Upload File

align connect (hmo c-snp) medicare part d plan · 2019. 10. 9. · criteria step therapy requires...

  • Home
  • Documents
  • Align Connect (HMO C-SNP) Medicare Part D Plan · 2019. 10. 9. · Criteria Step Therapy requires trial of CREON. Step Therapy Criteria Last Updated 10/09/2019 56 Products Affected
57
Align Connect (HMO C-SNP) Medicare Part D Plan Step Therapy Criteria Last Updated 10/09/2019 1 Products Affected APLENZIN 174MG ER TAB Details Criteria Step Therapy requires trial of generic bupropion SR or generic bupropion XL.

Upload: others

Post on 19-Feb-2021

2 views

Category:

Documents


0 download

Report

TRANSCRIPT

  • Align Connect (HMO C-SNP) Medicare Part D Plan

    Step Therapy Criteria

    Last Updated 10/09/2019

    1

    Products AffectedAPLENZIN 174MG ER TAB

    Details

    Criteria Step Therapy requires trial of generic bupropion SR or generic bupropion XL.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    2

    Products AffectedAPLENZIN 348MG ER TAB

    Details

    Criteria Step Therapy requires trial of generic bupropion SR or generic bupropion XL.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    3

    Products AffectedAPLENZIN 522MG ER TAB

    Details

    Criteria Step Therapy requires trial of generic bupropion SR or generic bupropion XL.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    4

    Products AffectedARANESP 10MCG/0.4ML SYRINGE

    Details

    Criteria Step Therapy requires trial of RETACRIT.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    5

    Products AffectedARANESP 100MCG/ML INJ

    Details

    Criteria Step Therapy requires trial of RETACRIT.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    6

    Products AffectedARANESP 100MCG/0.5ML SYRINGE

    Details

    Criteria Step Therapy requires trial of RETACRIT.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    7

    Products AffectedARANESP 150MCG/0.3ML SYRINGE

    Details

    Criteria Step Therapy requires trial of RETACRIT.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    8

    Products AffectedARANESP 200MCG/ML INJ

    Details

    Criteria Step Therapy requires trial of RETACRIT.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    9

    Products AffectedARANESP 200MCG/0.4ML SYRINGE

    Details

    Criteria Step Therapy requires trial of RETACRIT.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    10

    Products AffectedARANESP 25MCG/ML INJ

    Details

    Criteria Step Therapy requires trial of RETACRIT.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    11

    Products AffectedARANESP 25MCG/0.42ML SYRINGE

    Details

    Criteria Step Therapy requires trial of RETACRIT.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    12

    Products AffectedARANESP 300MCG/ML INJ

    Details

    Criteria Step Therapy requires trial of RETACRIT.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    13

    Products AffectedARANESP 300MCG/0.6ML SYRINGE

    Details

    Criteria Step Therapy requires trial of RETACRIT.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    14

    Products AffectedARANESP 40MCG/ML INJ

    Details

    Criteria Step Therapy requires trial of RETACRIT.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    15

    Products AffectedARANESP 40MCG/0.4ML SYRINGE

    Details

    Criteria Step Therapy requires trial of RETACRIT.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    16

    Products AffectedARANESP 500MCG/ML SYRINGE

    Details

    Criteria Step Therapy requires trial of RETACRIT.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    17

    Products AffectedARANESP 60MCG/ML INJ

    Details

    Criteria Step Therapy requires trial of RETACRIT.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    18

    Products AffectedARANESP 60MCG/0.3ML SYRINGE

    Details

    Criteria Step Therapy requires trial of RETACRIT.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    19

    Products AffectedDIFICID 200MG TAB

    Details

    Criteria Step Therapy requires trial of generic vancomycin capsules.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    20

    Products Affectedduloxetine 40mg dr cap

    Details

    Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine

    or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic

    musculoskeletal pain.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    21

    Products Affectedfebuxostat 40mg tab

    Details

    Criteria Step Therapy requires trial of generic allopurinol.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    22

    Products Affectedfebuxostat 80mg tab

    Details

    Criteria Step Therapy requires trial of generic allopurinol.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    23

    Products AffectedFETZIMA PACK

    Details

    Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine

    or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic

    musculoskeletal pain.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    24

    Products AffectedFETZIMA 120MG ER CAP

    Details

    Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine

    or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic

    musculoskeletal pain.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    25

    Products AffectedFETZIMA 20MG ER CAP

    Details

    Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine

    or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic

    musculoskeletal pain.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    26

    Products AffectedFETZIMA 40MG ER CAP

    Details

    Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine

    or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic

    musculoskeletal pain.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    27

    Products AffectedFETZIMA 80MG ER CAP

    Details

    Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine

    or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic

    musculoskeletal pain.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    28

    Products Affectedfluvoxamine maleate 100mg er cap

    Details

    Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine

    or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic

    musculoskeletal pain.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    29

    Products Affectedfluvoxamine maleate 150mg er cap

    Details

    Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine

    or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic

    musculoskeletal pain.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    30

    Products AffectedLATUDA 120MG TAB

    Details

    Criteria Step Therapy requires trial of generic quetiapine.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    31

    Products AffectedLATUDA 20MG TAB

    Details

    Criteria Step Therapy requires trial of generic quetiapine.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    32

    Products AffectedLATUDA 40MG TAB

    Details

    Criteria Step Therapy requires trial of generic quetiapine.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    33

    Products AffectedLATUDA 60MG TAB

    Details

    Criteria Step Therapy requires trial of generic quetiapine.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    34

    Products AffectedLATUDA 80MG TAB

    Details

    Criteria Step Therapy requires trial of generic quetiapine.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    35

    Products AffectedLEVALBUTEROL 45MCG INH

    Details

    Criteria Step Therapy requires trial of VENTOLIN HFA.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    36

    Products AffectedLONHALA 0.0025% INH SOLN

    Details

    Criteria Step Therapy requires trial of INCRUSE.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    37

    Products AffectedSYMPAZAN 10MG STRIP

    Details

    Criteria Step therapy requires trial of generic clobazam tablets.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    38

    Products AffectedSYMPAZAN 20MG STRIP

    Details

    Criteria Step therapy requires trial of generic clobazam tablets.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    39

    Products AffectedSYMPAZAN 5MG STRIP

    Details

    Criteria Step therapy requires trial of generic clobazam tablets.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    40

    Products AffectedTRINTELLIX 10MG TAB

    Details

    Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine

    or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic

    musculoskeletal pain.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    41

    Products AffectedTRINTELLIX 20MG TAB

    Details

    Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine

    or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic

    musculoskeletal pain.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    42

    Products AffectedTRINTELLIX 5MG TAB

    Details

    Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine

    or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic

    musculoskeletal pain.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    43

    Products AffectedULORIC 40MG TAB

    Details

    Criteria Step Therapy requires trial of generic allopurinol.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    44

    Products AffectedULORIC 80MG TAB

    Details

    Criteria Step Therapy requires trial of generic allopurinol.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    45

    Products AffectedVIIBRYD 10MG TAB

    Details

    Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine

    or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic

    musculoskeletal pain.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    46

    Products AffectedVIIBRYD 10/20MG STARTER PACK

    Details

    Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine

    or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic

    musculoskeletal pain.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    47

    Products AffectedVIIBRYD 20MG TAB

    Details

    Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine

    or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic

    musculoskeletal pain.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    48

    Products AffectedVIIBRYD 40MG TAB

    Details

    Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine

    or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic

    musculoskeletal pain.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    49

    Products AffectedXOPENEX 45MCG INH

    Details

    Criteria Step Therapy requires trial of VENTOLIN HFA.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    50

    Products AffectedZENPEP 10000-32000-42000UNIT DR CAP

    Details

    Criteria Step Therapy requires trial of CREON.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    51

    Products AffectedZENPEP 15000-47000-63000UNIT DR CAP

    Details

    Criteria Step Therapy requires trial of CREON.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    52

    Products AffectedZENPEP 20000-63000-84000UNIT DR CAP

    Details

    Criteria Step Therapy requires trial of CREON.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    53

    Products AffectedZENPEP 25000-79000-105000UNIT DR CAP

    Details

    Criteria Step Therapy requires trial of CREON.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    54

    Products AffectedZENPEP 3000-10000-14000UNIT DR CAP

    Details

    Criteria Step Therapy requires trial of CREON.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    55

    Products AffectedZENPEP 40000-126000-168000UNIT DR CAP

    Details

    Criteria Step Therapy requires trial of CREON.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    56

    Products AffectedZENPEP 5000-17000-24000UNIT DR CAP

    Details

    Criteria Step Therapy requires trial of CREON.

  • Step Therapy Criteria

    Last Updated 10/09/2019

    57

    Products AffectedZIOPTAN 0.0015% OPHTH SOLN

    Details

    Criteria Step Therapy requires trial of generic latanoprost.


STEP THERAPY CRITERIA - fm.formularynavigator.comfm.formularynavigator.com/MemberPages/pdf/CY2018LMHFPDPWrap_12354...STEP THERAPY CRITERIA This list is current as of May 1, 2018 and

Prior Authorization Criteria/Step Therapy – Centennial Care...OB/Gyn Vaginals clotrimazole vaginal OB/Gyn Vaginals miconazole vaginal Miscellaneous Contraceptives condoms, latex

2018 PacificSource Health Plans Step Therapy Criteria · Step 1 Drug(s): finasteride, dutasteride, terazosin Step 2 Drug(s): dutasteride-tamsulosin, Jalyn, Cardura XL, Rapaflo . 11

Select Step Therapy - Prescription Network

2021 STEP THERAPY CRITERIA

Step Therapy - Woodgrain

Actinic Keratosis Agents Step Therapy Guidelines...• Amrix (cyclobenzaprine HCl) ER oral capsule • Cyclobenzaprine ER oral capsule Step Therapy Requirements Step 1 Drug(s): •

Step-by-Step Guide to the Online Performance Management ... › ... › staff_eperformance_training_rev_032817.pdfWhat is the Performance Criteria? • The establish performance criteria

Prescription BlueSM PDP Select Core Comprehensive ......authorization or step therapy for these drugs. The clinical criteria for authorization are based on current medical information

CP.CPA.83 Step Therapy

STEP THERAPY CRITERIA FOR MEDICARE PART B DRUGS · 2020-04-01 · This document contains the Step Therapy protocols for Medicare Part B drugs that are associated with the Independent

2018 STEP THERAPY CRITERIA - Amazon Web … · 2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) ... TABLET,CRUSH RESISTANT,EXTENDED

Step Therapy Criteria - lmchealthplans.comSoliqua 100/33 100 unit-33 mcg/mL subcutaneous insulin pen Xultophy 100/3.6 100 unit-3.6 mg/mL (3 mL) subcutaneous insulin pen. Details. Criteria

Step Therapy Requirements 2021 Step Therapy Requirements Effective: 01/01/2021 . Last Updated: 09/29/2020. Y0027_21-157_C

Triple-S Advantage 2022 Step Therapy Criteria

THERAPY Criteria TWO DAY WORKSHOP

Antifungal therapy (combination, step-down, salvage)

2011 Medicare National Preferred 4 Tier Step Therapy Criteria · Updated: 08/2011 27 ANTIDEPRESSANTS-BUPROPION Affected Drugs STEP 1 DRUGS STEP 2 DRUGS bupropion APLENZIN® WELLBUTRIN

MAKING STEP THERAPY WORK - pemphigus.org

Visudyne™ (Verteporfin) Therapy. Visudyne Therapy: A Two-Step Process Step 1 Step 2 IV administration of a non-toxic, light activated drug Subsequent

Prescription BlueSM PDP Premium Standard Comprehensive ......authorization or step therapy for these drugs. The clinical criteria for authorization are based on current medical information

TX PA Duplicate Therapy Criteria Guidev26

SilverScript Choice (PDP) Step Therapy Criteria · PDF fileStep Therapy Criteria ... SilverScript Choice (PDP) ... proliferative diabetic retinopathy, neovascular glaucoma, retinopathy

Step Therapy Medications · Step Therapy Medications Step therapy is a limitation that requires you to try preferred medications before the plan will pay for another medication for

Step Therapy Criteria Medicare Advantage - Visitor · DOXERCALCIFEROL 0.5 MCG CAP, ... //ocrportal.hhs.gov/ocr/portal/lobby.jsf, ... Step Therapy Criteria Medicare Advantage

STEP THERAPY CRITERIA - fm.formularynavigator.comfm.formularynavigator.com/MemberPages/pdf/CY2018NC400465PDP_1… · STEP THERAPY CRITERIA ... BYETTA 10 MCG PEN SOLUTION PEN-

Step 1 · 2020-01-17 · Therapy Reports – Easy English Page 8 of 19 Step 6 Explicitly respond to the reasonable and necessary criteria Therapy reports must have information about

Step-by-Step Guide to Medicare Medical Nutrition Therapy ... · Step-by-Step Guide to Medicare Medical Nutrition Therapy (MNT) Reimbursement Addendum, March 2012 . 3 - Appendix A

STEP THERAPY CRITERIA...Y0042_PH443_C STEP THERAPY CRITERIA This list is current as of 12/01/2020 and pertains to the following formularies: 2020 Independent Health’s Medicare Advantage

APTC NEWSLETTER · Dialectical behavior therapy versus comprehen-sive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality

2017 Step Therapy (ST) Criteria - EmblemHealth/media/Files/PDF/Medicare/2017... · 2017 Step Therapy (ST) Criteria Some drugs require step therapy pre-approval. This means that your

Step Therapy Program Allergy-Asthma

STEP THERAPY CRITERIA...S4501_657_C FYI 09112020 STEP THERAPY CRITERIA This list is current as of January 1, 2021, and pertains to the following formularies: 2021 Pharmacy Benefit

Clinical Criteria for Hepatitis C (HCV) Therapy

SmithRx Step List Step List...SmithRx Step Therapy List | Page 1 SmithRx Standard Formulary Step Therapy List Revised: January 27, 2017 The following medications require prior use