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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