Step Therapy Criteria - lmchealthplans.comSoliqua 100/33 100 unit-33 mcg/mL subcutaneous insulin pen Xultophy 100/3.6 100 unit-3.6 mg/mL (3 mL) subcutaneous insulin pen. Details. Criteria

FID 20089

2020 Step Therapy

1

ANTIDEPRESSANTS,

SEROTONIN/NOREPINEPHRINE REUPTAKE

INHIBITORS LEON 2020

Products Affected

Step 1: bupropion HCl 100 mg tablet

bupropion HCl 75 mg tablet

bupropion HCl SR 100 mg tablet,12 hr

sustained-release


sustained-release


sustained-release

bupropion HCl XL 150 mg 24 hr tablet,

extended release


extended release

citalopram 10 mg tablet

citalopram 10 mg/5 mL oral solution



duloxetine 20 mg capsule,delayed release




escitalopram 10 mg tablet



escitalopram 5 mg/5 mL oral solution

fluoxetine 10 mg capsule

fluoxetine 10 mg tablet


fluoxetine 20 mg tablet

fluoxetine 20 mg/5 mL (4 mg/mL) oral

solution


fluoxetine 90 mg capsule,delayed release

fluvoxamine 100 mg tablet



fluvoxamine ER 100 mg capsule,extended

release 24 hr


release 24 hr

mirtazapine 15 mg disintegrating tablet

mirtazapine 15 mg tablet





mirtazapine 7.5 mg tablet

paroxetine 10 mg tablet




paroxetine ER 12.5 mg tablet,extended

release 24 hr

paroxetine ER 25 mg tablet,extended

release 24 hr


release 24 hr

sertraline 100 mg tablet

sertraline 20 mg/mL oral concentrate



trazodone 100 mg tablet




venlafaxine 100 mg tablet


venlafaxine 37.5 mg tablet



venlafaxine ER 150 mg capsule,extended

release 24 hr

venlafaxine ER 150 mg tablet,extended

release 24 hr


release 24 hr

2

venlafaxine ER 37.5 mg capsule,extended

release 24 hr

venlafaxine ER 37.5 mg tablet,extended

release 24 hr


release 24 hr


release 24 hr

Step 2: desvenlafaxine ER 100 mg tablet,extended

release 24 hr

desvenlafaxine ER 50 mg tablet,extended

release 24 hr

desvenlafaxine succinate ER 100 mg

tablet,extended release 24 hr





Fetzima 120 mg capsule,extended release

Fetzima 20 mg (2)-40 mg (26)

capsule,extended release,24 hr,dose pack




Paxil 10 mg/5 mL oral suspension

Trintellix 10 mg tablet



Viibryd 10 mg (7)-20 mg (23) tablets in a

dose pack

Viibryd 10 mg tablet



Details

Criteria Step-1 Drugs: bupropion, citalopram, duloxetine, escitalopram,

fluoxetine, fluvoxamine, mirtazapine, paroxetine, sertraline, trazodone

and venlafaxine. Step-2 Drugs: desvenlafaxine er, Fetzima, Paxil

Suspension, Trintellix and Viibryd. The member must have tried a 30 day

supply or more of at least two Step-1 drugs within the same step therapy

group within the previous 180 days as evidenced by a previous paid claim

under the prescription benefit or by physician documented use. Step-2

drugs are not covered unless the above step therapy criteria are met.

Patients who are currently taking or who have taken a step 2 drug at any

time in the past and discontinued their use may receive authorization

without trials of step 1 drugs. For patients with suicidal ideation, step 1

drugs do not need to be tried.

3

BETA-ADRENERGIC BLOCKING AGENTS LEON

2020

Products Affected

Step 1: carvedilol 12.5 mg tablet

carvedilol 25 mg tablet

carvedilol 3.125 mg tablet

carvedilol 6.25 mg tablet

Step 2: carvedilol phosphate ER 10 mg

capsule,ext.release24hr multiphase

carvedilol phosphate ER 20 mg






Details

Criteria Step-1 Drug: carvedilol tabs. Step-2 Drug: carvedilol ER caps. The

member must have tried a 30 day supply or more of one Step-1 drug

within the same step therapy group within the previous 130 days as

evidenced by a previous paid claim under the prescription benefit or by

physician documented use. Step-2 drug is not covered unless the above

step therapy criteria are met.

4

FIBRINIC ACID DERIVATIVES LEON 2020

Products Affected

Step 1: fenofibrate 150 mg capsule

fenofibrate 160 mg tablet

fenofibrate 50 mg capsule

fenofibrate 54 mg tablet

fenofibrate micronized 130 mg capsule





fenofibrate nanocrystallized 145 mg tablet

fenofibrate nanocrystallized 48 mg tablet

fenofibric acid (choline) 135 mg

capsule,delayed release



fenofibric acid 105 mg tablet

fenofibric acid 35 mg tablet

gemfibrozil 600 mg tablet

Step 2: fenofibrate 120 mg tablet fenofibrate 40 mg tablet

Details

Criteria Step-1 Drugs: fenofibrate 43mg, 48mg, 50mg, 54mg, 67mg, 130mg,

134mg, 145mg, 150mg, 160mg, 200mg and fenofibrinic acid 35mg,

45mg, 105mg, 135mg and gemfibrozil. Step-2 Drugs: fenofibrate 40mg

and 120mg. The member must have tried a 30 day supply or more of at

least one Step-1 drug within the same step therapy group within the

previous 130 days as evidenced by a previous paid claim under the

prescription benefit or by physician documented use. Step-2 drugs are not

covered unless the above step therapy criteria are met.

5

INJECTABLE DIABETIC COMBINATIONS LEON

2020

Products Affected

Step 1: Bydureon 2 mg/0.65 mL subcutaneous

pen injector

Bydureon BCise 2 mg/0.85 mL

subcutaneous auto-injector

Humulin 70/30 U-100 Insulin 100 unit/mL

subcutaneous suspension

Humulin 70/30 U-100 Insulin KwikPen

100 unit/mL subcutaneous

Humulin N NPH U-100 Insulin (isophane

susp) 100 unit/mL subcutaneous

Humulin N NPH U-100 Insulin KwikPen

100 unit/mL (3 mL) subcutaneous

Lantus Solostar U-100 Insulin 100

unit/mL (3 mL) subcutaneous pen

Lantus U-100 Insulin 100 unit/mL

subcutaneous solution

Levemir FlexTouch U-100 Insulin 100


Levemir U-100 Insulin 100 unit/mL


Ozempic 0.25 mg or 0.5 mg (2 mg/1.5

mL) subcutaneous pen injector

Ozempic 1 mg/dose (2 mg/1.5 mL)

subcutaneous pen injector

Toujeo Max U-300 SoloStar 300 unit/mL

(3 mL) subcutaneous insulin pen

Toujeo SoloStar U-300 Insulin 300

unit/mL (1.5 mL) subcutaneous pen

Tresiba FlexTouch U-100 insulin 100




Tresiba U-100 Insulin 100 unit/mL


Trulicity 0.75 mg/0.5 mL subcutaneous

pen injector

Trulicity 1.5 mg/0.5 mL subcutaneous pen

injector

Victoza 3-Pak 0.6 mg/0.1 mL (18 mg/3

mL) subcutaneous pen injector

Step 2: Soliqua 100/33 100 unit-33 mcg/mL

subcutaneous insulin pen

Xultophy 100/3.6 100 unit-3.6 mg/mL (3

mL) subcutaneous insulin pen

Details

Criteria Step-1 Drugs: basal insulin or GLP-1 agonist. Step-2 Drugs: Soliqua

and Xultophy. The member must have tried a 30 day supply or more of

any one Step-1 drug within the same step therapy group within the


prescription benefit or by physician documented use. Step-2 drug is not


6

METABOLIC BONE DISEASE AGENTS LEON

2020

Products Affected

Step 1: alendronate 10 mg tablet

alendronate 35 mg tablet




alendronate 70 mg/75 mL oral solution

ibandronate 150 mg tablet

Step 2: Binosto 70 mg effervescent tablet

Fosamax Plus D 70 mg-2,800 unit tablet

Fosamax Plus D 70 mg-5,600 unit tablet

risedronate 150 mg tablet



risedronate 35 mg tablet (12 pack)

risedronate 35 mg tablet (4 pack)

risedronate 35 mg tablet,delayed release


Details

Criteria Step-1 Drugs: alendronate sodium tablets and solution, and ibandronate

sodium tablets. Step-2 Drugs: Binosto, Fosamax Plus D and risedronate

sodium tablets. The member must have tried a 30 day supply or more of

at least two Step-1 drugs within the same step therapy group within the



covered unless the above step therapy criteria are met, or unless the

diagnosis is Paget's Disease, osteoporosis in men, or glucocorticoid-

induced osteoporosis, in which case the member would only need to try a

30 day supply of alendronate within the previous 180 days before

risedronate would be covered.

7

OPHTHALMIC ANTIGLAUCOMA AGENTS LEON

2020

Products Affected

Step 1: dorzolamide 2 % eye drops

Step 2: Azopt 1 % eye drops,suspension

Details

Criteria Step-1 Drugs: dorzolamide. Step-2 Drug: Azopt (brinzolamide). The






8

OPHTHALMIC ANTIHISTAMINES LEON 2020

Products Affected

Step 1: ketotifen 0.025 % (0.035 %) eye drops

olopatadine 0.1 % eye drops

olopatadine 0.2 % eye drops

Step 2: azelastine 0.05 % eye drops

epinastine 0.05 % eye drops

Pazeo 0.7 % eye drops

Details

Criteria Step-1 Drugs: ketotifen fumarate OTC, olopatadine 0.1%, and

olopatadine 0.2%. Step-2 Drugs: azelastine, epinastine, and Pazeo

(olopatadine 0.7%). The member must have tried a 30 day supply or

more of at least two Step-1 drugs within the same step therapy group

within the previous 90 days as evidenced by a previous paid claim under

the prescription benefit or by physician documented use. Step-2 drugs are

not covered unless the above step therapy criteria are met.

9

PROTON PUMP INHIBITORS LEON 2020

Products Affected

Step 1: esomeprazole magnesium 20 mg


esomeprazole magnesium 40 mg


lansoprazole 15 mg capsule,delayed

release

lansoprazole 15 mg delayed

release,disintegrating tablet

lansoprazole 30 mg capsule,delayed

release


release,disintegrating tablet

omeprazole 10 mg capsule,delayed release



pantoprazole 20 mg tablet,delayed release

pantoprazole 40 mg tablet,delayed release

rabeprazole 20 mg tablet,delayed release

Step 2: Dexilant 30 mg capsule, delayed release

Dexilant 60 mg capsule, delayed release

Protonix 40 mg granules delayed-release

packet

Details

Criteria Step-1 Drugs: esomeprazole magnesium, lansoprazole, Rx omeprazole,

pantoprazole and rabeprazole. Step-2 Drugs: Dexilant and Protonix

Granules (pantoprazole). The member must have tried a 30 day supply or

more of at least two Step-1 drugs within the same step therapy group

within the previous 180 days as evidenced by a previous paid claim under

the prescription benefit or by physician documented use. Step-2 drugs are

not covered unless the above step therapy criteria are met.

10

RHOPRESSA/ROCKLATAN LEON 2020

Products Affected

Step 1: Alphagan P 0.1 % eye drops

Azopt 1 % eye drops,suspension

betaxolol 0.5 % eye drops

Betimol 0.25 % eye drops

Betimol 0.5 % eye drops

Betoptic S 0.25 % eye drops,suspension

bimatoprost 0.03 % eye drops

brimonidine 0.15 % eye drops

brimonidine 0.2 % eye drops

carteolol 1 % eye drops

Combigan 0.2 %-0.5 % eye drops

dorzolamide 2 % eye drops

dorzolamide 22.3 mg-timolol 6.8 mg/mL

eye drops

dorzolamide-timolol (PF) 2 %-0.5 % eye

drops in a dropperette

latanoprost 0.005 % eye drops

levobunolol 0.5 % eye drops

Lumigan 0.01 % eye drops

Phospholine Iodide 0.125 % eye drops

pilocarpine 1 % eye drops



Simbrinza 1 %-0.2 % eye

drops,suspension

timolol maleate 0.25 % eye drops

timolol maleate 0.25 % eye gel forming

solution

timolol maleate 0.5 % eye drops


solution

Timoptic Ocudose (PF) 0.5 % eye drops in

a dropperette

travoprost 0.004 % eye drops

Step 2: Rhopressa 0.02 % eye drops Rocklatan 0.02 %-0.005 % eye drops

Details

Criteria Step-1 Drugs: Alphagan P, Azopt, betaxolol, betimol, betopic-S,

bimatoprost, brimonidine, carteolol, Combigan, dorzolamide,

dorzolamide/timolol, dorzolamide/timolol PF, latanoprost, levobunolol,

Lumigan, phospholine iodide, pilocarpine, Simbrinza, timolol, timolol

ophthalmic gel forming solution, Timoptic Ocudose, travoprost. Step-2

Drugs: Rocklatan, Rhopressa. The member must have tried a 30 day

supply or more of at least one Step-1 drug within the same step therapy

group within the previous 180 days as evidenced by a previous paid claim

under the prescription benefit or by physician documented use. Step-2

drugs are not covered unless the above step therapy criteria are met.

11

TOPICAL ANTIFUNGAL DRUGS LEON 2020

Products Affected

Step 1: ciclopirox 0.77 % topical cream

ciclopirox 0.77 % topical suspension

ciclopirox 8 % topical solution

clotrimazole 1 % topical cream

ketoconazole 2 % shampoo

ketoconazole 2 % topical cream

miconazole nitrate 2 % topical cream

miconazole nitrate 2 % topical spray

powder

Remedy Antifungal 2 % topical powder

Step 2: ciclopirox 0.77 % topical gel

ciclopirox 1 % shampoo

Ertaczo 2 % topical cream

luliconazole 1 % topical cream

Luzu 1 % topical cream

naftifine 1 % topical cream

naftifine 2 % topical cream

oxiconazole 1 % topical cream

Oxistat 1 % lotion

Details

Criteria Step-1 Drugs: ciclopirox 0.77% topical suspension, ciclopirox 0.77%

cream, ciclopirox 8% solution, clotrimazole OTC, ketoconazole 2%

cream, ketoconazole 2% shampoo and miconazole OTC. Step-2 Drugs:

ciclopirox 0.77% gel, ciclopirox 1% shampoo, Ertaczo, luliconazole 1%

cream, Luzu 1% cream, naftifine 1% cream, naftifine 2% cream,

oxiconazole nitrate 1% cream and Oxistat 1% lotion. The member must

have tried a 30 day supply or more of at least two Step-1 drugs within the

same step therapy group within the previous 180 days as evidenced by a

previous paid claim under the prescription benefit or by physician

documented use. Step-2 drugs are not covered unless the above step

therapy criteria are met.

12

TOPICAL ANTI-INFLAMMATORIES LEON 2020

Products Affected

Step 1: fluocinonide 0.05 % topical gel

fluocinonide 0.05 % topical ointment

fluocinonide 0.1 % topical cream

Fluocinonide-E 0.05 % topical cream

mometasone 0.1 % topical cream

mometasone 0.1 % topical ointment

triamcinolone acetonide 0.025 % lotion

triamcinolone acetonide 0.025 % topical

cream


ointment

triamcinolone acetonide 0.1 % lotion


cream


ointment


cream


ointment

Triderm 0.1 % topical cream

Step 2: desoximetasone 0.05 % topical cream

desoximetasone 0.05 % topical gel

desoximetasone 0.05 % topical ointment

desoximetasone 0.25 % topical cream

desoximetasone 0.25 % topical ointment

Details

Criteria Step-1 Drugs: fluocinonide (ointment, gel, cream), fluocinonide-E cream,

mometasone (cream, ointment), triamcinolone (cream, lotion, ointment)

and Triderm cream. Step-2 Drug: desoximetasone (cream, gel,

ointment). The member must have tried a 30 day supply or more of at

least one Step-1 drug within the same step therapy group within the




13

XHANCE LEON 2020

Products Affected

Step 1: mometasone 50 mcg/actuation nasal spray

Step 2: Xhance 93 mcg/actuation breath activated

aerosol

Details

Criteria Step-1 Drug: mometasone furoate nasal spray. Step-2 Drug: Xhance. The






14

Index

A alendronate 10 mg tablet ............................. 6

alendronate 35 mg tablet ............................. 6


alendronate 5 mg tablet ............................... 6


alendronate 70 mg/75 mL oral solution ...... 6

Alphagan P 0.1 % eye drops ..................... 10

azelastine 0.05 % eye drops ........................ 8

Azopt 1 % eye drops,suspension .......... 7, 10

B betaxolol 0.5 % eye drops ......................... 10

Betimol 0.25 % eye drops ......................... 10

Betimol 0.5 % eye drops ........................... 10

Betoptic S 0.25 % eye drops,suspension .. 10

bimatoprost 0.03 % eye drops ................... 10

Binosto 70 mg effervescent tablet ............... 6

brimonidine 0.15 % eye drops .................. 10

brimonidine 0.2 % eye drops .................... 10

bupropion HCl 100 mg tablet ................. 1, 2

bupropion HCl 75 mg tablet ................... 1, 2


sustained-release ................................. 1, 2






extended release .................................. 1, 2


extended release .................................. 1, 2

Bydureon 2 mg/0.65 mL subcutaneous pen

injector .................................................... 5

Bydureon BCise 2 mg/0.85 mL

subcutaneous auto-injector ...................... 5

C carteolol 1 % eye drops ............................. 10

carvedilol 12.5 mg tablet............................. 3

carvedilol 25 mg tablet................................ 3

carvedilol 3.125 mg tablet........................... 3

carvedilol 6.25 mg tablet............................. 3


capsule,ext.release24hr multiphase ......... 3







ciclopirox 0.77 % topical cream ............... 11

ciclopirox 0.77 % topical gel .................... 11

ciclopirox 0.77 % topical suspension........ 11

ciclopirox 1 % shampoo............................ 11

ciclopirox 8 % topical solution ................. 11

citalopram 10 mg tablet .......................... 1, 2

citalopram 10 mg/5 mL oral solution...... 1, 2



clotrimazole 1 % topical cream ................. 11

Combigan 0.2 %-0.5 % eye drops ............ 10

D desoximetasone 0.05 % topical cream ...... 12

desoximetasone 0.05 % topical gel ........... 12

desoximetasone 0.05 % topical ointment.. 12

desoximetasone 0.25 % topical cream ...... 12

desoximetasone 0.25 % topical ointment.. 12


release 24 hr ............................................ 2


release 24 hr ............................................ 2


tablet,extended release 24 hr ................... 2





Dexilant 30 mg capsule, delayed release .... 9

Dexilant 60 mg capsule, delayed release .... 9

dorzolamide 2 % eye drops ................... 7, 10

dorzolamide 22.3 mg-timolol 6.8 mg/mL

eye drops ............................................... 10

dorzolamide-timolol (PF) 2 %-0.5 % eye

drops in a dropperette............................ 10

duloxetine 20 mg capsule,delayed release . 1,

2


2

15


2


2

E epinastine 0.05 % eye drops........................ 8

Ertaczo 2 % topical cream ........................ 11

escitalopram 10 mg tablet ....................... 1, 2

escitalopram 20 mg tablet ....................... 1, 2

escitalopram 5 mg tablet ......................... 1, 2

escitalopram 5 mg/5 mL oral solution .... 1, 2


capsule,delayed release ........................... 9



F fenofibrate 120 mg tablet ............................ 4

fenofibrate 150 mg capsule ......................... 4

fenofibrate 160 mg tablet ............................ 4

fenofibrate 40 mg tablet .............................. 4

fenofibrate 50 mg capsule ........................... 4

fenofibrate 54 mg tablet .............................. 4

fenofibrate micronized 130 mg capsule ...... 4



fenofibrate micronized 43 mg capsule ........ 4

fenofibrate micronized 67 mg capsule ........ 4

fenofibrate nanocrystallized 145 mg tablet . 4

fenofibrate nanocrystallized 48 mg tablet ... 4





fenofibric acid 105 mg tablet ...................... 4

fenofibric acid 35 mg tablet ........................ 4

Fetzima 120 mg capsule,extended release .. 2

Fetzima 20 mg (2)-40 mg (26)

capsule,extended release,24 hr,dose pack 2

Fetzima 20 mg capsule,extended release .... 2



fluocinonide 0.05 % topical gel ................ 12

fluocinonide 0.05 % topical ointment ....... 12

fluocinonide 0.1 % topical cream ............. 12

Fluocinonide-E 0.05 % topical cream ....... 12

fluoxetine 10 mg capsule ........................ 1, 2

fluoxetine 10 mg tablet ........................... 1, 2


fluoxetine 20 mg tablet ........................... 1, 2

fluoxetine 20 mg/5 mL (4 mg/mL) oral

solution ................................................ 1, 2


fluoxetine 90 mg capsule,delayed release1, 2

fluvoxamine 100 mg tablet ..................... 1, 2

fluvoxamine 25 mg tablet ....................... 1, 2

fluvoxamine 50 mg tablet ....................... 1, 2


release 24 hr ........................................ 1, 2


release 24 hr ........................................ 1, 2

Fosamax Plus D 70 mg-2,800 unit tablet .... 6

Fosamax Plus D 70 mg-5,600 unit tablet .... 6

G gemfibrozil 600 mg tablet ........................... 4

H Humulin 70/30 U-100 Insulin 100 unit/mL

subcutaneous suspension ........................ 5

Humulin 70/30 U-100 Insulin KwikPen 100

unit/mL subcutaneous ............................. 5

Humulin N NPH U-100 Insulin (isophane

susp) 100 unit/mL subcutaneous ............. 5

Humulin N NPH U-100 Insulin KwikPen

100 unit/mL (3 mL) subcutaneous .......... 5

I ibandronate 150 mg tablet ........................... 6

K ketoconazole 2 % shampoo ....................... 11

ketoconazole 2 % topical cream ............... 11

ketotifen 0.025 % (0.035 %) eye drops....... 8

L lansoprazole 15 mg capsule,delayed release9


release,disintegrating tablet..................... 9

lansoprazole 30 mg capsule,delayed release9


release,disintegrating tablet..................... 9

Lantus Solostar U-100 Insulin 100 unit/mL

(3 mL) subcutaneous pen ........................ 5

Lantus U-100 Insulin 100 unit/mL

subcutaneous solution ............................. 5

latanoprost 0.005 % eye drops .................. 10

16

Levemir FlexTouch U-100 Insulin 100

unit/mL (3 mL) subcutaneous pen .......... 5

Levemir U-100 Insulin 100 unit/mL


levobunolol 0.5 % eye drops ..................... 10

luliconazole 1 % topical cream ................. 11

Lumigan 0.01 % eye drops ....................... 10

Luzu 1 % topical cream ............................ 11

M miconazole nitrate 2 % topical cream ....... 11

miconazole nitrate 2 % topical spray powder

............................................................... 11

mirtazapine 15 mg disintegrating tablet .. 1, 2

mirtazapine 15 mg tablet ......................... 1, 2





mirtazapine 7.5 mg tablet ........................ 1, 2

mometasone 0.1 % topical cream ............. 12

mometasone 0.1 % topical ointment ......... 12

mometasone 50 mcg/actuation nasal spray 13

N naftifine 1 % topical cream ....................... 11

naftifine 2 % topical cream ....................... 11

O olopatadine 0.1 % eye drops ....................... 8

olopatadine 0.2 % eye drops ....................... 8

omeprazole 10 mg capsule,delayed release 9



oxiconazole 1 % topical cream ................. 11

Oxistat 1 % lotion ..................................... 11

Ozempic 0.25 mg or 0.5 mg (2 mg/1.5 mL)

subcutaneous pen injector ....................... 5

Ozempic 1 mg/dose (2 mg/1.5 mL)


P pantoprazole 20 mg tablet,delayed release . 9

pantoprazole 40 mg tablet,delayed release . 9

paroxetine 10 mg tablet ........................... 1, 2





release 24 hr ........................................ 1, 2

paroxetine ER 25 mg tablet,extended release

24 hr .................................................... 1, 2


release 24 hr ........................................ 1, 2

Paxil 10 mg/5 mL oral suspension .............. 2

Pazeo 0.7 % eye drops ................................ 8

Phospholine Iodide 0.125 % eye drops ..... 10

pilocarpine 1 % eye drops ......................... 10



Protonix 40 mg granules delayed-release

packet ...................................................... 9

R rabeprazole 20 mg tablet,delayed release ... 9

Remedy Antifungal 2 % topical powder ... 11

Rhopressa 0.02 % eye drops ..................... 10

risedronate 150 mg tablet ............................ 6

risedronate 30 mg tablet .............................. 6

risedronate 35 mg tablet .............................. 6

risedronate 35 mg tablet (12 pack) .............. 6

risedronate 35 mg tablet (4 pack) ................ 6

risedronate 35 mg tablet,delayed release .... 6

risedronate 5 mg tablet ................................ 6

Rocklatan 0.02 %-0.005 % eye drops ....... 10

S sertraline 100 mg tablet ........................... 1, 2

sertraline 20 mg/mL oral concentrate ..... 1, 2

sertraline 25 mg tablet ............................. 1, 2

sertraline 50 mg tablet ............................. 1, 2

Simbrinza 1 %-0.2 % eye drops,suspension

............................................................... 10

Soliqua 100/33 100 unit-33 mcg/mL

subcutaneous insulin pen ........................ 5

T timolol maleate 0.25 % eye drops ............. 10


solution .................................................. 10

timolol maleate 0.5 % eye drops ............... 10


solution .................................................. 10

Timoptic Ocudose (PF) 0.5 % eye drops in a

dropperette ............................................ 10

Toujeo Max U-300 SoloStar 300 unit/mL (3

mL) subcutaneous insulin pen ................ 5

Toujeo SoloStar U-300 Insulin 300 unit/mL

(1.5 mL) subcutaneous pen ..................... 5

17

travoprost 0.004 % eye drops.................... 10

trazodone 100 mg tablet .......................... 1, 2



trazodone 50 mg tablet ............................ 1, 2





Tresiba U-100 Insulin 100 unit/mL


triamcinolone acetonide 0.025 % lotion ... 12


cream ..................................................... 12


ointment ................................................ 12

triamcinolone acetonide 0.1 % lotion ....... 12

triamcinolone acetonide 0.1 % topical cream

............................................................... 12


ointment ................................................ 12

triamcinolone acetonide 0.5 % topical cream

............................................................... 12


ointment ................................................ 12

Triderm 0.1 % topical cream .................... 12

Trintellix 10 mg tablet ................................ 2

Trintellix 20 mg tablet ................................ 2

Trintellix 5 mg tablet .................................. 2


injector .................................................... 5


injector .................................................... 5

V venlafaxine 100 mg tablet ....................... 1, 2

venlafaxine 25 mg tablet ......................... 1, 2

venlafaxine 37.5 mg tablet ...................... 1, 2




release 24 hr ........................................ 1, 2


release 24 hr ........................................ 1, 2


release 24 hr ........................................ 1, 2

venlafaxine ER 37.5 mg capsule,extended

release 24 hr ............................................ 2

venlafaxine ER 37.5 mg tablet,extended

release 24 hr ............................................ 2


release 24 hr ............................................ 2


release 24 hr ............................................ 2

Victoza 3-Pak 0.6 mg/0.1 mL (18 mg/3 mL)


Viibryd 10 mg (7)-20 mg (23) tablets in a

dose pack ................................................. 2

Viibryd 10 mg tablet ................................... 2



X Xhance 93 mcg/actuation breath activated

aerosol ................................................... 13

Xultophy 100/3.6 100 unit-3.6 mg/mL (3

mL) subcutaneous insulin pen ................ 5

Documents

Step Therapy Criteria - lmchealthplans.comSoliqua 100/33 100 unit-33 mcg/mL subcutaneous insulin pen Xultophy 100/3.6 100 unit-3.6 mg/mL (3 mL) subcutaneous insulin pen. Details. Criteria