VA Premier CompleteCare Drugs that Require Step Therapy Last Updated: 09/23/2014

Transcription

1 Atelvia Atelvia Claim will pay automatically for Atelvia if enrollee has a paid claim for at least a 1 days supply of alendronate in the past 365 days. Otherwise, Atelvia requires a step therapy exception request indicating: (1) history of inadequate treatment response with alendronate, OR (2) history of adverse event with alendronate, OR (3) alendronate is contraindicated. Effective Date: 10/01/2014 Page 1 of 14

2 Aubagio Aubagio Claim will pay automatically for aubagio if enrollee has a paid claim for at least a 1 days supply of MITOXANTRONE, REBIF, COPAXONE, or Betaseron in the past 365 days. Otherwise, aubagio requires a step therapy exception request indicating: (1) history of inadequate treatment response with MITOXANTRONE, REBIF, COPAXONE, or Betaseron, OR (2) history of adverse event with MITOXANTRONE, REBIF, COPAXONE, or Betaseron, OR (3) MITOXANTRONE, REBIF, COPAXONE, or Betaseron is contraindicated. Effective Date: 10/01/2014 Page 2 of 14

3 Brintellix Brintellix Claim will pay automatically for brintellix if enrollee has a paid claim for at least a 1 days supply of any 2 generic formulary antidepressants in the past 365 days. Otherwise, brintellix requires a step therapy exception request indicating: (1) history of inadequate treatment response with any 2 generic formulary antidepressants, OR (2) history of adverse event with any 2 generic formulary antidepressantss, OR (3) any 2 generic formulary antidepressants are contraindicated. Effective Date: 10/01/2014 Page 3 of 14

4 Celebrex Celebrex Claim will pay automatically for Celebrex if enrollee has a paid claim for at least a 1 days supply of Generic NSAID tablets or capsules in the past 365 days. Otherwise, Celebrex requires a step therapy exception request indicating: (1) history of inadequate treatment response with oral NSAIDs, OR (2) history of adverse event with oral NSAIDs, OR (3) oral NSAIDs are contraindicated. Effective Date: 10/01/2014 Page 4 of 14

5 Dexilant Dexilant Claim will pay automatically for Dexilant if enrollee has a paid claim for at least a 1 days supply of omeprazole or pantoprazole in the past 365 days. Otherwise, Dexilant requires a step therapy exception request indicating: (1) history of inadequate treatment response with omeprazole or pantoprazole, OR (2) history of adverse event with omeprazole or pantoprazole, OR (3) omeprazole or pantoprazole is contraindicated. Effective Date: 10/01/2014 Page 5 of 14

6 Dificid Dificid Claim will pay automatically for Dificid if enrollee has a paid claim for at least a 1 days supply of Generic Vancomycin capsules in the past 120 days. Otherwise, Dificid requires a step therapy exception request indicating: (1) history of inadequate treatment response with Vancomycin, OR (2) history of adverse event with Vancomycin, OR (3) Vancomycin is contraindicated. Effective Date: 10/01/2014 Page 6 of 14

7 Edari Edarbi Claim will pay automatically for Edarbi if enrollee has a paid claim for at least a 1 days supply of losartan in the past 365 days. Otherwise, Edarbi requires a step therapy exception request indicating: (1) history of inadequate treatment response with losartan, OR (2) history of adverse event with losartan, OR (3) losartan is contraindicated. Effective Date: 10/01/2014 Page 7 of 14

8 Edarychlor Edarbyclor Claim will pay automatically for Edarbychlor if enrollee has a paid claim for at least a 1 days supply of losartan/hctz or Edarbi in the past 365 days. Otherwise, Edarbychlor requires a step therapy exception request indicating: (1) history of inadequate treatment response with losartan/hctz or Edarbi, OR (2) history of adverse event with losartan/hctz or Edarbi, OR (3) losartan/hctz or Edarbi is contraindicated. Effective Date: 10/01/2014 Page 8 of 14

9 Enablex Enablex Claim will pay automatically for Enablex if enrollee has a paid claim for at least a 1 days supply of any generic formulary urinary anticholinergic in the past 365 days. Otherwise, Enablex requires a step therapy exception request indicating: (1) history of inadequate treatment response with generic formulary urinary anticholinergic, OR (2) history of adverse event with generic formulary urinary anticholinergic, OR (3) generic formulary urinary anticholinergic is contraindicated. Effective Date: 10/01/2014 Page 9 of 14

10 Fentanyl Fentanyl Transdermal Patch Claim will pay automatically for Fentanyl patches if enrollee has paid claims history for both Group A and Group B drugs. GROUP A Drugs: Any 1 days supply in the past 365 days of generic Oxymorphone ER (2) GROUP B Drugs: Any 1 days supply in the past 365 days of either Morphine ER or Methadone. Otherwise, the drug requires a step therapy exception request indicating any ONE of the following: (1) history of inadequate treatment response with Group A or Group B drugs, OR (2) history of adverse event with Group A or Group B drugs, OR (3) Group A or Group B drugs are contraindicated. Effective Date: 10/01/2014 Page 10 of 14

11 High Potency Statin Crestor Patient needs to have a paid claim for a Step 1 drug (atorvastatin) prior to filling a Step 2 drug (Crestor). Effective Date: 10/01/2014 Page 11 of 14

12 Myrbetriq Myrbetriq Claim will pay automatically for Myrbetriq if enrollee has a paid claim for at least a 1 days supply of any formulary urinary anticholinergic in the past 365 days. Otherwise, Myrbetriq requires a step therapy exception request indicating: (1) history of inadequate treatment response with formulary urinary anticholinergic, OR (2) history of adverse event with formulary urinary anticholinergic, OR (3) formulary urinary anticholinergic is contraindicated. Effective Date: 10/01/2014 Page 12 of 14

13 Uceris Uceris Claim will pay automatically for Uceris if enrollee has a paid claim for at least a 1 days supply of any formulary corticosteroid used to treat ulcerative colitis in the past 365 days. Otherwise, Uceris requires a step therapy exception request indicating: (1) history of inadequate treatment response with formulary corticosteroid used to treat ulcerative colitis, OR (2) history of adverse event with formulary corticosteroid used to treat ulcerative colitis, OR (3) formulary corticosteroid used to treat ulcerative colitis is contraindicated. Effective Date: 10/01/2014 Page 13 of 14

14 Uloric Uloric Claim will pay automatically for Uloric if enrollee has a paid claim for at least a 1 days supply of Allopurinol in the past 365 days. Otherwise, Uloric requires a step therapy exception request indicating: (1) history of inadequate treatment response with Allopurinol, OR (2) history of adverse event with Allopurinol, OR (3) Allopurinol is contraindicated. Effective Date: 10/01/2014 Page 14 of 14