ACTEMRA. Step Therapy Criteria HEALTH CHOICE EXCHANGE 2016 Effective Date: 01/01/2016. PRODUCT(s) AFFECTED ACTEMRA
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1 ACTEMRA ACTEMRA Claim will pay automatically for Actemra if enrollee has a paid claim for at least a 1 days supply of Enbrel and Humira in the past 365 days. Otherwise, Actemra requires a step therapy exception request indicating: (1) history of inadequate treatment response with Enbrel and Humira, OR (2) history of adverse event with Enbrel and Humira, OR (3) any contraindication to Enbrel and Humira. PAGE 1 LAST UPDATED 10/2015
2 AUBAGIO AUBAGIO Claim will pay automatically for Aubagio if enrollee has a paid claim for at least a 1 days supply of Copaxone, Gilenya, Rebif, Tysabri, Betaseron, or Extavia in the past 365 days. Otherwise, Aubagio requires a step therapy exception request indicating: (1) history of inadequate treatment response with Copaxone, Gilenya, Rebif, Tysabri, Betaseron, or Extavia, OR (2) history of adverse event with Copaxone, Gilenya, Rebif, Tysabri, Betaseron, or Extavia, OR (3) Copaxone, Gilenya, Rebif, Tysabri, Betaseron, or Extavia are contraindicated. PAGE 2 LAST UPDATED 10/2015
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 antidepressants, OR (3) any 2 generic formulary antidepressants are contraindicated. PAGE 3 LAST UPDATED 10/2015
4 CIMZIA - CIMZIA - CIMZIA PREFILLED - CIMZIA STARTER KIT Claim will pay automatically for Cimzia if enrollee has a paid claim for at least a 1 days supply of Enbrel and Humira in the past 365 days. Otherwise, Cimziarequires a step therapy exception request indicating: (1) history of inadequate treatment response with Enbrel and Humira, OR (2) history of adverse event with Enbrel and Humira, OR (3) any contraindication to Enbrel and Humira. PAGE 4 LAST UPDATED 10/2015
5 COSENTYX COSENTYX Claim will pay automatically for Cosentyx if enrollee has a paid claim for at least a 1 days supply of Enbrel and Humira in the past 365 days. Otherwise, cosentyx requires a step therapy exception request indicating: (1) history of inadequate treatment response with Enbrel and Humira, OR (2) history of adverse event with Enbrel and Humira, OR (3) any contraindication to Enbrel and Humira. PAGE 5 LAST UPDATED 10/2015
6 DIFICID DIFICID Claim will pay automatically for Dificid if enrollee has a paid claim for at least a 1 days supply of vancomycin 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 PAGE 6 LAST UPDATED 10/2015
7 EDARBI 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. PAGE 7 LAST UPDATED 10/2015
8 EDARBYCHLOR 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. PAGE 8 LAST UPDATED 10/2015
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 i 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. PAGE 9 LAST UPDATED 10/2015
10 LONG ACTING FENTANYL - FENTANYL 100 MCG/HR - FENTANYL 12 MCG/HR - FENTANYL 25 MCG/HR - FENTANYL 75 MCG/HR - FENTANYL PATCH 72HR 100 MCG/HR - FENTANYL PATCH 72HR 12 MCG/HR - FENTANYL PATCH 72HR 25 MCG/HR - FENTANYL PATCH 72HR 50 MCG/HR - FENTANYL PATCH 72HR 75 MCG/HR 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 brand Opana ER or 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. PAGE 10 LAST UPDATED 10/2015
11 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. PAGE 11 LAST UPDATED 10/2015
12 ORENCIA ORENCIA Claim will pay automatically for Orencia if enrollee has a paid claim for at least a 1 days supply of Enbrel and Humira in the past 365 days. Otherwise, Orenica requires a step therapy exception request indicating: (1) history of inadequate treatment response with Enbrel and Humira, OR (2) history of adverse event with Enbrel and Humira, OR (3) any contraindication to Enbrel and Humira. PAGE 12 LAST UPDATED 10/2015
13 UCERIS UCERIS TAB ER 24H 9 MG 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. PAGE 13 LAST UPDATED 10/2015
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. PAGE 14 LAST UPDATED 10/2015
15 XELJANZ XELJANZ Claim will pay automatically for Xeljanz if enrollee has a paid claim for at least a 1 days supply of Enbrel and Humira in the past 365 days. Otherwise, Xeljanz requires a step therapy exception request indicating: (1) history of inadequate treatment response with Enbrel and Humira, OR (2) history of adverse event with Enbrel and Humira, OR (3) any contraindication to Enbrel and Humira. PAGE 15 LAST UPDATED 10/2015
AUBAGIO. Step Therapy Criteria Health Choice Generations Formulary ID: 15179 Version 19 Effective Date: 11/1/2015. PRODUCT(s) AFFECTED AUBAGIO
AUBAGIO AUBAGIO Claim will pay automatically for AUBAGIO if enrollee has a paid claim for at least a 1 days supply of COPAXONE, REBIF, TYSABRI, BETASERON OR EXTAVIA in the past 365 days. Otherwise, AUBAGIO
Aubagio. AgeWell Drugs that Require Step Therapy Last Updated: 08/08/2014. Products Affected. Details AUBAGIO TAB 14MG AUBAGIO TAB 7MG
Aubagio AUBAGIO TAB 14MG AUBAGIO TAB 7MG Claim will pay automatically for AUBAGIO if enrollee has a paid claim for at least a 1 days supply of COPAXONE, REBIF, TYSABRI, BETASERON OR EXTAVIA in the past
VA Premier CompleteCare Drugs that Require Step Therapy Last Updated: 09/23/2014
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
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