALER Step Therapy requires trial of TWO (2) formulary generic Nasal Corticosteroids. If for nasal polyps, step therapy not required for BECONASE AQ. If for prophylaxis of seasonal allergic rhinitis, step therapy not required for mometasone. If for seasonal and perennial vasomotor nonallergic rhinitis, trial of fluticasone only required for BECONASE AQ. 14
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. 15
PANCREATIC ENZYMES_NVT 2015 PANCREAZE 10,500 UNIT-35,500 UNIT-61,500 UNIT CAPSULE,DELAYED PANCREAZE 16,800 UNIT-56,800 UNIT-98,400 UNIT CAPSULE,DELAYED PANCREAZE 2,600 UNIT-6,200 UNIT- 10,850 UNIT CAPSULE,DELAYED PANCREAZE 21,000 UNIT-54,700 UNIT-83,900 UNIT CAPSULE,DELAYED PANCREAZE 4,200 UNIT-14,200 UNIT- 24,600 UNIT CAPSULE,DELAYED PERTZYE 16,000 UNIT-57,500 UNIT- 60,500 UNIT CAPSULE,DELAYED PERTZYE 24,000-86,250-90,750 UNIT CAPSULE,DELAYED PERTZYE 4,000 UNIT-14,375 UNIT- 15,125 UNIT CAPSULE,DELAYED PERTZYE 8,000 UNIT-28,750 UNIT- 30,250 UNIT CAPSULE,DELAYED ZENPEP 10,000 UNIT-34,000 UNIT- 55,000 UNIT CAPSULE,DELAYED ZENPEP 10,000-32,000-42,000 UNIT CAPSULE,DELAYED ZENPEP 15,000 UNIT-51,000 UNIT- 82,000 UNIT CAPSULE,DELAYED ZENPEP 20,000 UNIT-68,000 UNIT- 109,000 UNIT CAPSULE,DELAYED ZENPEP 20,000-63,000-84,000 UNIT CAPSULE,DELAYED ZENPEP 25,000 UNIT-85,000 UNIT- 136,000 UNIT CAPSULE,DELAYED ZENPEP 25,000-79,000-105,000 UNIT CAPSULE,DELAYED ZENPEP 3,000 UNIT-10,000 UNIT- 16,000 UNIT CAPSULE,DELAYED ZENPEP 40,000 UNIT-136,000 UNIT- 218,000 UNIT CAPSULE,DELAYED ZENPEP 40,000-126,000-168,000 UNIT CAPSULE,DELAYED ZENPEP 5,000 UNIT-17,000 UNIT- 27,000 UNIT CAPSULE,DELAYED ZENPEP 5,000-17,000-24,000 UNIT CAPSULE,DELAYED Step Therapy requires trial of CREON in previous 120 days. 16
PENTASA_NVT 2015 PENTASA 250 MG CAPSULE,CONTROLLED PENTASA 500 MG CAPSULE,CONTROLLED Step Therapy requires trial of one of the following: mesalamine delayedrelease 1.2gm, mesalamine DR 800 mg, DELZICOL or LIALDA in previous 120 days. 17
RYTARY_NVT RYTARY 23.75 MG-95 MG CAPSULE,EXTENDED RYTARY 36.25 MG-145 MG CAPSULE,EXTENDED RYTARY 48.75 MG-195 MG CAPSULE,EXTENDED RYTARY 61.25 MG-245 MG CAPSULE,EXTENDED Step Therapy requires trial of carbidopa/levodopa ER tab. 18
ST_LETERMOVIR PREVYMIS 240 MG TABLET PREVYMIS 480 MG TABLET ST : Pending CMS Approval 19
ULORIC_NVT 2015 ULORIC 40 MG TABLET ULORIC 80 MG TABLET Step Therapy requires trial of allopurinol in previous 120 days. 20
URINARY ANTISPASMOTICS_NVT darifenacin er 15 mg tablet,extended release 24 hr darifenacin er 7.5 mg tablet,extended release 24 hr OXYTROL 3.9 MG/24 HR TRANSDERMAL PATCH TOVIAZ 4 MG TABLET,EXTENDED TOVIAZ 8 MG TABLET,EXTENDED Step Therapy requires trial of Vesicare OR Myrbetriq in previous 120 days. 21
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. 22
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. 23
ZIOPTAN_NVT ZIOPTAN (PF) 0.0015 % EYE DROPS IN A DROPPERETTE Step Therapy requires trial of latanoprost. 24
INDEX A acyclovir 5 % topical ointment... 1 ALPHAGAN P 0.1 % EYE DROPS... 2 APLENZIN 174 MG TABLET,EXTENDED... 5 APLENZIN 348 MG TABLET,EXTENDED... 5 APLENZIN 522 MG TABLET,EXTENDED... 5 ARANESP 10 MCG/0.4 ML (IN SYRINGE... 6 ARANESP 100 MCG/0.5 ML (IN SYRINGE... 6 ARANESP 100 MCG/ML (IN... 6 ARANESP 150 MCG/0.3 ML (IN SYRINGE... 6 ARANESP 200 MCG/0.4 ML (IN SYRINGE... 6 ARANESP 200 MCG/ML (IN... 6 ARANESP 25 MCG/0.42 ML (IN SYRINGE... 6 ARANESP 25 MCG/ML (IN... 6 ARANESP 300 MCG/0.6 ML (IN SYRINGE... 6 ARANESP 300 MCG/ML (IN... 6 ARANESP 40 MCG/0.4 ML (IN SYRINGE... 6 ARANESP 40 MCG/ML (IN... 6 ARANESP 500 MCG/ML (IN SYRINGE... 6 ARANESP 60 MCG/0.3 ML (IN SYRINGE... 6 ARANESP 60 MCG/ML (IN... 6 B BECONASE AQ 42 MCG (0.042 %) NASAL SPRAY... 14 BESIVANCE 0.6 % EYE DROPS,SUSPENSION... 15 budesonide 32 mcg/actuation nasal spray. 14 D darifenacin er 15 mg tablet,extended release 24 hr... 21 darifenacin er 7.5 mg tablet,extended release 24 hr... 21 DESVENLAFAXINE ER 100 MG TABLET,EXTENDED 24 HR... 4 DESVENLAFAXINE ER 50 MG TABLET,EXTENDED 24 HR... 4 DEXILANT 30 MG CAPSULE, DELAYED... 8 DEXILANT 60 MG CAPSULE, DELAYED... 8 DIFICID 200 MG TABLET... 9 donepezil 23 mg tablet... 7 duloxetine 40 mg capsule,delayed release.. 4 E epinephrine 0.15 mg/0.15 ml injection,autoinjector... 3 epinephrine 0.3 mg/0.3 ml injection, injector-auto... 3 ESTRING 2 MG (7.5 MCG/24 HOUR) VAGINAL RING... 11 F FETZIMA 120 MG CAPSULE,EXTENDED... 4 25
FETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED,24 HR,DOSE PACK... 4 FETZIMA 20 MG CAPSULE,EXTENDED... 4 FETZIMA 40 MG CAPSULE,EXTENDED... 4 FETZIMA 80 MG CAPSULE,EXTENDED... 4 fluvoxamine er 100 mg capsule,extended release 24 hr... 4 fluvoxamine er 150 mg capsule,extended release 24 hr... 4 G gatifloxacin 0.5 % eye drops... 15 M mometasone 50 mcg/actuation nasal spray 14 N NAMZARIC 14 MG-10 MG CAPSULE SPRINKLE,EXTENDED... 13 NAMZARIC 21 MG-10 MG CAPSULE SPRINKLE,EXTENDED... 13 NAMZARIC 28 MG-10 MG CAPSULE SPRINKLE,EXTENDED... 13 NAMZARIC 7 MG-10 MG CAPSULE SPRINKLE,EXTENDED... 13 NAMZARIC 7/14/21/28 MG-10 MG CAPSULE,SPRINKLE,ER 24HR,DOSE PACK... 13 NORITATE 1 % TOPICAL CREAM... 12 O olopatadine 0.1 % eye drops... 23 olopatadine 0.2 % eye drops... 23 OMNARIS 50 MCG NASAL SPRAY... 14 OXYTROL 3.9 MG/24 HR TRANSDERMAL PATCH... 21 P PANCREAZE 10,500 UNIT-35,500 UNIT- 61,500 UNIT CAPSULE,DELAYED... 16 PANCREAZE 16,800 UNIT-56,800 UNIT- 98,400 UNIT CAPSULE,DELAYED... 16 PANCREAZE 2,600 UNIT-6,200 UNIT- 10,850 UNIT CAPSULE,DELAYED... 16 PANCREAZE 21,000 UNIT-54,700 UNIT- 83,900 UNIT CAPSULE,DELAYED... 16 PANCREAZE 4,200 UNIT-14,200 UNIT- 24,600 UNIT CAPSULE,DELAYED... 16 PAZEO 0.7 % EYE DROPS... 23 PENTASA 250 MG CAPSULE,CONTROLLED 17 PENTASA 500 MG CAPSULE,CONTROLLED 17 PERTZYE 16,000 UNIT-57,500 UNIT- 60,500 UNIT CAPSULE,DELAYED... 16 PERTZYE 24,000-86,250-90,750 UNIT CAPSULE,DELAYED... 16 PERTZYE 4,000 UNIT-14,375 UNIT- 15,125 UNIT CAPSULE,DELAYED... 16 PERTZYE 8,000 UNIT-28,750 UNIT- 30,250 UNIT CAPSULE,DELAYED... 16 PEXEVA 10 MG TABLET... 4 PEXEVA 20 MG TABLET... 4 PEXEVA 30 MG TABLET... 4 PEXEVA 40 MG TABLET... 4 PREVYMIS 240 MG TABLET... 19 PREVYMIS 480 MG TABLET... 19 Q QNASL 40 MCG/ACTUATION NASAL AEROSOL SPRAY... 14 QNASL 80 MCG/ACTUATION NASAL AEROSOL SPRAY... 14 R RESTASIS 0.05 % EYE DROPS IN A DROPPERETTE... 10 RYTARY 23.75 MG-95 MG CAPSULE,EXTENDED... 18 RYTARY 36.25 MG-145 MG CAPSULE,EXTENDED... 18 26
RYTARY 48.75 MG-195 MG CAPSULE,EXTENDED... 18 RYTARY 61.25 MG-245 MG CAPSULE,EXTENDED... 18 T TOVIAZ 4 MG TABLET,EXTENDED... 21 TOVIAZ 8 MG TABLET,EXTENDED... 21 TRINTELLIX 10 MG TABLET... 4 TRINTELLIX 20 MG TABLET... 4 TRINTELLIX 5 MG TABLET... 4 U ULORIC 40 MG TABLET... 20 ULORIC 80 MG TABLET... 20 V vancomycin 125 mg capsule... 22 vancomycin 250 mg capsule... 22 VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK... 4 VIIBRYD 10 MG TABLET... 4 VIIBRYD 20 MG TABLET... 4 VIIBRYD 40 MG TABLET... 4 Z ZENPEP 10,000 UNIT-34,000 UNIT- 55,000 UNIT CAPSULE,DELAYED... 16 ZENPEP 10,000-32,000-42,000 UNIT CAPSULE,DELAYED... 16 ZENPEP 15,000 UNIT-51,000 UNIT- 82,000 UNIT CAPSULE,DELAYED... 16 ZENPEP 20,000 UNIT-68,000 UNIT- 109,000 UNIT CAPSULE,DELAYED... 16 ZENPEP 20,000-63,000-84,000 UNIT CAPSULE,DELAYED... 16 ZENPEP 25,000 UNIT-85,000 UNIT- 136,000 UNIT CAPSULE,DELAYED... 16 ZENPEP 25,000-79,000-105,000 UNIT CAPSULE,DELAYED... 16 ZENPEP 3,000 UNIT-10,000 UNIT-16,000 UNIT CAPSULE,DELAYED... 16 ZENPEP 40,000 UNIT-136,000 UNIT- 218,000 UNIT CAPSULE,DELAYED... 16 ZENPEP 40,000-126,000-168,000 UNIT CAPSULE,DELAYED... 16 ZENPEP 5,000 UNIT-17,000 UNIT-27,000 UNIT CAPSULE,DELAYED... 16 ZENPEP 5,000-17,000-24,000 UNIT CAPSULE,DELAYED... 16 ZETONNA 37 MCG/ACTUATION NASAL HFA INHALER... 14 ZIOPTAN (PF) 0.0015 % EYE DROPS IN A DROPPERETTE... 24 27