MEDICATION(S) SUBJECT TO STEP THERAPY
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1 ACE/ARB COMBO AZOR 5-20 MG TABLET, AZOR 5-40 MG TABLET, BENICAR HCT, MICARDIS HCT, TARKA, TEKTURNA HCT, TELMISARTAN-HYDROCHLOROTHIAZID, TRIBENZOR Claims for formulary step 2 ACE Inhibitor combination products or step 2 Angiotensin II Receptor Blocker (ARB) combination products will process after a formulary step 1 ACE, ARB, or ACE/ARB combination product within the past 120 days. PAGE 1 LAST UPDATED 09/2015
2 ANTIDIABETIC AGENTS ACTOPLUS MET XR, AVANDAMET 4 MG-500 MG TABLET, AVANDARYL 4 MG-1 MG TABLET, AVANDARYL 4 MG-2 MG TABLET, AVANDARYL 8 MG-4 MG TABLET, INVOKANA, JANUMET, JANUMET XR, KOMBIGLYZE XR, ONGLYZA, PRANDIMET, RIOMET Claims for formulary Brand Diabetes agents will process if there is a paid claim for a 30-day supply of formulary metformin or sulfonylurea within the past 90 days. PAGE 2 LAST UPDATED 09/2015
3 ANTIFUNGAL - AZOLE AGENTS NOXAFIL 40 MG/ML SUSPENSION, SPORANOX 10 MG/ML SOLUTION, VFEND 40 MG/ML SUSPENSION, VORICONAZOLE 40 MG/ML SUSP Claims for formulary Brand Antifungal Azole Agents will process if there is a 30 day supply of a formulary generic Antifungal Azole Agent within that past 60 days. PAGE 3 LAST UPDATED 09/2015
4 ANTIHYPERLIPIDEMICS CRESTOR, FENOFIBRIC ACID DR 135 MG CAP, FENOFIBRIC ACID DR 45 MG CAP, JUXTAPID 10 MG CAPSULE, JUXTAPID 20 MG CAPSULE, JUXTAPID 5 MG CAPSULE, KYNAMRO, TRILIPIX, VYTORIN MG TABLET Claims for formulary step 2 Antihyperlipidemics will process if there is a paid claim for at least a 30-day supply of a formulary step 1 Antihyperlipidemic within the past 120 days. PAGE 4 LAST UPDATED 09/2015
5 ASTHMA THERAPY DULERA, SYMBICORT Claims will process if there is a claim for a 30-day supply of Qvar, Flovent HFA or Serevent in the past 90 days. PAGE 5 LAST UPDATED 09/2015
6 BONE RESORPTION INHIBITORS - BISPHOSPHONATES AND COMBINATIONS ACTONEL 30 MG TABLET, ACTONEL 5 MG TABLET Claims for formulary step 2 Bone Resorption Inhibitors-Bisphosphonates and Combinations will process after a paid claim for at least a 30-day supply of a formulary step 1 Bone Resorption Inhibitors- Bisphosphonates and Combinations within the past 90 days. PAGE 6 LAST UPDATED 09/2015
7 BYETTA/VICTOZA/BYDUREON BYDUREON, BYDUREON PEN, BYETTA, VICTOZA 2-PAK, VICTOZA 3-PAK Claims for formulary step 2 byetta or victoza or bydureon will process after a paid claim with maximum dose of metformin (1,500mg/day) or TZD (pioglitazone at 45mg/day, rosiglitazone at 8mg/day) for 3 consecutive fills within the past 90 days. PAGE 7 LAST UPDATED 09/2015
8 NASAL ANTIALLERGY CLARINEX 0.5 MG/ML (2.5 MG/5) Claims for formulary step 2 Nasal Antiallergy will process if there is a paid claim for at least a 30-day supply of a formulary step 1 Nasal Antiallergy Agents within the past 180 days. PAGE 8 LAST UPDATED 09/2015
9 NSAIDS CELEBREX Claims for formulary step 2 NSAIDs will process if there are claims for at least a 30-day supply of two separate formulary step 1 NSAIDs within the past 180 days. PAGE 9 LAST UPDATED 09/2015
10 PPI NEXIUM I.V. 40 MG VIAL Claims for Nexium IV will process if there is a paid claim for Protonix IV within the past 30 days. PAGE 10 LAST UPDATED 09/2015
11 PROSTATIC HYPERTROPHY AGENTS JALYN, RAPAFLO Claims for formulary step 2 Prostatic Hypertrophy Agents will process if there is a paid claim for at least a 30-day supply of a formulary step 1 Prostatic Hypertrophy Agents within the past 180 days. PAGE 11 LAST UPDATED 09/2015
12 PROTON PUMP INHIBITOR DEXILANT, KAPIDEX Claims for formulary step 2 oral Proton Pump Inhibitors will process if there is a paid claim for a 30-day supply for a formulary step 1 oral Proton Pump Inhibitors within the past 90 days. PAGE 12 LAST UPDATED 09/2015
13 SMOKING CESSATION CHANTIX 0.5 MG TABLET, CHANTIX 1 MG TABLET, NICOTROL NS Claims will process for Nicotrol Inhaler or Chantix if there are 3 consecutive filles for a 30-day supply of Bupropan in the past 90 days. PAGE 13 LAST UPDATED 09/2015
14 URINARY ANTISPASMODICS MYRBETRIQ, VESICARE Claims for formulary step 2 Urinary Antispasmodics will process if there is a paid claim for a formulary step 1 Urinary Antispasmodics within the past 120 days. PAGE 14 LAST UPDATED 09/2015
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