2017 step therapy (st) criteria - emblemhealth/media/files/pdf/medicare/2017... · 2017 step...

2017 Step Therapy (ST) Criteria

Some drugs require step therapy pre-approval. This means that your doctor must have you first try a different drug to treat your medical condition before we will cover a drug that needs step therapy pre-approval.

Below you will find a table of drugs that require step therapy pre-approval. If you find your drug on this list, talk to your doctor about what other drugs you could try first.

To see if your drug is on the list, refer to the index located at the end of this document for the medication you are looking for.

Updated: 11`/2017 Y0026_124333 Approved 1/12/2014

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the

EmblemHealth companies

1

ANTIDIABETICS

Products Affected

Step 1:

metformin 1,000 mg tablet

metformin 500 mg tablet metformin 850 mg tablet metformin ER 1,000 mg 24 hr

tablet,extended release metformin ER 1,000 mg tablet,extended

release 24hr metformin ER 500 mg 24 hr

tablet,extended release

metformin ER 500 mg tablet,extended

release 24 hr metformin ER 500 mg tablet,extended

release 24hr

metformin ER 750 mg tablet,extended release 24 hr

pioglitazone 15 mg-metformin 500 mg tablet

pioglitazone 15 mg-metformin 850 mg

tablet

Step 2:

Actoplus Met XR 15 mg-1,000 mg tablet,extended release

Actoplus Met XR 30 mg-1,000 mg tablet,extended release

Cycloset 0.8 mg tablet

Details

Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of generic Metformin containing product, then the

member has met the criteria for coverage of Cycloset and/or ACTOPLUS MET XR at the applicable copayment/coinsurance.




2

BRAND ARB

Products Affected

Step 1:

amlodipine 10 mg-valsartan 160 mg tablet amlodipine 10 mg-valsartan 160 mg-

hydrochlorothiazide 12.5 mg tablet

amlodipine 10 mg-valsartan 160 mg-hydrochlorothiazide 25 mg tablet


hydrochlorothiazide 25 mg tablet


hydrochlorothiazide 12.5 mg tablet amlodipine 5 mg-valsartan 160 mg-

hydrochlorothiazide 25 mg tablet

amlodipine 5 mg-valsartan 320 mg tablet candesartan 16 mg tablet

candesartan 16 mg-hydrochlorothiazide 12.5 mg tablet

candesartan 32 mg tablet

candesartan 32 mg-hydrochlorothiazide 12.5 mg tablet

candesartan 32 mg-hydrochlorothiazide 25

mg tablet candesartan 4 mg tablet

candesartan 8 mg tablet irbesartan 150 mg tablet irbesartan 150 mg-hydrochlorothiazide

12.5 mg tablet irbesartan 300 mg tablet

irbesartan 300 mg-hydrochlorothiazide 12.5 mg tablet

irbesartan 75 mg tablet

losartan 100 mg tablet

losartan 100 mg-hydrochlorothiazide 12.5 mg tablet

losartan 100 mg-hydrochlorothiazide 25

mg tablet losartan 25 mg tablet

losartan 50 mg tablet losartan 50 mg-hydrochlorothiazide 12.5

mg tablet

telmisartan 20 mg tablet telmisartan 40 mg tablet

telmisartan 40 mg-hydrochlorothiazide 12.5 mg tablet

telmisartan 80 mg tablet

telmisartan 80 mg-hydrochlorothiazide 12.5 mg tablet

telmisartan 80 mg-hydrochlorothiazide 25 mg tablet

valsartan 160 mg tablet

valsartan 160 mg-hydrochlorothiazide 12.5 mg tablet

valsartan 160 mg-hydrochlorothiazide 25

mg tablet valsartan 320 mg tablet

valsartan 320 mg-hydrochlorothiazide 12.5 mg tablet


mg tablet valsartan 40 mg tablet

valsartan 80 mg tablet valsartan 80 mg-hydrochlorothiazide 12.5

mg tablet

Step 2:




3

Benicar 20 mg tablet Benicar 40 mg tablet

Benicar 5 mg tablet

Benicar HCT 20 mg-12.5 mg tablet Benicar HCT 40 mg-12.5 mg tablet

Benicar HCT 40 mg-25 mg tablet

Details

Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has

had previous history of one step one agent then the member has met the criteria for coverage of step 2 agent at the applicable

copayment/coinsurance




4

BRAND STATIN

Products Affected

Step 1:

amlodipine 10 mg-atorvastatin 10 mg tablet

amlodipine 10 mg-atorvastatin 20 mg

tablet amlodipine 10 mg-atorvastatin 40 mg

tablet amlodipine 10 mg-atorvastatin 80 mg

tablet

amlodipine 2.5 mg-atorvastatin 10 mg tablet




amlodipine 5 mg-atorvastatin 20 mg tablet amlodipine 5 mg-atorvastatin 40 mg tablet

amlodipine 5 mg-atorvastatin 80 mg tablet atorvastatin 10 mg tablet atorvastatin 20 mg tablet

atorvastatin 40 mg tablet atorvastatin 80 mg tablet

Step 2:

Crestor 10 mg tablet



Crestor 5 mg tablet

Details


had previous history of one step one agent then the member has met the criteria for coverage of step 2 agent at the applicable copayment/coinsurance




5

COREG CR

Products Affected

Step 1:

carvedilol 12.5 mg tablet carvedilol 25 mg tablet

carvedilol 3.125 mg tablet carvedilol 6.25 mg tablet

Step 2:

Coreg CR 10 mg capsule, extended release




Details


had previous history of generic Carvedilol, then the member has met the criteria for coverage of Brand Coreg CR at the applicable copayment/coinsurance.




6

ELIDEL

Products Affected

Step 1:

alclometasone 0.05 % topical cream alclometasone 0.05 % topical ointment amcinonide 0.1 % lotion

amcinonide 0.1 % topical cream amcinonide 0.1 % topical ointment

betamethasone dipropionate 0.05 % lotion betamethasone dipropionate 0.05 %

topical cream

betamethasone dipropionate 0.05 % topical ointment

betamethasone valerate 0.1 % lotion betamethasone valerate 0.1 % topical

cream

betamethasone valerate 0.1 % topical ointment

betamethasone valerate 0.12 % topical foam

betamethasone, augmented 0.05 % lotion

betamethasone, augmented 0.05 % topical cream

betamethasone, augmented 0.05 % topical

gel betamethasone, augmented 0.05 % topical

ointment clobetasol 0.05 % lotion clobetasol 0.05 % scalp solution

clobetasol 0.05 % shampoo clobetasol 0.05 % topical foam

clobetasol 0.05 % topical gel clobetasol 0.05 % topical ointment clobetasol-emollient 0.05 % topical cream

desonide 0.05 % lotion desonide 0.05 % topical cream

desonide 0.05 % topical ointment desoximetasone 0.05 % topical cream desoximetasone 0.05 % topical gel

desoximetasone 0.05 % topical ointment desoximetasone 0.25 % topical cream

desoximetasone 0.25 % topical ointment diflorasone 0.05 % topical cream diflorasone 0.05 % topical ointment

fluocinolone 0.01 % topical body oil fluocinolone 0.01 % topical cream

fluocinolone 0.01 % topical solution fluocinolone 0.025 % topical cream fluocinolone 0.025 % topical ointment

fluocinonide 0.05 % topical cream fluocinonide 0.05 % topical gel

fluocinonide 0.05 % topical ointment fluocinonide 0.05 % topical solution fluocinonide 0.1 % topical cream

Fluocinonide-E 0.05% topical cream fluticasone 0.005 % topical ointment fluticasone 0.05 % lotion

fluticasone 0.05 % topical cream halobetasol propionate 0.05 % topical

cream halobetasol propionate 0.05 % topical

ointment

hydrocortisone 1 % topical cream hydrocortisone 1 % topical ointment

hydrocortisone 2.5 % lotion hydrocortisone 2.5 % topical cream hydrocortisone 2.5 % topical ointment

hydrocortisone butyrate 0.1 % topical ointment




7

hydrocortisone butyrate 0.1 % topical solution

hydrocortisone butyrate-emollient 0.1 % topical cream

hydrocortisone valerate 0.2 % topical cream

hydrocortisone valerate 0.2 % topical

ointment mometasone 0.1 % topical cream

mometasone 0.1 % topical ointment mometasone 0.1 % topical solution prednicarbate 0.1 % topical cream

prednicarbate 0.1 % topical ointment triamcinolone acetonide 0.025 % lotion

triamcinolone acetonide 0.025 % topical cream

triamcinolone acetonide 0.025 % topical ointment

triamcinolone acetonide 0.1 % lotion triamcinolone acetonide 0.1 % topical

cream

triamcinolone acetonide 0.1 % topical ointment

triamcinolone acetonide 0.5 % topical cream

triamcinolone acetonide 0.5 % topical

ointment Triderm 0.1 % topical cream

Step 2: Elidel 1 % topical cream

Details

Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of one topical generic Corticosteroid, then the

member has met the criteria for coverage of Elidel at the applicable copayment/coinsurance.




8

GLYBURIDE

Products Affected

Step 1:

glimepiride 1 mg tablet glimepiride 2 mg tablet glimepiride 4 mg tablet

glipizide 10 mg tablet glipizide 2.5 mg-metformin 250 mg tablet

glipizide 2.5 mg-metformin 500 mg tablet glipizide 5 mg tablet glipizide 5 mg-metformin 500 mg tablet

glipizide ER 10 mg tablet, extended release 24 hr

glipizide ER 2.5 mg tablet, extended release 24 hr

glipizide ER 5 mg tablet, extended release

24 hr pioglitazone 30 mg-glimepiride 2 mg

tablet pioglitazone 30 mg-glimepiride 4 mg

tablet

Step 2: glyburide 1.25 mg tablet

glyburide 1.25 mg-metformin 250 mg tablet

glyburide 2.5 mg tablet glyburide 2.5 mg-metformin 500 mg tablet

glyburide 5 mg tablet

glyburide 5 mg-metformin 500 mg tablet glyburide micronized 1.5 mg tablet

glyburide micronized 3 mg tablet glyburide micronized 6 mg tablet

Details

Criteria As per the protocol, the member's electronic medication profile will be

reviewed over the prior 90 days. If the profile shows that the member has had previous history of one step one agent then the member has met the criteria for coverage of step 2 agent at the applicable





9

IMMUNOMODULATORS

Products Affected

Step 1:

Humira 10 mg/0.2 mL subcutaneous syringe kit

Humira 20 mg/0.4 mL subcutaneous

syringe kit Humira 40 mg/0.8 mL subcutaneous

syringe kit Humira Pediatric Crohn's Starter 40

mg/0.8 mL subcutaneous syringe kit

Humira Pediatric Crohn's Starter 40 mg/0.8 mL subcutaneous syringe kit (6 pack)

Humira Pen 40 mg/0.8 mL subcutaneous Humira Pen Crohn's-Ulc Colitis-Hid Sup

Starter 40 mg/0.8 mL subcut kit Humira Pen Psoriasis-Uveitis Starter 40

mg/0.8 mL subcutaneous kit

Step 2:

Actemra 200 mg/10 mL (20 mg/mL) intravenous solution

Actemra 400 mg/20 mL (20 mg/mL)

intravenous solution Actemra 80 mg/4 mL (20 mg/mL)

intravenous solution

Cimzia 400 mg/2 mL (200 mg/mL x 2) subcutaneous syringe kit

Cimzia Powder for Recon 400 mg (200

mg x 2 vials) subcutaneous kit Xeljanz 5 mg tablet

Xeljanz XR 11 mg tablet,extended release

Details


had previous history of Humira, then the member has met the criteria for coverage of Actemra, Xeljanz, Xeljanz XR or Cimzia at the applicable copayment/coinsurance.




10

NASAL STEROID

Products Affected

Step 1:

budesonide 32 mcg/actuation nasal spray flunisolide 25 mcg (0.025 %) nasal spray

fluticasone 50 mcg/actuation nasal spray,suspension

mometasone 50 mcg/actuation nasal spray

Step 2:

Nasonex 50 mcg/actuation Spray

Details

Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of one step one agent then the member has met the

criteria for coverage of step 2 agent at the applicable copayment/coinsurance




11

OPHTHALMIC ANTIHISTAMINES

Products Affected

Step 1:

epinastine 0.05 % eye drops Lastacaft 0.25 % eye drops olopatadine 0.1 % eye drops

olopatadine 0.2 % eye drops Pazeo 0.7 % eye drops

Step 2:

Pataday 0.2 % eye drops

Details

Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of generic ophthalmic antihistamine, Lastacaft

solution, or Pazeo then the member has met the criteria for coverage of Pataday solution at the applicable copayment/coinsurance.




12

OVERACTIVE BLADDER

Products Affected

Step 1:

darifenacin ER 15 mg tablet,extended release 24 hr

darifenacin ER 7.5 mg tablet,extended

release 24 hr oxybutynin chloride 5 mg tablet

oxybutynin chloride 5 mg/5 mL syrup oxybutynin chloride ER 10 mg

tablet,extended release 24 hr

oxybutynin chloride ER 15 mg tablet,extended release 24 hr

oxybutynin chloride ER 5 mg tablet,extended release 24 hr

tolterodine 1 mg tablet

tolterodine 2 mg tablet tolterodine ER 2 mg capsule,extended

release 24 hr tolterodine ER 4 mg capsule,extended

release 24 hr

trospium 20 mg tablet trospium ER 60 mg capsule,extended

release 24 hr

Step 2:

Enablex 15 mg tablet,extended release Enablex 7.5 mg tablet,extended release

Gelnique 10 % (100 mg/gram) transdermal gel packet

Details







13

VOLTAREN GEL

Products Affected

Step 1:

celecoxib 100 mg capsule celecoxib 200 mg capsule celecoxib 400 mg capsule

celecoxib 50 mg capsule diclofenac 1 % topical gel

diclofenac 50 mg-misoprostol 200 mcg tablet,immed.and delayed release

diclofenac 75 mg-misoprostol 200 mcg

tablet,immediate,delayed release diclofenac ER 100 mg tablet,extended

release 24 hr diclofenac potassium 50 mg tablet diclofenac sodium 25 mg tablet,delayed

release diclofenac sodium 50 mg tablet,delayed

release diclofenac sodium 75 mg tablet,delayed

release

diflunisal 500 mg tablet etodolac 200 mg capsule etodolac 300 mg capsule

etodolac 400 mg tablet etodolac 500 mg tablet

etodolac ER 400 mg tablet,extended release 24 hr

etodolac ER 500 mg tablet,extended

release 24 hr etodolac ER 600 mg tablet,extended

release 24 hr fenoprofen 600 mg tablet flurbiprofen 100 mg tablet

flurbiprofen 50 mg tablet ibuprofen 100 mg/5 mL oral suspension

ibuprofen 400 mg tablet ibuprofen 600 mg tablet ibuprofen 800 mg tablet

ketoprofen 50 mg capsule ketoprofen 75 mg capsule

ketoprofen ER 200 mg 24 hr capsule,extended release

meclofenamate 100 mg capsule

meclofenamate 50 mg capsule mefenamic acid 250 mg capsule

meloxicam 15 mg tablet meloxicam 7.5 mg tablet nabumetone 500 mg tablet

nabumetone 750 mg tablet Naprelan CR 750 mg tab,extended release

24 hr mphase naproxen 125 mg/5 mL oral suspension naproxen 250 mg tablet

naproxen 375 mg tablet naproxen 375 mg tablet,delayed release naproxen 500 mg tablet

naproxen 500 mg tablet,delayed release naproxen sodium 275 mg tablet

naproxen sodium 550 mg tablet naproxen sodium ER 375 mg

tablet,extended release 24hr mphase

oxaprozin 600 mg tablet piroxicam 10 mg capsule

piroxicam 20 mg capsule sulindac 150 mg tablet sulindac 200 mg tablet

tolmetin 400 mg capsule tolmetin 600 mg tablet




14

Step 2:

Voltaren 1 % topical gel

Details







15

Index

A Actemra 200 mg/10 mL (20 mg/mL)

intravenous solution ................................ 9 Actemra 400 mg/20 mL (20 mg/mL)

intravenous solution ................................ 9

Actemra 80 mg/4 mL (20 mg/mL) intravenous solution ................................ 9

Actoplus Met XR 15 mg-1,000 mg tablet,extended release ............................ 1

Actoplus Met XR 30 mg-1,000 mg

tablet,extended release ............................ 1 alclometasone 0.05 % topical cream....... 6, 7

alclometasone 0.05 % topical ointment .. 6, 7 amcinonide 0.1 % lotion ......................... 6, 7 amcinonide 0.1 % topical cream ............. 6, 7

amcinonide 0.1 % topical ointment ........ 6, 7 amlodipine 10 mg-atorvastatin 10 mg tablet

................................................................. 4 amlodipine 10 mg-atorvastatin 20 mg tablet

................................................................. 4

amlodipine 10 mg-atorvastatin 40 mg tablet................................................................. 4


................................................................. 4 amlodipine 10 mg-valsartan 160 mg tablet 2,

3 amlodipine 10 mg-valsartan 160 mg-

hydrochlorothiazide 12.5 mg tablet .... 2, 3

amlodipine 10 mg-valsartan 160 mg-hydrochlorothiazide 25 mg tablet ....... 2, 3

amlodipine 10 mg-valsartan 320 mg tablet 2, 3

amlodipine 10 mg-valsartan 320 mg-

hydrochlorothiazide 25 mg tablet ....... 2, 3 amlodipine 2.5 mg-atorvastatin 10 mg tablet

................................................................. 4 amlodipine 2.5 mg-atorvastatin 20 mg tablet

................................................................. 4

amlodipine 2.5 mg-atorvastatin 40 mg tablet................................................................. 4

amlodipine 5 mg-atorvastatin 10 mg tablet 4 amlodipine 5 mg-atorvastatin 20 mg tablet 4 amlodipine 5 mg-atorvastatin 40 mg tablet 4

amlodipine 5 mg-atorvastatin 80 mg tablet 4 amlodipine 5 mg-valsartan 160 mg tablet2, 3

amlodipine 5 mg-valsartan 160 mg-hydrochlorothiazide 12.5 mg tablet .... 2, 3

amlodipine 5 mg-valsartan 160 mg-

hydrochlorothiazide 25 mg tablet ....... 2, 3 amlodipine 5 mg-valsartan 320 mg tablet2, 3

atorvastatin 10 mg tablet ............................. 4 atorvastatin 20 mg tablet ............................. 4 atorvastatin 40 mg tablet ............................. 4

atorvastatin 80 mg tablet ............................. 4 B Benicar 20 mg tablet ............................... 2, 3 Benicar 40 mg tablet ............................... 2, 3 Benicar 5 mg tablet ................................. 2, 3

Benicar HCT 20 mg-12.5 mg tablet........ 2, 3 Benicar HCT 40 mg-12.5 mg tablet........ 2, 3 Benicar HCT 40 mg-25 mg tablet........... 2, 3

betamethasone dipropionate 0.05 % lotion 6, 7

betamethasone dipropionate 0.05 % topical cream ................................................... 6, 7

betamethasone dipropionate 0.05 % topical

ointment .............................................. 6, 7 betamethasone valerate 0.1 % lotion....... 6, 7

betamethasone valerate 0.1 % topical cream............................................................. 6, 7

betamethasone valerate 0.1 % topical

ointment .............................................. 6, 7 betamethasone valerate 0.12 % topical foam

............................................................. 6, 7 betamethasone, augmented 0.05 % lotion6, 7




16

betamethasone, augmented 0.05 % topical cream ................................................... 6, 7

betamethasone, augmented 0.05 % topical gel........................................................ 6, 7

betamethasone, augmented 0.05 % topical ointment .............................................. 6, 7

budesonide 32 mcg/actuation nasal spray . 10

C candesartan 16 mg tablet......................... 2, 3

candesartan 16 mg-hydrochlorothiazide 12.5 mg tablet.............................................. 2, 3

candesartan 32 mg tablet......................... 2, 3

candesartan 32 mg-hydrochlorothiazide 12.5 mg tablet.............................................. 2, 3

candesartan 32 mg-hydrochlorothiazide 25 mg tablet.............................................. 2, 3

candesartan 4 mg tablet........................... 2, 3

candesartan 8 mg tablet........................... 2, 3 carvedilol 12.5 mg tablet............................. 5

carvedilol 25 mg tablet................................ 5 carvedilol 3.125 mg tablet........................... 5 carvedilol 6.25 mg tablet............................. 5

celecoxib 100 mg capsule ................... 13, 14 celecoxib 200 mg capsule ................... 13, 14

celecoxib 400 mg capsule ................... 13, 14 celecoxib 50 mg capsule ..................... 13, 14 Cimzia 400 mg/2 mL (200 mg/mL x 2)

subcutaneous syringe kit ......................... 9 Cimzia Powder for Recon 400 mg (200 mg

x 2 vials) subcutaneous kit ...................... 9 clobetasol 0.05 % lotion.......................... 6, 7 clobetasol 0.05 % scalp solution ............. 6, 7

clobetasol 0.05 % shampoo..................... 6, 7 clobetasol 0.05 % topical foam ............... 6, 7

clobetasol 0.05 % topical gel .................. 6, 7 clobetasol 0.05 % topical ointment ......... 6, 7 clobetasol-emollient 0.05 % topical cream 6,

7 Coreg CR 10 mg capsule, extended release 5

Coreg CR 20 mg capsule, extended release 5 Coreg CR 40 mg capsule, extended release 5

Coreg CR 80 mg capsule, extended release 5 Crestor 10 mg tablet .................................... 4

Crestor 20 mg tablet .................................... 4 Crestor 40 mg tablet .................................... 4 Crestor 5 mg tablet ...................................... 4

Cycloset 0.8 mg tablet................................. 1 D darifenacin ER 15 mg tablet,extended

release 24 hr .......................................... 12 darifenacin ER 7.5 mg tablet,extended

release 24 hr .......................................... 12 desonide 0.05 % lotion............................ 6, 7

desonide 0.05 % topical cream ............... 6, 7 desonide 0.05 % topical ointment ........... 6, 7 desoximetasone 0.05 % topical cream .... 6, 7

desoximetasone 0.05 % topical gel ......... 6, 7 desoximetasone 0.05 % topical ointment 6, 7

desoximetasone 0.25 % topical cream .... 6, 7 desoximetasone 0.25 % topical ointment 6, 7 diclofenac 1 % topical gel ................... 13, 14

diclofenac 50 mg-misoprostol 200 mcg tablet,immed.and delayed release ... 13, 14

diclofenac 75 mg-misoprostol 200 mcg tablet,immediate,delayed release .... 13, 14

diclofenac ER 100 mg tablet,extended

release 24 hr .................................... 13, 14 diclofenac potassium 50 mg tablet...... 13, 14

diclofenac sodium 25 mg tablet,delayed release.............................................. 13, 14

diclofenac sodium 50 mg tablet,delayed

release.............................................. 13, 14 diclofenac sodium 75 mg tablet,delayed

release.............................................. 13, 14 diflorasone 0.05 % topical cream............ 6, 7 diflorasone 0.05 % topical ointment ....... 6, 7

diflunisal 500 mg tablet....................... 13, 14




17

E Elidel 1 % topical cream ......................... 6, 7

Enablex 15 mg tablet,extended release ..... 12 Enablex 7.5 mg tablet,extended release .... 12

epinastine 0.05 % eye drops...................... 11 etodolac 200 mg capsule ..................... 13, 14 etodolac 300 mg capsule ..................... 13, 14

etodolac 400 mg tablet ........................ 13, 14 etodolac 500 mg tablet ........................ 13, 14

etodolac ER 400 mg tablet,extended release 24 hr ................................................ 13, 14

etodolac ER 500 mg tablet,extended release

24 hr ................................................ 13, 14 etodolac ER 600 mg tablet,extended release

24 hr ................................................ 13, 14 F fenoprofen 600 mg tablet .................... 13, 14

flunisolide 25 mcg (0.025 %) nasal spray. 10 fluocinolone 0.01 % topical body oil ...... 6, 7

fluocinolone 0.01 % topical cream ......... 6, 7 fluocinolone 0.01 % topical solution ...... 6, 7 fluocinolone 0.025 % topical cream ....... 6, 7

fluocinolone 0.025 % topical ointment ... 6, 7 fluocinonide 0.05 % topical cream ......... 6, 7

fluocinonide 0.05 % topical gel .............. 6, 7 fluocinonide 0.05 % topical ointment ..... 6, 7 fluocinonide 0.05 % topical solution ...... 6, 7

fluocinonide 0.1 % topical cream ........... 6, 7 Fluocinonide-E 0.05% topical cream...... 6, 7

flurbiprofen 100 mg tablet .................. 13, 14 flurbiprofen 50 mg tablet .................... 13, 14 fluticasone 0.005 % topical ointment...... 6, 7

fluticasone 0.05 % lotion ........................ 6, 7 fluticasone 0.05 % topical cream ............ 6, 7

fluticasone 50 mcg/actuation nasal spray,suspension ................................... 10

G Gelnique 10 % (100 mg/gram) transdermal

gel packet .............................................. 12

glimepiride 1 mg tablet ............................... 8 glimepiride 2 mg tablet ............................... 8

glimepiride 4 mg tablet ............................... 8 glipizide 10 mg tablet.................................. 8

glipizide 2.5 mg-metformin 250 mg tablet . 8 glipizide 2.5 mg-metformin 500 mg tablet . 8 glipizide 5 mg tablet.................................... 8

glipizide 5 mg-metformin 500 mg tablet .... 8 glipizide ER 10 mg tablet, extended release

24 hr ........................................................ 8 glipizide ER 2.5 mg tablet, extended release

24 hr ........................................................ 8

glipizide ER 5 mg tablet, extended release 24 hr ........................................................ 8

glyburide 1.25 mg tablet ............................. 8 glyburide 1.25 mg-metformin 250 mg tablet

................................................................. 8

glyburide 2.5 mg tablet ............................... 8 glyburide 2.5 mg-metformin 500 mg tablet 8

glyburide 5 mg tablet .................................. 8 glyburide 5 mg-metformin 500 mg tablet ... 8 glyburide micronized 1.5 mg tablet ............ 8

glyburide micronized 3 mg tablet ............... 8 glyburide micronized 6 mg tablet ............... 8

H halobetasol propionate 0.05 % topical cream

............................................................. 6, 7

halobetasol propionate 0.05 % topical ointment .............................................. 6, 7

Humira 10 mg/0.2 mL subcutaneous syringe kit ............................................................ 9

Humira 20 mg/0.4 mL subcutaneous syringe

kit ............................................................ 9 Humira 40 mg/0.8 mL subcutaneous syringe

kit ............................................................ 9 Humira Pediatric Crohn's Starter 40 mg/0.8

mL subcutaneous syringe kit .................. 9

Humira Pediatric Crohn's Starter 40 mg/0.8 mL subcutaneous syringe kit (6 pack) .... 9




18

Humira Pen 40 mg/0.8 mL subcutaneous ... 9 Humira Pen Crohn's-Ulc Colitis-Hid Sup

Starter 40 mg/0.8 mL subcut kit ............. 9 Humira Pen Psoriasis-Uveitis Starter 40

mg/0.8 mL subcutaneous kit ................... 9 hydrocortisone 1 % topical cream........... 6, 7 hydrocortisone 1 % topical ointment ...... 6, 7

hydrocortisone 2.5 % lotion .................... 6, 7 hydrocortisone 2.5 % topical cream........ 6, 7

hydrocortisone 2.5 % topical ointment ... 6, 7 hydrocortisone butyrate 0.1 % topical

ointment .............................................. 6, 7

hydrocortisone butyrate 0.1 % topical solution................................................ 6, 7

hydrocortisone butyrate-emollient 0.1 % topical cream ....................................... 6, 7

hydrocortisone valerate 0.2 % topical cream

............................................................. 6, 7 hydrocortisone valerate 0.2 % topical

ointment .............................................. 6, 7 I ibuprofen 100 mg/5 mL oral suspension . 13,

14 ibuprofen 400 mg tablet ...................... 13, 14

ibuprofen 600 mg tablet ...................... 13, 14 ibuprofen 800 mg tablet ...................... 13, 14 irbesartan 150 mg tablet .......................... 2, 3

irbesartan 150 mg-hydrochlorothiazide 12.5 mg tablet.............................................. 2, 3

irbesartan 300 mg tablet .......................... 2, 3 irbesartan 300 mg-hydrochlorothiazide 12.5

mg tablet.............................................. 2, 3

irbesartan 75 mg tablet ............................ 2, 3 K ketoprofen 50 mg capsule ................... 13, 14 ketoprofen 75 mg capsule ................... 13, 14 ketoprofen ER 200 mg 24 hr

capsule,extended release ................. 13, 14

L Lastacaft 0.25 % eye drops ....................... 11

losartan 100 mg tablet ............................. 2, 3 losartan 100 mg-hydrochlorothiazide 12.5

mg tablet.............................................. 2, 3 losartan 100 mg-hydrochlorothiazide 25 mg

tablet.................................................... 2, 3

losartan 25 mg tablet ............................... 2, 3 losartan 50 mg tablet ............................... 2, 3

losartan 50 mg-hydrochlorothiazide 12.5 mg tablet.................................................... 2, 3

M meclofenamate 100 mg capsule .......... 13, 14 meclofenamate 50 mg capsule ............ 13, 14

mefenamic acid 250 mg capsule ......... 13, 14 meloxicam 15 mg tablet ...................... 13, 14 meloxicam 7.5 mg tablet ..................... 13, 14

metformin 1,000 mg tablet.......................... 1 metformin 500 mg tablet............................. 1

metformin 850 mg tablet............................. 1 metformin ER 1,000 mg 24 hr

tablet,extended release ............................ 1

metformin ER 1,000 mg tablet,extended release 24hr ............................................. 1

metformin ER 500 mg 24 hr tablet,extended release...................................................... 1

metformin ER 500 mg tablet,extended

release 24 hr ............................................ 1 metformin ER 500 mg tablet,extended

release 24hr ............................................. 1 metformin ER 750 mg tablet,extended

release 24 hr ............................................ 1

mometasone 0.1 % topical cream ........... 6, 7 mometasone 0.1 % topical ointment ....... 6, 7

mometasone 0.1 % topical solution ........ 6, 7 mometasone 50 mcg/actuation nasal spray10 N nabumetone 500 mg tablet .................. 13, 14 nabumetone 750 mg tablet .................. 13, 14




19

Naprelan CR 750 mg tab,extended release 24 hr mphase ................................... 13, 14

naproxen 125 mg/5 mL oral suspension .. 13, 14

naproxen 250 mg tablet....................... 13, 14 naproxen 375 mg tablet....................... 13, 14 naproxen 375 mg tablet,delayed release .. 13,

14 naproxen 500 mg tablet....................... 13, 14

naproxen 500 mg tablet,delayed release .. 13, 14

naproxen sodium 275 mg tablet .......... 13, 14

naproxen sodium 550 mg tablet .......... 13, 14 naproxen sodium ER 375 mg

tablet,extended release 24hr mphase13, 14 Nasonex 50 mcg/actuation Spray.............. 10 O olopatadine 0.1 % eye drops ..................... 11 olopatadine 0.2 % eye drops ..................... 11

oxaprozin 600 mg tablet...................... 13, 14 oxybutynin chloride 5 mg tablet ............... 12 oxybutynin chloride 5 mg/5 mL syrup...... 12

oxybutynin chloride ER 10 mg tablet,extended release 24 hr ................. 12

oxybutynin chloride ER 15 mg tablet,extended release 24 hr ................. 12

oxybutynin chloride ER 5 mg

tablet,extended release 24 hr ................. 12 P Pataday 0.2 % eye drops ........................... 11 Pazeo 0.7 % eye drops .............................. 11 pioglitazone 15 mg-metformin 500 mg

tablet........................................................ 1 pioglitazone 15 mg-metformin 850 mg

tablet........................................................ 1 pioglitazone 30 mg-glimepiride 2 mg tablet8 pioglitazone 30 mg-glimepiride 4 mg tablet8

piroxicam 10 mg capsule .................... 13, 14 piroxicam 20 mg capsule .................... 13, 14

prednicarbate 0.1 % topical cream .......... 6, 7 prednicarbate 0.1 % topical ointment ..... 6, 7

S sulindac 150 mg tablet ........................ 13, 14

sulindac 200 mg tablet ........................ 13, 14 T telmisartan 20 mg tablet .......................... 2, 3

telmisartan 40 mg tablet .......................... 2, 3 telmisartan 40 mg-hydrochlorothiazide 12.5

mg tablet.............................................. 2, 3 telmisartan 80 mg tablet .......................... 2, 3 telmisartan 80 mg-hydrochlorothiazide 12.5

mg tablet.............................................. 2, 3 telmisartan 80 mg-hydrochlorothiazide 25

mg tablet.............................................. 2, 3 tolmetin 400 mg capsule ..................... 13, 14 tolmetin 600 mg tablet ........................ 13, 14

tolterodine 1 mg tablet .............................. 12 tolterodine 2 mg tablet .............................. 12

tolterodine ER 2 mg capsule,extended release 24 hr .......................................... 12

tolterodine ER 4 mg capsule,extended

release 24 hr .......................................... 12 triamcinolone acetonide 0.025 % lotion . 6, 7

triamcinolone acetonide 0.025 % topical cream ................................................... 6, 7


ointment .............................................. 6, 7 triamcinolone acetonide 0.1 % lotion ..... 6, 7

triamcinolone acetonide 0.1 % topical cream............................................................. 6, 7


ointment .............................................. 6, 7 triamcinolone acetonide 0.5 % topical cream

............................................................. 6, 7 triamcinolone acetonide 0.5 % topical

ointment .............................................. 6, 7

Triderm 0.1 % topical cream................... 6, 7 trospium 20 mg tablet ............................... 12




20

trospium ER 60 mg capsule,extended release 24 hr ...................................................... 12

V valsartan 160 mg tablet ........................... 2, 3

valsartan 160 mg-hydrochlorothiazide 12.5 mg tablet.............................................. 2, 3


mg tablet.............................................. 2, 3 valsartan 320 mg tablet ........................... 2, 3


valsartan 320 mg-hydrochlorothiazide 25 mg tablet.............................................. 2, 3

valsartan 40 mg tablet ............................. 2, 3 valsartan 80 mg tablet ............................. 2, 3


Voltaren 1 % topical gel...................... 13, 14

X Xeljanz 5 mg tablet ..................................... 9

Xeljanz XR 11 mg tablet,extended release . 9




21

HIP Health Plan of New York (HIP) is an HMO plan with a Medicare contract. Group Health Incorporated (GHI) is a PPO plan and a standalone PDP with a Medicare contract. Enrollment in

HIP and GHI depends on contract renewal. HIP and GHI are EmblemHealth companies

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

Beneficiaries must use network pharmacies to access their premium and/or copayment/coinsurance may change on January 1, 2018. The formulary and pharmacy network

may change at any time. You will receive notice when necessary. This document includes EmblemHealth Medicare HMO/PPO partial formulary as of

November 1, 2017. For a complete, updated formulary, please visit our Web site at www.emblemhealth.com/medicare or call the Customer Service number below.

ATTENTION: If you speak other languages, language assistance services, free of charge, are

available to you. Call:

EmblemHealth Medicare HMO: 1-877-344-7364, Monday through Sunday, 8 am to 8 pm.

EmblemHealth Medicare PPO: 1-866-557-7300, Monday through Sunday, 8 am to 8 pm.

EmblemHealth Medicare PDP: 1-877-444-7241, Monday through Sunday, 8 am to 8 pm.

TTY/TDD users should call 711.

ATENCIÓN: Si usted habla español, tiene a su disposición, gratis, servicios de ayuda para

idiomas. Llame al:

EmblemHealth Medicare HMO: 1-877-344-7364, De lunes a domingo, 8 am to 8 pm.

EmblemHealth Medicare PPO: 1-866-557-7300, De lunes a domingo, 8 am to 8 pm

EmblemHealth Medicare PDP: 1-877-444-7241, De lunes a domingo, 8 am to 8 pm

Si necesita servicio TTY/TDD ayuda llame al 711

17204 v18

2017 step therapy (st) criteria - emblemhealth/media/files/pdf/medicare/2017... · 2017 step...

Documents