2016 Step Therapy Criteria

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1 2016 Step Therapy Criteria ANGIOTENSIN RECEPTOR BLOCKERS... 8 benazepril... 8 benazepril/amlodipine besylate... 8 benazepril/hctz... 8 captopril... 8 captopril/hctz... 8 enalapril... 8 enalapril maleate/hctz... 8 fosinopril... 8 fosinopril/hctz... 8 irbesartan... 8 irbesartan/hctz... 8 lisinopril... 8 lisinopril/hctz... 8 losartan... 8 losartan /hctz... 8 moexipril... 8 moexipril/hctz... 8 perindopril erbumine... 8 quinapril... 8 quinapril/hctz... 8 ramipril... 8 trandolapril... 8 Updated: 09/2016 1

2 valsartan... 8 valsartan/hctz... 8 amlodipine/valsartan... 8 amlodipine/valsartan/hctz... 8 AZOR... 8 BENICAR HCT... 8 BENICAR... 8 ANTIDEPRESSANTS... 9 citalopram... 9 escitalopram oxalate... 9 fluoxetine... 9 paroxetine... 9 sertraline... 9 venlafaxine ir/er... 9 DESVENLAFAXINE ER... 9 FETZIMA... 9 FETZIMA TITRATION PACK... 9 KHEDEZLA... 9 PRISTIQ... 9 ANTIDEPRESSANTS, OTHER citalopram escitalopram oxalate fluoxetine paroxetine sertraline Updated: 09/2016 2

3 VIIBRYD VIIBRYD STARTER PACK ANTIDIABETIC AGENTS metformin metformin er FARXIGA INVOKANA ANTIGOUT AGENTS allopurinol ULORIC ANTIHYPERTENSIVE AGENTS benazepril benazepril/amlodipine besylate benazepril/hctz captopril captopril/hctz enalapril enalapril maleate/hctz fosinopril fosinopril/hctz irbesartan irbesartan/hctz lisinopril lisinopril/hctz losartan Updated: 09/2016 3

4 losartan /hctz moexipril moexipril/hctz perindopril erbumine quinapril quinapril/hctz ramipril trandolapril valsartan valsartan/hctz TEKTURNA HCT TEKTURNA ATYPICAL ANTIPSYCHOTICS olanzapine/odt quetiapine fumarate risperidone/odt ziprasidone oral aripiprazole/odt FANAPT FANAPT TITRATION PACK LATUDA paliperidone er REXULTI SAPHRIS SEROQUEL XR Updated: 09/2016 4

5 VRAYLAR TM BISPHOSPHONATES alendronate ibandronate oral risedronate oral DYSLIPIDEMICS atorvastatin simvastatin rosuvastatin INVOKAMET INVOKANA metformin metformin ER INVOKAMET NONSTEROIDAL ANTI-INFLAMMATORY AGENTS diclofenac potassium diclofenac sodium ec/er diflunisal etodolac/er ibuprofen meloxicam nabumetone naproxen/ec naproxen sodium piroxicam Updated: 09/2016 5

6 sulindac celecoxib OPHTHALMIC ANTIGLAUCOMA AGENTS brimonidine tartrate carteolol levobunolol metipranolol timolol soln COMBIGAN OPHTHALMIC ANTIGLAUCOMA AGENTS, OTHER latanoprost LUMIGAN PROTON PUMP INHIBITORS lansoprazole omeprazole pantoprazole esomeprazole magnesium caps SMOKING CESSATION AGENTS buproban CHANTIX CHANTIX STARTING PACK CHANTIX CONTINUING PACK TRINTELLIX citalopram duloxetine Updated: 09/2016 6

7 escitalopram oxalate fluoxetine paroxetine sertraline venlafaxine ir/er TRINTELLIX TM XIGDUO XR FARXIGA metformin metformin ER XIGDUO XR Updated: 09/2016 7

8 ANGIOTENSIN RECEPTOR BLOCKERS benazepril benazepril/amlodipine besylate benazepril/hctz captopril captopril/hctz enalapril enalapril maleate/hctz fosinopril fosinopril/hctz irbesartan irbesartan/hctz lisinopril lisinopril/hctz losartan losartan /hctz moexipril moexipril/hctz perindopril erbumine quinapril quinapril/hctz ramipril trandolapril valsartan valsartan/hctz amlodipine/valsartan amlodipine/valsartan/hctz AZOR BENICAR HCT BENICAR Step 1 drugs are generic Losartan, Losartan HCT, Irbesartan, Irbesartan HCT, Valsartan, Valsartan HCT, Benazepril, Benazepril HCTZ, Benazepril with Amlodipine, Captopril, Captopril HCTZ, Enalapril, Enalapril HCTZ, Fosinopril, Fosinopril HCTZ, Lisinopril, Lisinopril HCTZ, Moexipril, Moexipril HCTZ, Perindopril, Quinapril, Quinapril HCTZ, Ramipril, Trandolapril. Step 2 drugs: Benicar, Benicar HCT, Azor, amlodipine with valsartan, amlodipine with valsartan HCT. The use of at least one Step 1 drug is required prior to the use of Step 2 drugs. A look back period for claims review for Step 1 drugs is 130 days. Updated: 09/2016 8

9 ANTIDEPRESSANTS ANTIDEPRESSANTS citalopram escitalopram oxalate fluoxetine paroxetine sertraline venlafaxine ir/er DESVENLAFAXINE ER FETZIMA FETZIMA TITRATION PACK KHEDEZLA PRISTIQ This Step Therapy Group is applicable to new starts. Step 1 drugs are generic Venlafaxine immediate-release, Venlafaxine ER capsules, Citalopram, Escitalopram, Fluoxetine, Paroxetine, Sertraline. Step 2 drugs: Pristiq, Desvenlafaxine ER, Khedezla, Fetzima, Fetzima titration pack. The use of at least one Step 1 drug is required prior to the use of Step 2 drugs. A look back period for claims review for Step 1 drugs is 130 days. Updated: 09/2016 9

10 ANTIDEPRESSANTS, OTHER citalopram escitalopram oxalate fluoxetine paroxetine sertraline VIIBRYD VIIBRYD STARTER PACK This Step Therapy Group is applicable to new starts. Step 1 drugs are generic Citalopram, Escitalopram, Fluoxetine, Paroxetine, Sertraline. Step 2 drug: Viibryd. The use of at least two Step 1 drugs is required prior to the use of a Step 2 drug. A look back period for claims review for Step 1 drugs is 130 days. Updated: 09/

11 ANTIDIABETIC AGENTS metformin metformin er FARXIGA INVOKANA Step 1 drugs are generic Metformin, Metformin ER. Step 2 drugs: Farxiga, Invokana. The use of at least one Step 1 drug is required prior to the use of Step 2 drugs. A look back period for claims review for a Step 1 drug is 130 days. Updated: 09/

12 ANTIGOUT AGENTS allopurinol ULORIC Step 1 drug is generic Allopurinol. Step 2 drug: Uloric. The use of a Step 1 drug is required prior to the use of a Step 2 drug. A look back period for claims review for a Step 1 drug is 130 days. Updated: 09/

13 ANTIHYPERTENSIVE AGENTS benazepril benazepril/amlodipine besylate benazepril/hctz captopril captopril/hctz enalapril enalapril maleate/hctz fosinopril fosinopril/hctz irbesartan irbesartan/hctz lisinopril lisinopril/hctz losartan losartan /hctz moexipril moexipril/hctz perindopril erbumine quinapril quinapril/hctz ramipril trandolapril valsartan valsartan/hctz TEKTURNA HCT TEKTURNA Step 1 drugs are generic ACE inhibitors, generic ACE inhibitor combination products, generic ARB, generic ARB combination products: Benazepril, Benazepril with HCTZ, Captopril, Captopril with HCTZ, Enalapril, Enalapril with HCTZ, Fosinopril, Fosinopril with HCTZ, Lisinopril, Lisinopril with HCTZ, Moexipril, Moexipril with HCTZ, Perindopril, Quinapril, Quinapril with HCTZ, Trandolapril, Ramipril, Amlodipine with Benazepril, Losartan, Losartan HCT, Irbesartan, Irbesartan HCT, Valsartan, Valsartan HCT. Step 2 drugs: Tekturna, Tekturna with HCTZ. The use of at least one Step 1 drug is required prior to the use of Step 2 drugs. A look back period for claims review for Step 1 drugs is 130 days. Updated: 09/

14 ATYPICAL ANTIPSYCHOTICS olanzapine/odt quetiapine fumarate risperidone/odt ziprasidone oral aripiprazole/odt FANAPT FANAPT TITRATION PACK LATUDA paliperidone er REXULTI SAPHRIS SEROQUEL XR VRAYLAR TM This Step Therapy Group is applicable to new starts. Step 1 drugs are generic Risperidone tabs, Risperidone oral solution, Risperidone ODT, Quetiapine immediate release tabs, Olanzapine oral, Olanzapine ODT, Ziprasidone oral. Step 2 drugs: Aripiprazole ODT, aripiprazole tabs, paliperidone ER, Fanapt, Fanapt Titration Pack, Latuda, Saphris, Seroquel XR, Rexulti, Vraylar. The use of at least one Step 1 drug is required prior to the use of Step 2 drugs. A look back period for claims review for Step 1 drugs is 130 days. A trial of at least one step 1 drug is not required if Aripiprazole ODT or aripiprazole tabs or Seroquel XR or Rexulti will be used as an adjunctive treatment for major depression (this process will be automated: the member's claims history will be utilized). A trial of at least one step 1 drug is not required if Aripiprazole ODT or aripiprazole tabs will be used for the treatment of Tourette's disorder (this process will be automated: the member's claims history will be utilized). Updated: 09/

15 BISPHOSPHONATES alendronate ibandronate oral risedronate oral Step 1 drug is generic Bisphosphonate: Alendronate. Step 2 drugs: Ibandronate 150mg tabs, risedronate. The use of a Step 1 drug is required prior to the use of Step 2 drugs. A look back period for claims review for a Step 1 drug is 130 days. Updated: 09/

16 DYSLIPIDEMICS atorvastatin simvastatin rosuvastatin Step 1 drugs are atorvastatin, simvastatin. Step 2 drug: rosuvastatin. The use of at least one Step 1 drug is required prior to the use of a Step 2 drug. A look back period for claims review for Step 1 drugs is 130 days. Updated: 09/

17 INVOKAMET INVOKANA metformin metformin ER INVOKAMET Step 1 drugs are Metformin, Metformin ER, Invokana. Step 2 drug: Invokamet. The use of at least one Step 1 drug is required prior to the use of a Step 2 drug. A look back period for claims review for Step 1 drugs is 130 days. Updated: 09/

18 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS diclofenac potassium diclofenac sodium ec/er diflunisal etodolac/er ibuprofen meloxicam nabumetone naproxen/ec naproxen sodium piroxicam sulindac celecoxib Step 1 drugs are generic NSAIDs: Ibuprofen, Naproxen, Naproxen EC, Naproxen Sodium, Piroxicam, Sulindac, Diclofenac Potassium, Diclofenac Sodium EC, Diclofenac Sodium ER, Etodolac, Etodolac ER, Nabumetone, Meloxicam, Diflunisal. Step 2 drug: celecoxib. The use of at least two Step 1 drugs is required prior to the use of a Step 2 drug. A look back period for claims review for Step 1 drugs is 130 days. A trial of two generic NSAIDs is not required if celecoxib will be used in patients on any of the following: warfarin, Coumadin, Jantoven, Pradaxa, Eliquis or Xarelto (this process will be automated: the members claims history will be utilized). Updated: 09/

19 OPHTHALMIC ANTIGLAUCOMA AGENTS brimonidine tartrate carteolol levobunolol metipranolol timolol soln COMBIGAN Step 1 drugs are the following generic ophthalmics: Brimonidine 0.2%, Carteolol, Levobunolol, Metipranolol, Timolol solution. Step 2 drug: Combigan. The use of at least one Step 1 drug is required prior to the use of a Step 2 drug. A look back period for claims review for Step 1 drugs is 130 days. Updated: 09/

20 OPHTHALMIC ANTIGLAUCOMA AGENTS, OTHER latanoprost LUMIGAN Step 1 drug is generic Latanoprost. Step 2 drug: Lumigan. The use of a Step 1 drug is required prior to the use of a Step 2 drug. A look back period for claims review for a Step 1 drug is 130 days. Updated: 09/

21 PROTON PUMP INHIBITORS lansoprazole omeprazole pantoprazole esomeprazole magnesium caps Step 1 drugs are generic Omeprazole (legend drug), generic Pantoprazole oral, generic Lansoprazole (legend drug). Step 2 drug: esomeprazole magnesium caps. The use of at least one Step 1 drug is required prior to the use of a Step 2 drug. A look back period for claims review for Step 1 drugs is 130 days. Updated: 09/

22 SMOKING CESSATION AGENTS buproban CHANTIX CHANTIX STARTING PACK CHANTIX CONTINUING PACK Step 1 drug is generic Buproban. Step 2 drugs: Chantix, Chantix starting pack, Chantix continuing pack. The use of a Step 1 drug is required prior to the use of Step 2 drugs. A look back period for claims review for a Step 1 drug is 130 days. Updated: 09/

23 TRINTELLIX citalopram duloxetine escitalopram oxalate fluoxetine paroxetine sertraline venlafaxine ir/er TRINTELLIX TM This Step Therapy Group is applicable to new starts. Step 1 drugs are generic Venlafaxine immediate-release, Venlafaxine ER capsules, Citalopram, Escitalopram, Fluoxetine, Paroxetine, Sertraline, Duloxetine. Step 2 drug: Trintellix. The use of at least two Step 1 drugs is required prior to the use of a Step 2 drug. A look back period for claims review for Step 1 drugs is 130 days. Updated: 09/

24 XIGDUO XR FARXIGA metformin metformin ER XIGDUO XR Step 1 drugs are Metformin, Metformin ER, Farxiga. Step 2 drug: Xigduo XR. The use of at least one Step 1 drug is required prior to the use of a Step 2 drug. A look back period for claims review for Step 1 drugs is 130 days. Updated: 09/

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