2014 Valley Baptist Medicare D Formulary Step Therapy Criteria

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1 2014 Valley Baptist Medicare D Formulary Step Therapy Products Affected ACTONEL TAB Last Updated 11/1/2014 Requires a trial of alendronate. 1

2 APLENZIN TAB Patient must have tried bupropion SR or bupropion XL in previous 180 days. 2

3 ARANESP ALBUMIN FREE INJ. 100MCG, 150MCG, 200MCG, 300MCG, 500MCG Step Therapy requires trial of PROCRIT. 3

4 ARANESP ALBUMIN FREE INJ. 25MCG/0.42ML, 25MCG/ML, 60MCG/0.3ML, 60MCG/ML Step Therapy requires trial of PROCRIT. 4

5 ARANESP ALBUMIN FREE INJ. 40MCG/0.4ML, 40MCG/ML Step Therapy requires trial of PROCRIT. 5

6 ARICEPT TAB 23MG Requires trial of donepezil 10mg in previous 180 days. 6

7 ATELVIA TAB Requires a trial of alendronate. 7

8 BECONASE AQ NASAL Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 8

9 BONIVA INJ. Requires a trial of alendronate. 9

10 BONIVA TAB 150MG Requires a trial of alendronate. 10

11 BRINTELLIX TAB Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 11

12 budesonide nasal inhaler Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 12

13 BYETTA INJ. Step Therapy requires trial of Victoza 13

14 DESVENLAFAXINE ER TAB Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 14

15 DEXILANT CAP Step Therapy requires trial of omeprazole, lansoprazole or pantoprazole in previous 180 days. 15

16 DIFICID TAB Step Therapy requires trial of VANCOCIN. 16

17 donepezil tab 23mg Requires trial of donepezil 10mg in previous 180 days. 17

18 eszopiclone tab Step Therapy requires trial of zolpidem or zaleplon in previous 180 days. 18

19 EXTAVIA INJ. Step Therapy requires trial of two of the following: AVONEX, REBIF or COPAXONE 19

20 FETZIMA ER CAP Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 20

21 FETZIMA TITRATION PACK Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 21

22 ibandronate inj. Requires a trial of alendronate. 22

23 ibandronate tab Requires a trial of alendronate. 23

24 INTUNIV Step Therapy requires trial of guanfacine IR in previous 180 days. 24

25 JENTADUETO TAB Step Therapy requires trial of Januvia or Janumet. 25

26 KHEDEZLA ER TAB Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 26

27 LUNESTA TAB Step Therapy requires trial of zolpidem or zaleplon in previous 180 days. 27

28 LUVOX CR TAB Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 28

29 METROGEL 1% Step Therapy requires trial of FINACEA. 29

30 NASACORT AQ Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 30

31 NORITATE CREAM Step Therapy requires trial of FINACEA. 31

32 OMNARIS NASAL Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 32

33 PERTZYE CAP Step Therapy requires trial of CREON and PANCREAZE. 33

34 PEXEVA TAB Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 34

35 PRISTIQ TAB Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 35

36 QNASL Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 36

37 RHINOCORT AQUA NASAL Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 37

38 risedronate sodium tab Requires a trial of alendronate. 38

39 TRADJENTA TAB Step Therapy requires trial of Januvia or Janumet. 39

40 ULORIC TAB Member has tried or was intolerant to allopurinol. 40

41 ULTRESA CAP Step Therapy requires trial of CREON and PANCREAZE. 41

42 VANCOCIN CAP 125MG Step Therapy requires trial of metronidazole in previous 180 days 42

43 VANCOCIN CAP 250MG Step Therapy requires trial of metronidazole in previous 180 days 43

44 vancomycin cap Step Therapy requires trial of metronidazole in previous 180 days 44

45 VIIBRYD TAB Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 45

46 XOPENEX HFA INHALER Step Therapy requires trial of VENTOLIN HFA 46

47 ZENPEP CAP Step Therapy requires trial of CREON and PANCREAZE. 47

48 ZETONNA NASAL Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 48

49 ZIOPTAN Step Therapy requires trial of latanoprost. 49

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