Align Connect (HMO C-SNP) Medicare Part D Plan
Step Therapy Criteria
Last Updated 10/09/2019
1
Products AffectedAPLENZIN 174MG ER TAB
Details
Criteria Step Therapy requires trial of generic bupropion SR or generic bupropion XL.
Step Therapy Criteria
Last Updated 10/09/2019
2
Products AffectedAPLENZIN 348MG ER TAB
Details
Criteria Step Therapy requires trial of generic bupropion SR or generic bupropion XL.
Step Therapy Criteria
Last Updated 10/09/2019
3
Products AffectedAPLENZIN 522MG ER TAB
Details
Criteria Step Therapy requires trial of generic bupropion SR or generic bupropion XL.
Step Therapy Criteria
Last Updated 10/09/2019
4
Products AffectedARANESP 10MCG/0.4ML SYRINGE
Details
Criteria Step Therapy requires trial of RETACRIT.
Step Therapy Criteria
Last Updated 10/09/2019
5
Products AffectedARANESP 100MCG/ML INJ
Details
Criteria Step Therapy requires trial of RETACRIT.
Step Therapy Criteria
Last Updated 10/09/2019
6
Products AffectedARANESP 100MCG/0.5ML SYRINGE
Details
Criteria Step Therapy requires trial of RETACRIT.
Step Therapy Criteria
Last Updated 10/09/2019
7
Products AffectedARANESP 150MCG/0.3ML SYRINGE
Details
Criteria Step Therapy requires trial of RETACRIT.
Step Therapy Criteria
Last Updated 10/09/2019
8
Products AffectedARANESP 200MCG/ML INJ
Details
Criteria Step Therapy requires trial of RETACRIT.
Step Therapy Criteria
Last Updated 10/09/2019
9
Products AffectedARANESP 200MCG/0.4ML SYRINGE
Details
Criteria Step Therapy requires trial of RETACRIT.
Step Therapy Criteria
Last Updated 10/09/2019
10
Products AffectedARANESP 25MCG/ML INJ
Details
Criteria Step Therapy requires trial of RETACRIT.
Step Therapy Criteria
Last Updated 10/09/2019
11
Products AffectedARANESP 25MCG/0.42ML SYRINGE
Details
Criteria Step Therapy requires trial of RETACRIT.
Step Therapy Criteria
Last Updated 10/09/2019
12
Products AffectedARANESP 300MCG/ML INJ
Details
Criteria Step Therapy requires trial of RETACRIT.
Step Therapy Criteria
Last Updated 10/09/2019
13
Products AffectedARANESP 300MCG/0.6ML SYRINGE
Details
Criteria Step Therapy requires trial of RETACRIT.
Step Therapy Criteria
Last Updated 10/09/2019
14
Products AffectedARANESP 40MCG/ML INJ
Details
Criteria Step Therapy requires trial of RETACRIT.
Step Therapy Criteria
Last Updated 10/09/2019
15
Products AffectedARANESP 40MCG/0.4ML SYRINGE
Details
Criteria Step Therapy requires trial of RETACRIT.
Step Therapy Criteria
Last Updated 10/09/2019
16
Products AffectedARANESP 500MCG/ML SYRINGE
Details
Criteria Step Therapy requires trial of RETACRIT.
Step Therapy Criteria
Last Updated 10/09/2019
17
Products AffectedARANESP 60MCG/ML INJ
Details
Criteria Step Therapy requires trial of RETACRIT.
Step Therapy Criteria
Last Updated 10/09/2019
18
Products AffectedARANESP 60MCG/0.3ML SYRINGE
Details
Criteria Step Therapy requires trial of RETACRIT.
Step Therapy Criteria
Last Updated 10/09/2019
19
Products AffectedDIFICID 200MG TAB
Details
Criteria Step Therapy requires trial of generic vancomycin capsules.
Step Therapy Criteria
Last Updated 10/09/2019
20
Products Affectedduloxetine 40mg dr cap
Details
Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine
or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic
musculoskeletal pain.
Step Therapy Criteria
Last Updated 10/09/2019
21
Products Affectedfebuxostat 40mg tab
Details
Criteria Step Therapy requires trial of generic allopurinol.
Step Therapy Criteria
Last Updated 10/09/2019
22
Products Affectedfebuxostat 80mg tab
Details
Criteria Step Therapy requires trial of generic allopurinol.
Step Therapy Criteria
Last Updated 10/09/2019
23
Products AffectedFETZIMA PACK
Details
Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine
or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic
musculoskeletal pain.
Step Therapy Criteria
Last Updated 10/09/2019
24
Products AffectedFETZIMA 120MG ER CAP
Details
Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine
or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic
musculoskeletal pain.
Step Therapy Criteria
Last Updated 10/09/2019
25
Products AffectedFETZIMA 20MG ER CAP
Details
Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine
or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic
musculoskeletal pain.
Step Therapy Criteria
Last Updated 10/09/2019
26
Products AffectedFETZIMA 40MG ER CAP
Details
Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine
or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic
musculoskeletal pain.
Step Therapy Criteria
Last Updated 10/09/2019
27
Products AffectedFETZIMA 80MG ER CAP
Details
Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine
or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic
musculoskeletal pain.
Step Therapy Criteria
Last Updated 10/09/2019
28
Products Affectedfluvoxamine maleate 100mg er cap
Details
Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine
or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic
musculoskeletal pain.
Step Therapy Criteria
Last Updated 10/09/2019
29
Products Affectedfluvoxamine maleate 150mg er cap
Details
Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine
or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic
musculoskeletal pain.
Step Therapy Criteria
Last Updated 10/09/2019
30
Products AffectedLATUDA 120MG TAB
Details
Criteria Step Therapy requires trial of generic quetiapine.
Step Therapy Criteria
Last Updated 10/09/2019
31
Products AffectedLATUDA 20MG TAB
Details
Criteria Step Therapy requires trial of generic quetiapine.
Step Therapy Criteria
Last Updated 10/09/2019
32
Products AffectedLATUDA 40MG TAB
Details
Criteria Step Therapy requires trial of generic quetiapine.
Step Therapy Criteria
Last Updated 10/09/2019
33
Products AffectedLATUDA 60MG TAB
Details
Criteria Step Therapy requires trial of generic quetiapine.
Step Therapy Criteria
Last Updated 10/09/2019
34
Products AffectedLATUDA 80MG TAB
Details
Criteria Step Therapy requires trial of generic quetiapine.
Step Therapy Criteria
Last Updated 10/09/2019
35
Products AffectedLEVALBUTEROL 45MCG INH
Details
Criteria Step Therapy requires trial of VENTOLIN HFA.
Step Therapy Criteria
Last Updated 10/09/2019
36
Products AffectedLONHALA 0.0025% INH SOLN
Details
Criteria Step Therapy requires trial of INCRUSE.
Step Therapy Criteria
Last Updated 10/09/2019
37
Products AffectedSYMPAZAN 10MG STRIP
Details
Criteria Step therapy requires trial of generic clobazam tablets.
Step Therapy Criteria
Last Updated 10/09/2019
38
Products AffectedSYMPAZAN 20MG STRIP
Details
Criteria Step therapy requires trial of generic clobazam tablets.
Step Therapy Criteria
Last Updated 10/09/2019
39
Products AffectedSYMPAZAN 5MG STRIP
Details
Criteria Step therapy requires trial of generic clobazam tablets.
Step Therapy Criteria
Last Updated 10/09/2019
40
Products AffectedTRINTELLIX 10MG TAB
Details
Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine
or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic
musculoskeletal pain.
Step Therapy Criteria
Last Updated 10/09/2019
41
Products AffectedTRINTELLIX 20MG TAB
Details
Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine
or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic
musculoskeletal pain.
Step Therapy Criteria
Last Updated 10/09/2019
42
Products AffectedTRINTELLIX 5MG TAB
Details
Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine
or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic
musculoskeletal pain.
Step Therapy Criteria
Last Updated 10/09/2019
43
Products AffectedULORIC 40MG TAB
Details
Criteria Step Therapy requires trial of generic allopurinol.
Step Therapy Criteria
Last Updated 10/09/2019
44
Products AffectedULORIC 80MG TAB
Details
Criteria Step Therapy requires trial of generic allopurinol.
Step Therapy Criteria
Last Updated 10/09/2019
45
Products AffectedVIIBRYD 10MG TAB
Details
Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine
or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic
musculoskeletal pain.
Step Therapy Criteria
Last Updated 10/09/2019
46
Products AffectedVIIBRYD 10/20MG STARTER PACK
Details
Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine
or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic
musculoskeletal pain.
Step Therapy Criteria
Last Updated 10/09/2019
47
Products AffectedVIIBRYD 20MG TAB
Details
Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine
or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic
musculoskeletal pain.
Step Therapy Criteria
Last Updated 10/09/2019
48
Products AffectedVIIBRYD 40MG TAB
Details
Criteria Step Therapy requires trial of one of the following generic SSRI's: escitalopram, sertraline, fluoxetine, citalopram, paroxetine
or fluvoxamine. If request is for duloxetine, step not required for diabetic peripheral neuropathy, fibromyalgia, or chronic
musculoskeletal pain.
Step Therapy Criteria
Last Updated 10/09/2019
49
Products AffectedXOPENEX 45MCG INH
Details
Criteria Step Therapy requires trial of VENTOLIN HFA.
Step Therapy Criteria
Last Updated 10/09/2019
50
Products AffectedZENPEP 10000-32000-42000UNIT DR CAP
Details
Criteria Step Therapy requires trial of CREON.
Step Therapy Criteria
Last Updated 10/09/2019
51
Products AffectedZENPEP 15000-47000-63000UNIT DR CAP
Details
Criteria Step Therapy requires trial of CREON.
Step Therapy Criteria
Last Updated 10/09/2019
52
Products AffectedZENPEP 20000-63000-84000UNIT DR CAP
Details
Criteria Step Therapy requires trial of CREON.
Step Therapy Criteria
Last Updated 10/09/2019
53
Products AffectedZENPEP 25000-79000-105000UNIT DR CAP
Details
Criteria Step Therapy requires trial of CREON.
Step Therapy Criteria
Last Updated 10/09/2019
54
Products AffectedZENPEP 3000-10000-14000UNIT DR CAP
Details
Criteria Step Therapy requires trial of CREON.
Step Therapy Criteria
Last Updated 10/09/2019
55
Products AffectedZENPEP 40000-126000-168000UNIT DR CAP
Details
Criteria Step Therapy requires trial of CREON.
Step Therapy Criteria
Last Updated 10/09/2019
56
Products AffectedZENPEP 5000-17000-24000UNIT DR CAP
Details
Criteria Step Therapy requires trial of CREON.
Step Therapy Criteria
Last Updated 10/09/2019
57
Products AffectedZIOPTAN 0.0015% OPHTH SOLN
Details
Criteria Step Therapy requires trial of generic latanoprost.