Step Therapy Criteria Standard

ANTIDEPRESSANTS, SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS PDP EGWP STANDARD

Products Affected Step 1:  bupropion hcl 100 mg tablet  fluvoxamine er 100 mg capsule,extended  bupropion hcl 75 mg tablet release 24 hr  bupropion hcl sr 100 mg tablet,12 hr  fluvoxamine er 150 mg capsule,extended sustained-release release 24 hr  bupropion hcl sr 150 mg tablet,12 hr  mirtazapine 15 mg disintegrating tablet sustained-release  mirtazapine 15 mg tablet  bupropion hcl sr 200 mg tablet,12 hr  mirtazapine 30 mg disintegrating tablet sustained-release  mirtazapine 30 mg tablet  bupropion hcl xl 150 mg 24 hr tablet,  mirtazapine 45 mg disintegrating tablet extended release  mirtazapine 45 mg tablet  bupropion hcl xl 300 mg 24 hr tablet,  mirtazapine 7.5 mg tablet extended release  paroxetine 10 mg tablet  citalopram 10 mg tablet  paroxetine 20 mg tablet  citalopram 10 mg/5 ml oral solution  paroxetine 30 mg tablet  citalopram 20 mg tablet  paroxetine 40 mg tablet  citalopram 40 mg tablet  paroxetine er 12.5 mg tablet,extended  duloxetine 20 mg capsule,delayed release release 24 hr  duloxetine 30 mg capsule,delayed release  paroxetine er 25 mg tablet,extended  duloxetine 40 mg capsule,delayed release release 24 hr  duloxetine 60 mg capsule,delayed release  paroxetine er 37.5 mg tablet,extended  escitalopram 10 mg tablet release 24 hr  escitalopram 20 mg tablet  sertraline 100 mg tablet  escitalopram 5 mg tablet  sertraline 20 mg/ml oral concentrate  escitalopram 5 mg/5 ml oral solution  sertraline 25 mg tablet  fluoxetine (pmdd) 10 mg tablet  sertraline 50 mg tablet  fluoxetine (pmdd) 20 mg tablet  trazodone 100 mg tablet  fluoxetine 10 mg capsule  trazodone 150 mg tablet  fluoxetine 10 mg tablet  trazodone 300 mg tablet  fluoxetine 20 mg capsule  trazodone 50 mg tablet  fluoxetine 20 mg tablet  venlafaxine 100 mg tablet  fluoxetine 20 mg/5 ml (4 mg/ml) oral  venlafaxine 25 mg tablet solution  venlafaxine 37.5 mg tablet  fluoxetine 40 mg capsule  venlafaxine 50 mg tablet  fluoxetine 60 mg tablet  venlafaxine 75 mg tablet  fluoxetine 90 mg capsule,delayed release  venlafaxine er 150 mg capsule,extended  fluvoxamine 100 mg tablet release 24 hr  fluvoxamine 25 mg tablet  venlafaxine er 150 mg tablet,extended  fluvoxamine 50 mg tablet release 24 hr

1  venlafaxine er 225 mg tablet,extended  venlafaxine er 75 mg capsule,extended release 24 hr release 24 hr  venlafaxine er 37.5 mg capsule,extended  venlafaxine er 75 mg tablet,extended release 24 hr release 24 hr  venlafaxine er 37.5 mg tablet,extended release 24 hr Step 2:  FETZIMA 120 MG  FETZIMA 80 MG CAPSULE,EXTENDED RELEASE CAPSULE,EXTENDED RELEASE  FETZIMA 20 MG (2)-40 MG (26)  PAXIL 10 MG/5 ML ORAL CAPSULE,EXTENDED RELEASE,24 SUSPENSION HR,DOSE PACK  VIIBRYD 10 MG (7)-20 MG (23)  FETZIMA 20 MG TABLETS IN A DOSE PACK CAPSULE,EXTENDED RELEASE  VIIBRYD 10 MG TABLET  FETZIMA 40 MG  VIIBRYD 20 MG TABLET CAPSULE,EXTENDED RELEASE  VIIBRYD 40 MG TABLET

Details

Criteria Step-1 Drugs: bupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, paroxetine, sertraline, trazodone and venlafaxine. Step-2 Drugs: Fetzima, Paxil Suspension and Viibryd. For Fetzima and Paxil Suspension, the member must have tried a 30 day supply or more of at least two Step-1 drugs within the same step therapy group within the previous 180 days as evidenced by a previous paid claim under the prescription benefit or by physician documented use. For Viibryd, only one Step-1 drug is required. Step-2 drugs are not covered unless the above step therapy criteria are met. Patients who are currently taking or who have taken a step 2 drug at any time in the past and discontinued their use may receive authorization without trials of step 1 drugs. For patients with suicidal ideation, step 1 drugs do not need to be tried.

2 ASTHMA PDP EGWP STANDARD

Products Affected Step 1:  ARNUITY ELLIPTA 100  FLOVENT DISKUS 250 MCG/ACTUATION POWDER FOR MCG/ACTUATION POWDER FOR INHALATION INHALATION  ARNUITY ELLIPTA 200  FLOVENT DISKUS 50 MCG/ACTUATION POWDER FOR MCG/ACTUATION POWDER FOR INHALATION INHALATION  ARNUITY ELLIPTA 50  FLOVENT HFA 110 MCG/ACTUATION MCG/ACTUATION POWDER FOR AEROSOL INHALER INHALATION  FLOVENT HFA 220 MCG/ACTUATION  FLOVENT DISKUS 100 AEROSOL INHALER MCG/ACTUATION POWDER FOR  FLOVENT HFA 44 MCG/ACTUATION INHALATION AEROSOL INHALER Step 2:  ASMANEX HFA 100  ASMANEX TWISTHALER 220 MCG/ACTUATION AEROSOL MCG/ACTUATION(14 DOSES) INHALER BREATH ACTIVATED INHALR  ASMANEX HFA 200  ASMANEX TWISTHALER 220 MCG/ACTUATION AEROSOL MCG/ACTUATION(30 DOSES) INHALER BREATH ACTIVATED INHALR  ASMANEX HFA 50 MCG/ACTUATION  ASMANEX TWISTHALER 220 AEROSOL INHALER MCG/ACTUATION(60 DOSES)  ASMANEX TWISTHALER 110 BREATH ACTIVATED INHALR MCG/ACTUATION(30 DOSES)  QVAR REDIHALER 40 BREATH ACTIVATED INHALR MCG/ACTUATION HFA BREATH  ASMANEX TWISTHALER 220 ACTIVATED AEROSOL MCG/ACTUATION(120 DOSES)  QVAR REDIHALER 80 BREATH ACTIVATED INHLR MCG/ACTUATION HFA BREATH ACTIVATED AEROSOL Details

Criteria Step-1 Drugs: Arnuity Ellipta, Flovent Diskus and Flovent HFA. Step-2 Drugs: Asmanex and Qvar. The member must have tried a 30 day supply or more of at least one Step-1 drug within the same step therapy group within the previous 365 days as evidenced by a previous paid claim under the prescription benefit or by physician documented use. Step-2 drugs are not covered unless the above step therapy criteria are met.

3 BISPHOSPHONATE PDP EGWP STANDARD

Products Affected Step 1:  alendronate 10 mg tablet  risedronate 30 mg tablet  alendronate 35 mg tablet  risedronate 35 mg tablet  alendronate 70 mg tablet  risedronate 35 mg tablet (12 pack)  alendronate 70 mg/75 ml oral solution  risedronate 35 mg tablet (4 pack)  ibandronate 150 mg tablet  risedronate 35 mg tablet,delayed release  risedronate 150 mg tablet  risedronate 5 mg tablet Step 2:  FOSAMAX PLUS D 70 MG-2,800 UNIT  FOSAMAX PLUS D 70 MG-5,600 UNIT TABLET TABLET

Details

Criteria Step-1 Drugs: alendronate sodium, ibandronate sodium tablets and risedronate sodium. Step-2 Drug: Fosamax Plus D. The member must have tried a 30 day supply or more of at least one Step-1 drug within the same step therapy group within the previous 365 days as evidenced by a previous paid claim under the prescription benefit or by physician documented use. Step-2 drug is not covered unless the above step therapy criteria are met.

4 DIPENTUM PDP EGWP STANDARD

Products Affected Step 1:  balsalazide 750 mg capsule  PENTASA 250 MG  mesalamine 1.2 gram tablet,delayed CAPSULE,CONTROLLED RELEASE release  PENTASA 500 MG  mesalamine 400 mg capsule (with delayed CAPSULE,CONTROLLED RELEASE release tablets inside)  sulfasalazine 500 mg tablet  mesalamine 800 mg tablet,delayed release  sulfasalazine 500 mg tablet,delayed  mesalamine er 0.375 gram release capsule,extended release 24 hr Step 2:  DIPENTUM 250 MG CAPSULE

Details

Criteria Step-1 Drugs: balsalazide, mesalamine DR, mesalamine ER, Pentasa and sulfasalazine. Step-2 Drug: Dipentum. The member must have tried a 30 day supply or more of at least two Step-1 drugs within the same step therapy group within the previous 180 days as evidenced by a previous paid claim under the prescription benefit or by physician documented use. Step-2 drug is not covered unless the above step therapy criteria are met.

5 DPP-4 PDP EGWP STANDARD

Products Affected Step 1:  JANUMET 50 MG-1,000 MG TABLET  JENTADUETO 2.5 MG-1,000 MG  JANUMET 50 MG-500 MG TABLET TABLET  JANUMET XR 100 MG-1,000 MG  JENTADUETO 2.5 MG-500 MG TABLET,EXTENDED RELEASE TABLET  JANUMET XR 50 MG-1,000 MG  JENTADUETO 2.5 MG-850 MG TABLET,EXTENDED RELEASE TABLET  JANUMET XR 50 MG-500 MG  JENTADUETO XR 2.5 MG-1,000 MG TABLET,EXTENDED RELEASE TABLET, EXTENDED RELEASE  JANUVIA 100 MG TABLET  JENTADUETO XR 5 MG-1,000 MG  JANUVIA 25 MG TABLET TABLET, EXTENDED RELEASE  JANUVIA 50 MG TABLET  TRADJENTA 5 MG TABLET Step 2:  KOMBIGLYZE XR 2.5 MG-1,000 MG  KOMBIGLYZE XR 5 MG-500 MG TABLET,EXTENDED RELEASE TABLET,EXTENDED RELEASE  KOMBIGLYZE XR 5 MG-1,000 MG  ONGLYZA 2.5 MG TABLET TABLET,EXTENDED RELEASE  ONGLYZA 5 MG TABLET

Details

Criteria Step-1 Drugs: Janumet, Janumet XR, Januvia, Jentadueto, Jentadueto XR and Tradjenta. Step-2 Drugs: Kombiglyze XR and Onglyza. The member must have tried a 30 day supply or more of at least one Step-1 drug within the same step therapy group within the previous 365 days as evidenced by a previous paid claim under the prescription benefit or by physician documented use. Step-2 drugs are not covered unless the above step therapy criteria are met.

6 FEBUXOSTAT PDP EGWP STANDARD

Products Affected Step 1:  allopurinol 100 mg tablet  allopurinol 300 mg tablet Step 2:  febuxostat 40 mg tablet  febuxostat 80 mg tablet

Details

Criteria Step-1 Drug: allopurinol. Step-2 Drug: febuxostat. The member must have tried a 30 day supply or more of at least one Step-1 drug within the same step therapy group within the previous 180 days as evidenced by a previous paid claim under the prescription benefit or by physician documented use. Step-2 drug is not covered unless the above step therapy criteria are met. Authorization for febuxostat may be given if the patient is receiving concomitant medications that have significant drug-drug interactions with the Step 1 agent (allopurinol) which are not noted with febuxostat tablets (e.g., cyclosporine, chlorpropamide).

7 GLAUCOMA PDP EGWP STANDARD

Products Affected Step 1:  ALPHAGAN P 0.1 % EYE DROPS  LUMIGAN 0.01 % EYE DROPS  bimatoprost 0.03 % eye drops  pilocarpine 1 % eye drops  brimonidine 0.15 % eye drops  pilocarpine 2 % eye drops  brimonidine 0.2 % eye drops  pilocarpine 4 % eye drops  brinzolamide 1 % eye drops,suspension  timolol maleate 0.25 % eye drops  carteolol 1 % eye drops  timolol maleate 0.25 % eye gel forming  COMBIGAN 0.2 %-0.5 % EYE DROPS solution  dorzolamide 2 % eye drops  timolol maleate 0.5 % eye drops  dorzolamide 22.3 mg-timolol 6.8 mg/ml  timolol maleate 0.5 % eye gel forming eye drops solution  dorzolamide-timolol (pf) 2 %-0.5 % eye  timolol maleate 0.5 % once daily eye drops in a dropperette drops  latanoprost 0.005 % eye drops  TRAVATAN Z 0.004 % EYE DROPS  levobunolol 0.5 % eye drops  travoprost 0.004 % eye drops Step 2:  RHOPRESSA 0.02 % EYE DROPS  ROCKLATAN 0.02 %-0.005 % EYE DROPS Details

Criteria Step-1 Drugs: Alphagan P, bimatoprost, brimonidine, brinzolamide, carteolol, Combigan, dorzolamide, dorzolamide/timolol, dorzolamide/timolol PF, latanoprost, levobunolol, Lumigan, pilocarpine, timolol, timolol ophthalmic gel forming solution, travoprost, Travatan Z. Step-2 Drugs: Rocklatan, Rhopressa. The member must have tried a 30 day supply or more of at least one Step-1 drug within the same step therapy group within the previous 180 days as evidenced by a previous paid claim under the prescription benefit or by physician documented use. Step-2 drugs are not covered unless the above step therapy criteria are met.

8 INSULIN PDP EGWP STANDARD

Products Affected Step 1:  HUMALOG JUNIOR KWIKPEN (U-  HUMALOG U-100 INSULIN 100 100) 100 UNIT/ML SUBCUTANEOUS UNIT/ML SUBCUTANEOUS HALF-UNIT PEN SOLUTION  HUMALOG KWIKPEN (U-100)  HUMULIN 70/30 U-100 INSULIN 100 INSULIN 100 UNIT/ML UNIT/ML SUBCUTANEOUS SUBCUTANEOUS SUSPENSION  HUMALOG KWIKPEN U-200 INSULIN  HUMULIN 70/30 U-100 INSULIN 200 UNIT/ML (3 ML) KWIKPEN 100 UNIT/ML SUBCUTANEOUS SUBCUTANEOUS  HUMALOG MIX 50-50 (U-100)  HUMULIN N NPH U-100 INSULIN INSULIN 100 UNIT/ML (ISOPHANE SUSP) 100 UNIT/ML SUBCUTANEOUS SUSPENSION SUBCUTANEOUS  HUMALOG MIX 50-50 KWIKPEN U-  HUMULIN N NPH U-100 INSULIN 100 INSULIN 100 UNIT/ML KWIKPEN 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN SUBCUTANEOUS  HUMALOG MIX 75-25 (U-100)  HUMULIN R REGULAR U-100 INSULIN 100 UNIT/ML INSULIN 100 UNIT/ML INJECTION SUBCUTANEOUS SUSPENSION SOLUTION  HUMALOG MIX 75-25 KWIKPEN U-  HUMULIN R U-500 (CONC) INSULIN 100 INSULIN 100 UNIT/ML KWIKPEN 500 UNIT/ML (3 ML) SUBCUTANEOUS PEN SUBCUTANEOUS  HUMALOG U-100 INSULIN 100  HUMULIN R U-500 UNIT/ML SUBCUTANEOUS (CONCENTRATED) INSULIN 500 CARTRIDGE UNIT/ML SUBCUTANEOUS SOLN Step 2:  NOVOLIN 70/30 U-100 INSULIN 100  NOVOLIN R REGULAR U-100 UNIT/ML SUBCUTANEOUS INSULIN 100 UNIT/ML INJECTION SUSPENSION SOLUTION  NOVOLIN 70-30 FLEXPEN U-100  NOVOLOG FLEXPEN U-100 INSULIN INSULIN 100 UNIT/ML (70-30) ASPART 100 UNIT/ML (3 ML) SUBCUTANEOUS SUBCUTANEOUS  NOVOLIN N FLEXPEN 100 UNIT/ML  NOVOLOG MIX 70-30 FLEXPEN U-100 (3 ML) SUBCUTANEOUS INSULIN INSULIN 100 UNIT/ML PEN SUBCUTANEOUS PEN  NOVOLIN N NPH U-100 INSULIN  NOVOLOG MIX 70-30 U-100 INSULIN ISOPHANE 100 UNIT/ML 100 UNIT/ML SUBCUTANEOUS SUBCUTANEOUS SUSP SOLUTION  NOVOLIN R FLEXPEN 100 UNIT/ML  NOVOLOG PENFILL U-100 INSULIN (3 ML) SUBCUTANEOUS INSULIN ASPART 100 UNIT/ML PEN SUBCUTANEOUS CARTRIDGE

9  NOVOLOG U-100 INSULIN ASPART SOLUTION 100 UNIT/ML SUBCUTANEOUS Details

Criteria Step-1 Drugs: Humalog, Humalog Mix, Humulin and Humulin 70/30. Step-2 Drugs: Novolog, Novolog Mix, Novolin and Novolin 70/30. The member must have tried a 30 day supply or more of at least one Step-1 drug within the same step therapy group within the previous 365 days as evidenced by a previous paid claim under the prescription benefit or by physician documented use. Step-2 drugs are not covered unless the above step therapy criteria are met.

10 METFORMIN ER (GENERIC FOR GLUMETZA) PDP EGWP STANDARD

Products Affected Step 1:  metformin er 1,000 mg tablet,extended  metformin er 500 mg tablet,extended release 24hr release 24hr  metformin er 500 mg tablet,extended  metformin er 750 mg tablet,extended release 24 hr release 24 hr Step 2:  metformin er 1,000 mg 24 hr  metformin er 500 mg 24 hr tablet,extended tablet,extended release release

Details

Criteria Step-1 Drugs: metformin ER 500mg, 750mg tablets (generic Glucophage XR) and metformin ER 500mg, 1000mg tablets (generic Fortamet). Step- 2 Drug: metformin ER 500mg and 1000mg tablets (generic Glumetza). The member must have tried a 30 day supply or more of both generic Glucophage XR AND generic Fortamet within the previous 180 days as evidenced by a previous paid claim under the prescription benefit or by physician documented use. Step-2 drugs are not covered unless the above step therapy criteria are met.

11 RYTARY PDP EGWP STANDARD

Products Affected Step 1:  carbidopa 10 mg-levodopa 100 mg  carbidopa 25 mg-levodopa 250 mg disintegrating tablet disintegrating tablet  carbidopa 10 mg-levodopa 100 mg tablet  carbidopa 25 mg-levodopa 250 mg tablet  carbidopa 12.5 mg-levodopa 50 mg-  carbidopa 31.25 mg-levodopa 125 mg- entacapone 200 mg tablet entacapone 200 mg tablet  carbidopa 18.75 mg-levodopa 75 mg-  carbidopa 37.5 mg-levodopa 150 mg- entacapone 200 mg tablet entacapone 200 mg tablet  carbidopa 25 mg-levodopa 100 mg  carbidopa 50 mg-levodopa 200 mg- disintegrating tablet entacapone 200 mg tablet  carbidopa 25 mg-levodopa 100 mg tablet  carbidopa er 25 mg-levodopa 100 mg  carbidopa 25 mg-levodopa 100 mg- tablet,extended release entacapone 200 mg tablet  carbidopa er 50 mg-levodopa 200 mg tablet,extended release Step 2:  RYTARY 23.75 MG-95 MG  RYTARY 48.75 MG-195 MG CAPSULE,EXTENDED RELEASE CAPSULE,EXTENDED RELEASE  RYTARY 36.25 MG-145 MG  RYTARY 61.25 MG-245 MG CAPSULE,EXTENDED RELEASE CAPSULE,EXTENDED RELEASE

Details

Criteria Step-1 Drugs: carbidopa/levodopa, carbidopa/levodopa ER, carbidopa/levodopa ODT, and carbidopa/levodopa/entacapone. Step-2 Drug: Rytary. The member must have tried a 30 day supply or more of at least one Step-1 drug within the same step therapy group within the previous 180 days as evidenced by a previous paid claim under the prescription benefit or by physician documented use. Step-2 drug is not covered unless the above step therapy criteria are met.

12 TRINTELLIX PDP EGWP STANDARD

Products Affected Step 1:  bupropion hcl 100 mg tablet  fluvoxamine er 150 mg capsule,extended  bupropion hcl 75 mg tablet release 24 hr  bupropion hcl sr 100 mg tablet,12 hr  mirtazapine 15 mg disintegrating tablet sustained-release  mirtazapine 15 mg tablet  bupropion hcl sr 150 mg tablet,12 hr  mirtazapine 30 mg disintegrating tablet sustained-release  mirtazapine 30 mg tablet  bupropion hcl sr 200 mg tablet,12 hr  mirtazapine 45 mg disintegrating tablet sustained-release  mirtazapine 45 mg tablet  bupropion hcl xl 150 mg 24 hr tablet,  mirtazapine 7.5 mg tablet extended release  paroxetine 10 mg tablet  bupropion hcl xl 300 mg 24 hr tablet,  paroxetine 20 mg tablet extended release  paroxetine 30 mg tablet  citalopram 10 mg tablet  paroxetine 40 mg tablet  citalopram 10 mg/5 ml oral solution  paroxetine er 12.5 mg tablet,extended  citalopram 20 mg tablet release 24 hr  citalopram 40 mg tablet  paroxetine er 25 mg tablet,extended  duloxetine 20 mg capsule,delayed release release 24 hr  duloxetine 30 mg capsule,delayed release  paroxetine er 37.5 mg tablet,extended  duloxetine 40 mg capsule,delayed release release 24 hr  duloxetine 60 mg capsule,delayed release  sertraline 100 mg tablet  escitalopram 10 mg tablet  sertraline 20 mg/ml oral concentrate  escitalopram 20 mg tablet  sertraline 25 mg tablet  escitalopram 5 mg tablet  sertraline 50 mg tablet  escitalopram 5 mg/5 ml oral solution  trazodone 100 mg tablet  fluoxetine (pmdd) 10 mg tablet  trazodone 150 mg tablet  fluoxetine (pmdd) 20 mg tablet  trazodone 300 mg tablet  fluoxetine 10 mg capsule  trazodone 50 mg tablet  fluoxetine 10 mg tablet  venlafaxine 100 mg tablet  fluoxetine 20 mg capsule  venlafaxine 25 mg tablet  fluoxetine 20 mg tablet  venlafaxine 37.5 mg tablet  fluoxetine 20 mg/5 ml (4 mg/ml) oral  venlafaxine 50 mg tablet solution  venlafaxine 75 mg tablet  fluoxetine 40 mg capsule  venlafaxine er 150 mg capsule,extended  fluoxetine 60 mg tablet release 24 hr  fluoxetine 90 mg capsule,delayed release  venlafaxine er 150 mg tablet,extended  fluvoxamine 100 mg tablet release 24 hr  fluvoxamine 25 mg tablet  venlafaxine er 225 mg tablet,extended  fluvoxamine 50 mg tablet release 24 hr  fluvoxamine er 100 mg capsule,extended  venlafaxine er 37.5 mg capsule,extended release 24 hr release 24 hr

13  venlafaxine er 37.5 mg tablet,extended  venlafaxine er 75 mg tablet,extended release 24 hr release 24 hr  venlafaxine er 75 mg capsule,extended release 24 hr Step 2:  TRINTELLIX 10 MG TABLET  TRINTELLIX 5 MG TABLET  TRINTELLIX 20 MG TABLET Details

Criteria Step-1 Drugs: bupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, paroxetine, sertraline, trazodone and venlafaxine. Step-2 Drug: Trintellix. The member must have tried a 30 day supply or more of one Step-1 drug within the same step therapy group within the previous 180 days as evidenced by a previous paid claim under the prescription benefit or by physician documented use. Step-2 drug is not covered unless the above step therapy criteria are met. Patients who are currently taking or who have taken a step 2 drug at any time in the past and discontinued their use may receive authorization without trials of step 1 drugs. For patients with suicidal ideation, step 1 drugs do not need to be tried.

14 TRIPTAN PDP EGWP STANDARD

Products Affected Step 1:  naratriptan 1 mg tablet  sumatriptan 4 mg/0.5 ml subcutaneous  naratriptan 2.5 mg tablet pen injector  rizatriptan 10 mg disintegrating tablet  sumatriptan 5 mg/actuation nasal spray  rizatriptan 10 mg tablet  sumatriptan 50 mg tablet  rizatriptan 5 mg disintegrating tablet  sumatriptan 6 mg/0.5 ml subcutaneous  rizatriptan 5 mg tablet cartridge (refill)  sumatriptan 100 mg tablet  sumatriptan 6 mg/0.5 ml subcutaneous  sumatriptan 20 mg/actuation nasal spray pen injector  sumatriptan 25 mg tablet  sumatriptan 6 mg/0.5 ml subcutaneous  sumatriptan 4 mg/0.5 ml subcutaneous solution cartridge (refill) Step 2:  almotriptan malate 12.5 mg tablet  eletriptan 40 mg tablet  almotriptan malate 6.25 mg tablet  frovatriptan 2.5 mg tablet  eletriptan 20 mg tablet Details

Criteria Step-1 Drugs: naratriptan hcl, rizatriptan benzoate and sumatriptan. Step-2 Drugs: almotriptan malate, eletriptan and frovatriptan. The member must have tried a 14 day supply or more of at least one Step-1 drug within the same step therapy group within the previous 365 days as evidenced by a previous paid claim under the prescription benefit or by physician documented use. Step-2 drugs are not covered unless the above step therapy criteria are met.

15 XHANCE PDP EGWP STANDARD

Products Affected Step 1:  fluticasone propionate 50 mcg/actuation nasal spray,suspension Step 2:  XHANCE 93 MCG/ACTUATION BREATH ACTIVATED AEROSOL

Details

Criteria Step-1 Drugs: fluticasone propionate nasal spray. Step-2 Drugs: Xhance. The member must have tried a 30 day supply or more of one Step-1 drugs within the same step therapy group within the previous 180 days as evidenced by a previous paid claim under the prescription benefit or by physician documented use. Step-2 drug is not covered unless the above step therapy criteria are met.

16 Index

A brinzolamide 1 % eye drops,suspension ..... 8 alendronate 10 mg tablet ...... 4 bupropion hcl 100 mg tablet ...... 1, 2, 13, 14 alendronate 35 mg tablet ...... 4 bupropion hcl 75 mg tablet ...... 1, 2, 13, 14 alendronate 70 mg tablet ...... 4 bupropion hcl sr 100 mg tablet,12 hr alendronate 70 mg/75 ml oral solution ...... 4 sustained-release ...... 1, 2, 13, 14 allopurinol 100 mg tablet ...... 7 bupropion hcl sr 150 mg tablet,12 hr allopurinol 300 mg tablet ...... 7 sustained-release ...... 1, 2, 13, 14 almotriptan malate 12.5 mg tablet ...... 15 bupropion hcl sr 200 mg tablet,12 hr almotriptan malate 6.25 mg tablet ...... 15 sustained-release ...... 1, 2, 13, 14 ALPHAGAN P 0.1 % EYE DROPS ...... 8 bupropion hcl xl 150 mg 24 hr tablet, ARNUITY ELLIPTA 100 extended release ...... 1, 2, 13, 14 MCG/ACTUATION POWDER FOR bupropion hcl xl 300 mg 24 hr tablet, INHALATION ...... 3 extended release ...... 1, 2, 13, 14 ARNUITY ELLIPTA 200 C MCG/ACTUATION POWDER FOR carbidopa 10 mg-levodopa 100 mg INHALATION ...... 3 disintegrating tablet ...... 12 ARNUITY ELLIPTA 50 carbidopa 10 mg-levodopa 100 mg tablet . 12 MCG/ACTUATION POWDER FOR carbidopa 12.5 mg-levodopa 50 mg- INHALATION ...... 3 entacapone 200 mg tablet...... 12 ASMANEX HFA 100 MCG/ACTUATION carbidopa 18.75 mg-levodopa 75 mg- AEROSOL INHALER...... 3 entacapone 200 mg tablet...... 12 ASMANEX HFA 200 MCG/ACTUATION carbidopa 25 mg-levodopa 100 mg AEROSOL INHALER...... 3 disintegrating tablet ...... 12 ASMANEX HFA 50 MCG/ACTUATION carbidopa 25 mg-levodopa 100 mg tablet . 12 AEROSOL INHALER...... 3 carbidopa 25 mg-levodopa 100 mg- ASMANEX TWISTHALER 110 entacapone 200 mg tablet...... 12 MCG/ACTUATION(30 DOSES) carbidopa 25 mg-levodopa 250 mg BREATH ACTIVATED INHALR...... 3 disintegrating tablet ...... 12 ASMANEX TWISTHALER 220 carbidopa 25 mg-levodopa 250 mg tablet . 12 MCG/ACTUATION(120 DOSES) carbidopa 31.25 mg-levodopa 125 mg- BREATH ACTIVATED INHLR ...... 3 entacapone 200 mg tablet...... 12 ASMANEX TWISTHALER 220 carbidopa 37.5 mg-levodopa 150 mg- MCG/ACTUATION(14 DOSES) entacapone 200 mg tablet...... 12 BREATH ACTIVATED INHALR...... 3 carbidopa 50 mg-levodopa 200 mg- ASMANEX TWISTHALER 220 entacapone 200 mg tablet...... 12 MCG/ACTUATION(30 DOSES) carbidopa er 25 mg-levodopa 100 mg BREATH ACTIVATED INHALR...... 3 tablet,extended release ...... 12 ASMANEX TWISTHALER 220 carbidopa er 50 mg-levodopa 200 mg MCG/ACTUATION(60 DOSES) tablet,extended release ...... 12 BREATH ACTIVATED INHALR...... 3 carteolol 1 % eye drops ...... 8 B citalopram 10 mg tablet ...... 1, 2, 13, 14 balsalazide 750 mg capsule ...... 5 citalopram 10 mg/5 ml oral solution 1, 2, 13, bimatoprost 0.03 % eye drops ...... 8 14 brimonidine 0.15 % eye drops ...... 8 citalopram 20 mg tablet ...... 1, 2, 13, 14 brimonidine 0.2 % eye drops ...... 8 citalopram 40 mg tablet ...... 1, 2, 13, 14

17 COMBIGAN 0.2 %-0.5 % EYE DROPS ... 8 FLOVENT DISKUS 50 D MCG/ACTUATION POWDER FOR DIPENTUM 250 MG CAPSULE ...... 5 INHALATION ...... 3 dorzolamide 2 % eye drops ...... 8 FLOVENT HFA 110 MCG/ACTUATION dorzolamide 22.3 mg-timolol 6.8 mg/ml eye AEROSOL INHALER...... 3 drops ...... 8 FLOVENT HFA 220 MCG/ACTUATION dorzolamide-timolol (pf) 2 %-0.5 % eye AEROSOL INHALER...... 3 drops in a dropperette...... 8 FLOVENT HFA 44 MCG/ACTUATION duloxetine 20 mg capsule,delayed release . 1, AEROSOL INHALER...... 3 2, 13, 14 fluoxetine (pmdd) 10 mg tablet... 1, 2, 13, 14 duloxetine 30 mg capsule,delayed release . 1, fluoxetine (pmdd) 20 mg tablet... 1, 2, 13, 14 2, 13, 14 fluoxetine 10 mg capsule ...... 1, 2, 13, 14 duloxetine 40 mg capsule,delayed release . 1, fluoxetine 10 mg tablet ...... 1, 2, 13, 14 2, 13, 14 fluoxetine 20 mg capsule ...... 1, 2, 13, 14 duloxetine 60 mg capsule,delayed release . 1, fluoxetine 20 mg tablet ...... 1, 2, 13, 14 2, 13, 14 fluoxetine 20 mg/5 ml (4 mg/ml) oral E solution ...... 1, 2, 13, 14 eletriptan 20 mg tablet ...... 15 fluoxetine 40 mg capsule ...... 1, 2, 13, 14 eletriptan 40 mg tablet ...... 15 fluoxetine 60 mg tablet ...... 1, 2, 13, 14 escitalopram 10 mg tablet ...... 1, 2, 13, 14 fluoxetine 90 mg capsule,delayed release .. 1, escitalopram 20 mg tablet ...... 1, 2, 13, 14 2, 13, 14 escitalopram 5 mg tablet ...... 1, 2, 13, 14 fluticasone propionate 50 mcg/actuation escitalopram 5 mg/5 ml oral solution1, 2, 13, nasal spray,suspension ...... 16 14 fluvoxamine 100 mg tablet ...... 1, 2, 13, 14 F fluvoxamine 25 mg tablet ...... 1, 2, 13, 14 febuxostat 40 mg tablet ...... 7 fluvoxamine 50 mg tablet ...... 1, 2, 13, 14 febuxostat 80 mg tablet ...... 7 fluvoxamine er 100 mg capsule,extended FETZIMA 120 MG release 24 hr ...... 1, 2, 13, 14 CAPSULE,EXTENDED RELEASE ...... 2 fluvoxamine er 150 mg capsule,extended FETZIMA 20 MG (2)-40 MG (26) release 24 hr ...... 1, 2, 13, 14 CAPSULE,EXTENDED RELEASE,24 FOSAMAX PLUS D 70 MG-2,800 UNIT HR,DOSE PACK ...... 2 TABLET ...... 4 FETZIMA 20 MG CAPSULE,EXTENDED FOSAMAX PLUS D 70 MG-5,600 UNIT RELEASE ...... 2 TABLET ...... 4 FETZIMA 40 MG CAPSULE,EXTENDED frovatriptan 2.5 mg tablet ...... 15 RELEASE ...... 2 H FETZIMA 80 MG CAPSULE,EXTENDED HUMALOG JUNIOR KWIKPEN (U-100) RELEASE ...... 2 100 UNIT/ML SUBCUTANEOUS FLOVENT DISKUS 100 HALF-UNIT PEN ...... 9, 10 MCG/ACTUATION POWDER FOR HUMALOG KWIKPEN (U-100) INSULIN INHALATION ...... 3 100 UNIT/ML SUBCUTANEOUS .. 9, 10 FLOVENT DISKUS 250 HUMALOG KWIKPEN U-200 INSULIN MCG/ACTUATION POWDER FOR 200 UNIT/ML (3 ML) INHALATION ...... 3 SUBCUTANEOUS...... 9, 10

18 HUMALOG MIX 50-50 (U-100) INSULIN JANUMET XR 50 MG-1,000 MG 100 UNIT/ML SUBCUTANEOUS TABLET,EXTENDED RELEASE ...... 6 SUSPENSION ...... 9, 10 JANUMET XR 50 MG-500 MG HUMALOG MIX 50-50 KWIKPEN U-100 TABLET,EXTENDED RELEASE ...... 6 INSULIN 100 UNIT/ML JANUVIA 100 MG TABLET ...... 6 SUBCUTANEOUS PEN ...... 9, 10 JANUVIA 25 MG TABLET ...... 6 HUMALOG MIX 75-25 (U-100) INSULIN JANUVIA 50 MG TABLET ...... 6 100 UNIT/ML SUBCUTANEOUS JENTADUETO 2.5 MG-1,000 MG SUSPENSION ...... 9, 10 TABLET ...... 6 HUMALOG MIX 75-25 KWIKPEN U-100 JENTADUETO 2.5 MG-500 MG TABLET INSULIN 100 UNIT/ML ...... 6 SUBCUTANEOUS PEN ...... 9, 10 JENTADUETO 2.5 MG-850 MG TABLET HUMALOG U-100 INSULIN 100 ...... 6 UNIT/ML SUBCUTANEOUS JENTADUETO XR 2.5 MG-1,000 MG CARTRIDGE ...... 9, 10 TABLET, EXTENDED RELEASE ...... 6 HUMALOG U-100 INSULIN 100 JENTADUETO XR 5 MG-1,000 MG UNIT/ML SUBCUTANEOUS TABLET, EXTENDED RELEASE ...... 6 SOLUTION...... 9, 10 K HUMULIN 70/30 U-100 INSULIN 100 KOMBIGLYZE XR 2.5 MG-1,000 MG UNIT/ML SUBCUTANEOUS TABLET,EXTENDED RELEASE ...... 6 SUSPENSION ...... 9, 10 KOMBIGLYZE XR 5 MG-1,000 MG HUMULIN 70/30 U-100 INSULIN TABLET,EXTENDED RELEASE ...... 6 KWIKPEN 100 UNIT/ML KOMBIGLYZE XR 5 MG-500 MG SUBCUTANEOUS...... 9, 10 TABLET,EXTENDED RELEASE ...... 6 HUMULIN N NPH U-100 INSULIN L (ISOPHANE SUSP) 100 UNIT/ML latanoprost 0.005 % eye drops ...... 8 SUBCUTANEOUS...... 9, 10 levobunolol 0.5 % eye drops ...... 8 HUMULIN N NPH U-100 INSULIN LUMIGAN 0.01 % EYE DROPS ...... 8 KWIKPEN 100 UNIT/ML (3 ML) M SUBCUTANEOUS...... 9, 10 mesalamine 1.2 gram tablet,delayed release 5 HUMULIN R REGULAR U-100 INSULIN mesalamine 400 mg capsule (with delayed 100 UNIT/ML INJECTION SOLUTION release tablets inside) ...... 5 ...... 9, 10 mesalamine 800 mg tablet,delayed release . 5 HUMULIN R U-500 (CONC) INSULIN mesalamine er 0.375 gram capsule,extended KWIKPEN 500 UNIT/ML (3 ML) release 24 hr ...... 5 SUBCUTANEOUS...... 9, 10 metformin er 1,000 mg 24 hr tablet,extended HUMULIN R U-500 (CONCENTRATED) release ...... 11 INSULIN 500 UNIT/ML metformin er 1,000 mg tablet,extended SUBCUTANEOUS SOLN ...... 9, 10 release 24hr ...... 11 I metformin er 500 mg 24 hr tablet,extended ibandronate 150 mg tablet ...... 4 release ...... 11 J metformin er 500 mg tablet,extended release JANUMET 50 MG-1,000 MG TABLET ... 6 24 hr ...... 11 JANUMET 50 MG-500 MG TABLET ...... 6 metformin er 500 mg tablet,extended release JANUMET XR 100 MG-1,000 MG 24hr ...... 11 TABLET,EXTENDED RELEASE ...... 6

19 metformin er 750 mg tablet,extended release NOVOLOG U-100 INSULIN ASPART 100 24 hr ...... 11 UNIT/ML SUBCUTANEOUS mirtazapine 15 mg disintegrating tablet . 1, 2, SOLUTION...... 10 13, 14 O mirtazapine 15 mg tablet ...... 1, 2, 13, 14 ONGLYZA 2.5 MG TABLET ...... 6 mirtazapine 30 mg disintegrating tablet . 1, 2, ONGLYZA 5 MG TABLET ...... 6 13, 14 P mirtazapine 30 mg tablet ...... 1, 2, 13, 14 paroxetine 10 mg tablet ...... 1, 2, 13, 14 mirtazapine 45 mg disintegrating tablet . 1, 2, paroxetine 20 mg tablet ...... 1, 2, 13, 14 13, 14 paroxetine 30 mg tablet ...... 1, 2, 13, 14 mirtazapine 45 mg tablet ...... 1, 2, 13, 14 paroxetine 40 mg tablet ...... 1, 2, 13, 14 mirtazapine 7.5 mg tablet ...... 1, 2, 13, 14 paroxetine er 12.5 mg tablet,extended N release 24 hr ...... 1, 2, 13, 14 naratriptan 1 mg tablet ...... 15 paroxetine er 25 mg tablet,extended release naratriptan 2.5 mg tablet ...... 15 24 hr ...... 1, 2, 13, 14 NOVOLIN 70/30 U-100 INSULIN 100 paroxetine er 37.5 mg tablet,extended UNIT/ML SUBCUTANEOUS release 24 hr ...... 1, 2, 13, 14 SUSPENSION ...... 9, 10 PAXIL 10 MG/5 ML ORAL SUSPENSION NOVOLIN 70-30 FLEXPEN U-100 ...... 2 INSULIN 100 UNIT/ML (70-30) PENTASA 250 MG SUBCUTANEOUS...... 9, 10 CAPSULE,CONTROLLED RELEASE. 5 NOVOLIN N FLEXPEN 100 UNIT/ML (3 PENTASA 500 MG ML) SUBCUTANEOUS INSULIN PEN CAPSULE,CONTROLLED RELEASE. 5 ...... 9, 10 pilocarpine 1 % eye drops ...... 8 NOVOLIN N NPH U-100 INSULIN pilocarpine 2 % eye drops ...... 8 ISOPHANE 100 UNIT/ML pilocarpine 4 % eye drops ...... 8 SUBCUTANEOUS SUSP ...... 9, 10 Q NOVOLIN R FLEXPEN 100 UNIT/ML (3 QVAR REDIHALER 40 ML) SUBCUTANEOUS INSULIN PEN MCG/ACTUATION HFA BREATH ...... 9, 10 ACTIVATED AEROSOL ...... 3 NOVOLIN R REGULAR U-100 INSULIN QVAR REDIHALER 80 100 UNIT/ML INJECTION SOLUTION MCG/ACTUATION HFA BREATH ...... 9, 10 ACTIVATED AEROSOL ...... 3 NOVOLOG FLEXPEN U-100 INSULIN R ASPART 100 UNIT/ML (3 ML) RHOPRESSA 0.02 % EYE DROPS ...... 8 SUBCUTANEOUS...... 9, 10 risedronate 150 mg tablet ...... 4 NOVOLOG MIX 70-30 FLEXPEN U-100 risedronate 30 mg tablet ...... 4 INSULIN 100 UNIT/ML risedronate 35 mg tablet ...... 4 SUBCUTANEOUS PEN ...... 9, 10 risedronate 35 mg tablet (12 pack) ...... 4 NOVOLOG MIX 70-30 U-100 INSULIN risedronate 35 mg tablet (4 pack) ...... 4 100 UNIT/ML SUBCUTANEOUS risedronate 35 mg tablet,delayed release .... 4 SOLUTION...... 9, 10 risedronate 5 mg tablet ...... 4 NOVOLOG PENFILL U-100 INSULIN rizatriptan 10 mg disintegrating tablet ...... 15 ASPART 100 UNIT/ML rizatriptan 10 mg tablet ...... 15 SUBCUTANEOUS CARTRIDG ..... 9, 10 rizatriptan 5 mg disintegrating tablet ...... 15 rizatriptan 5 mg tablet ...... 15

20 ROCKLATAN 0.02 %-0.005 % EYE timolol maleate 0.5 % once daily eye drops 8 DROPS ...... 8 TRADJENTA 5 MG TABLET ...... 6 RYTARY 23.75 MG-95 MG TRAVATAN Z 0.004 % EYE DROPS ...... 8 CAPSULE,EXTENDED RELEASE .... 12 travoprost 0.004 % eye drops...... 8 RYTARY 36.25 MG-145 MG trazodone 100 mg tablet ...... 1, 2, 13, 14 CAPSULE,EXTENDED RELEASE .... 12 trazodone 150 mg tablet ...... 1, 2, 13, 14 RYTARY 48.75 MG-195 MG trazodone 300 mg tablet ...... 1, 2, 13, 14 CAPSULE,EXTENDED RELEASE .... 12 trazodone 50 mg tablet ...... 1, 2, 13, 14 RYTARY 61.25 MG-245 MG TRINTELLIX 10 MG TABLET ...... 14 CAPSULE,EXTENDED RELEASE .... 12 TRINTELLIX 20 MG TABLET ...... 14 S TRINTELLIX 5 MG TABLET ...... 14 sertraline 100 mg tablet ...... 1, 2, 13, 14 V sertraline 20 mg/ml oral concentrate 1, 2, 13, venlafaxine 100 mg tablet ...... 1, 2, 13, 14 14 venlafaxine 25 mg tablet ...... 1, 2, 13, 14 sertraline 25 mg tablet ...... 1, 2, 13, 14 venlafaxine 37.5 mg tablet ...... 1, 2, 13, 14 sertraline 50 mg tablet ...... 1, 2, 13, 14 venlafaxine 50 mg tablet ...... 1, 2, 13, 14 sulfasalazine 500 mg tablet ...... 5 venlafaxine 75 mg tablet ...... 1, 2, 13, 14 sulfasalazine 500 mg tablet,delayed release 5 venlafaxine er 150 mg capsule,extended sumatriptan 100 mg tablet ...... 15 release 24 hr ...... 1, 2, 13, 14 sumatriptan 20 mg/actuation nasal spray .. 15 venlafaxine er 150 mg tablet,extended sumatriptan 25 mg tablet ...... 15 release 24 hr ...... 1, 2, 13, 14 sumatriptan 4 mg/0.5 ml subcutaneous venlafaxine er 225 mg tablet,extended cartridge (refill) ...... 15 release 24 hr ...... 2, 13, 14 sumatriptan 4 mg/0.5 ml subcutaneous pen venlafaxine er 37.5 mg capsule,extended injector ...... 15 release 24 hr ...... 2, 13, 14 sumatriptan 5 mg/actuation nasal spray .... 15 venlafaxine er 37.5 mg tablet,extended sumatriptan 50 mg tablet ...... 15 release 24 hr ...... 2, 14 sumatriptan 6 mg/0.5 ml subcutaneous venlafaxine er 75 mg capsule,extended cartridge (refill) ...... 15 release 24 hr ...... 2, 14 sumatriptan 6 mg/0.5 ml subcutaneous pen venlafaxine er 75 mg tablet,extended release injector ...... 15 24 hr ...... 2, 14 sumatriptan 6 mg/0.5 ml subcutaneous VIIBRYD 10 MG (7)-20 MG (23) solution ...... 15 TABLETS IN A DOSE PACK ...... 2 T VIIBRYD 10 MG TABLET ...... 2 timolol maleate 0.25 % eye drops ...... 8 VIIBRYD 20 MG TABLET ...... 2 timolol maleate 0.25 % eye gel forming VIIBRYD 40 MG TABLET ...... 2 solution ...... 8 X timolol maleate 0.5 % eye drops ...... 8 XHANCE 93 MCG/ACTUATION timolol maleate 0.5 % eye gel forming BREATH ACTIVATED AEROSOL ... 16 solution ...... 8