2020 GRS Premier Step Therapy Document

AggrenoxProducts Affected• AGGRENOX CAPSULE EXTENDED

RELEASE 12 HOUR 25-200 MG ORAL• aspirin-dipyridamole er capsule extended

release 12 hour 25-200 mg oral

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): clopidigrel. Step 2 Drug(s): Aggrenox (aspirin/extended-release dipyridamole). Applies to New Starts Only.

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Albuterol HFAProducts Affected• levalbuterol tartrate aerosol 45 mcg/act

inhalation• PROAIR DIGIHALER AEROSOL POWDER

BREATH ACTIVATED 108 MCG/ACT INHALATION

• VENTOLIN HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION

• XOPENEX HFA AEROSOL 45 MCG/ACT INHALATION

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): ProAir HFA, ProAir Respiclick, Proventil HFA, albuterol HFA. Step 2 Drug(s): Xopenex HFA (levalbuterol hfa), Ventolin HFA, ProAir Digihaler (albuterol).

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AntaraProducts Affected• ANTARA CAPSULE 30 MG ORAL • ANTARA CAPSULE 90 MG ORALDetails

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): gemfibrozil, fenofibrate, fenofibrate acid, fenofibrate micronized. Step 2 Drug(s): Antara.

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AptiomProducts Affected• APTIOM TABLET 200 MG ORAL• APTIOM TABLET 400 MG ORAL

• APTIOM TABLET 600 MG ORAL• APTIOM TABLET 800 MG ORAL

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Lamotrigine IR, Levetiracetam IR\XR, Oxcarbazepine IR, Roweepra IR\XR, Topiramate IR/XR, Zonisamide. Step 2 Drug(s): Aptiom (eslicarbazepine). Applies to New Starts Only.

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Aricept 23mg-AProducts Affected• ARICEPT TABLET 23 MG ORAL • donepezil hcl tablet 23 mg oral

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): donepezil, donepezil disintegrating tablet. Step 2 Drug(s): Aricept 23mg (donepezil 23mg). New starts Only.

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CyclosetProducts Affected• CYCLOSET TABLET 0.8 MG ORALDetails

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): metformin. Step 2 Drug(s): Cycloset (bromocriptine mesylate)

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DexilantProducts Affected• DEXILANT CAPSULE DELAYED RELEASE

30 MG ORAL• DEXILANT CAPSULE DELAYED RELEASE

60 MG ORALDetails

Criteria If the patient has tried ONE Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): omeprazole, pantoprazole, or lansoprazole. Step 2 Drug(s): Dexilant (dexlansoprazole). New Starts

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FanaptProducts Affected• FANAPT TABLET 1 MG ORAL• FANAPT TABLET 10 MG ORAL• FANAPT TABLET 12 MG ORAL• FANAPT TABLET 2 MG ORAL• FANAPT TABLET 4 MG ORAL

• FANAPT TABLET 6 MG ORAL• FANAPT TABLET 8 MG ORAL• FANAPT TITRATION PACK TABLET 1 & 2

& 4 & 6 MG ORAL

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): olanzapine, paliperidone, quetiapine fumarate, risperidone, ziprasidone. Step 2 Drug(s): Fanapt (iloperidone), Fanapt Titration Pack (iloperidone). Applies to New Starts Only.

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Glumetza ERProducts Affected• GLUMETZA TABLET EXTENDED RELEASE

24 HOUR 1000 MG ORAL• GLUMETZA TABLET EXTENDED RELEASE

24 HOUR 500 MG ORALDetails

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): metformin ER. Step 2 Drug(s): Brand Glumetza ER

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Innopran XLProducts Affected• INNOPRAN XL CAPSULE EXTENDED

RELEASE 24 HOUR 120 MG ORAL• INNOPRAN XL CAPSULE EXTENDED

RELEASE 24 HOUR 80 MG ORALDetails

Criteria If the patient has tried TWO Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): acebutolol, atenolol, betaxolol, bisoprolol, Bystolic, metoprolol tartrate, metoprolol succinate ER, nadolol, pindolol, propranolol/ER, timolol. Step 2 Drug(s): Innopran XL. NEW Starts

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LunestaProducts Affected• LUNESTA TABLET 1 MG ORAL• LUNESTA TABLET 2 MG ORAL

• LUNESTA TABLET 3 MG ORAL

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): eszopiclone. Step 2 Drug(s): Brand Lunesta.

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LuzuProducts Affected• luliconazole cream 1 % external • LUZU CREAM 1 % EXTERNALDetails

Criteria If the patient has tried TWO Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Ciclopirox cream/suspension/gel/shampoo, Clotrimazole cream/solution, Ketoconazole cream/shampoo, Ciclodan cream, Loprox 0.77 cream/suspension, Nystatin cream/ointment/powder. Step 2 Drug(s): Luzu (luliconazole).

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Meloxicam LineProducts Affected• QMIIZ ODT TABLET DISPERSIBLE 15 MG

ORAL• QMIIZ ODT TABLET DISPERSIBLE 7.5

MG ORAL• VIVLODEX CAPSULE 10 MG ORAL• VIVLODEX CAPSULE 5 MG ORAL

Details

Criteria If the patient has tried TWO Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Celecoxib, Diclofenac Potassium, Diclofenac Sodium IR/ER, Diclofenac-Misoprost, Diflunisal, Etodolac IR/ER, Fenoprofen Calcium, Flurbiprofen, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac Tromethamine, Meclofenamate Sodium, Mefenamic Acid, Meloxicam, Nabumetone, Naproxen Sodium, Naproxen, Oxaprozin, Piroxicam, Sulindac, Tolmetin Sodium. Step 2 Drug(s): Vivlodex (meloxicam), Qmiiz ODT (meloxicam).

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MSB AzorProducts Affected• AZOR TABLET 10-20 MG ORAL• AZOR TABLET 10-40 MG ORAL

• AZOR TABLET 5-20 MG ORAL• AZOR TABLET 5-40 MG ORAL

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Amlodipine-Olmesartan. Step 2 Drug(s): Brand Azor. NEW Starts

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MSB Benicar LineProducts Affected• BENICAR HCT TABLET 20-12.5 MG ORAL• BENICAR HCT TABLET 40-12.5 MG ORAL• BENICAR HCT TABLET 40-25 MG ORAL

• BENICAR TABLET 20 MG ORAL• BENICAR TABLET 40 MG ORAL• BENICAR TABLET 5 MG ORAL

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Olmesartan Medoxomil, Olmesartan Medoxomil HCTZ. Step 2 Drug(s): Brand Benicar/Benicar HCT. NEW Starts

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MSB CrestorProducts Affected• CRESTOR TABLET 10 MG ORAL• CRESTOR TABLET 20 MG ORAL

• CRESTOR TABLET 40 MG ORAL• CRESTOR TABLET 5 MG ORAL

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Rosuvastatin. Step 2 Drug(s): Brand Crestor. NEW Starts

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MSB LipitorProducts Affected• LIPITOR TABLET 10 MG ORAL• LIPITOR TABLET 20 MG ORAL

• LIPITOR TABLET 40 MG ORAL• LIPITOR TABLET 80 MG ORAL

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Atorvastatin. Step 2 Drug(s): Brand Lipitor. NEW Starts

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MSB ParkinsonProducts Affected• LODOSYN TABLET 25 MG ORAL• MIRAPEX ER TABLET EXTENDED

RELEASE 24 HOUR 0.375 MG ORAL• MIRAPEX ER TABLET EXTENDED

RELEASE 24 HOUR 0.75 MG ORAL• MIRAPEX ER TABLET EXTENDED

RELEASE 24 HOUR 1.5 MG ORAL• MIRAPEX ER TABLET EXTENDED

RELEASE 24 HOUR 2.25 MG ORAL• MIRAPEX ER TABLET EXTENDED

RELEASE 24 HOUR 3 MG ORAL• MIRAPEX ER TABLET EXTENDED

RELEASE 24 HOUR 3.75 MG ORAL• MIRAPEX ER TABLET EXTENDED

RELEASE 24 HOUR 4.5 MG ORAL• REQUIP XL TABLET EXTENDED RELEASE

24 HOUR 12 MG ORAL

• REQUIP XL TABLET EXTENDED RELEASE 24 HOUR 4 MG ORAL

• REQUIP XL TABLET EXTENDED RELEASE 24 HOUR 6 MG ORAL

• REQUIP XL TABLET EXTENDED RELEASE 24 HOUR 8 MG ORAL

• RYTARY CAPSULE EXTENDED RELEASE 23.75-95 MG ORAL

• RYTARY CAPSULE EXTENDED RELEASE 36.25-145 MG ORAL

• RYTARY CAPSULE EXTENDED RELEASE 48.75-195 MG ORAL

• RYTARY CAPSULE EXTENDED RELEASE 61.25-245 MG ORAL

• SINEMET TABLET 10-100 MG ORAL• SINEMET TABLET 25-100 MG ORAL• SINEMET TABLET 25-250 MG ORAL

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): carbidopa, carbidopa/levodopa IR/ER, pramipexole IR/ER, ropinirole IR/ER. Step 2 Drug(s): Lodosyn, Mirapex ER, Requip XL, Rytary (carbidopa/levodopa), Sinemet.

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MSB TribenzorProducts Affected• TRIBENZOR TABLET 20-5-12.5 MG ORAL• TRIBENZOR TABLET 40-10-12.5 MG

ORAL

• TRIBENZOR TABLET 40-10-25 MG ORAL• TRIBENZOR TABLET 40-5-12.5 MG ORAL• TRIBENZOR TABLET 40-5-25 MG ORAL

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Olmesartan Amlodipine HCTZ. Step 2 Drug(s): Brand Tribenzor. NEW Starts

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MSB Wellbutrin XL/SRProducts Affected• WELLBUTRIN SR TABLET EXTENDED

RELEASE 12 HOUR 100 MG ORAL• WELLBUTRIN SR TABLET EXTENDED

RELEASE 12 HOUR 150 MG ORAL• WELLBUTRIN SR TABLET EXTENDED

RELEASE 12 HOUR 200 MG ORAL• WELLBUTRIN XL TABLET EXTENDED

RELEASE 24 HOUR 150 MG ORAL• WELLBUTRIN XL TABLET EXTENDED

RELEASE 24 HOUR 300 MG ORAL

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Buproprion. Step 2 Drug(s): Brand Wellbutrin/Budeprion XL/SR NEW Starts

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Nasal Steroid - HProducts Affected• BECONASE AQ SUSPENSION 42

MCG/SPRAY NASAL• NASONEX SUSPENSION 50 MCG/ACT

NASAL• OMNARIS SUSPENSION 50 MCG/ACT

NASAL• QNASL AEROSOL SOLUTION 80

MCG/ACT NASAL• QNASL CHILDRENS AEROSOL SOLUTION

40 MCG/ACT NASAL• XHANCE EXHALER SUSPENSION 93

MCG/ACT NASAL• ZETONNA AEROSOL SOLUTION 37

MCG/ACT NASAL

Details

Criteria If the patient has tried TWO step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 drugs: mometasone furoate nasal spray, fluticasone propionate nasal spray or flunisolide nasal spray. Step 2 drugs: Beconase AQ (beclomethasone dipropionate monohydrate), Nasonex, Omnaris (ciclesonide), Veramyst (fluticasone furoate), Qnasl (beclomethasone dipropionate), Zetonna (ciclesonide), Rhinocort AQ, or Xhance (fluticasone) may be authorized. For diagnosis Vasomotor Rhinitis, Beconase AQ may be authorized after trial of fluticasone propionate. For diagnosis of nasal polyps, Beconase AQ (beclomethasone), Xhance (fluticasone) and Brand Nasonex may be authorized after trial of Mometasone furoate nasal spray.

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NexiumProducts Affected• esomeprazole magnesium capsule

delayed release 20 mg oral• esomeprazole magnesium capsule

delayed release 40 mg oral• ESOMEPRAZOLE STRONTIUM CAPSULE

DELAYED RELEASE 49.3 MG ORAL• NEXIUM CAPSULE DELAYED RELEASE 20

MG ORAL

• NEXIUM CAPSULE DELAYED RELEASE 40 MG ORAL

• NEXIUM PACKET 10 MG ORAL• NEXIUM PACKET 2.5 MG ORAL• NEXIUM PACKET 20 MG ORAL• NEXIUM PACKET 40 MG ORAL• NEXIUM PACKET 5 MG ORAL

Details

Criteria If the patient has tried TWO Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): omeprazole, pantoprazole, or lansoprazole. Step 2 Drug(s): Nexium (esomeprazole mag DR), esomeprazole. New Starts

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NP Bisphosphonates - GProducts Affected• ACTONEL TABLET 150 MG ORAL• ACTONEL TABLET 30 MG ORAL• ACTONEL TABLET 35 MG ORAL• ACTONEL TABLET 5 MG ORAL• BONIVA TABLET 150 MG ORAL• FOSAMAX PLUS D TABLET 70-2800 MG-

UNIT ORAL• FOSAMAX PLUS D TABLET 70-5600 MG-

UNIT ORAL• FOSAMAX TABLET 70 MG ORAL

• risedronate sodium tablet 150 mg oral• risedronate sodium tablet 30 mg oral• risedronate sodium tablet 35 mg oral• risedronate sodium tablet 35 mg oral (12

pack)• risedronate sodium tablet 35 mg oral (4

pack)• risedronate sodium tablet 5 mg oral• risedronate sodium tablet delayed

release 35 mg oral

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Alendronate, ibandronate tablets. Step 2 Drug(s): Actonel, Boniva tablets, Fosamax plus D, Fosamax 70mg (tab/sol), Risedronate.

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NP Fast Acting InsulinProducts Affected• NOVOLIN 70/30 FLEXPEN RELION

SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML SUBCUTANEOUS

• NOVOLIN 70/30 FLEXPEN SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML SUBCUTANEOUS

• NOVOLIN 70/30 RELION SUSPENSION (70-30) 100 UNIT/ML SUBCUTANEOUS

• NOVOLIN 70/30 SUSPENSION (70-30)

100 UNIT/ML SUBCUTANEOUS• NOVOLIN N RELION SUSPENSION 100

UNIT/ML SUBCUTANEOUS• NOVOLIN N SUSPENSION 100 UNIT/ML

SUBCUTANEOUS• NOVOLIN R RELION SOLUTION 100

UNIT/ML INJECTION• NOVOLIN R SOLUTION 100 UNIT/ML

INJECTION

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Humulin N, R, 70 30, R 500 (pen/vial/cartridge). Step 2 Drug(s): Novolin N, R, 70 30 (pen/vial/cartridge). New starts Only.

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NP LAMA LABAProducts Affected• BEVESPI AEROSPHERE AEROSOL 9-4.8

MCG/ACT INHALATION• UTIBRON NEOHALER CAPSULE 27.5-

15.6 MCG INHALATIONDetails

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): ANORO Ellipta (umeclidinium-vilanterol) or Stiolto Respimat (tiotropium/olodaterol) Step 2 Drug(s): Utibron Neohaler (glycopyrrolate/indacaterol) or Bevespi Aerosphere (glycopyrrolate-formoterol fumarate).

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NP Long Acting InsulinProducts Affected• BASAGLAR KWIKPEN SOLUTION PEN-

INJECTOR 100 UNIT/ML SUBCUTANEOUS

• TRESIBA FLEXTOUCH SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS

• TRESIBA FLEXTOUCH SOLUTION PEN-INJECTOR 200 UNIT/ML SUBCUTANEOUS

• TRESIBA SOLUTION 100 UNIT/ML SUBCUTANEOUS

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Lantus (Insulin Glargine), Levemir (Insulin Detemir), Toujeo (Insulin Glargine). Step 2 Drug(s): Basaglar (Insulin Glargine), Tresiba (insulin degludec). New starts Only.

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NP OAB - GProducts Affected• DETROL LA CAPSULE EXTENDED

RELEASE 24 HOUR 2 MG ORAL• DETROL LA CAPSULE EXTENDED

RELEASE 24 HOUR 4 MG ORAL• DETROL TABLET 1 MG ORAL• DETROL TABLET 2 MG ORAL• DITROPAN XL TABLET EXTENDED

RELEASE 24 HOUR 10 MG ORAL• DITROPAN XL TABLET EXTENDED

RELEASE 24 HOUR 5 MG ORAL

• ENABLEX TABLET EXTENDED RELEASE 24 HOUR 15 MG ORAL

• ENABLEX TABLET EXTENDED RELEASE 24 HOUR 7.5 MG ORAL

• GELNIQUE GEL 10 % TRANSDERMAL• GELNIQUE PUMP GEL 10 %

TRANSDERMAL• OXYTROL PATCH TWICE WEEKLY 3.9

MG/24HR TRANSDERMAL

Details

Criteria If the patient has tried Toviaz/Myrbetriq and one of the following: darifenacin ER, oxybutynin, oxybutynin solution, oxybutynin ER, tolterodine IR/ER, solifenacin, OR trospium IR/ER. Then Detrol/Detrol LA, Ditropan XL, Enablex, Gelnique (oxybutynin), Oxytrol, Sanctura, Sanctura XR may be authorized.

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NP Phosphate Binder - GProducts Affected• FOSRENOL PACKET 1000 MG ORAL• FOSRENOL PACKET 750 MG ORAL• FOSRENOL TABLET CHEWABLE 1000 MG

ORAL• FOSRENOL TABLET CHEWABLE 500 MG

ORAL• FOSRENOL TABLET CHEWABLE 750 MG

ORAL

• PHOSLO CAPSULE 667 MG ORAL• PHOSLYRA SOLUTION 667 MG/5ML

ORAL• RENAGEL TABLET 800 MG ORAL• sevelamer hcl tablet 400 mg oral• sevelamer hcl tablet 800 mg oral• VELPHORO TABLET CHEWABLE 500 MG

ORAL

Details

Criteria If the patient has tried calcium acetate AND Renvela (sevelamer carbonate). Then Eliphos, Fosrenol (lanthanum carbonate), PhosLo, Phoslyra, Renagel (sevelamer hcl), Velphoro (sucroferric oxyhydroxide) may be authorized.

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NP Rapid Insulin - BProducts Affected• ADMELOG SOLOSTAR SOLUTION PEN-

INJECTOR 100 UNIT/ML SUBCUTANEOUS

• ADMELOG SOLUTION 100 UNIT/ML SUBCUTANEOUS

• APIDRA SOLOSTAR SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS

• APIDRA SOLUTION 100 UNIT/ML INJECTION

• FIASP FLEXTOUCH SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS

• FIASP PENFILL SOLUTION CARTRIDGE 100 UNIT/ML SUBCUTANEOUS

• FIASP SOLUTION 100 UNIT/ML SUBCUTANEOUS

• NOVOLOG FLEXPEN SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS

• NOVOLOG MIX 70/30 FLEXPEN SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML SUBCUTANEOUS

• NOVOLOG MIX 70/30 SUSPENSION (70-30) 100 UNIT/ML SUBCUTANEOUS

• NOVOLOG PENFILL SOLUTION CARTRIDGE 100 UNIT/ML SUBCUTANEOUS

• NOVOLOG SOLUTION 100 UNIT/ML SUBCUTANEOUS

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Humalog (Insulin Lispro), Humalog Mix (Insulin Lispro/insulin lispro protamine). Step 2 Drug(s): Admelog, Apidra (Insulin Glulisine), Fiasp (Insulin Aspart), Novolog (Insulin Aspart), Novolog Mix (Insulin Aspart/insulin aspart protamine). New starts Only.

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NP Topical SteroidsProducts Affected• BRYHALI LOTION 0.01 % EXTERNAL • LEXETTE FOAM 0.05 % EXTERNALDetails

Criteria If the patient has tried TWO Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): clobetasol propionate sol, Clobex (clobetasol propionate) lotion/spray, halobetasol foam, Olux (clobetasol propionate) lotion/foam, Olux-E (clobetasol propionate) foam, Temovate (clobetasol propionate) cream, Ultravate (halobetasol propionate) lotion. Step 2 Drug(s): Bryhali (halobetasol lotion), LEXETTE (halobetasol foam).

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Pennsaid 2%Products Affected• PENNSAID SOLUTION 2 %

TRANSDERMALDetails

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): diclofenac 1.5% drops, diclofenac 1% gel. Step 2 Drug(s): Pennsaid (diclofenac sod) Topical Solution

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PERT AgentsProducts Affected• PANCREAZE CAPSULE DELAYED

RELEASE PARTICLES 10500 UNIT ORAL• PANCREAZE CAPSULE DELAYED

RELEASE PARTICLES 16800 UNIT ORAL• PANCREAZE CAPSULE DELAYED

RELEASE PARTICLES 21000 UNIT ORAL• PANCREAZE CAPSULE DELAYED

RELEASE PARTICLES 2600 UNIT ORAL• PANCREAZE CAPSULE DELAYED

RELEASE PARTICLES 4200 UNIT ORAL• PERTZYE CAPSULE DELAYED RELEASE

PARTICLES 16000 UNIT ORAL• PERTZYE CAPSULE DELAYED RELEASE

PARTICLES 24000-86250 UNIT ORAL• PERTZYE CAPSULE DELAYED RELEASE

PARTICLES 4000 UNIT ORAL

• PERTZYE CAPSULE DELAYED RELEASE PARTICLES 8000 UNIT ORAL

• ZENPEP CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT ORAL

• ZENPEP CAPSULE DELAYED RELEASE PARTICLES 15000-47000 UNIT ORAL

• ZENPEP CAPSULE DELAYED RELEASE PARTICLES 20000-63000 UNIT ORAL

• ZENPEP CAPSULE DELAYED RELEASE PARTICLES 25000-79000 UNIT ORAL

• ZENPEP CAPSULE DELAYED RELEASE PARTICLES 3000-14000 UNIT ORAL

• ZENPEP CAPSULE DELAYED RELEASE PARTICLES 40000-126000 UNIT ORAL

• ZENPEP CAPSULE DELAYED RELEASE PARTICLES 5000-24000 UNIT ORAL

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Creon. Step 2 Drug(s): Pancreaze, Pancrelipase, Pertzye, Ultresa, and Zenpep. New Starts Only

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RanexaProducts Affected• RANEXA TABLET EXTENDED RELEASE 12

HOUR 1000 MG ORAL• RANEXA TABLET EXTENDED RELEASE 12

HOUR 500 MG ORAL

• ranolazine er tablet extended release 12 hour 1000 mg oral

• ranolazine er tablet extended release 12 hour 500 mg oral

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): any formulary Beta-blocker, Calcium-channel blocker, or Long-acting nitrate. Step 2 Drug(s): Ranexa (ranolazine)

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Sinemet CR 25-100 mgProducts Affected• SINEMET CR TABLET EXTENDED

RELEASE 25-100 MG ORALDetails

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Carbidopa/Levodopa ER 25-100 mg. Step 2 Drug(s): Sinemet CR 25-100 mg.

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Sinemet CR 50-200 mgProducts Affected• SINEMET CR TABLET EXTENDED

RELEASE 50-200 MG ORALDetails

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Carbidopa/Levodopa ER 50-200 mg, Sinemet CR 25-100 mg. Step 2 Drug(s): Sinemet CR 50-200 mg. Generic Sinemet 50-200 mg CR is not required if the individual has been previously approved for brand Sinemet 25-100 mg CR.

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SymproicProducts Affected• SYMPROIC TABLET 0.2 MG ORALDetails

Criteria If the patient has tried a Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Movantik (naloxegol). Step 2 Drug(s): Symproic (naldemedine).

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Thioridazine HRM - BProducts Affected• thioridazine hcl tablet 10 mg oral• thioridazine hcl tablet 100 mg oral

• thioridazine hcl tablet 25 mg oral• thioridazine hcl tablet 50 mg oral

Details

Criteria If the patient has tried TWO Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Abilify (aripiprazole), Fanapt (iloperidone), Invega (paliperidone), Latuda, Olanzapine, Quetiapine, Risperidone, Ziprasidone. Step 2 Drug(s): Thioridazine. New Starts Only

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TivorbexProducts Affected• TIVORBEX CAPSULE 20 MG ORAL • TIVORBEX CAPSULE 40 MG ORALDetails

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Celecoxib, Diclofenac Potassium, Diclofenac Sodium IR/ER, Diclofenac-Misoprost, Diflunisal, Etodolac IR/ER, Fenoprofen Calcium, Flurbiprofen, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac Tromethamine, Meclofenamate Sodium, Mefenamic Acid, Meloxicam, Nabumetone, Naproxen Sodium, Naproxen, Oxaprozin, Piroxicam, Sulindac, Tolmetin Sodium. Step 2 Drug(s): Tivorbex (indomethacin submicronized).

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TolakProducts Affected• TOLAK CREAM 4 % EXTERNALDetails

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Aldara (imiquimod), Carac (fluorouracil), fluorouracil, Picato, Zyclara (imiquimod). Step 2 Drug(s): Tolak (fluorouracil).

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TrintellixProducts Affected• TRINTELLIX TABLET 10 MG ORAL• TRINTELLIX TABLET 20 MG ORAL

• TRINTELLIX TABLET 5 MG ORAL

Details

Criteria If the patient has tried TWO Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): citalopram, desvenlafaxine ER, escitalopram, fluoxetine, fluvoxamine, paroxetine, paroxetine CR, sertraline, venlafaxine IR/ER. Step 2 Drug(s): Trintellix (Vortioxetine). Applies to New Starts Only.

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UloricProducts Affected• ULORIC TABLET 40 MG ORAL • ULORIC TABLET 80 MG ORALDetails

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): allopurinol. Step 2 Drug(s): Uloric . Approve without trial of step 1 drug if Patient has contraindication to allopurinol use.

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ValtrexProducts Affected• VALTREX TABLET 1 GM ORAL • VALTREX TABLET 500 MG ORALDetails

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): valacylovir. Step 2 Drug(s): Valtrex

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ViibrydProducts Affected• VIIBRYD STARTER PACK KIT 10 & 20

MG ORAL• VIIBRYD TABLET 10 MG ORAL

• VIIBRYD TABLET 20 MG ORAL• VIIBRYD TABLET 40 MG ORAL

Details

Criteria If the patient has tried TWO Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): citalopram, desvenlafaxine ER, escitalopram, fluoxetine, fluvoxamine, paroxetine, paroxetine CR, sertraline, venlafaxine IR/ER. Step 2 Drug(s): Viibryd (vilazodone), Viibryd Titration Pack (vilazodone). Applies to New Starts Only.

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IndexACTONEL TABLET 150 MG ORAL..........23ACTONEL TABLET 30 MG ORAL............23ACTONEL TABLET 35 MG ORAL............23ACTONEL TABLET 5 MG ORAL............. 23ADMELOG SOLOSTAR SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS................................. 29ADMELOG SOLUTION 100 UNIT/ML SUBCUTANEOUS................................. 29AGGRENOX CAPSULE EXTENDED RELEASE 12 HOUR 25-200 MG ORAL......1ANTARA CAPSULE 30 MG ORAL............. 3ANTARA CAPSULE 90 MG ORAL............. 3APIDRA SOLOSTAR SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS................................. 29APIDRA SOLUTION 100 UNIT/ML INJECTION......................................... 29APTIOM TABLET 200 MG ORAL..............4APTIOM TABLET 400 MG ORAL..............4APTIOM TABLET 600 MG ORAL..............4APTIOM TABLET 800 MG ORAL..............4ARICEPT TABLET 23 MG ORAL...............5aspirin-dipyridamole er capsule extended release 12 hour 25-200 mg oral......................................................1AZOR TABLET 10-20 MG ORAL.............14AZOR TABLET 10-40 MG ORAL.............14AZOR TABLET 5-20 MG ORAL.............. 14AZOR TABLET 5-40 MG ORAL.............. 14BASAGLAR KWIKPEN SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS................................. 26BECONASE AQ SUSPENSION 42 MCG/SPRAY NASAL............................. 21BENICAR HCT TABLET 20-12.5 MG ORAL................................................. 15BENICAR HCT TABLET 40-12.5 MG ORAL................................................. 15BENICAR HCT TABLET 40-25 MG ORAL 15BENICAR TABLET 20 MG ORAL............ 15BENICAR TABLET 40 MG ORAL............ 15BENICAR TABLET 5 MG ORAL.............. 15

BEVESPI AEROSPHERE AEROSOL 9-4.8 MCG/ACT INHALATION....................... 25BONIVA TABLET 150 MG ORAL............ 23BRYHALI LOTION 0.01 % EXTERNAL... 30CRESTOR TABLET 10 MG ORAL............16CRESTOR TABLET 20 MG ORAL............16CRESTOR TABLET 40 MG ORAL............16CRESTOR TABLET 5 MG ORAL............. 16CYCLOSET TABLET 0.8 MG ORAL...........6DETROL LA CAPSULE EXTENDED RELEASE 24 HOUR 2 MG ORAL............ 27DETROL LA CAPSULE EXTENDED RELEASE 24 HOUR 4 MG ORAL............ 27DETROL TABLET 1 MG ORAL............... 27DETROL TABLET 2 MG ORAL............... 27DEXILANT CAPSULE DELAYED RELEASE 30 MG ORAL...........................7DEXILANT CAPSULE DELAYED RELEASE 60 MG ORAL...........................7DITROPAN XL TABLET EXTENDED RELEASE 24 HOUR 10 MG ORAL.......... 27DITROPAN XL TABLET EXTENDED RELEASE 24 HOUR 5 MG ORAL............ 27donepezil hcl tablet 23 mg oral.............. 5ENABLEX TABLET EXTENDED RELEASE 24 HOUR 15 MG ORAL........................ 27ENABLEX TABLET EXTENDED RELEASE 24 HOUR 7.5 MG ORAL....................... 27esomeprazole magnesium capsule delayed release 20 mg oral..................22esomeprazole magnesium capsule delayed release 40 mg oral..................22ESOMEPRAZOLE STRONTIUM CAPSULE DELAYED RELEASE 49.3 MG ORAL................................................. 22FANAPT TABLET 1 MG ORAL..................8FANAPT TABLET 10 MG ORAL................8FANAPT TABLET 12 MG ORAL................8FANAPT TABLET 2 MG ORAL..................8FANAPT TABLET 4 MG ORAL..................8FANAPT TABLET 6 MG ORAL..................8FANAPT TABLET 8 MG ORAL..................8

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FANAPT TITRATION PACK TABLET 1 & 2 & 4 & 6 MG ORAL.............................. 8FIASP FLEXTOUCH SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS................................. 29FIASP PENFILL SOLUTION CARTRIDGE 100 UNIT/ML SUBCUTANEOUS............ 29FIASP SOLUTION 100 UNIT/ML SUBCUTANEOUS................................. 29FOSAMAX PLUS D TABLET 70-2800 MG-UNIT ORAL...................................23FOSAMAX PLUS D TABLET 70-5600 MG-UNIT ORAL...................................23FOSAMAX TABLET 70 MG ORAL........... 23FOSRENOL PACKET 1000 MG ORAL......28FOSRENOL PACKET 750 MG ORAL........28FOSRENOL TABLET CHEWABLE 1000 MG ORAL............................................28FOSRENOL TABLET CHEWABLE 500 MG ORAL............................................28FOSRENOL TABLET CHEWABLE 750 MG ORAL............................................28GELNIQUE GEL 10 % TRANSDERMAL...27GELNIQUE PUMP GEL 10 % TRANSDERMAL................................... 27GLUMETZA TABLET EXTENDED RELEASE 24 HOUR 1000 MG ORAL.........9GLUMETZA TABLET EXTENDED RELEASE 24 HOUR 500 MG ORAL.......... 9INNOPRAN XL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG ORAL.........10INNOPRAN XL CAPSULE EXTENDED RELEASE 24 HOUR 80 MG ORAL.......... 10levalbuterol tartrate aerosol 45 mcg/act inhalation................................ 2LEXETTE FOAM 0.05 % EXTERNAL.......30LIPITOR TABLET 10 MG ORAL............. 17LIPITOR TABLET 20 MG ORAL............. 17LIPITOR TABLET 40 MG ORAL............. 17LIPITOR TABLET 80 MG ORAL............. 17LODOSYN TABLET 25 MG ORAL........... 18luliconazole cream 1 % external...........12LUNESTA TABLET 1 MG ORAL..............11LUNESTA TABLET 2 MG ORAL..............11

LUNESTA TABLET 3 MG ORAL..............11LUZU CREAM 1 % EXTERNAL...............12MIRAPEX ER TABLET EXTENDED RELEASE 24 HOUR 0.375 MG ORAL......18MIRAPEX ER TABLET EXTENDED RELEASE 24 HOUR 0.75 MG ORAL........18MIRAPEX ER TABLET EXTENDED RELEASE 24 HOUR 1.5 MG ORAL......... 18MIRAPEX ER TABLET EXTENDED RELEASE 24 HOUR 2.25 MG ORAL........18MIRAPEX ER TABLET EXTENDED RELEASE 24 HOUR 3 MG ORAL............ 18MIRAPEX ER TABLET EXTENDED RELEASE 24 HOUR 3.75 MG ORAL........18MIRAPEX ER TABLET EXTENDED RELEASE 24 HOUR 4.5 MG ORAL......... 18NASONEX SUSPENSION 50 MCG/ACT NASAL................................................21NEXIUM CAPSULE DELAYED RELEASE 20 MG ORAL.......................................22NEXIUM CAPSULE DELAYED RELEASE 40 MG ORAL.......................................22NEXIUM PACKET 10 MG ORAL............. 22NEXIUM PACKET 2.5 MG ORAL............ 22NEXIUM PACKET 20 MG ORAL............. 22NEXIUM PACKET 40 MG ORAL............. 22NEXIUM PACKET 5 MG ORAL............... 22NOVOLIN 70/30 FLEXPEN RELION SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML SUBCUTANEOUS............ 24NOVOLIN 70/30 FLEXPEN SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML SUBCUTANEOUS............ 24NOVOLIN 70/30 RELION SUSPENSION (70-30) 100 UNIT/ML SUBCUTANEOUS.24NOVOLIN 70/30 SUSPENSION (70-30) 100 UNIT/ML SUBCUTANEOUS............ 24NOVOLIN N RELION SUSPENSION 100 UNIT/ML SUBCUTANEOUS................... 24NOVOLIN N SUSPENSION 100 UNIT/ML SUBCUTANEOUS................... 24NOVOLIN R RELION SOLUTION 100 UNIT/ML INJECTION........................... 24

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NOVOLIN R SOLUTION 100 UNIT/ML INJECTION......................................... 24NOVOLOG FLEXPEN SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS................................. 29NOVOLOG MIX 70/30 FLEXPEN SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML SUBCUTANEOUS............ 29NOVOLOG MIX 70/30 SUSPENSION (70-30) 100 UNIT/ML SUBCUTANEOUS.29NOVOLOG PENFILL SOLUTION CARTRIDGE 100 UNIT/ML SUBCUTANEOUS................................. 29NOVOLOG SOLUTION 100 UNIT/ML SUBCUTANEOUS................................. 29OMNARIS SUSPENSION 50 MCG/ACT NASAL................................................21OXYTROL PATCH TWICE WEEKLY 3.9 MG/24HR TRANSDERMAL.................... 27PANCREAZE CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT ORAL................................................. 32PANCREAZE CAPSULE DELAYED RELEASE PARTICLES 16800 UNIT ORAL................................................. 32PANCREAZE CAPSULE DELAYED RELEASE PARTICLES 21000 UNIT ORAL................................................. 32PANCREAZE CAPSULE DELAYED RELEASE PARTICLES 2600 UNIT ORAL. 32PANCREAZE CAPSULE DELAYED RELEASE PARTICLES 4200 UNIT ORAL. 32PENNSAID SOLUTION 2 % TRANSDERMAL................................... 31PERTZYE CAPSULE DELAYED RELEASE PARTICLES 16000 UNIT ORAL............. 32PERTZYE CAPSULE DELAYED RELEASE PARTICLES 24000-86250 UNIT ORAL... 32PERTZYE CAPSULE DELAYED RELEASE PARTICLES 4000 UNIT ORAL............... 32PERTZYE CAPSULE DELAYED RELEASE PARTICLES 8000 UNIT ORAL............... 32PHOSLO CAPSULE 667 MG ORAL..........28

PHOSLYRA SOLUTION 667 MG/5ML ORAL................................................. 28PROAIR DIGIHALER AEROSOL POWDER BREATH ACTIVATED 108 MCG/ACT INHALATION......................... 2QMIIZ ODT TABLET DISPERSIBLE 15 MG ORAL............................................13QMIIZ ODT TABLET DISPERSIBLE 7.5 MG ORAL............................................13QNASL AEROSOL SOLUTION 80 MCG/ACT NASAL.................................21QNASL CHILDRENS AEROSOL SOLUTION 40 MCG/ACT NASAL........... 21RANEXA TABLET EXTENDED RELEASE 12 HOUR 1000 MG ORAL.....................33RANEXA TABLET EXTENDED RELEASE 12 HOUR 500 MG ORAL.......................33ranolazine er tablet extended release 12 hour 1000 mg oral..........................33ranolazine er tablet extended release 12 hour 500 mg oral........................... 33RENAGEL TABLET 800 MG ORAL.......... 28REQUIP XL TABLET EXTENDED RELEASE 24 HOUR 12 MG ORAL.......... 18REQUIP XL TABLET EXTENDED RELEASE 24 HOUR 4 MG ORAL............ 18REQUIP XL TABLET EXTENDED RELEASE 24 HOUR 6 MG ORAL............ 18REQUIP XL TABLET EXTENDED RELEASE 24 HOUR 8 MG ORAL............ 18risedronate sodium tablet 150 mg oral..23risedronate sodium tablet 30 mg oral... 23risedronate sodium tablet 35 mg oral... 23risedronate sodium tablet 35 mg oral (12 pack)........................................... 23risedronate sodium tablet 35 mg oral (4 pack)............................................. 23risedronate sodium tablet 5 mg oral..... 23risedronate sodium tablet delayed release 35 mg oral.............................. 23RYTARY CAPSULE EXTENDED RELEASE 23.75-95 MG ORAL............... 18RYTARY CAPSULE EXTENDED RELEASE 36.25-145 MG ORAL..............18

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RYTARY CAPSULE EXTENDED RELEASE 48.75-195 MG ORAL..............18RYTARY CAPSULE EXTENDED RELEASE 61.25-245 MG ORAL..............18sevelamer hcl tablet 400 mg oral..........28sevelamer hcl tablet 800 mg oral..........28SINEMET CR TABLET EXTENDED RELEASE 25-100 MG ORAL.................. 34SINEMET CR TABLET EXTENDED RELEASE 50-200 MG ORAL.................. 35SINEMET TABLET 10-100 MG ORAL......18SINEMET TABLET 25-100 MG ORAL......18SINEMET TABLET 25-250 MG ORAL......18SYMPROIC TABLET 0.2 MG ORAL.........36thioridazine hcl tablet 10 mg oral......... 37thioridazine hcl tablet 100 mg oral........37thioridazine hcl tablet 25 mg oral......... 37thioridazine hcl tablet 50 mg oral......... 37TIVORBEX CAPSULE 20 MG ORAL........ 38TIVORBEX CAPSULE 40 MG ORAL........ 38TOLAK CREAM 4 % EXTERNAL.............39TRESIBA FLEXTOUCH SOLUTION PEN-INJECTOR 100 UNIT/ML SUBCUTANEOUS................................. 26TRESIBA FLEXTOUCH SOLUTION PEN-INJECTOR 200 UNIT/ML SUBCUTANEOUS................................. 26TRESIBA SOLUTION 100 UNIT/ML SUBCUTANEOUS................................. 26TRIBENZOR TABLET 20-5-12.5 MG ORAL................................................. 19TRIBENZOR TABLET 40-10-12.5 MG ORAL................................................. 19TRIBENZOR TABLET 40-10-25 MG ORAL................................................. 19TRIBENZOR TABLET 40-5-12.5 MG ORAL................................................. 19TRIBENZOR TABLET 40-5-25 MG ORAL 19TRINTELLIX TABLET 10 MG ORAL........ 40TRINTELLIX TABLET 20 MG ORAL........ 40TRINTELLIX TABLET 5 MG ORAL..........40ULORIC TABLET 40 MG ORAL.............. 41ULORIC TABLET 80 MG ORAL.............. 41

UTIBRON NEOHALER CAPSULE 27.5-15.6 MCG INHALATION....................... 25VALTREX TABLET 1 GM ORAL.............. 42VALTREX TABLET 500 MG ORAL.......... 42VELPHORO TABLET CHEWABLE 500 MG ORAL............................................28VENTOLIN HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION... 2VIIBRYD STARTER PACK KIT 10 & 20 MG ORAL............................................43VIIBRYD TABLET 10 MG ORAL............. 43VIIBRYD TABLET 20 MG ORAL............. 43VIIBRYD TABLET 40 MG ORAL............. 43VIVLODEX CAPSULE 10 MG ORAL........ 13VIVLODEX CAPSULE 5 MG ORAL.......... 13WELLBUTRIN SR TABLET EXTENDED RELEASE 12 HOUR 100 MG ORAL.........20WELLBUTRIN SR TABLET EXTENDED RELEASE 12 HOUR 150 MG ORAL.........20WELLBUTRIN SR TABLET EXTENDED RELEASE 12 HOUR 200 MG ORAL.........20WELLBUTRIN XL TABLET EXTENDED RELEASE 24 HOUR 150 MG ORAL.........20WELLBUTRIN XL TABLET EXTENDED RELEASE 24 HOUR 300 MG ORAL.........20XHANCE EXHALER SUSPENSION 93 MCG/ACT NASAL.................................21XOPENEX HFA AEROSOL 45 MCG/ACT INHALATION........................................ 2ZENPEP CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT ORAL... 32ZENPEP CAPSULE DELAYED RELEASE PARTICLES 15000-47000 UNIT ORAL... 32ZENPEP CAPSULE DELAYED RELEASE PARTICLES 20000-63000 UNIT ORAL... 32ZENPEP CAPSULE DELAYED RELEASE PARTICLES 25000-79000 UNIT ORAL... 32ZENPEP CAPSULE DELAYED RELEASE PARTICLES 3000-14000 UNIT ORAL..... 32ZENPEP CAPSULE DELAYED RELEASE PARTICLES 40000-126000 UNIT ORAL. 32ZENPEP CAPSULE DELAYED RELEASE PARTICLES 5000-24000 UNIT ORAL..... 32

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ZETONNA AEROSOL SOLUTION 37 MCG/ACT NASAL.................................21

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