2021 Step Therapy Protocols - Imperial Health Plan...• saphris tablet sublingual 10 mg sublingual...
Transcript of 2021 Step Therapy Protocols - Imperial Health Plan...• saphris tablet sublingual 10 mg sublingual...
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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
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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.
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**Criteria Pending CMS Review**
ANTICONVULSANTS
Products Affected Step 2:
• APTIOM TABLET 200 MG ORAL
• APTIOM TABLET 400 MG ORAL
• APTIOM TABLET 600 MG ORAL
• APTIOM TABLET 800 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
• BRIVIACT TABLET 100 MG ORAL
• BRIVIACT TABLET 25 MG ORAL
• BRIVIACT TABLET 50 MG ORAL
• BRIVIACT TABLET 75 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
• FYCOMPA TABLET 12 MG ORAL
• FYCOMPA TABLET 2 MG ORAL
• FYCOMPA TABLET 4 MG ORAL
• FYCOMPA TABLET 6 MG ORAL
• FYCOMPA TABLET 8 MG ORAL
• NAYZILAM SOLUTION 5 MG/0.1ML
NASAL
• PEGANONE TABLET 250 MG ORAL
• SPRITAM TABLET DISINTEGRATING
SOLUBLE 1000 MG ORAL
• SPRITAM TABLET DISINTEGRATING
SOLUBLE 250 MG ORAL
• SPRITAM TABLET DISINTEGRATING
SOLUBLE 500 MG ORAL
• SPRITAM TABLET DISINTEGRATING
SOLUBLE 750 MG ORAL
• SYMPAZAN FILM 10 MG ORAL
• SYMPAZAN FILM 20 MG ORAL
• SYMPAZAN FILM 5 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
• VIMPAT TABLET 150 MG ORAL
• VIMPAT TABLET 200 MG ORAL
• VIMPAT TABLET 50 MG ORAL
• XCOPRI (250 MG DAILY DOSE)
TABLET THERAPY PACK 50 & 200
MG ORAL
• XCOPRI (350 MG DAILY DOSE)
TABLET THERAPY PACK 150 & 200
MG ORAL
• XCOPRI TABLET 100 MG ORAL
• XCOPRI TABLET 150 MG ORAL
• XCOPRI TABLET 200 MG ORAL
• XCOPRI TABLET 50 MG ORAL
• XCOPRI TABLET THERAPY PACK 14
X 12.5 MG & 14 X 25 MG ORAL
• XCOPRI TABLET THERAPY PACK 14
X 150 MG & 14 X200 MG ORAL
• XCOPRI TABLET THERAPY PACK 14
X 50 MG & 14 X100 MG ORAL
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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.
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ANTIDEPRESSANTS
Products Affected Step 2:
• DRIZALMA SPRINKLE CAPSULE
DELAYED RELEASE SPRINKLE 20
MG ORAL
• DRIZALMA SPRINKLE CAPSULE
DELAYED RELEASE SPRINKLE 30
MG ORAL
• DRIZALMA SPRINKLE CAPSULE
DELAYED RELEASE SPRINKLE 40
MG ORAL
• DRIZALMA SPRINKLE CAPSULE
DELAYED RELEASE SPRINKLE 60
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 CAPSULE EXTENDED
RELEASE 24 HOUR 20 MG ORAL
• FETZIMA CAPSULE EXTENDED
RELEASE 24 HOUR 40 MG ORAL
• FETZIMA CAPSULE EXTENDED
RELEASE 24 HOUR 80 MG ORAL
• FETZIMA TITRATION CAPSULE ER
24 HOUR THERAPY PACK 20 & 40 MG
ORAL
• MARPLAN TABLET 10 MG ORAL
• TRINTELLIX TABLET 10 MG ORAL
• TRINTELLIX TABLET 20 MG ORAL
• TRINTELLIX TABLET 5 MG ORAL
• VIIBRYD STARTER PACK KIT 10 &
20 MG ORAL
• VIIBRYD TABLET 10 MG ORAL
• VIIBRYD TABLET 20 MG ORAL
• VIIBRYD TABLET 40 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.
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ATOMOXETINE
Products Affected Step 2:
• atomoxetine hcl capsule 10 mg oral
• atomoxetine hcl capsule 100 mg oral
• atomoxetine hcl capsule 18 mg oral
• atomoxetine hcl capsule 25 mg oral
• atomoxetine hcl capsule 40 mg oral
• atomoxetine hcl capsule 60 mg oral
• atomoxetine hcl capsule 80 mg oral
Details
Criteria Criteria applies to new starts only. Claim will pay automatically for
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.
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ATYPICALS
Products Affected Step 2:
• ABILIFY MAINTENA PREFILLED
SYRINGE 300 MG INTRAMUSCULAR
• ABILIFY MAINTENA PREFILLED
SYRINGE 400 MG INTRAMUSCULAR
• ABILIFY MAINTENA SUSPENSION
RECONSTITUTED ER 300 MG
INTRAMUSCULAR
• ABILIFY MAINTENA SUSPENSION
RECONSTITUTED ER 400 MG
INTRAMUSCULAR
• ABILIFY MYCITE TABLET 10 MG
ORAL
• ABILIFY MYCITE TABLET 15 MG
ORAL
• ABILIFY MYCITE TABLET 2 MG
ORAL
• ABILIFY MYCITE TABLET 20 MG
ORAL
• ABILIFY MYCITE TABLET 30 MG
ORAL
• ABILIFY MYCITE TABLET 5 MG
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
• clozapine tablet dispersible 150 mg oral
• clozapine tablet dispersible 200 mg oral
• clozapine tablet dispersible 25 mg oral
• FANAPT TABLET 1 MG ORAL
• FANAPT TABLET 10 MG ORAL
• FANAPT TABLET 12 MG ORAL
• FANAPT TABLET 2 MG ORAL
• FANAPT TABLET 4 MG ORAL
• FANAPT TABLET 6 MG ORAL
• FANAPT TABLET 8 MG ORAL
• FANAPT TITRATION PACK TABLET
1 & 2 & 4 & 6 MG ORAL
• INVEGA SUSTENNA SUSPENSION
PREFILLED SYRINGE 117 MG/0.75ML
INTRAMUSCULAR
• INVEGA SUSTENNA SUSPENSION
PREFILLED SYRINGE 156 MG/ML
INTRAMUSCULAR
• INVEGA SUSTENNA SUSPENSION
PREFILLED SYRINGE 234 MG/1.5ML
INTRAMUSCULAR
• INVEGA SUSTENNA SUSPENSION
PREFILLED SYRINGE 39 MG/0.25ML
INTRAMUSCULAR
• INVEGA SUSTENNA SUSPENSION
PREFILLED SYRINGE 78 MG/0.5ML
INTRAMUSCULAR
• INVEGA TRINZA SUSPENSION
PREFILLED SYRINGE 273
MG/0.875ML INTRAMUSCULAR
• INVEGA TRINZA SUSPENSION
PREFILLED SYRINGE 410
MG/1.315ML INTRAMUSCULAR
• INVEGA TRINZA SUSPENSION
PREFILLED SYRINGE 546 MG/1.75ML
INTRAMUSCULAR
• INVEGA TRINZA SUSPENSION
PREFILLED SYRINGE 819
MG/2.625ML INTRAMUSCULAR
• LATUDA TABLET 120 MG ORAL
• LATUDA TABLET 20 MG ORAL
• LATUDA TABLET 40 MG ORAL
• LATUDA TABLET 60 MG ORAL
• LATUDA TABLET 80 MG ORAL
• REXULTI TABLET 0.25 MG ORAL
• REXULTI TABLET 0.5 MG ORAL
• REXULTI TABLET 1 MG ORAL
• REXULTI TABLET 2 MG ORAL
• REXULTI TABLET 3 MG ORAL
• REXULTI TABLET 4 MG ORAL
• RISPERDAL CONSTA SUSPENSION
RECONSTITUTED ER 12.5 MG
INTRAMUSCULAR
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• RISPERDAL CONSTA SUSPENSION
RECONSTITUTED ER 25 MG
INTRAMUSCULAR
• RISPERDAL CONSTA SUSPENSION
RECONSTITUTED ER 37.5 MG
INTRAMUSCULAR
• RISPERDAL CONSTA SUSPENSION
RECONSTITUTED ER 50 MG
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
• SECUADO PATCH 24 HOUR 5.7
MG/24HR TRANSDERMAL
• SECUADO PATCH 24 HOUR 7.6
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
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RYTARY
Products Affected Step 2:
• RYTARY CAPSULE EXTENDED
RELEASE 23.75-95 MG ORAL
• RYTARY CAPSULE EXTENDED
RELEASE 36.25-145 MG ORAL
• RYTARY CAPSULE EXTENDED
RELEASE 48.75-195 MG ORAL
• RYTARY CAPSULE EXTENDED
RELEASE 61.25-245 MG ORAL
Details
Criteria Criteria applies to new starts only. Claim will pay automatically for
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.
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STATIN
Products Affected Step 2:
• LIVALO TABLET 1 MG ORAL
• LIVALO TABLET 2 MG ORAL
• LIVALO TABLET 4 MG ORAL
• ZYPITAMAG TABLET 2 MG ORAL
• ZYPITAMAG TABLET 4 MG ORAL
Details
Criteria Criteria applies to new starts only. Claim will pay automatically for
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.
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Index
A ABILIFY MAINTENA PREFILLED
SYRINGE 300 MG INTRAMUSCULAR
............................................................. 5, 6
ABILIFY MAINTENA PREFILLED
SYRINGE 400 MG INTRAMUSCULAR
............................................................. 5, 6
ABILIFY MAINTENA SUSPENSION
RECONSTITUTED ER 300 MG
INTRAMUSCULAR .......................... 5, 6
ABILIFY MAINTENA SUSPENSION
RECONSTITUTED ER 400 MG
INTRAMUSCULAR .......................... 5, 6
ABILIFY MYCITE TABLET 10 MG
ORAL .................................................. 5, 6
ABILIFY MYCITE TABLET 15 MG
ORAL .................................................. 5, 6
ABILIFY MYCITE TABLET 2 MG ORAL
............................................................. 5, 6
ABILIFY MYCITE TABLET 20 MG
ORAL .................................................. 5, 6
ABILIFY MYCITE TABLET 30 MG
ORAL .................................................. 5, 6
ABILIFY MYCITE TABLET 5 MG ORAL
............................................................. 5, 6
APTIOM TABLET 200 MG ORAL....... 1, 2
APTIOM TABLET 400 MG ORAL....... 1, 2
APTIOM TABLET 600 MG ORAL....... 1, 2
APTIOM TABLET 800 MG ORAL....... 1, 2
atomoxetine hcl capsule 10 mg oral ............ 4
atomoxetine hcl capsule 100 mg oral .......... 4
atomoxetine hcl capsule 18 mg oral ............ 4
atomoxetine hcl capsule 25 mg oral ............ 4
atomoxetine hcl capsule 40 mg oral ............ 4
atomoxetine hcl capsule 60 mg oral ............ 4
atomoxetine hcl capsule 80 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
BRIVIACT TABLET 25 MG ORAL ..... 1, 2
BRIVIACT TABLET 50 MG ORAL ..... 1, 2
BRIVIACT TABLET 75 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 150 mg oral . 5, 6
clozapine tablet dispersible 200 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
DELAYED RELEASE SPRINKLE 20
MG ORAL .............................................. 3
DRIZALMA SPRINKLE CAPSULE
DELAYED RELEASE SPRINKLE 30
MG ORAL .............................................. 3
DRIZALMA SPRINKLE CAPSULE
DELAYED RELEASE SPRINKLE 40
MG ORAL .............................................. 3
DRIZALMA SPRINKLE CAPSULE
DELAYED RELEASE SPRINKLE 60
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
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FANAPT TABLET 12 MG ORAL ........ 5, 6
FANAPT TABLET 2 MG ORAL .......... 5, 6
FANAPT TABLET 4 MG ORAL .......... 5, 6
FANAPT TABLET 6 MG ORAL .......... 5, 6
FANAPT TABLET 8 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
FETZIMA CAPSULE EXTENDED
RELEASE 24 HOUR 20 MG ORAL ..... 3
FETZIMA CAPSULE EXTENDED
RELEASE 24 HOUR 40 MG ORAL ..... 3
FETZIMA CAPSULE EXTENDED
RELEASE 24 HOUR 80 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
FYCOMPA TABLET 4 MG ORAL....... 1, 2
FYCOMPA TABLET 6 MG ORAL....... 1, 2
FYCOMPA TABLET 8 MG ORAL....... 1, 2
I INVEGA SUSTENNA SUSPENSION
PREFILLED SYRINGE 117
MG/0.75ML INTRAMUSCULAR .... 5, 6
INVEGA SUSTENNA SUSPENSION
PREFILLED SYRINGE 156 MG/ML
INTRAMUSCULAR .......................... 5, 6
INVEGA SUSTENNA SUSPENSION
PREFILLED SYRINGE 234 MG/1.5ML
INTRAMUSCULAR .......................... 5, 6
INVEGA SUSTENNA SUSPENSION
PREFILLED SYRINGE 39 MG/0.25ML
INTRAMUSCULAR .......................... 5, 6
INVEGA SUSTENNA SUSPENSION
PREFILLED SYRINGE 78 MG/0.5ML
INTRAMUSCULAR .......................... 5, 6
INVEGA TRINZA SUSPENSION
PREFILLED SYRINGE 273
MG/0.875ML INTRAMUSCULAR... 5, 6
INVEGA TRINZA SUSPENSION
PREFILLED SYRINGE 410
MG/1.315ML INTRAMUSCULAR... 5, 6
INVEGA TRINZA SUSPENSION
PREFILLED SYRINGE 546
MG/1.75ML INTRAMUSCULAR .... 5, 6
INVEGA TRINZA SUSPENSION
PREFILLED SYRINGE 819
MG/2.625ML INTRAMUSCULAR... 5, 6
L LATUDA TABLET 120 MG ORAL ..... 5, 6
LATUDA TABLET 20 MG ORAL ....... 5, 6
LATUDA TABLET 40 MG ORAL ....... 5, 6
LATUDA TABLET 60 MG ORAL ....... 5, 6
LATUDA TABLET 80 MG ORAL ....... 5, 6
LIVALO TABLET 1 MG ORAL ............... 8
LIVALO TABLET 2 MG ORAL ............... 8
LIVALO TABLET 4 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
REXULTI TABLET 2 MG ORAL ......... 5, 6
REXULTI TABLET 3 MG ORAL ......... 5, 6
REXULTI TABLET 4 MG ORAL ......... 5, 6
RISPERDAL CONSTA SUSPENSION
RECONSTITUTED ER 12.5 MG
INTRAMUSCULAR .......................... 5, 6
RISPERDAL CONSTA SUSPENSION
RECONSTITUTED ER 25 MG
INTRAMUSCULAR .............................. 6
RISPERDAL CONSTA SUSPENSION
RECONSTITUTED ER 37.5 MG
INTRAMUSCULAR .............................. 6
RISPERDAL CONSTA SUSPENSION
RECONSTITUTED ER 50 MG
INTRAMUSCULAR .............................. 6
RYTARY CAPSULE EXTENDED
RELEASE 23.75-95 MG ORAL ............ 7
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RYTARY CAPSULE EXTENDED
RELEASE 36.25-145 MG ORAL .......... 7
RYTARY CAPSULE EXTENDED
RELEASE 48.75-195 MG ORAL .......... 7
RYTARY CAPSULE EXTENDED
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
SECUADO PATCH 24 HOUR 5.7
MG/24HR TRANSDERMAL ................ 6
SECUADO PATCH 24 HOUR 7.6
MG/24HR TRANSDERMAL ................ 6
SPRITAM TABLET DISINTEGRATING
SOLUBLE 1000 MG ORAL .............. 1, 2
SPRITAM TABLET DISINTEGRATING
SOLUBLE 250 MG ORAL ................ 1, 2
SPRITAM TABLET DISINTEGRATING
SOLUBLE 500 MG ORAL ................ 1, 2
SPRITAM TABLET DISINTEGRATING
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
VIIBRYD TABLET 20 MG ORAL ........... 3
VIIBRYD TABLET 40 MG ORAL ........... 3
VIMPAT SOLUTION 10 MG/ML ORAL 1,
2
VIMPAT TABLET 100 MG ORAL....... 1, 2
VIMPAT TABLET 150 MG ORAL....... 1, 2
VIMPAT TABLET 200 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)
TABLET THERAPY PACK 50 & 200
MG ORAL .......................................... 1, 2
XCOPRI (350 MG DAILY DOSE)
TABLET THERAPY PACK 150 & 200
MG ORAL .......................................... 1, 2
XCOPRI TABLET 100 MG ORAL ....... 1, 2
XCOPRI TABLET 150 MG ORAL ....... 1, 2
XCOPRI TABLET 200 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
XCOPRI TABLET THERAPY PACK 14 X
150 MG & 14 X200 MG ORAL ......... 1, 2
XCOPRI TABLET THERAPY PACK 14 X
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