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

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

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

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

Last Updated 6/1/2019

Step Therapy Criteria

Products AffectedARANESP 100MCG/ML INJ

DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria

5

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

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

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

Last Updated 6/1/2019

Step Therapy Criteria

Products AffectedARANESP 200MCG/ML INJ

DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria

9

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

Last Updated 6/1/2019

Step Therapy Criteria

Products AffectedARANESP 25MCG/ML INJ

DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria

11

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

Last Updated 6/1/2019

Step Therapy Criteria

Products AffectedARANESP 300MCG/ML INJ

DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria

13

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

Last Updated 6/1/2019

Step Therapy Criteria

Products AffectedARANESP 40MCG/ML INJ

DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria

15

Last Updated 6/1/2019

Step Therapy Criteria

Products AffectedARANESP 500MCG/ML SYRINGE

DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria

16

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

Last Updated 6/1/2019

Step Therapy Criteria

Products AffectedARANESP 60MCG/ML INJ

DetailsStep Therapy requires trial of PROCRIT, EPOGEN or RETACRIT.Criteria

18

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

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

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

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

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

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

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

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

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

Last Updated 6/1/2019

Step Therapy Criteria

Products AffectedDIFICID 200MG TAB

DetailsStep Therapy requires trial of generic vancomycin capsules.Criteria

28

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Last Updated 6/1/2019

Step Therapy Criteria

Products AffectedLONHALA 0.0025% INH SOLN

DetailsStep Therapy requires trial of INCRUSE.Criteria

55

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Last Updated 6/1/2019

Step Therapy Criteria

Products AffectedSYMPAZAN 10MG STRIP

DetailsStep therapy requires trial of generic clobazam tablets.Criteria

77

Last Updated 6/1/2019

Step Therapy Criteria

Products AffectedSYMPAZAN 20MG STRIP

DetailsStep therapy requires trial of generic clobazam tablets.Criteria

78

Last Updated 6/1/2019

Step Therapy Criteria

Products AffectedSYMPAZAN 5MG STRIP

DetailsStep therapy requires trial of generic clobazam tablets.Criteria

79

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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