Health Alliance Plan 2021Date Effective 10012021Formulary ID 21357 V171ESRDProducts AffectedStep 2lanthanum 1000 mg chewable tabletlanthanum 500 mg chewable tabletlanthanum 750 mg chewable tabletsev ID: 898275
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1 Step Therapy Criteria Health Alliance
Step Therapy Criteria Health Alliance Plan 2021 Date Effective: 10 /01/2021 Formulary ID 21357, V#17 1 ESRD Products Affected Step 2: lanthanum 1,000 mg chewable tablet lanthanum 500 mg chewable tablet lanthanum 750 mg chewable tablet sevelamer carbonate 800 mg tablet sevelamer HCl 400 mg tablet sevelamer HCl 800 mg tablet Details Criteria For new starts only, claims for sevelamer or lanthanum will process if a claim for calcium acetate is processed within 120 days. Step Therapy Criteria Health Alliance Plan 2021 Date Effective: 10 / 01/2021 Formulary ID 21357, V#17 2 FLUVASTATIN Products Affected Step 2: fluvastatin 20 mg capsule fluvastatin 40 mg capsule fluvastatin ER 80 mg tablet,extended release 24 hr Details Criteria Fo
2 r new starts only, claims for fluvastati
r new starts only, claims for fluvastatin will process if a claim for simvastatin, atorvastatin, or rosuvastatin is processed in the past 120 days. Step Therapy Criteria Health Alliance Plan 2021 Date Effective: 10 /01/2021 Formulary ID 21357, V#17 3 GLP - 1 AGONISTS Products Affected Step 2: 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 Ozempic 1 mg/dose (4 mg/3 mL) subcutaneous pen injector Rybelsus 14 mg tablet Rybelsus 3 mg tablet Rybelsus 7 mg tablet Trulicity 0.75 mg/0.5 mL subcutaneous pen injector Trulicity 1.5 mg/0.5 mL subcutaneous pen injector Trulicity 3 mg/0.5 mL subcutan eous pen injector Trulicity 4.5 mg/0.5 mL subcutaneous pen injector Victoza 2
3 - Pak 0.6 mg/0.1 mL (18 mg/3 mL) subcu
- Pak 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous pen injector Victoza 3 - Pak 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous pen injector Details Criteria For new starts only, claims will process for Victoza, Trulicity, Ozempic or Rybelsus if a claim for metformin has been processed in the past 120 days. Exceptions are permitted for beneficiaries with type 2 diabetes and multiple cardiovascular risk factors or established cardiovascular disease. Step Therapy Criteria Health Alliance Plan 2021 Date Effective: 10 / 01/2021 Formulary ID 21357, V#17 4 LINZESS Products Affected Step 2: Linzess 145 mcg capsule Linzess 290 mcg capsule Linzess 72 mcg capsule Details Criteria For new starts only, claim s for linaclotide will process if a claim for lubiprostone is processed in the past 1
4 20 days. Step Therapy Criteria Healt
20 days. Step Therapy Criteria Health Alliance Plan 2021 Date Effective: 10 /01/2021 Formulary ID 21357, V#17 5 ULORIC Products Affected Step 2: febuxostat 40 mg tablet febuxostat 80 mg tablet Details Criteria For new starts only, claims for febuxostat will process if a claim for allopurinol 300 mg is processed in the past 120 days. Step Therapy Criteria Health Alliance Plan 2021 Date Effective: 10 / 01/2021 6 Index F febuxostat 40 mg tablet ............................... 5 febuxostat 80 mg tablet ............................... 5 fluvastatin 20 mg capsule ............................ 2 fluvastatin 40 mg capsule ............................ 2 fluvastatin ER 80 mg tablet,extended release 24 hr ................................ .......................
5 . 2 L lanthanum 1,000 mg che wable
. 2 L lanthanum 1,000 mg che wable tablet .......... 1 lanthanum 500 mg chewable tablet ............. 1 lanthanum 750 mg chewable tablet ............. 1 Linzess 145 mcg capsule ............................ 4 Linzess 290 mcg capsule ............................ 4 Linzess 72 mcg capsule .............................. 4 O Ozempic 0.25 mg or 0.5 mg (2 mg/1.5 mL) subcutaneous pen injector ....................... 3 Ozempic 1 mg/dose (2 mg/ 1.5 mL) subcutaneous pen injector ....................... 3 Ozempic 1 mg/dose (4 mg/3 mL) subcutaneous pen injector ....................... 3 R Rybelsus 14 mg tablet ................................ . 3 Rybelsus 3 mg tablet ................................ ... 3 Rybelsus 7 mg tablet ................................ ... 3
6 S sevelamer carbonate 800 mg tablet
S sevelamer carbonate 800 mg tablet ............. 1 sevelamer HCl 400 mg tablet ...................... 1 sevelamer H Cl 800 mg tablet ...................... 1 T Trulicity 0.75 mg/0.5 mL subcutaneous pen injector ................................ .................... 3 Trulicity 1.5 mg/0.5 mL subcutaneous pen injector ................................ .................... 3 Trulicity 3 mg/0.5 mL subcutaneous pen injector ................................ .................... 3 Trulicity 4.5 mg/0.5 mL subcutaneous pen injector ................................ .................... 3 V Victoza 2 - Pak 0.6 mg/0.1 m L (18 mg/3 mL) subcutaneous pen injector ....................... 3 Victoza 3 - Pak 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous pen injector ....................... 3