Step Therapy Criteria

Step Therapy Criteria Simply Health Care 2015 – Formulary ID: 15377 – Version: 11 Last Updated: 08/12/2014

ADHD STIMULANTS-S(SHC)

Products Affected

 Daytrana  Daytrana  Focalin Xr CP24 10MG, 20MG,  Strattera 25MG, 35MG, 5MG

Details Criteria Patient needs to have a paid claim for two generic formulary ADHD stimulant medication.

1 ANTIDEPRESSANTS-S(SHC)

Products Affected

 Aplenzin  Aplenzin  Brintellix  Pexeva  Fetzima  Pristiq  Fetzima Titration Pack  Viibryd  Forfivo XL

Details Criteria Patient needs to have a paid claim for TWO of the following formulary products: bupropion, mirtazapine, generic SSRI, or generic SNRI.

2 ANTIFUNGAL-S(SHC)

Products Affected

 Mentax

Details Criteria Patient needs to have a paid claim for one formulary generic topical antifungal agent

3 ANTISPASMODICS-S(SHC)

Products Affected

 Gelnique GEL 10%  Gelnique GEL 10%  Oxytrol  Vesicare  Toviaz

Details Criteria Patient needs to have a paid claim for one generic formulary antispasmodic agent

4 ARB-S(SHC)

Products Affected

 Benicar  Benicar  Benicar Hct  Micardis Hct  Edarbi

Details Criteria Patient needs to have a paid claim for one generic formulary ARB or ARB-diuretic combination

5 ATOPIC DERMATITIS-S(SHC)

Products Affected

 Elidel  Protopic

Details Criteria Patient needs to have a paid claim for one formulary topical corticosteroid

6 ATYPICAL ANTIPSYCHOTICS-S(SHC)

Products Affected

 Abilify ORAL SOLN  Abilify ORAL SOLN  Abilify TABS  Invega  Abilify Discmelt  Latuda  Abilify Maintena INJ 300MG  Saphris  Fanapt  Seroquel Xr

Details Criteria Patient needs to have a paid claim for one generic formulary atypical antipsychotic agent

7 BISPHOSPHONATES-S5T

Products Affected

 Actonel  Actonel  Atelvia  Fosamax Plus D

Details Criteria Patient needs to have a paid claim for one generic formulary oral bisphosphonate agent

8 DIFICID-S(SHC)

Products Affected

 Dificid

Details Criteria Patient needs to have a paid claim for generic oral vancomycin

9 DPP4 INHIBITORS-S(SHC)

Products Affected

 Jentadueto  Jentadueto  Kombiglyze Xr  Onglyza

Details Criteria Patient needs to have a paid claim for metformin or formulary metformin/sulfonylurea combinations

10 FENOFIBRATES-S(SHC)

Products Affected

 Antara CAPS 30MG, 90MG  Antara CAPS 30MG, 90MG  Fenoglide  Lipofen

Details Criteria Patient needs to have a paid claim for one generic formulary fibric acid or fenofibrate

11 GLP1 AGONIST-S(SHC)

Products Affected

 Bydureon  Bydureon  Byetta  Victoza

Details Criteria Patient needs to have a paid claim for metformin or formulary metformin/sulfonylurea combinations

12 NASAL STEROIDS-S(SHC)

Products Affected

 Nasonex  Nasonex  Rhinocort Aqua  Veramyst

Details Criteria Patient needs to have a paid claim for one generic formulary intranasal corticosteroid agent

13 NEUPRO-S(SHC)

Products Affected

 Neupro

Details Criteria Patient needs to have a paid claim for one generic formulary dopamine agonist agent

14 OPHTHALMIC PROSTAGLANDINS-S(SHC)

Products Affected

 Rescula

Details Criteria Patient needs to have a paid claim for one generic formulary ophthalmic prostaglandin product.

15 PPI-S(SHC)

Products Affected

 Dexilant  Nexium

Details Criteria Patient needs to have a paid claim for one generic formulary proton pump inhibitor

16 STATINS-S(SHC)

Products Affected

 Advicor  Advicor  Lescol XL  Vytorin  Livalo

Details Criteria Patient needs to have a paid claim for one generic formulary HMG-CoA reductase inhibitor (statin)

17 TRIPTANS-S(SHC)

Products Affected

 Axert  Axert  Frova  Zomig SOLN 2.5MG  Relpax  Zomig Nasal Spray

Details Criteria Patient needs to have a paid claim for one generic formulary serotonin 5- HT1 receptor antagonist (triptans)

18 ULORIC-S(SHC)

Products Affected

 Uloric

Details Criteria Patient needs to have a paid claim for allopurinol

19 INDEX

A F Abilify...... 7 Fanapt...... 7 Abilify Discmelt...... 7 Fenofibrates-s(shc)...... 11 Abilify Maintena...... 7 Fenoglide...... 11 Actonel...... 8 Fetzima...... 2 Adhd Stimulants-s(shc)...... 1 Fetzima Titration Pack...... 2 Advicor...... 17 Focalin Xr...... 1 Antara...... 11 Forfivo XL...... 2 Antidepressants-s(shc)...... 2 Fosamax Plus D...... 8 Antifungal-s(shc)...... 3 Frova...... 18 Antispasmodics-s(shc)...... 4 G Aplenzin...... 2 Arb-s(shc)...... 5 Gelnique...... 4 Atelvia...... 8 Glp1 Agonist-s(shc)...... 12 Atopic Dermatitis-s(shc)...... 6 I Atypical Antipsychotics-s(shc)...... 7 Invega...... 7 Axert...... 18 J B Jentadueto...... 10 Benicar...... 5 Benicar Hct...... 5 K Bisphosphonates-s5t...... 8 Kombiglyze Xr...... 10 Brintellix...... 2 Bydureon...... 12 L Byetta...... 12 Latuda...... 7 D Lescol XL...... 17 Lipofen...... 11 Daytrana...... 1 Livalo...... 17 Dexilant...... 16 Dificid...... 9 M Dificid-s(shc)...... 9 Mentax...... 3 Dpp4 Inhibitors-s(shc)...... 10 Micardis Hct...... 5 E N Edarbi...... 5 Nasal Steroids-s(shc)...... 13 Elidel...... 6 Nasonex...... 13 Neupro...... 14 Neupro-s(shc)...... 14

20 Nexium...... 16 Statins-s(shc)...... 17 O Strattera...... 1 Onglyza...... 10 T Ophthalmic Prostaglandins-s(shc)...... 15 Toviaz...... 4 Oxytrol...... 4 Triptans-s(shc)...... 18 P U Pexeva...... 2 Uloric...... 19 Ppi-s(shc)...... 16 Uloric-s(shc)...... 19 Pristiq...... 2 V Protopic...... 6 Veramyst...... 13 R Vesicare...... 4 Relpax...... 18 Victoza...... 12 Rescula...... 15 Viibryd...... 2 Rhinocort Aqua...... 13 Vytorin...... 17 S Z Saphris...... 7 Zomig...... 18 Seroquel Xr...... 7 Zomig Nasal Spray...... 18