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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.