2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step...
Transcript of 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step...
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2019 Navitus Medicare Formulary
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedAPLENZIN 174MG ER TAB
DetailsStep Therapy requires trial of generic bupropion SR or generic bupropion XL in previous 180 days.Criteria
1
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedAPLENZIN 348MG ER TAB
DetailsStep Therapy requires trial of generic bupropion SR or generic bupropion XL in previous 180 days.Criteria
2
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedAPLENZIN 522MG ER TAB
DetailsStep Therapy requires trial of generic bupropion SR or generic bupropion XL in previous 180 days.Criteria
3
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedARANESP 100MCG/0.5ML SYRINGE
DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria
4
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedARANESP 100MCG/ML INJ
DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria
5
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedARANESP 10MCG/0.4ML SYRINGE
DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria
6
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedARANESP 150MCG/0.3ML SYRINGE
DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria
7
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedARANESP 200MCG/0.4ML SYRINGE
DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria
8
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedARANESP 200MCG/ML INJ
DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria
9
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedARANESP 25MCG/0.42ML SYRINGE
DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria
10
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedARANESP 25MCG/ML INJ
DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria
11
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedARANESP 300MCG/0.6ML SYRINGE
DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria
12
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedARANESP 300MCG/ML INJ
DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria
13
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedARANESP 40MCG/0.4ML SYRINGE
DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria
14
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedARANESP 40MCG/ML INJ
DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria
15
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedARANESP 500MCG/ML SYRINGE
DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria
16
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedARANESP 60MCG/0.3ML SYRINGE
DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria
17
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedARANESP 60MCG/ML INJ
DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria
18
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedARICEPT 23MG TAB
DetailsStep Therapy requires trial of generic donepezil 10mg in previous 180 days.Criteria
19
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedCRESTOR 10MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
20
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedCRESTOR 20MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
21
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedCRESTOR 40MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
22
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedCRESTOR 5MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
23
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedDETROL 1MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary Urinary Antispasmodic AND Myrbetriq in previous 180 days.Criteria
24
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedDETROL 2MG ER CAP
DetailsStep Therapy requires trial of one (1) generic formulary Urinary Antispasmodic AND Myrbetriq in previous 180 days.Criteria
25
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedDETROL 2MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary Urinary Antispasmodic AND Myrbetriq in previous 180 days.Criteria
26
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedDETROL 4MG ER CAP
DetailsStep Therapy requires trial of one (1) generic formulary Urinary Antispasmodic AND Myrbetriq in previous 180 days.Criteria
27
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedDIFICID 200MG TAB
DetailsStep Therapy requires trial of generic vancomycin capsules.Criteria
28
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedDITROPAN 10MG XL TAB
DetailsStep Therapy requires trial of one (1) generic formulary Urinary Antispasmodic AND Myrbetriq in previous 180 days.Criteria
29
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedDITROPAN 5MG XL TAB
DetailsStep Therapy requires trial of one (1) generic formulary Urinary Antispasmodic AND Myrbetriq in previous 180 days.Criteria
30
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Last Updated 6/1/2019
Step Therapy Criteria
Products Affecteddonepezil 23mg tab
DetailsStep Therapy requires trial of generic donepezil 10mg in previous 180 days.Criteria
31
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedDULOXETINE 40MG DR CAP
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
32
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedENABLEX 15MG ER TAB
DetailsStep Therapy requires trial of one (1) generic formulary Urinary Antispasmodic AND Myrbetriq in previous 180 days.Criteria
33
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedENABLEX 7.5MG ER TAB
DetailsStep Therapy requires trial of one (1) generic formulary Urinary Antispasmodic AND Myrbetriq in previous 180 days.Criteria
34
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedESTRING 2MG VAGINAL RING
DetailsStep Therapy requires trial of PREMARIN VAGINAL CREAM OR generic estradiol vaginal cream in previous 180 days.Criteria
35
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedFEMRING 0.05MG/24HR VAGINAL RING
DetailsStep Therapy requires trial of PREMARIN VAGINAL CREAM OR generic estradiol vaginal cream in previous 180 days.Criteria
36
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedFEMRING 0.1MG/24HR VAGINAL RING
DetailsStep Therapy requires trial of PREMARIN VAGINAL CREAM OR generic estradiol vaginal cream in previous 180 days.Criteria
37
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedFETZIMA 120MG ER CAP
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
38
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedFETZIMA 20MG ER CAP
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
39
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedFETZIMA 40MG ER CAP
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
40
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedFETZIMA 80MG ER CAP
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
41
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedFETZIMA PACK
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
42
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Last Updated 6/1/2019
Step Therapy Criteria
Products Affectedfluvoxamine maleate 100mg er cap
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
43
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Last Updated 6/1/2019
Step Therapy Criteria
Products Affectedfluvoxamine maleate 150mg er cap
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
44
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedGELNIQUE 10% GEL
DetailsStep Therapy requires trial of one (1) generic formulary Urinary Antispasmodic AND Myrbetriq in previous 180 days.Criteria
45
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedLESCOL 80MG XL TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
46
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedLEVALBUTEROL 45MCG INH
DetailsStep Therapy requires trial of VENTOLIN HFA in previous 180 days.Criteria
47
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedLIPITOR 10MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
48
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Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedLIPITOR 20MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
49
![Page 50: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/50.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedLIPITOR 40MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
50
![Page 51: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/51.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedLIPITOR 80MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
51
![Page 52: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/52.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedLIVALO 1MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
52
![Page 53: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/53.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedLIVALO 2MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
53
![Page 54: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/54.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedLIVALO 4MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
54
![Page 55: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/55.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedLONHALA 0.0025% INH SOLN
DetailsStep Therapy requires trial of INCRUSE.Criteria
55
![Page 56: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/56.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedNAMZARIC 10-21MG ER CAP
DetailsPatient has tried or was intolerant to generic donepezil AND generic memantine.Criteria
56
![Page 57: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/57.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedNAMZARIC 10-7MG ER CAP
DetailsPatient has tried or was intolerant to generic donepezil AND generic memantine.Criteria
57
![Page 58: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/58.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedNAMZARIC 14-10MG ER CAP
DetailsPatient has tried or was intolerant to generic donepezil AND generic memantine.Criteria
58
![Page 59: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/59.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedNAMZARIC 28-10MG ER CAP
DetailsPatient has tried or was intolerant to generic donepezil AND generic memantine.Criteria
59
![Page 60: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/60.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedNAMZARIC TITRATION PACK
DetailsPatient has tried or was intolerant to generic donepezil AND generic memantine.Criteria
60
![Page 61: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/61.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedOXYTROL 3.9MG/24HR PATCH
DetailsStep Therapy requires trial of one (1) generic formulary Urinary Antispasmodic AND Myrbetriq in previous 180 days.Criteria
61
![Page 62: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/62.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedPANCREAZE 10500-25000-43750UNIT DR CAP
DetailsStep Therapy requires trial of CREON in previous 180 days.Criteria
62
![Page 63: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/63.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedPANCREAZE 16800-40000-70000UNIT DR CAP
DetailsStep Therapy requires trial of CREON in previous 180 days.Criteria
63
![Page 64: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/64.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedPANCREAZE 21000-37000-61000UNIT DR CAP
DetailsStep Therapy requires trial of CREON in previous 180 days.Criteria
64
![Page 65: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/65.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedPANCREAZE 2600-6200-10850UNIT DR CAP
DetailsStep Therapy requires trial of CREON in previous 180 days.Criteria
65
![Page 66: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/66.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedPANCREAZE 4200-10000-17500UNIT DR CAP
DetailsStep Therapy requires trial of CREON in previous 180 days.Criteria
66
![Page 67: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/67.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedPERTZYE 16000-57500-60500UNIT DR CAP
DetailsStep Therapy requires trial of CREON in previous 180 days.Criteria
67
![Page 68: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/68.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedPERTZYE 4000-14375-15125UNIT DR CAP
DetailsStep Therapy requires trial of CREON in previous 180 days.Criteria
68
![Page 69: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/69.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedPERTZYE 8000-28750-30250UNIT DR CAP
DetailsStep Therapy requires trial of CREON in previous 180 days.Criteria
69
![Page 70: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/70.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedPRAVACHOL 20MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
70
![Page 71: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/71.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedPRAVACHOL 40MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
71
![Page 72: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/72.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedPRAVACHOL 80MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
72
![Page 73: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/73.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedPRISTIQ 100MG ER TAB
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
73
![Page 74: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/74.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedPRISTIQ 25MG ER TAB
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
74
![Page 75: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/75.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedPRISTIQ 50MG ER TAB
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
75
![Page 76: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/76.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedSPIRIVA 1.25MCG RESPIMAT INH
DetailsStep Therapy requires trial of ADVAIR, BREO, DULERA, or FLUTICASONE/SALMETEROL.Criteria
76
![Page 77: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/77.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedSYMPAZAN 10MG STRIP
DetailsStep therapy requires trial of generic clobazam tablets.Criteria
77
![Page 78: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/78.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedSYMPAZAN 20MG STRIP
DetailsStep therapy requires trial of generic clobazam tablets.Criteria
78
![Page 79: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/79.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedSYMPAZAN 5MG STRIP
DetailsStep therapy requires trial of generic clobazam tablets.Criteria
79
![Page 80: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/80.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedTRINTELLIX 10MG TAB
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
80
![Page 81: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/81.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedTRINTELLIX 20MG TAB
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
81
![Page 82: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/82.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedTRINTELLIX 5MG TAB
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
82
![Page 83: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/83.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedULORIC 40MG TAB
DetailsStep Therapy requires trial of generic allopurinol in previous 180 days.Criteria
83
![Page 84: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/84.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedULORIC 80MG TAB
DetailsStep Therapy requires trial of generic allopurinol in previous 180 days.Criteria
84
![Page 85: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/85.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedVIIBRYD 10/20MG STARTER PACK
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
85
![Page 86: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/86.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedVIIBRYD 10MG TAB
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
86
![Page 87: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/87.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedVIIBRYD 20MG TAB
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
87
![Page 88: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/88.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedVIIBRYD 40MG TAB
DetailsStep Therapy requires trial of one of the following generic SSRI's in previous 180 days: escitalopram, sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic musculoskeletal pain.
Criteria
88
![Page 89: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/89.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedXOPENEX 45MCG INH
DetailsStep Therapy requires trial of VENTOLIN HFA in previous 180 days.Criteria
89
![Page 90: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/90.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedZENPEP 10000-32000-42000UNIT DR CAP
DetailsStep Therapy requires trial of CREON in previous 180 days.Criteria
90
![Page 91: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/91.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedZENPEP 15000-47000-63000UNIT DR CAP
DetailsStep Therapy requires trial of CREON in previous 180 days.Criteria
91
![Page 92: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/92.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedZENPEP 20000-63000-84000UNIT DR CAP
DetailsStep Therapy requires trial of CREON in previous 180 days.Criteria
92
![Page 93: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/93.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedZENPEP 25000-79000-105000UNIT DR CAP
DetailsStep Therapy requires trial of CREON in previous 180 days.Criteria
93
![Page 94: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/94.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedZENPEP 3000-10000-14000UNIT DR CAP
DetailsStep Therapy requires trial of CREON in previous 180 days.Criteria
94
![Page 95: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/95.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedZENPEP 40000-126000-168000UNIT DR CAP
DetailsStep Therapy requires trial of CREON in previous 180 days.Criteria
95
![Page 96: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/96.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedZENPEP 5000-17000-24000UNIT DR CAP
DetailsStep Therapy requires trial of CREON in previous 180 days.Criteria
96
![Page 97: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/97.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedZIOPTAN 0.0015% OPHTH SOLN
DetailsStep Therapy requires trial of generic latanoprost in previous 180 days.Criteria
97
![Page 98: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/98.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedZOCOR 10MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
98
![Page 99: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/99.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedZOCOR 20MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
99
![Page 100: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/100.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedZOCOR 40MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
100
![Page 101: 2019 Navitus Medicare Formulary - COEHA...2019 Navitus Medicare Formulary Last Updated 6/1/2019 Step Therapy Criteria Products Affected APLENZIN 174MG ER TAB Details Criteria Step](https://reader033.fdocuments.in/reader033/viewer/2022060416/5f142f3609cc705df57c583b/html5/thumbnails/101.jpg)
Last Updated 6/1/2019
Step Therapy Criteria
Products AffectedZOCOR 80MG TAB
DetailsStep Therapy requires trial of one (1) generic formulary statin in previous 180 days.Criteria
101