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2014 Valley Baptist Medicare D Formulary Step Therapy Criteria

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2014 Valley Baptist Medicare D Formulary

Last Updated 11/1/2014

Products Affected

ACTONEL TAB

Details

Requires a trial of alendronate. Criteria

(2)

APLENZIN TAB

Details

Patient must have tried bupropion SR or bupropion XL in previous 180 days. Criteria

(3)

ARANESP ALBUMIN FREE INJ. 100MCG, 150MCG, 200MCG, 300MCG, 500MCG

Details

Step Therapy requires trial of PROCRIT. Criteria

(4)

ARANESP ALBUMIN FREE INJ. 25MCG/0.42ML, 25MCG/ML, 60MCG/0.3ML, 60MCG/ML

Details

Step Therapy requires trial of PROCRIT. Criteria

(5)

ARANESP ALBUMIN FREE INJ. 40MCG/0.4ML, 40MCG/ML

Details

Step Therapy requires trial of PROCRIT. Criteria

(6)

ARICEPT TAB 23MG

Details

Requires trial of donepezil 10mg in previous 180 days. Criteria

(7)

ATELVIA TAB

Details

Requires a trial of alendronate. Criteria

(8)

BECONASE AQ NASAL

Details

Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST.

Criteria

(9)

BONIVA INJ.

Details

Requires a trial of alendronate. Criteria

(10)

BONIVA TAB 150MG

Details

Requires a trial of alendronate. Criteria

(11)

BRINTELLIX TAB

Details

Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine.

Criteria

(12)

budesonide nasal inhaler

Details

Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST.

Criteria

(13)

BYETTA INJ.

Details

Step Therapy requires trial of Victoza Criteria

(14)

DESVENLAFAXINE ER TAB

Details

Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine.

Criteria

(15)

DEXILANT CAP

Details

Step Therapy requires trial of omeprazole, lansoprazole or pantoprazole in previous 180 days. Criteria

(16)

DIFICID TAB

Details

Step Therapy requires trial of VANCOCIN. Criteria

(17)

donepezil tab 23mg

Details

Requires trial of donepezil 10mg in previous 180 days. Criteria

(18)

eszopiclone tab

Details

Step Therapy requires trial of zolpidem or zaleplon in previous 180 days. Criteria

(19)

EXTAVIA INJ.

Details

Step Therapy requires trial of two of the following: AVONEX, REBIF or COPAXONE Criteria

(20)

FETZIMA ER CAP

Details

Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine.

Criteria

(21)

FETZIMA TITRATION PACK

Details

Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine.

Criteria

(22)

ibandronate inj.

Details

Requires a trial of alendronate. Criteria

(23)

ibandronate tab

Details

Requires a trial of alendronate. Criteria

(24)

INTUNIV

Details

Step Therapy requires trial of guanfacine IR in previous 180 days. Criteria

(25)

JENTADUETO TAB

Details

Step Therapy requires trial of Januvia or Janumet. Criteria

(26)

KHEDEZLA ER TAB

Details

Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine.

Criteria

(27)

LUNESTA TAB

Details

Step Therapy requires trial of zolpidem or zaleplon in previous 180 days. Criteria

(28)

LUVOX CR TAB

Details

Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine.

Criteria

(29)

METROGEL 1%

Details

Step Therapy requires trial of FINACEA. Criteria

(30)

NASACORT AQ

Details

Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST.

Criteria

(31)

NORITATE CREAM

Details

Step Therapy requires trial of FINACEA. Criteria

(32)

OMNARIS NASAL

Details

Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST.

Criteria

(33)

PERTZYE CAP

Details

Step Therapy requires trial of CREON and PANCREAZE. Criteria

(34)

PEXEVA TAB

Details

Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine.

Criteria

(35)

PRISTIQ TAB

Details

Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine.

Criteria

(36)

QNASL

Details

Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST.

Criteria

(37)

RHINOCORT AQUA NASAL

Details

Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST.

Criteria

(38)

risedronate sodium tab

Details

Requires a trial of alendronate. Criteria

(39)

TRADJENTA TAB

Details

Step Therapy requires trial of Januvia or Janumet. Criteria

(40)

ULORIC TAB

Details

Member has tried or was intolerant to allopurinol. Criteria

(41)

ULTRESA CAP

Details

Step Therapy requires trial of CREON and PANCREAZE. Criteria

(42)

VANCOCIN CAP 125MG

Details

Step Therapy requires trial of metronidazole in previous 180 days Criteria

(43)

VANCOCIN CAP 250MG

Details

Step Therapy requires trial of metronidazole in previous 180 days Criteria

(44)

vancomycin cap

Details

Step Therapy requires trial of metronidazole in previous 180 days Criteria

(45)

VIIBRYD TAB

Details

Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine.

Criteria

(46)

XOPENEX HFA INHALER

Details

Step Therapy requires trial of VENTOLIN HFA Criteria

(47)

ZENPEP CAP

Details

Step Therapy requires trial of CREON and PANCREAZE. Criteria

(48)

ZETONNA NASAL

Details

Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST.

Criteria

(49)

ZIOPTAN

Details

Step Therapy requires trial of latanoprost. Criteria

References

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