DIFICID

Products Affected

Step 2:

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

  • DIFICID TABLET 200 MG ORAL

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

Details
Criteria / Claim will pay automatically for Dificid if enrollee has a paid claim for at least a 1 days supply of vancomycin in the past. 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.

GLP1-INSULIN

Products Affected

Step 2:

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

  • XULTOPHY SOLUTION PEN-INJECTOR 100-3.6 UNIT-MG/ML SUBCUTANEOUS

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

Details
Criteria / Claim will pay automatically for Xultophy if enrollee has a paid claim for at least a one day supply for step level 1 agent (LANTUS, LEVEMIR, TOUJEO, TRESIBA, OR VICTOZA). Otherwise, Xultophy requires a step therapy exception request indicating: (1) history of inadequate treatment response with step 1 agent, OR (2) history of adverse event with step 1 agent, OR (3) step 1 agent is contraindicated.

LIVALO

Products Affected

Step 2:

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

  • LIVALO TABLET 1 MG ORAL
  • LIVALO TABLET 2 MG ORAL
  • LIVALO TABLET 4 MG ORAL

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

Details
Criteria / Claim will pay automatically for Livalo if enrollee has a paid claim for at least a 1 days supply of atorvastatin, lovastatin, pravastatin, or simvastatin in the past. Otherwise Livalo requires a step therapy exception request indicating: (1) history of inadequate treatment response with atorvvastatin, lovastatin, pravastatin, or simvastatin OR (2) history of adverse event with atorvastatin, lovastatin, pravastatin, or simvastatin OR (3) atorvastatin, lovastatin, pravastatin, or simvastatin is contraindicated.

LONG ACTING FENTANYL

Products Affected

Step 2:

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

  • fentanyl patch 72 hour 100 mcg/hr transdermal
  • fentanyl patch 72 hour 12 mcg/hr transdermal
  • fentanyl patch 72 hour 25 mcg/hr transdermal
  • fentanyl patch 72 hour 37.5 mcg/hr transdermal
  • fentanyl patch 72 hour 50 mcg/hr transdermal
  • fentanyl patch 72 hour 62.5 mcg/hr transdermal
  • fentanyl patch 72 hour 75 mcg/hr transdermal
  • fentanyl patch 72 hour 87.5 mcg/hr transdermal

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

Details
Criteria / Claim will pay automatically for Fentanyl patches if enrollee has paid claims history for at least 1 days supply of either Morphine ER or Methadone in the past. Otherwise, the drug requires a step therapy exception request indicating any ONE of the following: (1) history of inadequate treatment response with Morphine ER or Methadone OR (2) history of adverse event with Morphine ER or methadone, OR (3) Morphine ER or Methadone are contraindicated.

MYRBETRIQ

Products Affected

Step 2:

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

  • MYRBETRIQ TABLET EXTENDED RELEASE 24 HOUR 25 MG ORAL
  • MYRBETRIQ TABLET EXTENDED RELEASE 24 HOUR 50 MG ORAL

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

Details
Criteria / 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. 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.

PROLIA

Products Affected

Step 2:

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

  • PROLIA SOLUTION 60 MG/ML SUBCUTANEOUS

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

Details
Criteria / Patient needs to have a paid claim for one Step 1 drug (alendronate, ibandronate, pamidronate, or zolendronic acid) prior to filling a Prolia. For osteoporosis prophylaxis in men at high risk for bone fractures after receiving androgen deprivation therapy for nonmetastatic prostate cancer and in women at high risk for bone fractures after receiving adjuvant aromatase inhibitor therapy for breast cancer, Prolia will be approved.

RHEUMATOID ARTHRITIS

Products Affected

Step 2:

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

  • ACTEMRA SOLUTION 200 MG/10ML INTRAVENOUS
  • ACTEMRA SOLUTION 400 MG/20ML INTRAVENOUS
  • ACTEMRA SOLUTION 80 MG/4ML INTRAVENOUS
  • ACTEMRA SOLUTION PREFILLED SYRINGE 162 MG/0.9ML SUBCUTANEOUS
  • CIMZIA KIT 2 X 200 MG SUBCUTANEOUS
  • CIMZIA PREFILLED KIT 2 X 200 MG/ML SUBCUTANEOUS
  • COSENTYX 300 DOSE SOLUTION PREFILLED SYRINGE 150 MG/ML SUBCUTANEOUS
  • COSENTYX SENSOREADY 300 DOSE SOLUTION AUTO-INJECTOR 150 MG/ML SUBCUTANEOUS
  • KINERET SOLUTION PREFILLED SYRINGE 100 MG/0.67ML SUBCUTANEOUS
  • ORENCIA CLICKJECT SOLUTION AUTO-INJECTOR 125 MG/ML SUBCUTANEOUS
  • ORENCIA SOLUTION PREFILLED SYRINGE 125 MG/ML SUBCUTANEOUS
  • ORENCIA SOLUTION PREFILLED SYRINGE 50 MG/0.4ML SUBCUTANEOUS
  • ORENCIA SOLUTION PREFILLED SYRINGE 87.5 MG/0.7ML SUBCUTANEOUS
  • ORENCIA SOLUTION RECONSTITUTED 250 MG INTRAVENOUS
  • SIMPONI ARIA SOLUTION 50 MG/4ML INTRAVENOUS
  • SIMPONI SOLUTION AUTO-INJECTOR 100 MG/ML SUBCUTANEOUS
  • SIMPONI SOLUTION AUTO-INJECTOR 50 MG/0.5ML SUBCUTANEOUS
  • SIMPONI SOLUTION PREFILLED SYRINGE 100 MG/ML SUBCUTANEOUS
  • SIMPONI SOLUTION PREFILLED SYRINGE 50 MG/0.5ML SUBCUTANEOUS
  • STELARA SOLUTION 45 MG/0.5ML SUBCUTANEOUS
  • STELARA SOLUTION PREFILLED SYRINGE 45 MG/0.5ML SUBCUTANEOUS
  • STELARA SOLUTION PREFILLED SYRINGE 90 MG/ML SUBCUTANEOUS
  • XELJANZ TABLET 5 MG ORAL

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

Details
Criteria / Claim will pay automatically for Actemra, Cimzia, Kineret, Orencia, Simponi, Stelara, Cosentyx or Xeljanz if enrollee has a paid claim for at least a 1 days supply of Enbrel AND Humira in the past. Enrollee does NOT need history of Humira prior to Actemra, Cimzia, Kineret, Orencia, Simponi, Stelara, Cosentyx or Xeljanz if diagnosed with Polyarticular Juvenile Idiopathic Arthritis (PJIA). Enrollee does NOT need history of Enbrel prior to Actemra, Cimzia, Kineret, Orencia, Simponi, Stelara, Cosentyx or Xeljanz if disgnosed with Crohns Disease (CD), Ulcerative Colitis (UC), Juvenile Idiopathic arthritis (JIA) or Systemic Juvenile Idiopathic arthritis (SJIA). Otherwise, Actemra, Cimzia, Kineret, Orencia, Simponi, Stelara, Cosentyx or 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) Enbrel AND Humira is contraindicated. For diagnosis cryopyrin-associated periodic syndromes, Kineret will be approved. For diagnosis of Giant Cell Arteritis, Actemra will be approved.

TRINTELLIX

Products Affected

Step 2:

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

  • TRINTELLIX TABLET 10 MG ORAL
  • TRINTELLIX TABLET 20 MG ORAL
  • TRINTELLIX TABLET 5 MG ORAL

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

Details
Criteria / Claim will pay automatically for trintellix if enrollee has a paid claim for at least a 1 days supply of any 2 generic formulary antidepressants in the past. Otherwise, trintellix 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 antidepressantss , OR (3) any 2 generic formulary antidepressants are contraindicated.

UCERIS

Products Affected

Step 2:

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

  • UCERIS FOAM 2 MG/ACT RECTAL
  • UCERIS TABLET EXTENDED RELEASE 24 HOUR 9 MG ORAL

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

Details
Criteria / 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. 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.

ULORIC

Products Affected

Step 2:

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

  • ULORIC TABLET 40 MG ORAL
  • ULORIC TABLET 80 MG ORAL

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

Details
Criteria / Claim will pay automatically for Uloric if enrollee has a paid claim for at least a 1 days supply of Allopurinol in the past. 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.

VRAYLAR

Products Affected

Step 2:

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

  • VRAYLAR CAPSULE 1.5 MG ORAL
  • VRAYLAR CAPSULE 3 MG ORAL
  • VRAYLAR CAPSULE 4.5 MG ORAL
  • VRAYLAR CAPSULE 6 MG ORAL
  • VRAYLAR CAPSULE THERAPY PACK 1.5 & 3 MG ORAL

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

Details
Criteria / Claim will pay automatically for VRAYLAR if enrollee has a paid claim for at least a 1 days supply of ARIPIPRAZOLE, OLANZAPINE, QUETIAPINE, QUITIAPINE ER, RISPERIDONE, ZIPRASIDONE OR LATUDA in the past. Otherwise, Vraylar requires a step therapy exception request indicating any ONE of criteria 1,2,3, OR 4: (1) history of inadequate treatment response with ARIPIPRAZOLE, OLANZAPINE, QUETIAPINE, QUITIAPINE ER, RISPERIDONE, ZIPRASIDONE, or LATUDA OR (2) history of adverse event with ARIPIPRAZOLE, OLANZAPINE, QUETIAPINE, QUITIAPINE ER, RISPERIDONE, ZIPRASIDONE, or LATUDA OR (3) ARIPIPRAZOLE, OLANZAPINE, QUETIAPINE, QUITIAPINE ER, RISPERIDONE, ZIPRASIDONE or LATUDA are contraindicated. OR (4) FOR Diagnosis OF MANIC EPIPISODES ASSOCIATED WTIH BIPOLAR DISORDER, THE COVERAGE DETERMINATION WILL BE APPROVED WITHOUT REQUIREMENT OF CONTRAINDICATION TO LATUDA.

XTANDI

Products Affected

Step 2:

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

  • XTANDI CAPSULE 40 MG ORAL

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

Details
Criteria / Claim will pay automatically for Xtandi if enrollee has a paid claim for at least a 1 days supply of Zytiga in the past. Otherwise, Xtandi requires a step therapy exception request indicating: (1) history of inadequate treatment response with Zytiga, OR (2) history of adverse event with Zytiga, OR (3)Zytiga is contraindicated.

Formulary ID: 18327 Version 7

Last Updated: 03/01/2018

1

Alphabetical Listing

1

A

ACTEMRA SOLUTION 200 MG/10ML INTRAVENOUS7, 8

ACTEMRA SOLUTION 400 MG/20ML INTRAVENOUS7, 8

ACTEMRA SOLUTION 80 MG/4ML INTRAVENOUS7, 8

ACTEMRA SOLUTION PREFILLED SYRINGE 162 MG/0.9ML SUBCUTANEOUS7, 8

C

CIMZIA KIT 2 X 200 MG SUBCUTANEOUS7, 8

CIMZIA PREFILLED KIT 2 X 200 MG/ML SUBCUTANEOUS7, 8

COSENTYX 300 DOSE SOLUTION PREFILLED SYRINGE 150 MG/ML SUBCUTANEOUS 7, 8

COSENTYX SENSOREADY 300 DOSE SOLUTION AUTO-INJECTOR 150 MG/ML SUBCUTANEOUS 7, 8

D

DIFICID TABLET 200 MG ORAL...... 1

F

fentanyl patch 72 hour 100 mcg/hr transdermal4

fentanyl patch 72 hour 12 mcg/hr transdermal4

fentanyl patch 72 hour 25 mcg/hr transdermal4

fentanyl patch 72 hour 37.5 mcg/hr transdermal4

fentanyl patch 72 hour 50 mcg/hr transdermal4

fentanyl patch 72 hour 62.5 mcg/hr transdermal4

fentanyl patch 72 hour 75 mcg/hr transdermal4

fentanyl patch 72 hour 87.5 mcg/hr transdermal4

K

KINERET SOLUTION PREFILLED SYRINGE 100 MG/0.67ML SUBCUTANEOUS7, 8

L

LIVALO TABLET 1 MG ORAL...... 3

LIVALO TABLET 2 MG ORAL...... 3

LIVALO TABLET 4 MG ORAL...... 3

M

MYRBETRIQ TABLET EXTENDED RELEASE 24 HOUR 25 MG ORAL5

MYRBETRIQ TABLET EXTENDED RELEASE 24 HOUR 50 MG ORAL5

O

ORENCIA CLICKJECT SOLUTION AUTO-INJECTOR 125 MG/ML SUBCUTANEOUS 7, 8

ORENCIA SOLUTION PREFILLED SYRINGE 125 MG/ML SUBCUTANEOUS7, 8

ORENCIA SOLUTION PREFILLED SYRINGE 50 MG/0.4ML SUBCUTANEOUS7, 8

ORENCIA SOLUTION PREFILLED SYRINGE 87.5 MG/0.7ML SUBCUTANEOUS7, 8

ORENCIA SOLUTION RECONSTITUTED 250 MG INTRAVENOUS7, 8

P

PROLIA SOLUTION 60 MG/ML SUBCUTANEOUS6

S

SIMPONI ARIA SOLUTION 50 MG/4ML INTRAVENOUS7, 8

SIMPONI SOLUTION AUTO-INJECTOR 100 MG/ML SUBCUTANEOUS7, 8

SIMPONI SOLUTION AUTO-INJECTOR 50 MG/0.5ML SUBCUTANEOUS7, 8

SIMPONI SOLUTION PREFILLED SYRINGE 100 MG/ML SUBCUTANEOUS7, 8

SIMPONI SOLUTION PREFILLED SYRINGE 50 MG/0.5ML SUBCUTANEOUS7, 8

STELARA SOLUTION 45 MG/0.5ML SUBCUTANEOUS7, 8

STELARA SOLUTION PREFILLED SYRINGE 45 MG/0.5ML SUBCUTANEOUS7, 8

STELARA SOLUTION PREFILLED SYRINGE 90 MG/ML SUBCUTANEOUS7, 8

T

TRINTELLIX TABLET 10 MG ORAL..9

TRINTELLIX TABLET 20 MG ORAL..9

TRINTELLIX TABLET 5 MG ORAL...9

U

UCERIS FOAM 2 MG/ACT RECTAL..10

UCERIS TABLET EXTENDED RELEASE 24 HOUR 9 MG ORAL10

ULORIC TABLET 40 MG ORAL...... 11

ULORIC TABLET 80 MG ORAL...... 11

V

VRAYLAR CAPSULE 1.5 MG ORAL..12

VRAYLAR CAPSULE 3 MG ORAL...12

VRAYLAR CAPSULE 4.5 MG ORAL..12

VRAYLAR CAPSULE 6 MG ORAL...12

VRAYLAR CAPSULE THERAPY PACK 1.5 & 3 MG ORAL12

X

XELJANZ TABLET 5 MG ORAL....7, 8

XTANDI CAPSULE 40 MG ORAL....13

XULTOPHY SOLUTION PEN-INJECTOR 100-3.6 UNIT-MG/ML SUBCUTANEOUS2

1

1