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2022 Group Plus
Formulary ID 22800 Version 1
You can contact Humana for the most recent list of drugs by calling the number on the back of your Humana member identification card, TTY: 711 Monday through Friday, 8 a.m. - 9 p.m. Eastern time or visiting the website listed in your Annual Notice of Change (ANOC) or Evidence of Coverage (EOC).
Step Therapy Criteria
Effective 06/01/2022
ABSORICA
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: Amnesteem, Claravis, Isotretinoin, Myorisan, or Zenatane.
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ABSORICA LD
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: Amnesteem, Claravis, Isotretinoin, Myorisan, or Zenatane.
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ACTICLATE
Criteria Details The member has had previous treatment or intolerance with oral immediate release doxycycline (e.g. doxycycline monohydrate 50 mg capsule/tablet, doxycycline 75 mg tablet, 100 mg capsule/tablet).
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ACULAR
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months, contraindication, or intolerance to Ilevro ophthalimic solution and one of the following: ketorolac ophthalimic solution or diclofenac ophthalimic solution or Flurbiprofen ophthalimic solution.
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ACULAR LS
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months, contraindication, or intolerance to Ilevro ophthalimic solution and one of the following: ketorolac ophthalimic solution or diclofenac ophthalimic solution or Flurbiprofen ophthalimic solution.
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ACUVAIL (PF)
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months, contraindication, or intolerance to Ilevro ophthalimic solution and one of the following: ketorolac ophthalimic solution or diclofenac ophthalimic solution or Flurbiprofen ophthalimic solution.
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ADLYXIN
Criteria Details An automatic approval will be given to members who have had previous treatment with at least two preferred GLP 1 Analogs (e.g. Victoza, Trulicity, Ozempic, Bydureon, Rybelsus).
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ADMELOG SOLOSTAR U-100 INSULIN
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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ADMELOG U-100 INSULIN LISPRO
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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AGGRENOX
Criteria Details An automatic approval will be given to members who have had previous treatment with clopidogrel.
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AIRDUO DIGIHALER
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: Wixela Inhub, fluticasone-salmeterol, Symbicort, Advair HFA/Diskus, or Breo Ellipta.
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AIRDUO RESPICLICK
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: Wixela Inhub, fluticasone-salmeterol, Symbicort, Advair HFA/Diskus, or Breo Ellipta.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 12 of 275
almotriptan malate
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: naratriptan, sumatriptan or rizatriptan.
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ALREX
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with two of the following eye drops: Durezol 0.05%, prednisolone sodium phosphate 1%, prednisolone acetate 1%, Dexamethasone 0.1%, Fluorometholone 0.1%, Lotemax SM 0.38%.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 14 of 275
ALTOPREV
Criteria Details An automatic approval will be given to members who have had previous treatment with ezetimibe and one of the following: lovastatin, atorvastatin, rosuvastatin, simvastatin, or pravastatin.
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ALVESCO
Criteria Details An automatic approval will be given to members who have had previous treatment with Flovent HFA/Diskus and Arnuity Ellipta
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amoxicil-clarithromy-lansopraz
Criteria Details An automatic approval will be given to members who have had previous treatment, intolerance, or contraindication with Pylera.
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AMRIX
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with tizanidine tablets AND baclofen tablets.
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APIDRA SOLOSTAR U-100 INSULIN
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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APIDRA U-100 INSULIN
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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APLENZIN
Criteria Details A automatic approval will be given to members who have had prior therapy with a generic bupropion product (75mg/100mg IR, 100mg/150mg/200mg SR, or 150mg/300mg XL) and at least 1 other SSRI, SNRI or mirtazapine.
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APRISO
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to two of the following: sulfasalazine, balsalazide capsules, mesalamine enema or mesalamine 0.375g extended-release.
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ARMONAIR DIGIHALER
Criteria Details An automatic approval will be given to members who have had previous treatment with Flovent HFA/Diskus and Arnuity Ellipta
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ASACOL HD
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to two of the following: sulfasalazine, balsalazide capsules, mesalamine enema or mesalamine 0.375g extended-release.
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ASMANEX HFA
Criteria Details An automatic approval will be given to members who have had previous treatment with Flovent HFA/Diskus and Arnuity Ellipta
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ASMANEX TWISTHALER
Criteria Details An automatic approval will be given to members who have had previous treatment with Flovent HFA/Diskus and Arnuity Ellipta
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aspirin-dipyridamole
Criteria Details An automatic approval will be given to members who have had previous treatment with clopidogrel.
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ATACAND
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: lisinopril, lisinopril-HCTZ, ramipril, benazepril, benazepril-HCTZ, quinapril, quinapril-HCTZ, enalapril, enalapril-HCTZ, Losartan, Losartan-HCTZ, Valsartan, Valsartan-HCTZ, Irbesartan, Irbesartan-HCTZ, Olmesartan, Olmesartan-HCTZ.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 28 of 275
ATACAND HCT
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: lisinopril, lisinopril-HCTZ, ramipril, benazepril, benazepril-HCTZ, quinapril, quinapril-HCTZ, enalapril, enalapril-HCTZ, Losartan, Losartan-HCTZ, Valsartan, Valsartan-HCTZ, Irbesartan, Irbesartan-HCTZ, Olmesartan, Olmesartan-HCTZ.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 29 of 275
avidoxy
Criteria Details The member has had previous treatment or intolerance with oral immediate release doxycycline (e.g. doxycycline monohydrate 50 mg capsule/tablet, doxycycline 75 mg tablet, 100 mg capsule/tablet).
Y0040_ GHHJPMNES_C Updated 06/2022 Page 30 of 275
AZASITE
Criteria Details The member has had previous treatment within the past 12 months or intolerance to two of the following: ciprofloxacin eye drops, levofloxacin eye drops, moxifloxacin eye drops (generic Vigamox), or ofloxacin eye drops.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 31 of 275
azelaic acid
Criteria Details An automatic approval will be given to members who have had previous treatment with topical metronidazole.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 32 of 275
azelastine-fluticasone
Criteria Details An approval will be given to members who have had previous treatment with two of the following: Fluticasone nasal spray, Azelastine nasal spray, Flunisolide nasal spray. If the member has nasal polyps OR for prophylaxis to seasonal allergic rhinitis, the request will be approved.
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AZOPT
Criteria Details An automatic approval will be given to members who have had previous treatment with: Brimonidine ophthalimic solution AND dorzolamide ophthalimic solution.
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BECONASE AQ
Criteria Details An approval will be given to members who have had previous treatment with two of the following: Fluticasone nasal spray, Azelastine nasal spray, Flunisolide nasal spray. If the member has nasal polyps OR for prophylaxis to seasonal allergic rhinitis, the request will be approved.
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bepotastine besilate
Criteria Details An automatic approval will be given to members who have had previous trial with at least two of the following agents: olopatadine 0.2%, azelastine, or cromolyn eye drops.
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BEPREVE
Criteria Details An automatic approval will be given to members who have had previous trial with at least two of the following agents: olopatadine 0.2%, azelastine, or cromolyn eye drops.
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BESIVANCE
Criteria Details The member has had previous treatment within the past 12 months or intolerance to two of the following: ciprofloxacin eye drops, levofloxacin eye drops, moxifloxacin eye drops (generic Vigamox), or ofloxacin eye drops.
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BETIMOL
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following eye drops: LEVOBUNOLOL 0.5%, TIMOLOL 0.25%, TIMOLOL 0.5%, BETAXOLOL HCL 0.5%.
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BETOPTIC S
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following eye drops: LEVOBUNOLOL 0.5%, TIMOLOL 0.25%, TIMOLOL 0.5%, BETAXOLOL HCL 0.5%.
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BINOSTO
Criteria Details An automatic approval will be given to members who have had previous treatment with Alendronate.
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brinzolamide
Criteria Details An automatic approval will be given to members who have had previous treatment with: Brimonidine ophthalimic solution AND dorzolamide ophthalimic solution.
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BROMSITE
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months, contraindication, or intolerance to Ilevro ophthalimic solution and one of the following: ketorolac ophthalimic solution or diclofenac ophthalimic solution or Flurbiprofen ophthalimic solution.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 43 of 275
BRYHALI
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following topical generic products: triamcinolone, mometasone, fluticasone, betamethasone, or clobetasol.
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bupropion hcl
Criteria Details A automatic approval will be given to members who have had prior therapy with a generic bupropion product (75mg/100mg IR, 100mg/150mg/200mg SR, or 150mg/300mg XL) and at least 1 other SSRI, SNRI or mirtazapine.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 45 of 275
BYETTA
Criteria Details An automatic approval will be given to members who have had previous treatment with at least two preferred GLP 1 Analogs (e.g. Victoza, Trulicity, Ozempic, Bydureon, Rybelsus).
Y0040_ GHHJPMNES_C Updated 06/2022 Page 46 of 275
calcipotriene
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following topical generic products: triamcinolone, mometasone, fluticasone, betamethasone, or clobetasol.
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calcitriol
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following topical generic products: triamcinolone, mometasone, fluticasone, betamethasone, or clobetasol.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 48 of 275
CAMBIA
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following oral generics: Meloxicam, Diclofenac, Ibuprofen, Naproxen.
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CANASA
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to two of the following: sulfasalazine, balsalazide capsules, mesalamine enema or mesalamine 0.375g extended-release.
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chlorzoxazone
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with tizanidine tablets AND baclofen tablets.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 51 of 275
CLARINEX-D 12 HOUR
Criteria Details An automatic approval will be given to members who have had previous treatment with fluticasone nasal, flunisolide nasal, or levocetirizine.
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CLENPIQ
Criteria Details An automatic approval will be given to members who have had a trial, intolerance, or contraindication to Suprep OR Sutab.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 53 of 275
CLOBEX
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following topical generic products: triamcinolone, mometasone, fluticasone, betamethasone, or clobetasol.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 54 of 275
CONZIP
Criteria Details An automatic approval will be given to members who have had a trial with immediate release tramadol AND extended release tramadol tablets.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 55 of 275
CORDRAN
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following topical generic products: triamcinolone, mometasone, fluticasone, betamethasone, or clobetasol.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 56 of 275
coremino
Criteria Details The member has previous treatment or intolerance with a generic immediate-release minocycline formulation.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 57 of 275
COSOPT
Criteria Details An automatic approval will be given to members who have had previous treatment with dorzolamide/timolol ophthalmic solution
Y0040_ GHHJPMNES_C Updated 06/2022 Page 58 of 275
COSOPT (PF)
Criteria Details An automatic approval will be given to members who have had previous treatment with dorzolamide/timolol ophthalmic solution
Y0040_ GHHJPMNES_C Updated 06/2022 Page 59 of 275
cyclobenzaprine
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with tizanidine tablets AND baclofen tablets.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 60 of 275
CYCLOSET
Criteria Details An automatic approval will be given to members who have had previous treatment with, contraindication, or intolerance to a metformin containing medicine.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 61 of 275
darifenacin
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: Oxybutynin (IR or ER), Toviaz, Myrbetriq, or Gemtesa.
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DARTISLA
Criteria Details Member has previous treatment or intolerance to glycopyrrolate tablet.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 63 of 275
DELZICOL
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to two of the following: sulfasalazine, balsalazide capsules, mesalamine enema or mesalamine 0.375g extended-release.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 64 of 275
desloratadine
Criteria Details An automatic approval will be given to members who have had previous treatment with fluticasone nasal, flunisolide nasal, or levocetirizine.
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desvenlafaxine
Criteria Details An automatic approval will be given to members who have had previous treatment with venlafaxine (IR or ER) AND duloxetine.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 66 of 275
diclofenac potassium
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following oral generics: Meloxicam, Diclofenac, Ibuprofen, Naproxen.
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DIPENTUM
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to two of the following: sulfasalazine, balsalazide capsules, mesalamine enema or mesalamine 0.375g extended-release.
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DORYX
Criteria Details The member has had previous treatment or intolerance with oral immediate release doxycycline (e.g. doxycycline monohydrate 50 mg capsule/tablet, doxycycline 75 mg tablet, 100 mg capsule/tablet).
Y0040_ GHHJPMNES_C Updated 06/2022 Page 69 of 275
DORYX MPC
Criteria Details The member has had previous treatment or intolerance with oral immediate release doxycycline (e.g. doxycycline monohydrate 50 mg capsule/tablet, doxycycline 75 mg tablet, 100 mg capsule/tablet).
Y0040_ GHHJPMNES_C Updated 06/2022 Page 70 of 275
doxycycline hyclate
Criteria Details The member has had previous treatment or intolerance with oral immediate release doxycycline (e.g. doxycycline monohydrate 50 mg capsule/tablet, doxycycline 75 mg tablet, 100 mg capsule/tablet).
Y0040_ GHHJPMNES_C Updated 06/2022 Page 71 of 275
doxycycline monohydrate
Criteria Details The member has had previous treatment or intolerance with oral immediate release doxycycline (e.g. doxycycline monohydrate 50 mg capsule/tablet, doxycycline 75 mg tablet, 100 mg capsule/tablet).
Y0040_ GHHJPMNES_C Updated 06/2022 Page 72 of 275
DULERA
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: Wixela Inhub, fluticasone-salmeterol, Symbicort, Advair HFA/Diskus, or Breo Ellipta.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 73 of 275
DYMISTA
Criteria Details An approval will be given to members who have had previous treatment with two of the following: Fluticasone nasal spray, Azelastine nasal spray, Flunisolide nasal spray. If the member has nasal polyps OR for prophylaxis to seasonal allergic rhinitis, the request will be approved.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 74 of 275
EDARBI
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: lisinopril, lisinopril-HCTZ, ramipril, benazepril, benazepril-HCTZ, quinapril, quinapril-HCTZ, enalapril, enalapril-HCTZ, Losartan, Losartan-HCTZ, Valsartan, Valsartan-HCTZ, Irbesartan, Irbesartan-HCTZ, Olmesartan, Olmesartan-HCTZ.
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EDARBYCLOR
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: lisinopril, lisinopril-HCTZ, ramipril, benazepril, benazepril-HCTZ, quinapril, quinapril-HCTZ, enalapril, enalapril-HCTZ, Losartan, Losartan-HCTZ, Valsartan, Valsartan-HCTZ, Irbesartan, Irbesartan-HCTZ, Olmesartan, Olmesartan-HCTZ.
Y0040_ GHHJPMNES_C Updated 06/2022 Page 76 of 275
eletriptan
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: naratriptan, sumatriptan or rizatriptan.
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ELYXYB
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following oral generics: Meloxicam, Diclofenac, Ibuprofen, Naproxen.
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ENABLEX
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: Oxybutynin (IR or ER), Toviaz, Myrbetriq, or Gemtesa.
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epinastine
Criteria Details An automatic approval will be given to members who have had previous trial with at least two of the following agents: olopatadine 0.2%, azelastine, or cromolyn eye drops.
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EPSOLAY
Criteria Details An automatic approval will be given to members who have had previous treatment with topical metronidazole.
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EZALLOR SPRINKLE
Criteria Details An automatic approval will be given to members who have had previous treatment with ezetimibe and one of the following: lovastatin, atorvastatin, rosuvastatin, simvastatin, or pravastatin.
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ezetimibe-rosuvastatin
Criteria Details An automatic approval will be given to members who have had previous treatment with ezetimibe and one of the following: lovastatin, atorvastatin, rosuvastatin, simvastatin, or pravastatin.
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febuxostat
Criteria Details An automatic approval will be given to members who have had previous treatment with Allopurinol.
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fenofibrate micronized
Criteria Details An automatic approval will be given to members who have had previous treatment to one strength of generic fenofibrate tablet (145mg, 160mg, 48mg,54 mg) AND one strength of generic fenofibrate micronized capsule (200 mg, 134 mg, 67 mg).
Y0040_ GHHJPMNES_C Updated 06/2022 Page 85 of 275
fenoprofen
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following oral generics: Meloxicam, Diclofenac, Ibuprofen, Naproxen.
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FEXMID
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with tizanidine tablets AND baclofen tablets.
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FINACEA
Criteria Details An automatic approval will be given to members who have had previous treatment with topical metronidazole.
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FLAREX
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with two of the following eye drops: Durezol 0.05%, prednisolone sodium phosphate 1%, prednisolone acetate 1%, Dexamethasone 0.1%, Fluorometholone 0.1%, Lotemax SM 0.38%.
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FLOLIPID
Criteria Details An automatic approval will be given to members who have had previous treatment with ezetimibe and one of the following: lovastatin, atorvastatin, rosuvastatin, simvastatin, or pravastatin.
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fluvastatin
Criteria Details An automatic approval will be given to members who have had previous treatment with ezetimibe and one of the following: lovastatin, atorvastatin, rosuvastatin, simvastatin, or pravastatin.
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FML FORTE
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with two of the following eye drops: Durezol 0.05%, prednisolone sodium phosphate 1%, prednisolone acetate 1%, Dexamethasone 0.1%, Fluorometholone 0.1%, Lotemax SM 0.38%.
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FML LIQUIFILM
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with two of the following eye drops: Durezol 0.05%, prednisolone sodium phosphate 1%, prednisolone acetate 1%, Dexamethasone 0.1%, Fluorometholone 0.1%, Lotemax SM 0.38%.
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FML S.O.P.
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with two of the following eye drops: Durezol 0.05%, prednisolone sodium phosphate 1%, prednisolone acetate 1%, Dexamethasone 0.1%, Fluorometholone 0.1%, Lotemax SM 0.38%.
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FORFIVO XL
Criteria Details A automatic approval will be given to members who have had prior therapy with a generic bupropion product (75mg/100mg IR, 100mg/150mg/200mg SR, or 150mg/300mg XL) and at least 1 other SSRI, SNRI or mirtazapine.
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FORTAMET
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to metformin IR (generic Glucophage) OR metformin ER (generic Glucophage XR) for at least 3 months.
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FOSAMAX PLUS D
Criteria Details An automatic approval will be given to members who have had previous treatment with Alendronate.
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FOSRENOL
Criteria Details The member has had previous treatment, intolerance to, or contraindication to calcium acetate (tablet OR capsule) AND sevelamer carbonate.
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FROVA
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: naratriptan, sumatriptan or rizatriptan.
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frovatriptan
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: naratriptan, sumatriptan or rizatriptan.
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GELNIQUE
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: Oxybutynin (IR or ER), Toviaz, Myrbetriq, or Gemtesa.
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GLUCAGON (HCL) EMERGENCY KIT
Criteria Details An automatic approval will be given to members who have had previous treatment with GlucaGen Hypokit, Zegalogue, Baqsimi, or Gvoke and documented lack of ability to use preferred product.
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glucagon emergency kit (human)
Criteria Details An automatic approval will be given to members who have had previous treatment with GlucaGen Hypokit, Zegalogue, Baqsimi, or Gvoke and documented lack of ability to use preferred product.
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GLUMETZA
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to metformin IR (generic Glucophage) OR metformin ER (generic Glucophage XR) for at least 3 months.
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GOLYTELY
Criteria Details An automatic approval will be given to members who have had a trial, intolerance, or contraindication to Suprep OR Sutab.
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GRALISE
Criteria Details This applies to new starts only. An automatic approval will be given to members who have had a previous treatment or intolerance to gabapentin AND at least one of the following: Lidocaine 5% topical patch or pregabalin (e.g. Lyrica).
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HUMALOG JUNIOR KWIKPEN U-100
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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HUMALOG KWIKPEN INSULIN
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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HUMALOG MIX 50-50 INSULN U-100
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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HUMALOG MIX 50-50 KWIKPEN
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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HUMALOG MIX 75-25 KWIKPEN
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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HUMALOG MIX 75-25(U-100)INSULN
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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HUMALOG U-100 INSULIN
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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HUMULIN 70/30 U-100 INSULIN
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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HUMULIN 70/30 U-100 KWIKPEN
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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HUMULIN N NPH INSULIN KWIKPEN
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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HUMULIN N NPH U-100 INSULIN
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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HUMULIN R REGULAR U-100 INSULN
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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hydrocodone bitartrate
Criteria Details An automatic approval will be given to members who have had a trial of at least two of the following long acting opioid products: fentanyl patch, morphine ER tab, Xtampza ER, buprenorphine transdermal patch, Belbuca.
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hydromorphone
Criteria Details An automatic approval will be given to members who have had a trial of at least two of the following long acting opioid products: fentanyl patch, morphine ER tab, Xtampza ER, buprenorphine transdermal patch, Belbuca.
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HYSINGLA ER
Criteria Details An automatic approval will be given to members who have had a trial of at least two of the following long acting opioid products: fentanyl patch, morphine ER tab, Xtampza ER, buprenorphine transdermal patch, Belbuca.
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imiquimod
Criteria Details The member has had previous treatment, or intolerance to generic imiquimod 5% cream.
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IMPEKLO
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following topical generic products: triamcinolone, mometasone, fluticasone, betamethasone, or clobetasol.
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INSULIN LISPRO
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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INSULIN LISPRO PROTAMIN-LISPRO
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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INVELTYS
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with two of the following eye drops: Durezol 0.05%, prednisolone sodium phosphate 1%, prednisolone acetate 1%, Dexamethasone 0.1%, Fluorometholone 0.1%, Lotemax SM 0.38%.
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ivermectin
Criteria Details An automatic approval will be given to members who have had previous treatment with topical metronidazole.
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KADIAN
Criteria Details An automatic approval will be given to members who have had a trial of at least two of the following long acting opioid products: fentanyl patch, morphine ER tab, Xtampza ER, buprenorphine transdermal patch, Belbuca.
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KAPSPARGO SPRINKLE
Criteria Details The member has had previous treatment with at least TWO of the following generic beta blockers: carvedilol tablet, atenolol tablet, metoprolol (tartrate OR succinate).
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lanthanum
Criteria Details The member has had previous treatment, intolerance to, or contraindication to calcium acetate (tablet OR capsule) AND sevelamer carbonate.
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LASTACAFT
Criteria Details An automatic approval will be given to members who have had previous trial with at least two of the following agents: olopatadine 0.2%, azelastine, or cromolyn eye drops.
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LESCOL
Criteria Details An automatic approval will be given to members who have had previous treatment with ezetimibe and one of the following: lovastatin, atorvastatin, rosuvastatin, simvastatin, or pravastatin.
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LESCOL XL
Criteria Details An automatic approval will be given to members who have had previous treatment with ezetimibe and one of the following: lovastatin, atorvastatin, rosuvastatin, simvastatin, or pravastatin.
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levalbuterol tartrate
Criteria Details An automatic approval will be given to members who have had previous treatment with generic albuterol HFA and Ventolin HFA.
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levorphanol tartrate
Criteria Details The member has had a trial, intolerance, or contraindication to TWO of the following agents: immediate release formulations of oxycodone, hydromorphone, or morphine sulfate, one of which must have been used within the past 12 months.
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LIALDA
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to two of the following: sulfasalazine, balsalazide capsules, mesalamine enema or mesalamine 0.375g extended-release.
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LIVALO
Criteria Details An automatic approval will be given to members who have had previous treatment with both of the following: Zypitamag and ezetimibe.
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LORZONE
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with tizanidine tablets AND baclofen tablets.
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LOTEMAX
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with two of the following eye drops: Durezol 0.05%, prednisolone sodium phosphate 1%, prednisolone acetate 1%, Dexamethasone 0.1%, Fluorometholone 0.1%, Lotemax SM 0.38%.
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loteprednol etabonate
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with two of the following eye drops: Durezol 0.05%, prednisolone sodium phosphate 1%, prednisolone acetate 1%, Dexamethasone 0.1%, Fluorometholone 0.1%, Lotemax SM 0.38%.
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luliconazole
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months, contraindication, or intolerance to two of the following: clotrimazole cream, ciclopirox 0.77% cream/gel/suspension, or ketoconazole cream.
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LUXIQ
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following topical generic products: triamcinolone, mometasone, fluticasone, betamethasone, or clobetasol.
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LUZU
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months, contraindication, or intolerance to two of the following: clotrimazole cream, ciclopirox 0.77% cream/gel/suspension, or ketoconazole cream.
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LYUMJEV KWIKPEN U-100 INSULIN
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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LYUMJEV KWIKPEN U-200 INSULIN
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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LYUMJEV U-100 INSULIN
Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).
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LYVISPAH
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with tizanidine tablets AND baclofen tablets.
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MAXIDEX
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with two of the following eye drops: Durezol 0.05%, prednisolone sodium phosphate 1%, prednisolone acetate 1%, Dexamethasone 0.1%, Fluorometholone 0.1%, Lotemax SM 0.38%.
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mesalamine
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to two of the following: sulfasalazine, balsalazide capsules, mesalamine enema or mesalamine 0.375g extended-release.
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metformin
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to metformin IR (generic Glucophage) OR metformin ER (generic Glucophage XR) for at least 3 months.
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METROGEL
Criteria Details An automatic approval will be given to members who have had previous treatment with topical metronidazole.
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MICARDIS
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: lisinopril, lisinopril-HCTZ, ramipril, benazepril, benazepril-HCTZ, quinapril, quinapril-HCTZ, enalapril, enalapril-HCTZ, Losartan, Losartan-HCTZ, Valsartan, Valsartan-HCTZ, Irbesartan, Irbesartan-HCTZ, Olmesartan, Olmesartan-HCTZ.
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MICARDIS HCT
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: lisinopril, lisinopril-HCTZ, ramipril, benazepril, benazepril-HCTZ, quinapril, quinapril-HCTZ, enalapril, enalapril-HCTZ, Losartan, Losartan-HCTZ, Valsartan, Valsartan-HCTZ, Irbesartan, Irbesartan-HCTZ, Olmesartan, Olmesartan-HCTZ.
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minocycline
Criteria Details The member has previous treatment or intolerance with a generic immediate-release minocycline formulation.
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MINOLIRA ER
Criteria Details The member has previous treatment or intolerance with a generic immediate-release minocycline formulation.
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MIRAPEX
Criteria Details An automatic approval will be given to members who have had previous treatment with Pramipexole IR AND Ropinirole IR.
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MIRAPEX ER
Criteria Details An automatic approval will be given to members who have had previous treatment with Pramipexole IR AND Ropinirole IR.
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MIRVASO
Criteria Details An automatic approval will be given to members who have had previous treatment with topical metronidazole.
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mometasone
Criteria Details An approval will be given to members who have had previous treatment with two of the following: Fluticasone nasal spray, Azelastine nasal spray, Flunisolide nasal spray. If the member has nasal polyps OR for prophylaxis to seasonal allergic rhinitis, the request will be approved.
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mondoxyne nl
Criteria Details The member has had previous treatment or intolerance with oral immediate release doxycycline (e.g. doxycycline monohydrate 50 mg capsule/tablet, doxycycline 75 mg tablet, 100 mg capsule/tablet).
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MONODOX
Criteria Details The member has had previous treatment or intolerance with oral immediate release doxycycline (e.g. doxycycline monohydrate 50 mg capsule/tablet, doxycycline 75 mg tablet, 100 mg capsule/tablet).
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morgidox
Criteria Details The member has had previous treatment or intolerance with oral immediate release doxycycline (e.g. doxycycline monohydrate 50 mg capsule/tablet, doxycycline 75 mg tablet, 100 mg capsule/tablet).
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MORPHABOND ER
Criteria Details An automatic approval will be given to members who have had a trial of at least two of the following long acting opioid products: fentanyl patch, morphine ER tab, Xtampza ER, buprenorphine transdermal patch, Belbuca.
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morphine
Criteria Details An automatic approval will be given to members who have had a trial of at least two of the following long acting opioid products: fentanyl patch, morphine ER tab, Xtampza ER, buprenorphine transdermal patch, Belbuca.
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MOVIPREP
Criteria Details An automatic approval will be given to members who have had a trial, intolerance, or contraindication to Suprep OR Sutab.
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MOXEZA
Criteria Details The member has had previous treatment within the past 12 months or intolerance to two of the following: ciprofloxacin eye drops, levofloxacin eye drops, moxifloxacin eye drops (generic Vigamox), or ofloxacin eye drops.
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moxifloxacin
Criteria Details The member has had previous treatment within the past 12 months or intolerance to two of the following: ciprofloxacin eye drops, levofloxacin eye drops, moxifloxacin eye drops (generic Vigamox), or ofloxacin eye drops.
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mupirocin calcium
Criteria Details The member has had previous treatment within the past 12 months or intolerance with mupirocin topical ointment.
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naftifine
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months, contraindication, or intolerance to two of the following: clotrimazole cream, ciclopirox 0.77% cream/gel/suspension, or ketoconazole cream.
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NAFTIN
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months, contraindication, or intolerance to two of the following: clotrimazole cream, ciclopirox 0.77% cream/gel/suspension, or ketoconazole cream.
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NALFON
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following oral generics: Meloxicam, Diclofenac, Ibuprofen, Naproxen.
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NAPRELAN CR
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following oral generics: Meloxicam, Diclofenac, Ibuprofen, Naproxen.
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naproxen sodium
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following oral generics: Meloxicam, Diclofenac, Ibuprofen, Naproxen.
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NASONEX
Criteria Details An approval will be given to members who have had previous treatment with two of the following: Fluticasone nasal spray, Azelastine nasal spray, Flunisolide nasal spray. If the member has nasal polyps OR for prophylaxis to seasonal allergic rhinitis, the request will be approved.
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NEVANAC
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months, contraindication, or intolerance to Ilevro ophthalimic solution and one of the following: ketorolac ophthalimic solution or diclofenac ophthalimic solution or Flurbiprofen ophthalimic solution.
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NORITATE
Criteria Details An automatic approval will be given to members who have had previous treatment with topical metronidazole.
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NORLIQVA
Criteria Details Pending CMS Review
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NUCYNTA
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months, contraindication, or intolerance to at least two (2) of the following agents: oxycodone IR, hydromorphone, morphine sulfate IR.
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NUCYNTA ER
Criteria Details An automatic approval will be given to members who have had a trial of at least two of the following long acting opioid products: fentanyl patch, morphine ER tab, Xtampza ER, buprenorphine transdermal patch, Belbuca.
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NULYTELY LEMON-LIME
Criteria Details An automatic approval will be given to members who have had a trial, intolerance, or contraindication to Suprep OR Sutab.
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NULYTELY WITH FLAVOR PACKS
Criteria Details An automatic approval will be given to members who have had a trial, intolerance, or contraindication to Suprep OR Sutab.
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okebo
Criteria Details The member has had previous treatment or intolerance with oral immediate release doxycycline (e.g. doxycycline monohydrate 50 mg capsule/tablet, doxycycline 75 mg tablet, 100 mg capsule/tablet).
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olopatadine
Criteria Details An approval will be given to members who have had previous treatment with two of the following: Fluticasone nasal spray, Azelastine nasal spray, Flunisolide nasal spray. If the member has nasal polyps OR for prophylaxis to seasonal allergic rhinitis, the request will be approved.
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OMECLAMOX-PAK
Criteria Details An automatic approval will be given to members who have had previous treatment, intolerance, or contraindication with Pylera.
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omeprazole-sodium bicarbonate
Criteria Details An approval will be given to members who have had previous treatment or intolerance to omeprazole AND pantoprazole. For the diagnosis of reduction of risk of upper GI bleeding in critically ill patients, pantoprazole therapy is not required.
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OMNARIS
Criteria Details An approval will be given to members who have had previous treatment with two of the following: Fluticasone nasal spray, Azelastine nasal spray, Flunisolide nasal spray. If the member has nasal polyps OR for prophylaxis to seasonal allergic rhinitis, the request will be approved.
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ONZETRA XSAIL
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: naratriptan, sumatriptan or rizatriptan.
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ORACEA
Criteria Details The member has had previous treatment or intolerance with oral immediate release doxycycline (e.g. doxycycline monohydrate 50 mg capsule/tablet, doxycycline 75 mg tablet, 100 mg capsule/tablet).
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OSMOPREP
Criteria Details An automatic approval will be given to members who have had a trial, intolerance, or contraindication to Suprep OR Sutab.
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OXTELLAR XR
Criteria Details An automatic approval will be given to members who have had prior therapy with immediate release oxcarbazepine.
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oxymorphone
Criteria Details An automatic approval will be given to members who have had a trial of at least two of the following long acting opioid products: fentanyl patch, morphine ER tab, Xtampza ER, buprenorphine transdermal patch, Belbuca.
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OXYTROL
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: Oxybutynin (IR or ER), Toviaz, Myrbetriq, or Gemtesa.
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PANCREAZE
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to Creon AND Zenpep.
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PATANASE
Criteria Details An approval will be given to members who have had previous treatment with two of the following: Fluticasone nasal spray, Azelastine nasal spray, Flunisolide nasal spray. If the member has nasal polyps OR for prophylaxis to seasonal allergic rhinitis, the request will be approved.
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peg3350-sod sul-nacl-kcl-asb-c
Criteria Details An automatic approval will be given to members who have had a trial, intolerance, or contraindication to Suprep OR Sutab.
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PENTASA
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to two of the following: sulfasalazine, balsalazide capsules, mesalamine enema or mesalamine 0.375g extended-release.
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PERTZYE
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to Creon AND Zenpep.
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PHOSLYRA
Criteria Details The member has had previous treatment, intolerance to, or contraindication to calcium acetate (tablet OR capsule) AND sevelamer carbonate.
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PLENVU
Criteria Details An automatic approval will be given to members who have had a trial, intolerance, or contraindication to Suprep OR Sutab.
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pramipexole
Criteria Details An automatic approval will be given to members who have had previous treatment with Pramipexole IR AND Ropinirole IR.
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PRED FORTE
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with two of the following eye drops: Durezol 0.05%, prednisolone sodium phosphate 1%, prednisolone acetate 1%, Dexamethasone 0.1%, Fluorometholone 0.1%, Lotemax SM 0.38%.
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PRED MILD
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with two of the following eye drops: Durezol 0.05%, prednisolone sodium phosphate 1%, prednisolone acetate 1%, Dexamethasone 0.1%, Fluorometholone 0.1%, Lotemax SM 0.38%.
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PREPOPIK
Criteria Details An automatic approval will be given to members who have had a trial, intolerance, or contraindication to Suprep OR Sutab.
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PROAIR DIGIHALER
Criteria Details An automatic approval will be given to members who have had previous treatment with generic albuterol HFA and Ventolin HFA.
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PROAIR HFA
Criteria Details An automatic approval will be given to members who have had previous treatment with generic albuterol HFA and Ventolin HFA.
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PROAIR RESPICLICK
Criteria Details An automatic approval will be given to members who have had previous treatment with generic albuterol HFA and Ventolin HFA.
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PROLENSA
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months, contraindication, or intolerance to Ilevro ophthalimic solution and one of the following: ketorolac ophthalimic solution or diclofenac ophthalimic solution or Flurbiprofen ophthalimic solution.
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PROVENTIL HFA
Criteria Details An automatic approval will be given to members who have had previous treatment with generic albuterol HFA and Ventolin HFA.
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PULMICORT FLEXHALER
Criteria Details An automatic approval will be given to members who have had previous treatment with Flovent HFA/Diskus and Arnuity Ellipta
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QNASL
Criteria Details An approval will be given to members who have had previous treatment with two of the following: Fluticasone nasal spray, Azelastine nasal spray, Flunisolide nasal spray. If the member has nasal polyps OR for prophylaxis to seasonal allergic rhinitis, the request will be approved.
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QVAR REDIHALER
Criteria Details An automatic approval will be given to members who have had previous treatment with Flovent HFA/Diskus and Arnuity Ellipta
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ramelteon
Criteria Details The member has had previous treatment, intolerance or contraindication with Belsomra or trazodone.
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RELAFEN
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following oral generics: Meloxicam, Diclofenac, Ibuprofen, Naproxen.
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RELAFEN DS
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following oral generics: Meloxicam, Diclofenac, Ibuprofen, Naproxen.
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RELPAX
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: naratriptan, sumatriptan or rizatriptan.
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RENAGEL
Criteria Details The member has had previous treatment, intolerance to, or contraindication to calcium acetate (tablet OR capsule) AND sevelamer carbonate.
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REQUIP XL
Criteria Details An automatic approval will be given to members who have had previous treatment with Pramipexole IR AND Ropinirole IR.
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RHOFADE
Criteria Details An automatic approval will be given to members who have had previous treatment with topical metronidazole.
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RHOPRESSA
Criteria Details An automatic approval will be given to members who have had previous treatment, contraindication, or intolerance to a prostaglandin analog.
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ROCKLATAN
Criteria Details An automatic approval will be given to members who have had previous treatment, contraindication, or intolerance to a prostaglandin analog.
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ropinirole
Criteria Details An automatic approval will be given to members who have had previous treatment with Pramipexole IR AND Ropinirole IR.
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rosadan
Criteria Details An automatic approval will be given to members who have had previous treatment with topical metronidazole.
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ROSZET
Criteria Details An automatic approval will be given to members who have had previous treatment with ezetimibe and one of the following: lovastatin, atorvastatin, rosuvastatin, simvastatin, or pravastatin.
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ROZEREM
Criteria Details The member has had previous treatment, intolerance or contraindication with Belsomra or trazodone.
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RYTARY
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to an immediate-release or extended-release Carbidopa-Levodopa containing product.
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sevelamer hcl
Criteria Details The member has had previous treatment, intolerance to, or contraindication to calcium acetate (tablet OR capsule) AND sevelamer carbonate.
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SEYSARA
Criteria Details The member has previous treatment or intolerance with a generic immediate-release minocycline formulation.
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SIMBRINZA
Criteria Details An automatic approval will be given to members who have had previous treatment with: Brimonidine ophthalimic solution AND dorzolamide ophthalimic solution.
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SOAANZ
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: furosemide tablet, bumetanide table, or torsemide tablet.
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SOLODYN
Criteria Details The member has previous treatment or intolerance with a generic immediate-release minocycline formulation.
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SOOLANTRA
Criteria Details An automatic approval will be given to members who have had previous treatment with topical metronidazole.
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SORILUX
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following topical generic products: triamcinolone, mometasone, fluticasone, betamethasone, or clobetasol.
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SPRITAM
Criteria Details An automatic approval will be given to members who have had prior therapy with levetiracetam and one of the following: lamotrigine, carbamazepine, topiramate, divalproex, or phenytoin.
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sumatriptan-naproxen
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: naratriptan, sumatriptan or rizatriptan.
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TALICIA
Criteria Details An automatic approval will be given to members who have had previous treatment, intolerance, or contraindication with Pylera.
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TARGADOX
Criteria Details The member has had previous treatment or intolerance with oral immediate release doxycycline (e.g. doxycycline monohydrate 50 mg capsule/tablet, doxycycline 75 mg tablet, 100 mg capsule/tablet).
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TEKTURNA HCT
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: lisinopril, lisinopril-HCTZ, ramipril, benazepril, benazepril-HCTZ, quinapril, quinapril-HCTZ, enalapril, enalapril-HCTZ, Losartan, Losartan-HCTZ, Valsartan, Valsartan-HCTZ, Irbesartan, Irbesartan-HCTZ, Olmesartan, Olmesartan-HCTZ.
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telmisartan-hydrochlorothiazid
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: lisinopril, lisinopril-HCTZ, ramipril, benazepril, benazepril-HCTZ, quinapril, quinapril-HCTZ, enalapril, enalapril-HCTZ, Losartan, Losartan-HCTZ, Valsartan, Valsartan-HCTZ, Irbesartan, Irbesartan-HCTZ, Olmesartan, Olmesartan-HCTZ.
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TIMOPTIC
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following eye drops: LEVOBUNOLOL 0.5%, TIMOLOL 0.25%, TIMOLOL 0.5%, BETAXOLOL HCL 0.5%.
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TIMOPTIC OCUDOSE (PF)
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following eye drops: LEVOBUNOLOL 0.5%, TIMOLOL 0.25%, TIMOLOL 0.5%, BETAXOLOL HCL 0.5%.
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TIVORBEX
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following oral generics: Meloxicam, Diclofenac, Ibuprofen, Naproxen.
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tizanidine
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with tizanidine tablets AND baclofen tablets.
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TOSYMRA
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: naratriptan, sumatriptan or rizatriptan.
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tramadol
Criteria Details An automatic approval will be given to members who have had a trial with immediate release tramadol AND extended release tramadol tablets.
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TRAVATAN Z
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: latanoprost, travaprost, Lumigan, Rocklatan, or Vyzulta.
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TREXIMET
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: naratriptan, sumatriptan or rizatriptan.
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TRINTELLIX
Criteria Details An automatic approval will be given to members who have had prior therapy, intolerance, or contraindication with a generic SSRI, SNRI, a generic bupropion product (75mg/100mg IR, 100mg/150mg/200mg SR, or 150mg/300mg XL) or mirtazapine.
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ULORIC
Criteria Details An automatic approval will be given to members who have had previous treatment with Allopurinol.
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VALSARTAN
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: lisinopril, lisinopril-HCTZ, ramipril, benazepril, benazepril-HCTZ, quinapril, quinapril-HCTZ, enalapril, enalapril-HCTZ, Losartan, Losartan-HCTZ, Valsartan, Valsartan-HCTZ, Irbesartan, Irbesartan-HCTZ, Olmesartan, Olmesartan-HCTZ.
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VECTICAL
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following topical generic products: triamcinolone, mometasone, fluticasone, betamethasone, or clobetasol.
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VELPHORO
Criteria Details The member has had previous treatment, intolerance to, or contraindication to calcium acetate (tablet OR capsule) AND sevelamer carbonate.
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VIBRAMYCIN (CALCIUM)
Criteria Details The member has had previous treatment or intolerance with oral immediate release doxycycline (e.g. doxycycline monohydrate 50 mg capsule/tablet, doxycycline 75 mg tablet, 100 mg capsule/tablet).
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VIBRAMYCIN (MONO)
Criteria Details The member has had previous treatment or intolerance with oral immediate release doxycycline (e.g. doxycycline monohydrate 50 mg capsule/tablet, doxycycline 75 mg tablet, 100 mg capsule/tablet).
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VIOKACE
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to Creon AND Zenpep.
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VOQUEZNA DUAL PAK
Criteria Details An automatic approval will be given to members who have had previous treatment, intolerance, or contraindication with Pylera.
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VOQUEZNA TRIPLE PAK
Criteria Details An automatic approval will be given to members who have had previous treatment, intolerance, or contraindication with Pylera.
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XELPROS
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: latanoprost, travaprost, Lumigan, Rocklatan, or Vyzulta.
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XIMINO
Criteria Details The member has previous treatment or intolerance with a generic immediate-release minocycline formulation.
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XOPENEX HFA
Criteria Details An automatic approval will be given to members who have had previous treatment with generic albuterol HFA and Ventolin HFA.
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ZANAFLEX
Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with tizanidine tablets AND baclofen tablets.
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ZEGERID
Criteria Details An approval will be given to members who have had previous treatment or intolerance to omeprazole AND pantoprazole. For the diagnosis of reduction of risk of upper GI bleeding in critically ill patients, pantoprazole therapy is not required.
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ZEMBRACE SYMTOUCH
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: naratriptan, sumatriptan or rizatriptan.
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ZETONNA
Criteria Details An approval will be given to members who have had previous treatment with two of the following: Fluticasone nasal spray, Azelastine nasal spray, Flunisolide nasal spray. If the member has nasal polyps OR for prophylaxis to seasonal allergic rhinitis, the request will be approved.
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zileuton
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to montelukast AND zafirlukast.
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ZIOPTAN (PF)
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: latanoprost, travaprost, Lumigan, Rocklatan, or Vyzulta.
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ZIPSOR
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following oral generics: Meloxicam, Diclofenac, Ibuprofen, Naproxen.
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ZOHYDRO ER
Criteria Details An automatic approval will be given to members who have had a trial of at least two of the following long acting opioid products: fentanyl patch, morphine ER tab, Xtampza ER, buprenorphine transdermal patch, Belbuca.
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zolmitriptan
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: naratriptan, sumatriptan or rizatriptan.
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ZOMIG
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: naratriptan, sumatriptan or rizatriptan.
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ZOMIG ZMT
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: naratriptan, sumatriptan or rizatriptan.
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ZORVOLEX
Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following oral generics: Meloxicam, Diclofenac, Ibuprofen, Naproxen.
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ZYCLARA
Criteria Details The member has had previous treatment, or intolerance to generic imiquimod 5% cream.
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ZYFLO
Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to montelukast AND zafirlukast.
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ZYMAXID
Criteria Details The member has had previous treatment within the past 12 months or intolerance to two of the following: ciprofloxacin eye drops, levofloxacin eye drops, moxifloxacin eye drops (generic Vigamox), or ofloxacin eye drops.
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ZYPITAMAG
Criteria Details An automatic approval will be given to members who have had previous treatment with one of the following statins: simvastatin, pravastatin, lovastatin, atorvastatin or rosuvastatin.
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