Step Therapy Criteria Health Alliance Plan 2021 Date Effective: 10/01/2021

ESRD

Products Affected Step 2:  lanthanum 1,000 mg chewable tablet  sevelamer 800 mg tablet  lanthanum 500 mg chewable tablet  sevelamer HCl 400 mg tablet  lanthanum 750 mg chewable tablet  sevelamer HCl 800 mg tablet

Details

Criteria For new starts only, claims for sevelamer or lanthanum will process if a claim for is processed within 120 days.

Formulary ID 21357, V#17 1 Step Therapy Criteria Health Alliance Plan 2021 Date Effective: 10/01/2021

FLUVASTATIN

Products Affected Step 2:  fluvastatin 20 mg capsule  fluvastatin ER 80 mg tablet,extended  fluvastatin 40 mg capsule release 24 hr

Details

Criteria For new starts only, claims for fluvastatin will process if a claim for simvastatin, atorvastatin, or rosuvastatin is processed in the past 120 days.

Formulary ID 21357, V#17 2 Step Therapy Criteria Health Alliance Plan 2021 Date Effective: 10/01/2021

GLP-1 AGONISTS

Products Affected Step 2:  Ozempic 0.25 mg or 0.5 mg (2 mg/1.5  Trulicity 1.5 mg/0.5 mL subcutaneous pen mL) subcutaneous pen injector injector  Ozempic 1 mg/dose (2 mg/1.5 mL)  Trulicity 3 mg/0.5 mL subcutaneous pen subcutaneous pen injector injector  Ozempic 1 mg/dose (4 mg/3 mL)  Trulicity 4.5 mg/0.5 mL subcutaneous pen subcutaneous pen injector injector  Rybelsus 14 mg tablet  Victoza 2-Pak 0.6 mg/0.1 mL (18 mg/3  Rybelsus 3 mg tablet mL) subcutaneous pen injector  Rybelsus 7 mg tablet  Victoza 3-Pak 0.6 mg/0.1 mL (18 mg/3  Trulicity 0.75 mg/0.5 mL subcutaneous mL) subcutaneous pen injector pen injector Details

Criteria For new starts only, claims will process for Victoza, Trulicity, Ozempic or Rybelsus if a claim for metformin has been processed in the past 120 days. Exceptions are permitted for beneficiaries with type 2 diabetes and multiple cardiovascular risk factors or established cardiovascular disease.

Formulary ID 21357, V#17 3 Step Therapy Criteria Health Alliance Plan 2021 Date Effective: 10/01/2021

LINZESS

Products Affected Step 2:  Linzess 145 mcg capsule  Linzess 72 mcg capsule  Linzess 290 mcg capsule Details

Criteria For new starts only, claims for linaclotide will process if a claim for lubiprostone is processed in the past 120 days.

Formulary ID 21357, V#17 4 Step Therapy Criteria Health Alliance Plan 2021 Date Effective: 10/01/2021

ULORIC

Products Affected Step 2:  40 mg tablet  febuxostat 80 mg tablet

Details

Criteria For new starts only, claims for febuxostat will process if a claim for 300 mg is processed in the past 120 days.

Formulary ID 21357, V#17 5 Step Therapy Criteria Health Alliance Plan 2021 Date Effective: 10/01/2021

Index

F R febuxostat 40 mg tablet ...... 5 Rybelsus 14 mg tablet ...... 3 febuxostat 80 mg tablet ...... 5 Rybelsus 3 mg tablet ...... 3 fluvastatin 20 mg capsule ...... 2 Rybelsus 7 mg tablet ...... 3 fluvastatin 40 mg capsule ...... 2 S fluvastatin ER 80 mg tablet,extended release sevelamer carbonate 800 mg tablet ...... 1 24 hr ...... 2 sevelamer HCl 400 mg tablet ...... 1 L sevelamer HCl 800 mg tablet ...... 1 lanthanum 1,000 mg chewable tablet ...... 1 T lanthanum 500 mg chewable tablet ...... 1 Trulicity 0.75 mg/0.5 mL subcutaneous pen lanthanum 750 mg chewable tablet ...... 1 injector ...... 3 Linzess 145 mcg capsule ...... 4 Trulicity 1.5 mg/0.5 mL subcutaneous pen Linzess 290 mcg capsule ...... 4 injector ...... 3 Linzess 72 mcg capsule ...... 4 Trulicity 3 mg/0.5 mL subcutaneous pen O injector ...... 3 Ozempic 0.25 mg or 0.5 mg (2 mg/1.5 mL) Trulicity 4.5 mg/0.5 mL subcutaneous pen subcutaneous pen injector ...... 3 injector ...... 3 Ozempic 1 mg/dose (2 mg/1.5 mL) V subcutaneous pen injector ...... 3 Victoza 2-Pak 0.6 mg/0.1 mL (18 mg/3 mL) Ozempic 1 mg/dose (4 mg/3 mL) subcutaneous pen injector ...... 3 subcutaneous pen injector ...... 3 Victoza 3-Pak 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous pen injector ...... 3

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