WELLCARE HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 10/2014)

Transcription

1 WELLCARE HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 10/2014) **To get updated information about the drugs covered by WellCare, please visit our website ( or call Customer Service. Our phone number is available on our Contact Us page.

2 ANTI-ANXIETY AGENTS Meprobamate Tablet 200 MG Oral Meprobamate Tablet 400 MG Oral Trial of at least 30 days of two generic alternatives including venlafaxine er, duloxetine, buspirone, or brand or generic paroxetine within the past 100 days. Updated 10/2014

3 ANTIDEPRESSANT AGENTS Viibryd Kit 10 & 20 & 40 MG Oral Viibryd Tablet 10 MG Oral Viibryd Tablet 20 MG Oral Viibryd Tablet 40 MG Oral Trial of at least 30 days of two generic alternatives including citalopram, escitalopram, paroxetine, fluoxetine, sertraline, bupropion, and venlafaxine er capsules within the past 100 days.

4 ANTI-INFECTIVE AGENTS Xifaxan Tablet 200 MG Oral Xifaxan Tablet 550 MG Oral PENDING CMS APPROVAL

5 ATYPICAL ANTIPSYCHOTICS Latuda Tablet 120 MG Oral Latuda Tablet 20 MG Oral Latuda Tablet 40 MG Oral Latuda Tablet 60 MG Oral Latuda Tablet 80 MG Oral Saphris Tablet Sublingual 10 MG Sublingual Saphris Tablet Sublingual 5 MG Sublingual Trial of at least 30 days of generic risperidone, olanzapine, quetiapine, or ziprasidone within the past 100 days.

6 DIABETES AGENTS Glyburide Micronized Tablet 1.5 MG Oral Glyburide Micronized Tablet 3 MG Oral Glyburide Micronized Tablet 6 MG Oral Glyburide Tablet 1.25 MG Oral Glyburide Tablet 2.5 MG Oral Glyburide Tablet 5 MG Oral Glyburide-Metformin Tablet MG Oral Glyburide-Metformin Tablet MG Oral Glyburide-Metformin Tablet MG Oral Trial of at least 30 days of two generic alternatives including glipizide and glimepiride within the past 100 days.

7 DOPAMINE AGONIST AGENTS Neupro Patch 24 HR 1 MG/24HR Transdermal Neupro Patch 24 HR 2 MG/24HR Transdermal Neupro Patch 24 HR 3 MG/24HR Transdermal Neupro Patch 24 HR 4 MG/24HR Transdermal Neupro Patch 24 HR 6 MG/24HR Transdermal Neupro Patch 24 HR 8 MG/24HR Transdermal Trial of at least 30 days of both generic immediate release pramipexole and immediate release ropinirole within the past 100 days.

8 GOUT AGENTS Uloric Tablet 40 MG Oral Uloric Tablet 80 MG Oral Trial of at least 30 days of generic allopurinol within the past 100 days.

9 MUSCLE RELAXANT AGENTS Carisoprodol Tablet 350 MG Oral Cyclobenzaprine HCl Tablet 10 MG Oral Cyclobenzaprine HCl Tablet 5 MG Oral Methocarbamol Tablet 500 MG Oral Methocarbamol Tablet 750 MG Oral Trial of at least 30 days of two generic alternative including balcofen and tizanidine tablets within the past 100 days.

10 NSAID AGENTS Indomethacin Capsule 25 MG Oral Indomethacin Capsule 50 MG Oral Trial of at least 30 days of two generic alternatives including diclofenac, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, ketoprofen, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, or sulindac within the past 100 days.

11 OSTEOPOROSIS AGENTS Prolia Solution 60 MG/ML Subcutaneous Trial of at least 30 days of oral alendronate, ibandronate, raloxifene, Premarin, Prempro, estradiol, Jinteli, or zoledronic acid 5mg/100ml within the past 365 days. Approve for use to increase bone mass in men receiving androgren deprivation therapy for nonmetastatic prostate cancer and in women receiving aromatase inhibitor therapy for breast cancer.

12 POSTHERPETIC NEURALGIA AGENTS Gralise Starter 300 & 600 MG Oral Gralise Tablet 300 MG Oral Gralise Tablet 600 MG Oral Trial of at least 30 days of gabapentin or Lyrica within the past 100 days.