2021 step therapy protocols - imperial health plan...• saphris tablet sublingual 10 mg sublingual...

I M P E R I A L I N S U R A N C E C O M PA N I E S

2021 Step Therapy Protocols

Imperial Insurance Company Traditional (HMO) 003

Imperial Insurance Company Dual (HMO D-SNP) 004

Imperial Insurance Traditional Plus (HMO) 007

Imperial Insurance Value (HMO C-SNP) 005

IR_258 H2793 Step Therapy Programs_C ENG 09/16/20

STEP THERAPY PROGRAMS

How do I request an exception to the Imperial Insurance Companies Inc. Formulary (HMO) (HMO SNP)?

You can ask Imperial Insurance Companies Inc. (HMO) (HMO SNP) to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover your drug even if it is not on our formulary. • You can ask us to waive coverage restrictions or limits on your drug. For example, being

required to first try certain drugs to treat your medical condition before we will cover another drug for that condition or generic version of a drug instead of the original brand name drug.

• You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. “Also, you may not ask us to provide a higher level of coverage for drugs that are in the specialty tier.”

Generally, Imperial Insurance Companies will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician’s supporting statement.

Your physician must submit a statement supporting your coverage determination or exception request. In order to help us make a decision more quickly, you should include supporting medical information from your doctor when you submit your exception request.

What if I have additional questions? You can call us at: 1-833-667-3497 (seven days a week, 24 hours a day) if you have any additional questions. If you have a hearing or speech impairment, please call us at TTY 711.

1

**Criteria Pending CMS Review**

ANTICONVULSANTS

Products Affected Step 2:

• APTIOM TABLET 200 MG ORAL




• BANZEL SUSPENSION 40 MG/ML

ORAL

• BANZEL TABLET 200 MG ORAL

• BANZEL TABLET 400 MG ORAL

• BRIVIACT SOLUTION 10 MG/ML

ORAL

• BRIVIACT TABLET 10 MG ORAL





• CELONTIN CAPSULE 300 MG ORAL

• DIASTAT ACUDIAL GEL 10 MG

RECTAL

• DIASTAT ACUDIAL GEL 20 MG

RECTAL

• DIASTAT PEDIATRIC GEL 2.5 MG

RECTAL

• DILANTIN CAPSULE 30 MG ORAL

• FYCOMPA SUSPENSION 0.5 MG/ML

ORAL

• FYCOMPA TABLET 10 MG ORAL






• NAYZILAM SOLUTION 5 MG/0.1ML

NASAL

• PEGANONE TABLET 250 MG ORAL

• SPRITAM TABLET DISINTEGRATING

SOLUBLE 1000 MG ORAL


SOLUBLE 250 MG ORAL


SOLUBLE 500 MG ORAL


SOLUBLE 750 MG ORAL

• SYMPAZAN FILM 10 MG ORAL



• VALTOCO 10 MG DOSE LIQUID 10

MG/0.1ML NASAL

• VALTOCO 15 MG DOSE LIQUID

THERAPY PACK 7.5 MG/0.1ML

NASAL

• VALTOCO 20 MG DOSE LIQUID

THERAPY PACK 10 MG/0.1ML NASAL

• VALTOCO 5 MG DOSE LIQUID 5

MG/0.1ML NASAL

• VIMPAT SOLUTION 10 MG/ML ORAL

• VIMPAT TABLET 100 MG ORAL




• XCOPRI (250 MG DAILY DOSE)

TABLET THERAPY PACK 50 & 200

MG ORAL

• XCOPRI (350 MG DAILY DOSE)


MG ORAL

• XCOPRI TABLET 100 MG ORAL




• XCOPRI TABLET THERAPY PACK 14

X 12.5 MG & 14 X 25 MG ORAL


X 150 MG & 14 X200 MG ORAL


X 50 MG & 14 X100 MG ORAL

2

Details

Criteria Criteria applies to new starts only. Claim will pay automatically for brand

Formulary anticonvulsants if enrollee has a paid claim for at least a 1 day

supply of any generic Formulary anticonvulsant or Epitol in the past 365

days. Otherwise, brand anticonvulsants require a step therapy exception

request indicating 1.) history of inadequate treatment response with a

generic Formulary anticonvulsant or Epitol, 2.) history of adverse event

with a generic Formulary anticonvulsant or Epitol, or 3.) Generic

Formulary anticonvulsants or Epitol are contraindicated.

3

ANTIDEPRESSANTS


• DRIZALMA SPRINKLE CAPSULE

DELAYED RELEASE SPRINKLE 20

MG ORAL



MG ORAL



MG ORAL



MG ORAL

• EMSAM PATCH 24 HOUR 12

MG/24HR TRANSDERMAL

• EMSAM PATCH 24 HOUR 6 MG/24HR

TRANSDERMAL

• EMSAM PATCH 24 HOUR 9 MG/24HR

TRANSDERMAL

• FETZIMA CAPSULE EXTENDED

RELEASE 24 HOUR 120 MG ORAL







• FETZIMA TITRATION CAPSULE ER

24 HOUR THERAPY PACK 20 & 40 MG

ORAL

• MARPLAN TABLET 10 MG ORAL

• TRINTELLIX TABLET 10 MG ORAL



• VIIBRYD STARTER PACK KIT 10 &

20 MG ORAL

• VIIBRYD TABLET 10 MG ORAL



Details

Criteria Criteria applies to new starts only. Claim will pay automatically for

Drizalma, Emsam, Fetzima, Marplan, Trintellix or Viibryd if enrollee has

a paid claim for at least a 1 day supply of any generic Formulary

antidepressant in the past 365 days. Otherwise, Drizalma, Emsam,

Fetzima, Marplan, Trintellix or Viibryd require a step therapy exception

request indicating: (1) history of inadequate treatment response with Step

1 Antidepressant, (2) history of adverse event with Step 1 Antidepressant

, or (3) Step 1 Antidepressant is contraindicated.

4

ATOMOXETINE


• atomoxetine hcl capsule 10 mg oral







Details


Atomoxetine if enrollee has paid claim for any 1 day supply any of the

following CNS stimulants in the past 365 days: amphetamine salts,

dexmethylphenidate, dextroamphetamine, methylphenidate or guanfacine

ER. Otherwise, Atomoxetine requires a step therapy exception request

indicating: (1) history of inadequate treatment response with

amphetamine salts, dexmethylphenidate,

dextroamphetaminemethylphenidate, or guanfacine ER, (2) history of

adverse event with amphetamine salts, dexmethylphenidate,

dextroamphetamine, methylphenidate, or guanfacine ER, or

(3)amphetamine salts, dexmethylphenidate, dextroamphetamine,

methylphenidate or guanfacine ER is contraindicated.

5

ATYPICALS


• ABILIFY MAINTENA PREFILLED

SYRINGE 300 MG INTRAMUSCULAR

• ABILIFY MAINTENA PREFILLED


• ABILIFY MAINTENA SUSPENSION

RECONSTITUTED ER 300 MG

INTRAMUSCULAR

• ABILIFY MAINTENA SUSPENSION


INTRAMUSCULAR

• ABILIFY MYCITE TABLET 10 MG

ORAL


ORAL


ORAL


ORAL


ORAL


ORAL

• CAPLYTA CAPSULE 42 MG ORAL

• clozapine tablet 100 mg oral

• clozapine tablet 200 mg oral

• clozapine tablet dispersible 100 mg oral

• clozapine tablet dispersible 12.5 mg oral




• FANAPT TABLET 1 MG ORAL







• FANAPT TITRATION PACK TABLET

1 & 2 & 4 & 6 MG ORAL

• INVEGA SUSTENNA SUSPENSION

PREFILLED SYRINGE 117 MG/0.75ML

INTRAMUSCULAR


PREFILLED SYRINGE 156 MG/ML

INTRAMUSCULAR



INTRAMUSCULAR



INTRAMUSCULAR



INTRAMUSCULAR

• INVEGA TRINZA SUSPENSION

PREFILLED SYRINGE 273

MG/0.875ML INTRAMUSCULAR






INTRAMUSCULAR




• LATUDA TABLET 120 MG ORAL





• REXULTI TABLET 0.25 MG ORAL

• REXULTI TABLET 0.5 MG ORAL

• REXULTI TABLET 1 MG ORAL




• RISPERDAL CONSTA SUSPENSION

RECONSTITUTED ER 12.5 MG

INTRAMUSCULAR

6



INTRAMUSCULAR



INTRAMUSCULAR



INTRAMUSCULAR

• SAPHRIS TABLET SUBLINGUAL 10

MG SUBLINGUAL

• SAPHRIS TABLET SUBLINGUAL 2.5

MG SUBLINGUAL

• SAPHRIS TABLET SUBLINGUAL 5

MG SUBLINGUAL

• SECUADO PATCH 24 HOUR 3.8

MG/24HR TRANSDERMAL


MG/24HR TRANSDERMAL


MG/24HR TRANSDERMAL

• VERSACLOZ SUSPENSION 50 MG/ML

ORAL

• VRAYLAR CAPSULE 1.5 MG ORAL

• VRAYLAR CAPSULE 3 MG ORAL

• VRAYLAR CAPSULE 4.5 MG ORAL

• VRAYLAR CAPSULE 6 MG ORAL

• VRAYLAR CAPSULE THERAPY

PACK 1.5 & 3 MG ORAL

• ZYPREXA RELPREVV SUSPENSION

RECONSTITUTED 210 MG

INTRAMUSCULAR

Details

Criteria Criteria applies to new starts only. Claim will pay automatically for brand

Formulary atypical antipsychotics if enrollee has a paid claim for at least

a 1 days supply of any generic formulary atypicals in the past 365 days.

Otherwise, Non-Preferred antipsychotics require a step therapy exception

request indicating any ONE of the following (1) Diagnosis that is not

covered by generic formulary products, (2) History of inadequate

treatment response with generic formulary products, (3) History of

adverse event with generic formulary products, or (4) Generic formulary

products are contraindicated

7

RYTARY


• RYTARY CAPSULE EXTENDED

RELEASE 23.75-95 MG ORAL







Details


Rytary if enrollee has a paid claim for at least a 1 days supply of generic

Carbidopa, Carbidopa/Levodopa, or Carbidopa/Levodopa/Entacapone in

the past 365 days. Otherwise, Rytary requires a step therapy exception

request indicating: (1) history of inadequate treatment response with

Carbidopa, Carbidopa/Levodopa, or Carbidopa/Levodopa/Entacapone, (2)

history of adverse event with Carbidopa, Carbidopa/Levodopa, or

Carbidopa/Levodopa/Entacapone, or (3) Carbidopa, Carbidopa/Levodopa,

or Carbidopa/Levodopa/Entacapone is contraindicated.

8

STATIN


• LIVALO TABLET 1 MG ORAL



• ZYPITAMAG TABLET 2 MG ORAL

• ZYPITAMAG TABLET 4 MG ORAL

Details


Livalo or Zypitamag if enrollee has a paid claim for at least a 1 days

supply of any generic formulary statin in the past 365 days. Otherwise,

Livalo or Zypitamag requires a step therapy exception request indicating:

(1) history of inadequate treatment response with any generic formulary

statin, (2) history of adverse event with any generic formulary statin, or

(3) any generic formulary statin is contraindicated.

9

Index

A ABILIFY MAINTENA PREFILLED


............................................................. 5, 6

ABILIFY MAINTENA PREFILLED


............................................................. 5, 6

ABILIFY MAINTENA SUSPENSION


INTRAMUSCULAR .......................... 5, 6

ABILIFY MAINTENA SUSPENSION


INTRAMUSCULAR .......................... 5, 6

ABILIFY MYCITE TABLET 10 MG

ORAL .................................................. 5, 6


ORAL .................................................. 5, 6

ABILIFY MYCITE TABLET 2 MG ORAL

............................................................. 5, 6


ORAL .................................................. 5, 6


ORAL .................................................. 5, 6

ABILIFY MYCITE TABLET 5 MG ORAL

............................................................. 5, 6

APTIOM TABLET 200 MG ORAL....... 1, 2




atomoxetine hcl capsule 10 mg oral ............ 4

atomoxetine hcl capsule 100 mg oral .......... 4






B BANZEL SUSPENSION 40 MG/ML

ORAL .................................................. 1, 2

BANZEL TABLET 200 MG ORAL ...... 1, 2

BANZEL TABLET 400 MG ORAL ...... 1, 2

BRIVIACT SOLUTION 10 MG/ML ORAL

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

BRIVIACT TABLET 10 MG ORAL ..... 1, 2

BRIVIACT TABLET 100 MG ORAL ... 1, 2




C CAPLYTA CAPSULE 42 MG ORAL ... 5, 6

CELONTIN CAPSULE 300 MG ORAL 1, 2

clozapine tablet 100 mg oral ................... 5, 6

clozapine tablet 200 mg oral ................... 5, 6

clozapine tablet dispersible 100 mg oral . 5, 6

clozapine tablet dispersible 12.5 mg oral 5, 6



clozapine tablet dispersible 25 mg oral ... 5, 6

D DIASTAT ACUDIAL GEL 10 MG

RECTAL ............................................. 1, 2

DIASTAT ACUDIAL GEL 20 MG

RECTAL ............................................. 1, 2

DIASTAT PEDIATRIC GEL 2.5 MG

RECTAL ............................................. 1, 2

DILANTIN CAPSULE 30 MG ORAL .. 1, 2

DRIZALMA SPRINKLE CAPSULE


MG ORAL .............................................. 3



MG ORAL .............................................. 3



MG ORAL .............................................. 3



MG ORAL .............................................. 3

E EMSAM PATCH 24 HOUR 12 MG/24HR

TRANSDERMAL................................... 3

EMSAM PATCH 24 HOUR 6 MG/24HR

TRANSDERMAL................................... 3

EMSAM PATCH 24 HOUR 9 MG/24HR

TRANSDERMAL................................... 3

F FANAPT TABLET 1 MG ORAL .......... 5, 6

FANAPT TABLET 10 MG ORAL ........ 5, 6

10

FANAPT TABLET 12 MG ORAL ........ 5, 6

FANAPT TABLET 2 MG ORAL .......... 5, 6




FANAPT TITRATION PACK TABLET 1

& 2 & 4 & 6 MG ORAL ..................... 5, 6

FETZIMA CAPSULE EXTENDED

RELEASE 24 HOUR 120 MG ORAL ... 3


RELEASE 24 HOUR 20 MG ORAL ..... 3





FETZIMA TITRATION CAPSULE ER 24

HOUR THERAPY PACK 20 & 40 MG

ORAL ...................................................... 3

FYCOMPA SUSPENSION 0.5 MG/ML

ORAL .................................................. 1, 2

FYCOMPA TABLET 10 MG ORAL..... 1, 2

FYCOMPA TABLET 12 MG ORAL..... 1, 2

FYCOMPA TABLET 2 MG ORAL....... 1, 2




I INVEGA SUSTENNA SUSPENSION


MG/0.75ML INTRAMUSCULAR .... 5, 6

INVEGA SUSTENNA SUSPENSION

PREFILLED SYRINGE 156 MG/ML

INTRAMUSCULAR .......................... 5, 6



INTRAMUSCULAR .......................... 5, 6



INTRAMUSCULAR .......................... 5, 6



INTRAMUSCULAR .......................... 5, 6

INVEGA TRINZA SUSPENSION


MG/0.875ML INTRAMUSCULAR... 5, 6






MG/1.75ML INTRAMUSCULAR .... 5, 6




L LATUDA TABLET 120 MG ORAL ..... 5, 6

LATUDA TABLET 20 MG ORAL ....... 5, 6




LIVALO TABLET 1 MG ORAL ............... 8



M MARPLAN TABLET 10 MG ORAL ........ 3

N NAYZILAM SOLUTION 5 MG/0.1ML

NASAL ............................................... 1, 2

P PEGANONE TABLET 250 MG ORAL 1, 2

R REXULTI TABLET 0.25 MG ORAL .... 5, 6

REXULTI TABLET 0.5 MG ORAL ...... 5, 6

REXULTI TABLET 1 MG ORAL ......... 5, 6




RISPERDAL CONSTA SUSPENSION


INTRAMUSCULAR .......................... 5, 6



INTRAMUSCULAR .............................. 6



INTRAMUSCULAR .............................. 6



INTRAMUSCULAR .............................. 6

RYTARY CAPSULE EXTENDED

RELEASE 23.75-95 MG ORAL ............ 7

11


RELEASE 36.25-145 MG ORAL .......... 7


RELEASE 48.75-195 MG ORAL .......... 7


RELEASE 61.25-245 MG ORAL .......... 7

S SAPHRIS TABLET SUBLINGUAL 10 MG

SUBLINGUAL ....................................... 6

SAPHRIS TABLET SUBLINGUAL 2.5

MG SUBLINGUAL................................ 6

SAPHRIS TABLET SUBLINGUAL 5 MG

SUBLINGUAL ....................................... 6

SECUADO PATCH 24 HOUR 3.8

MG/24HR TRANSDERMAL ................ 6





SPRITAM TABLET DISINTEGRATING

SOLUBLE 1000 MG ORAL .............. 1, 2


SOLUBLE 250 MG ORAL ................ 1, 2


SOLUBLE 500 MG ORAL ................ 1, 2


SOLUBLE 750 MG ORAL ................ 1, 2

SYMPAZAN FILM 10 MG ORAL ........ 1, 2

SYMPAZAN FILM 20 MG ORAL ........ 1, 2

SYMPAZAN FILM 5 MG ORAL .......... 1, 2

T TRINTELLIX TABLET 10 MG ORAL ..... 3

TRINTELLIX TABLET 20 MG ORAL ..... 3

TRINTELLIX TABLET 5 MG ORAL ....... 3

V VALTOCO 10 MG DOSE LIQUID 10

MG/0.1ML NASAL ............................ 1, 2

VALTOCO 15 MG DOSE LIQUID

THERAPY PACK 7.5 MG/0.1ML

NASAL ............................................... 1, 2

VALTOCO 20 MG DOSE LIQUID

THERAPY PACK 10 MG/0.1ML

NASAL ............................................... 1, 2

VALTOCO 5 MG DOSE LIQUID 5

MG/0.1ML NASAL ............................ 1, 2

VERSACLOZ SUSPENSION 50 MG/ML

ORAL ...................................................... 6

VIIBRYD STARTER PACK KIT 10 & 20

MG ORAL .............................................. 3

VIIBRYD TABLET 10 MG ORAL ........... 3



VIMPAT SOLUTION 10 MG/ML ORAL 1,

2

VIMPAT TABLET 100 MG ORAL....... 1, 2



VIMPAT TABLET 50 MG ORAL......... 1, 2

VRAYLAR CAPSULE 1.5 MG ORAL ..... 6

VRAYLAR CAPSULE 3 MG ORAL ........ 6

VRAYLAR CAPSULE 4.5 MG ORAL ..... 6

VRAYLAR CAPSULE 6 MG ORAL ........ 6

VRAYLAR CAPSULE THERAPY PACK

1.5 & 3 MG ORAL ................................. 6

X XCOPRI (250 MG DAILY DOSE)


MG ORAL .......................................... 1, 2

XCOPRI (350 MG DAILY DOSE)


MG ORAL .......................................... 1, 2

XCOPRI TABLET 100 MG ORAL ....... 1, 2



XCOPRI TABLET 50 MG ORAL ......... 1, 2

XCOPRI TABLET THERAPY PACK 14 X

12.5 MG & 14 X 25 MG ORAL ......... 1, 2


150 MG & 14 X200 MG ORAL ......... 1, 2


50 MG & 14 X100 MG ORAL ........... 1, 2

Z ZYPITAMAG TABLET 2 MG ORAL ...... 8

ZYPITAMAG TABLET 4 MG ORAL ...... 8

ZYPREXA RELPREVV SUSPENSION

RECONSTITUTED 210 MG

INTRAMUSCULAR .............................. 6

H2793 Step Therapy Cover 2021IR_258 H2793 Step Therapy Programs_C ENG 09.16.20How do I request an exception to the Imperial Insurance Companies Inc. Formulary (HMO) (HMO SNP)?Your physician must submit a statement supporting your coverage determination or exception request. In order to help us make a decision more quickly, you should include supporting medical information from your doctor when you submit your exception req...

CY2021_Imperial_Standard_MAPD_5T_21353_ST_Marketing_01012021

2021 step therapy protocols - imperial health plan...• saphris tablet sublingual 10 mg sublingual...

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