Download Last Updated 4/3/2017

Value Based Preventative Drug List:
STEP THERAPY CRITERIA
Last Updated 4/3/2017
Condition
Copay
Acne
N100 ST
Acne
N100 ST
Acne
N100 ST
AL<35
ADHD
N100 ST
Allergic
Rhinitis
NP ST
Step Edit
Drug
Aczone 5%
Noritate 1%
Cream
Tretinoin
Microsphere
Gel
Dexmethylph
enidate IR and
ER
Beclomethaso
ne, Beconase
AQ,
Flunisolide,
Qnasl,
Omnaris,
Zetonna
Adrenaclick
Step Therapy Criteria
Requires a trial of 2 preferred topical antibiotic agents (Metronidazole 1% gel or 0.75% cream,
Clindamycin 1%, Clindamycin 1%/Benzoyl Peroxide 1.2-2.5% (generics of Duac, Neuac) or
Erythromycin 2%,3%,5% (generics of Benzamycin, Erygel), or Sulfacetamide 10%) before Aczone
5% is covered at 100% member cost. Azcone 7.5% is not covered.
Requires a trial of a preferred agent Metronidazole 0.075% gel, 1% gel or 0.75% cream before
brand Noritate 1% cream is covered at 100% member cost.
Requires step of topical Tretinoin gel or cream (and PA required for age greater than 35 years
old) before Tretinoin Microsphere gel is covered at 100% member cost.
Requires step of Methylphenidate before Dexmethylphenidate IR or ER is covered at 100%
member cost.
Requires step of TWO preferred agents (Fluticasone Rx nasal spray, Rhinocort OTC or Nasacort
OTC) before a non-preferred nasal spray is covered at 100% member cost.
Not Covered: Fluticasone nasal OTC, Triamcinolone nasal Rx, Budesonide, Rhincort Aqua Rx,
and Dymista.
Anaphylaxis
NP ST
AntiInflammato
ry Agents
NP ST
PA SP
Antiplatelet
Asthma /
COPD
Asthma /
COPD
Asthma /
COPD
PDL ST
PA
PDL ST
PA
PDL ST
PA
PDL ST
Behavioral
Health
NP ST
PA
Behavioral
Health
Behavioral
Health
Behavioral
Health
NP ST
PA
N100 ST
Fetzima
N100/
NP ST
Rexulti,
Nuplazid
Requires a trial of preferred agents Duloxetine, Venlafaxine, or Desvenlafaxine before nonpreferred agent Fetzima is covered at 100% member cost
requires a trial of aripiprazole before Latuda will be covered at 100% member cost. PA forms are
located here: http://www.pplusic.com/providers/pharmacy/drug-prior-authorization-forms
Requires a trial of one preferred agent (e.g. aripiprazole, quetiapine) before Rexulti or Nuplazid
will be covered at 100% member cost.
Behavioral
Health
Clot
Prevention
COPD
N100 ST
Trintellix
Requires a trial of two preferred SSRIs before Trintellix will be covered at 100% member cost.
Pradaxa
Required step of Xarelto and Eliquis before Pradaxa is covered at 100% member cost.
Spiriva, Seebri
COPD
NP ST
PA
NP ST
PA
N100 ST
Diabetes
NP ST
Requires step of one fill of Incruse, Anoro-Ellipta or Tudorza before Spiriva or Seebri are covered
at 100% member cost.
Requires step of one fill of Incruse or Anoro-Ellipta before Atrovent is covered at 100% member
cost.
Requires a trial of both alogliptin and Januvia before a non-preferred agent is covered at 100%
member cost.
Cimzia,
Kineret,
Orencia,
Simponi
Taltz
Brilinta
Advair, BreoEllipta
Flovent,
Alvesco
Levalbuterol
HFA
(Xopenex
HFA)
Fanapt,
Saphris
Latuda
Atrovent
HFA
Kombiglyze
XR,
Jentadueto,
Onglyza,
Tradjenta
Requires step of one fill of Epipen or Epipen Jr. or generic Epinephrine Auto-Inject in the last 12
months before Adrenaclick is covered at 100% member cost. Auvi-Q is not covered.
Requires step of preferred agents by indication before Cimzia, Kineret, Orencia, Simponi, or Taltz
are covered at 100% member cost. Anti-Inflammatory PA form is located here:
https://www.pplusic.com/documents/upload/p6830-anti-inflammatory-bio-by-indication-paform.pdf
Requires step of Aspirin, Clopidogrel or Ticlopidine before Brilinta is covered at 20% member
cost.
Requires step of Symbicort and Dulera before Advair or Breo-Ellipta is covered at 20% member
cost. Other alternatives include Asmanex, QVAR, and Pulmicort.
Requires step of Asmanex, QVAR and Pulmicort before Flovent is covered at 20% member cost.
Requires step of one fill of Ventolin HFA before Levalbuterol HFA is covered at 20% member
cost.
Requires a trial of 2 preferred atypical neuroleptics (Aripiprazole, Quetiapine, Risperidone, etc.)
before Fanapt or Saphris are covered at 100% member cost.
Value Based Preventative Drug List:
STEP THERAPY CRITERIA
Last Updated 4/3/2017
Diabetes
Diabetes
NP ST
PA
NP ST
PA
PDL ST
Diabetes
PDL ST
Epilepsy
N100 ST
Apidra,
Novolog
Levemir,
Tresiba
Byetta,
Bydureon
Farxiga,
Xigduo XR
Briviact
Eye drops:
Anthistamin
e
Eye drops:
Anthistamin
e
Eye drops:
Glaucoma
Fungal
Infection
Granulocyte
Stimulators
Growth
Hormone
N100 ST
Olopatadine
Requires step of preferred insulin product before a non-preferred product is covered at 100%
member cost.
Required step of preferred insulin product before non-preferred product is covered at 100%
member cost.
Requires step of Tanzeum and Victoza before Byetta or Bydureon are covered at 20% member
cost.
Requires step of ONE: Invokana, Invokamet, Invokamet XR, Jardiance or Synjardy before Farxiga
or Xigduo XR are covered at 20% member cost.
Requires a trial of one preferred agent (e.g. Levetiracetam) before Briviact is covered at 100%
member cost.
Requires a trial of OTC Ketotifen before Olopatadine 0.1% is covered at 100% member cost.
NP ST
Pazeo,
Pataday
Requires a trial of OTC Ketotifen and Olopatadine 0.1% before Pazeo or Pataday are covered at
100% member cost.
N100 ST
Requires a trial of preferred Combigan before Azopt or Simbrinza are covered at 100% member
cost.
Requires step of Clotrimazole, Fluconazole, Terbinifine, Itraconazole or Voriconizole before
Ketoconazole tablets are covered at 100% member cost.
Requires a trial of a preferred agent Granix before non-preferred agents Neupogen or Zarxio are
covered at 100% member cost.
Requires step of Norditropin before Humatrope, Nutropin, Omnitrope or Saizen are covered at
100% member cost.
Hormone:
Vaginal
Estrogens
NP ST
Hepatitis C
N100 ST
PA SP
High
Triglyceride
s
Hyperlipide
mia
Hyperlipide
mia
Hypertensio
n
Hypertensio
n
PDL ST
PDL ST
Azopt,
Simbrinza
Ketoconazole
tablets
Neupogen,
Zarxio
Humatrope,
Nutropin,
Omnitrope,
Saizen
Premarin
Cream,
Yuvafem
Tablets
Daklinza,
Harvoni,
Olysio,
Sovaldi,
Technivie,
Viekira
Omega-3
Acid Ethyl
Esters
Advicor,
Simcor
Niacin ER
PDL ST
Moexipril
PDL ST
Inflammato
ry Bowel
Disease
Insomnia
N100 ST
Candesartan,
Telmisartan,
Olmesartan,
Eprosartan
Asacol,
Delzicol
N100 ST
Belsomra
Irritable
Bowel
Constipatio
n
Irritable
Bowel
Diarrhea
N100 ST
PA
Amitiza
NP ST
PA
Viberzi
Diabetes
N100 ST
N100 SP
PA ST
NP ST
PA SP
NP ST
Requires a trial of Estrace Cream before non-preferred agents Premarin Cream or Yuvafem
tablets are covered at 100% member cost. Yuvafem tablets have a quantity limit of 8 tablets per
month.
Requires a trial of Zepatier (Genotypes 1 and 4) or Epclusa (Genotypes 2, 3, 5, or 6) before nonpreferred agents are covered at 100% member cost.
Requires step of OTC Fish Oil (MaxEPA, Super Omega-3, Fish Oil Concentrate) or Fenofibrate
before Omega-3 Acid Ethyl Esters is covered at a $0 copay.
Requires step of adequate trial (minimum 4 weeks) of statin therapy before Advicor or Simcor is
covered at 100% member cost.
Requires step of adequate trial (minimum 4 weeks) of statin therapy before Niacin ER is covered
at a $0 copay.
Requires step of Lisinopril, Enalapril, Ramipril, and Benazepril before Moexipril is covered at a $0
copay.
Requires a trial of one preferred generic agent (Losartan, Irbesartan, Valsartan, or
Valsartan/HCTZ) before a non-preferred agent is covered at a $0 copay.
Requires step of Apriso and Lialda before Asacol or Delzicol are covered at 100% member cost.
Requires step of one preferred agent (Doxepin, Trazodone, Zolpidem, Zaleplon, Eszopiclone,
Ramelteon, Temazepam, Quazepam or Triazolam) before Belsomra is covered at 100% member
cost.
Requires a trial of Linzess before Amitiza is covered at 100% member cost. PA form is located
here: http://www.pplusic.com/providers/pharmacy/drug-prior-authorization-forms.
Requires a trial of one preferred agent in each therapeutic class before Viberzi is covered at 100%
member cost.
1) One Anti-diarrheal (Loperamide or Diphenoxylate/Atropine)
Value Based Preventative Drug List:
STEP THERAPY CRITERIA
Last Updated 4/3/2017
2)
Migraine
NP ST
Multiple
Sclerosis
N100 ST
PA SP
Osteoporosi
s
Overactive
Bladder
PDL ST
Prostate
Cancer
Prostate
Enlarged
(BPH)
Psoriasis
N100 ST
PA SP
NP ST
PA
KEY:
PA =
SP =
AL =
PDL =
PDL =
N100 =
NP =
P+6394-1605
NP ST
N100 ST
Axert,
Relpax,
Frovatriptan,
Zomig,
Zolmitriptan
Aubagio,
Betaseron,
Extavia,
Glatopa,
Rebif,
Zinbryta
Risedronate
One Antispasmodic/Anticholinergic (Dicyclomine, Hyoscyamine,
Chlordiazepoxide/Clindinium (Librax), Atropine/Hyoscyamine/Scopolamine (Donnatal))
PA form is located here: http://www.pplusic.com/providers/pharmacy/drug-prior-authorizationforms.
Requires step of two formulary agents (Sumatriptan, Rizatriptan, and Naratriptan) before nonpreferred agents are covered at 100% member cost.
Requires step of four preferred agents (Avonex, Plegridy, Copaxone, Tecfidera and Gilenya)
before a non-preferred agent (Aubagio, Betaseron, Extavia, Rebif, Zinbryta; this includes medically
infused drugs Tysabri, Lemtrada, Mitoxantrone) is covered at 100% member cost or medical
coinsurance.
Requires a trial of Alendronate before Risedronate is covered at a $0 copay.
Darifenacin
(Enablex),
Toviaz
Xtandi
Requires step of two generic agents (Oxybutynin, Tolterodine, and Trospium) before Darifenacin
or Toviaz are covered at 100% member cost.
Cialis
Requires step of an adequate trial (e.g. 6 months) of a 5-alpha-reductase inhibitor (Finasteride)
AND an alpha-1-blocker antagonist (Terazosin, Tamsulosin) AND diagnosis of BPH before Cialis
is covered at 100% member cost.
Requires trial of Calcipotriene before Enstilar is covered at 100% member cost.
Enstilar
Requires step of Zytiga before is Xtandi is covered at 100% member cost.
Prescriber’s office must fax a completed “Prior Authorization Request Form” to Physicians Plus Pharmacy Services at 608-3270324. Forms are available at http://www.pplusic.com/providers/pharmacy or call Pharmacy Services at 608-260-7803 or 800545-5015 to request a form.
All specialty drugs must be filled at an in-network specialty pharmacy. Most specialty drugs require prior authorization. If
approved, these products are covered at the tier designated and are directed to an in-network pharmacy.
Age Limit. PA required outside of age range.
Preventative Drug List (PDL) Generics are available at a $0 copay.
Preventative Drug List (PDL) Brands are available at a 20% coinsurance applies to max out of pocket but not the deductible.
Not on the Preventative Drug List: preferred formulary Generics and Brands covered at 100% coinsurance and applies to the
deductible and max out of pocket.
Not Preferred Medications: Generics and Brands covered at 100% and applies to the deductible and max out of pocket.