Step Therapy Criteria Health Alliance Plan 2021 Date Effective: 10/01/2021
ESRD
Products Affected Step 2: lanthanum 1,000 mg chewable tablet sevelamer carbonate 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 calcium acetate 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: febuxostat 40 mg tablet febuxostat 80 mg tablet
Details
Criteria For new starts only, claims for febuxostat will process if a claim for allopurinol 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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