SelectHealth Advantage 2019 Step Therapy Criteria Previous trial on at least ONE: Generic topical acne treatment. Previous trial of Suprep

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Krzysztof Podgórski
4 lat temu
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1 ACNE ADAPAL/BEN P AZELEX DAPSONE TRETINOIN ACTONEL ANTICONVULSANT ANTIDEPRESSION ANTIPSYCHOTIC ASTHMA RISEDRON SOD RISEDRONATE APTIOM OXTELLAR XR SPRITAM FETZIMA KHEDEZLA TRINTELLIX ARISTADA FANAPT LATUDA PALIPERIDONE SAPHRIS ADVAIR HFA BREO ELLIPTA Previous trial on at least ONE: Generic topical acne treatment alendronate carbamezapine, divalproex, epitol, ethosuximide, felbamate, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, tiagabine, topiramate, valproic acid, zonisamide bupropion, citalopram, escitalopram, fluoxetine, fluvoxamine, maprotiline, mirtazapine, paroxetine, sertraline, venlafaxine aripiprazole, clozapine, fluoxetine-olanzapine, haloperidol, olanzapine, quetiapine, risperidone, ziprasidone Previous trial on ONE of the following: 1. Symbicort 2. Fluticasone/Salmeterol BELSOMRA BELSOMRA eszopiclone, zaleplon, zolpidem, zolpidem ER BEVESPI UTIBRON Previous trial on Stiolto or Bevespi BUDESONIDE BUDESONIDE TAB Previous trial of ONE of the following: Apriso, Delzicol, Mesalamine, Pentasa CAPEX CAPEX clobetasol shampoo OR ciclopirox shampoo 1% CLENPIQ CLENPIQ PLENVU Previous trial of Suprep 1

2 CLONIDINE CLONIDINE TAB Previous trial on guanfacine er CORDRAN CORDRAN 80X3 Previous trial on at least ONE: Generic topical steroid CORLANOR CORLANOR acebutolol, atenolol, bisoprolol, labetolol, metoprolol, nadolol, pindolol, propranolol, timolol DEMSER DEMSER phenoxybenzamine DEPRESSION APLENZIN BUPROPION DESVENLAFAX EMSAM FORFIVO XL PEXEVA VIIBRYD bupropion, citalopram, escitalopram, fluoxetine, fluvoxamine, maprotiline, mirtazapine, paroxetine, sertraline, venlafaxine DERM PIMECROLIMUS tacrolimus AND betamethasone, clobetasol, hydrocortisone, triamcinolone 2

3 DIABETES ALOG/PIOGLIT ALOGLIPTIN ALOGLIPTIN/ GLYXAMBI INVOKAMET INVOKAMET XR INVOKANA JARDIANCE JENTADUETO SYNJARDY SYNJARDY XR TRADJENTA TRULICITY VICTOZA Previous trial on metformin OR metformin ER DPPIV KOMBIGLYZ XR ONGLYZA 1. alogliptin 2. alogliptin/metformin 3. alogliptin/pioglitazone AND 1. Glyxambi 2. Jentaduetto 3. Tradjenta EQUETRO EQUETRO CAP carbamezapine er, clozapine, fluoxetine-olanzapine, haloperidol, olanzapine, quetiapine, risperidone, ziprasidone EUCRISA EUCRISA OIN Previous trial of at least ONE of the following: 1. Topical Corticosteroid 2. Topical tacrolimus EURAX EURAX Lindane Shampoo OR Permethrin Cream OR desonide 3

4 EXALGO HYDROMORPHON fentanyl patches, methadone, morphine ER, oxycodone er, oxymorphone ER, Zohydro ER GABAPENTIN GRALISE GRALISE STAR HORIZANT generic gabapentin OR pramipexole GASTRO MESALAMINE Apriso, balsalazide, Pentasa, sulfasalazine GLP1 ADLYXIN BYDUREON BC BYDUREON PEN BYETTA Previous trial on BOTH of the following: 1. Trulicity 2. Victoza ICS ALVESCO PULMICORT QVAR REDIHA QVAR REDIHAL Flovent OR Arnuity AND Asmanex LABA-LAMA ANORO ELLIPT Previous trail on BOTH of the following: 1. Tudorza 2. Bevespi LAMA INCRUSE ELPT SEEBRI NEOHA TUDORZA PRES For Tudorza: Previous trial on Spiriva For Incruse or Seebri: Previous trial on Tudorza LUNESTA ESZOPICLONE NAMENDA OAB MEMANTINE HC NAMENDA XR DARIFENACIN GELNIQUE zolpidem or zaleplon immediate release Memantine oxybutynin, oxybutynin er, tolterodine, tolterodine er, trospium, trospium er 4

5 OXYCONTIN OXYCODONE fentanyl patches, hydromorphone er, methadone, morphine ER, oxymorphone ER, Zohydro ER PICATO PICATO GEL 0.015% PICATO GEL 0.05% 1. Fluorouracil 5% 2. Imiquimod 5% RANEXA RANOLAZINE amlodipine, atenolol, diltiazem, isosorbide dinitrate, isosorbide mononitrate, metoprolol, propranolol, verapamil RAPAFLO SILODOSIN Previous trial of at least TWO of the following: alfuzosin, doxazosin, dutasteride, dutasteride/tamsulosin, finasteride, prazosin, tamsulosin, terazosin RASUVO RASUVO generic methotrexate REXULTI REXULTI Previous therapy on: aripiprazole AND Latuda OR quetiapine ER RYTARY RYTARY carbidopa/levodopa SA OPIOID OXYMORPHONE APAP/codeine, codiene sulfate, hydrocodone/apap, hydrocodone/ibu, hydromorphone, morphine IR, oxycodone, oxycodone/apap, oxycodone/asa, oxycodone/ibu SABA PROAIR RESPI Albuterol inhaler 5

6 SOLIQUA SOLIQUA metformin AND glimepiride, glipizide, tolozamide, nateglinide, repaglinide acarbose, miglitol, alogliptin, Tradjenta, pioglitazone, Steglatro, or insulin STATIN STEGLATRO STIMULANTS LIVALO TAB 1MG LIVALO TAB 2MG LIVALO TAB 4MG SEGLUROMET TAB STEGLATRO TAB DAYTRANA VYVANSE SYMLIN SYMLINPEN 60 SYMLNPEN 120 TEKTURNA ALISKIREN TEKTURNA HCT TIZANIDINE TIZANIDINE CAP 2MG TIZANIDINE CAP 4MG TIZANIDINE CAP 6MG atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin 10 mg, simvastatin Jardiance OR Synjardy AND Invokana OR Invokamet Previous trial on at least ONE: generic long-acting stimulant OR Diagnosis of binge eating disorder insulin benazepril, benazepril-hctz, captopril, captopril-hctz, enalapril, enalapril-hctz, fosinopril, fosinopril-hctz, lisinopril, lisinopril-hctz, quinapril, quinapril-hctz, ramipril AND candesartan, candesartan-hctz, eprosartan, irbesartan, irbesartan-hctz, losartan, losartan-hctz, olmesartan, olmesartan-hctz, telmisartan, telmisartan-hctz, valsartan, valsartan-hctz tizanidine tablets TOVIAZ TOVIAZ Previous trial on Myrbetriq TRIPTAN FROVATRIPTAN sumatriptan OR rizatriptan 6

7 TRULANCE MOTEGRITY Previous trial on Linzess TRULANCE UCERIS FOAM UCERIS colocort enema, hydrocortisone enema, or mesalamine enema ULORIC ULORIC allopurinol VELPHORO AURYXIA VELPHORO sevelamer VRAYLAR VRAYLAR aripiprazole AND clozapine, fluoxetine-olanzapine, haloperidol, olanzapine, quetiapine, risperidone, ziprasidone VYZULTA WELCHOL RHOPRESSA ROCKLATAN VYZULTA COLESEVELAM WELCHOL latanoprost ZELAPAR ZELAPAR selegiline ZOHYDRO XTAMPZA ER ZOHYDRO ER atorvastatin, fluvastatin/er, lovastatin, pravastatin, rosuvastatin, simvastatin AND previous trial on at least ONE of the following: cholestyramine, colestipol fentanyl patches, hydromorphone er, methadone, morphine ER, oxycodone er, oxymorphone ER 7

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