absorica - docushare-web.apps.external.pioneer.humana.com

2022 Group Plus

Formulary ID 22800 Version 1

You can contact Humana for the most recent list of drugs by calling the number on the back of your Humana member identification card, TTY: 711 Monday through Friday, 8 a.m. - 9 p.m. Eastern time or visiting the website listed in your Annual Notice of Change (ANOC) or Evidence of Coverage (EOC).

Step Therapy Criteria

Effective 06/01/2022

ABSORICA

Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: Amnesteem, Claravis, Isotretinoin, Myorisan, or Zenatane.

Y0040_ GHHJPMNES_C Updated 06/2022 of 275

ABSORICA LD

Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: Amnesteem, Claravis, Isotretinoin, Myorisan, or Zenatane.


ACTICLATE

Criteria Details The member has had previous treatment or intolerance with oral immediate release doxycycline (e.g. doxycycline monohydrate 50 mg capsule/tablet, doxycycline 75 mg tablet, 100 mg capsule/tablet).


ACULAR

Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months, contraindication, or intolerance to Ilevro ophthalimic solution and one of the following: ketorolac ophthalimic solution or diclofenac ophthalimic solution or Flurbiprofen ophthalimic solution.


ACULAR LS



ACUVAIL (PF)



ADLYXIN

Criteria Details An automatic approval will be given to members who have had previous treatment with at least two preferred GLP 1 Analogs (e.g. Victoza, Trulicity, Ozempic, Bydureon, Rybelsus).


ADMELOG SOLOSTAR U-100 INSULIN

Criteria Details An automatic approval will be given to members who have had previous treatment with Novolog (insulin aspart), Novolog Mix (insulin aspart protamine / insulin aspart), Novolin R (regular insulin), Novolin N (NPH insulin), Novolin 70/30 (NPH insulin / regular insulin), or Fiasp (insulin aspart).


ADMELOG U-100 INSULIN LISPRO



AGGRENOX

Criteria Details An automatic approval will be given to members who have had previous treatment with clopidogrel.


AIRDUO DIGIHALER

Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: Wixela Inhub, fluticasone-salmeterol, Symbicort, Advair HFA/Diskus, or Breo Ellipta.


AIRDUO RESPICLICK



almotriptan malate

Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: naratriptan, sumatriptan or rizatriptan.


ALREX

Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with two of the following eye drops: Durezol 0.05%, prednisolone sodium phosphate 1%, prednisolone acetate 1%, Dexamethasone 0.1%, Fluorometholone 0.1%, Lotemax SM 0.38%.


ALTOPREV

Criteria Details An automatic approval will be given to members who have had previous treatment with ezetimibe and one of the following: lovastatin, atorvastatin, rosuvastatin, simvastatin, or pravastatin.


ALVESCO

Criteria Details An automatic approval will be given to members who have had previous treatment with Flovent HFA/Diskus and Arnuity Ellipta


amoxicil-clarithromy-lansopraz

Criteria Details An automatic approval will be given to members who have had previous treatment, intolerance, or contraindication with Pylera.


AMRIX

Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months with tizanidine tablets AND baclofen tablets.


APIDRA SOLOSTAR U-100 INSULIN



APIDRA U-100 INSULIN



APLENZIN

Criteria Details A automatic approval will be given to members who have had prior therapy with a generic bupropion product (75mg/100mg IR, 100mg/150mg/200mg SR, or 150mg/300mg XL) and at least 1 other SSRI, SNRI or mirtazapine.


APRISO

Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to two of the following: sulfasalazine, balsalazide capsules, mesalamine enema or mesalamine 0.375g extended-release.


ARMONAIR DIGIHALER



ASACOL HD



ASMANEX HFA



ASMANEX TWISTHALER



aspirin-dipyridamole

Criteria Details An automatic approval will be given to members who have had previous treatment with clopidogrel.


ATACAND

Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: lisinopril, lisinopril-HCTZ, ramipril, benazepril, benazepril-HCTZ, quinapril, quinapril-HCTZ, enalapril, enalapril-HCTZ, Losartan, Losartan-HCTZ, Valsartan, Valsartan-HCTZ, Irbesartan, Irbesartan-HCTZ, Olmesartan, Olmesartan-HCTZ.


ATACAND HCT



avidoxy



AZASITE

Criteria Details The member has had previous treatment within the past 12 months or intolerance to two of the following: ciprofloxacin eye drops, levofloxacin eye drops, moxifloxacin eye drops (generic Vigamox), or ofloxacin eye drops.


azelaic acid

Criteria Details An automatic approval will be given to members who have had previous treatment with topical metronidazole.


azelastine-fluticasone

Criteria Details An approval will be given to members who have had previous treatment with two of the following: Fluticasone nasal spray, Azelastine nasal spray, Flunisolide nasal spray. If the member has nasal polyps OR for prophylaxis to seasonal allergic rhinitis, the request will be approved.


AZOPT

Criteria Details An automatic approval will be given to members who have had previous treatment with: Brimonidine ophthalimic solution AND dorzolamide ophthalimic solution.


BECONASE AQ



bepotastine besilate

Criteria Details An automatic approval will be given to members who have had previous trial with at least two of the following agents: olopatadine 0.2%, azelastine, or cromolyn eye drops.


BEPREVE



BESIVANCE



BETIMOL

Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following eye drops: LEVOBUNOLOL 0.5%, TIMOLOL 0.25%, TIMOLOL 0.5%, BETAXOLOL HCL 0.5%.


BETOPTIC S



BINOSTO

Criteria Details An automatic approval will be given to members who have had previous treatment with Alendronate.


brinzolamide



BROMSITE



BRYHALI

Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following topical generic products: triamcinolone, mometasone, fluticasone, betamethasone, or clobetasol.


bupropion hcl



BYETTA

Criteria Details An automatic approval will be given to members who have had previous treatment with at least two preferred GLP 1 Analogs (e.g. Victoza, Trulicity, Ozempic, Bydureon, Rybelsus).


calcipotriene



calcitriol



CAMBIA

Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following oral generics: Meloxicam, Diclofenac, Ibuprofen, Naproxen.


CANASA



chlorzoxazone



CLARINEX-D 12 HOUR

Criteria Details An automatic approval will be given to members who have had previous treatment with fluticasone nasal, flunisolide nasal, or levocetirizine.


CLENPIQ

Criteria Details An automatic approval will be given to members who have had a trial, intolerance, or contraindication to Suprep OR Sutab.


CLOBEX



CONZIP

Criteria Details An automatic approval will be given to members who have had a trial with immediate release tramadol AND extended release tramadol tablets.


CORDRAN



coremino

Criteria Details The member has previous treatment or intolerance with a generic immediate-release minocycline formulation.


COSOPT

Criteria Details An automatic approval will be given to members who have had previous treatment with dorzolamide/timolol ophthalmic solution


COSOPT (PF)

Criteria Details An automatic approval will be given to members who have had previous treatment with dorzolamide/timolol ophthalmic solution


cyclobenzaprine



CYCLOSET

Criteria Details An automatic approval will be given to members who have had previous treatment with, contraindication, or intolerance to a metformin containing medicine.


darifenacin

Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: Oxybutynin (IR or ER), Toviaz, Myrbetriq, or Gemtesa.


DARTISLA

Criteria Details Member has previous treatment or intolerance to glycopyrrolate tablet.


DELZICOL



desloratadine

Criteria Details An automatic approval will be given to members who have had previous treatment with fluticasone nasal, flunisolide nasal, or levocetirizine.


desvenlafaxine

Criteria Details An automatic approval will be given to members who have had previous treatment with venlafaxine (IR or ER) AND duloxetine.


diclofenac potassium



DIPENTUM



DORYX



DORYX MPC



doxycycline hyclate



doxycycline monohydrate



DULERA



DYMISTA



EDARBI



EDARBYCLOR



eletriptan



ELYXYB



ENABLEX



epinastine



EPSOLAY



EZALLOR SPRINKLE



ezetimibe-rosuvastatin



febuxostat

Criteria Details An automatic approval will be given to members who have had previous treatment with Allopurinol.


fenofibrate micronized

Criteria Details An automatic approval will be given to members who have had previous treatment to one strength of generic fenofibrate tablet (145mg, 160mg, 48mg,54 mg) AND one strength of generic fenofibrate micronized capsule (200 mg, 134 mg, 67 mg).


fenoprofen



FEXMID



FINACEA



FLAREX



FLOLIPID



fluvastatin



FML FORTE



FML LIQUIFILM



FML S.O.P.



FORFIVO XL



FORTAMET

Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to metformin IR (generic Glucophage) OR metformin ER (generic Glucophage XR) for at least 3 months.


FOSAMAX PLUS D

Criteria Details An automatic approval will be given to members who have had previous treatment with Alendronate.


FOSRENOL

Criteria Details The member has had previous treatment, intolerance to, or contraindication to calcium acetate (tablet OR capsule) AND sevelamer carbonate.


FROVA



frovatriptan



GELNIQUE



GLUCAGON (HCL) EMERGENCY KIT

Criteria Details An automatic approval will be given to members who have had previous treatment with GlucaGen Hypokit, Zegalogue, Baqsimi, or Gvoke and documented lack of ability to use preferred product.


glucagon emergency kit (human)

Criteria Details An automatic approval will be given to members who have had previous treatment with GlucaGen Hypokit, Zegalogue, Baqsimi, or Gvoke and documented lack of ability to use preferred product.


GLUMETZA



GOLYTELY



GRALISE

Criteria Details This applies to new starts only. An automatic approval will be given to members who have had a previous treatment or intolerance to gabapentin AND at least one of the following: Lidocaine 5% topical patch or pregabalin (e.g. Lyrica).


HUMALOG JUNIOR KWIKPEN U-100



HUMALOG KWIKPEN INSULIN



HUMALOG MIX 50-50 INSULN U-100



HUMALOG MIX 50-50 KWIKPEN



HUMALOG MIX 75-25 KWIKPEN



HUMALOG MIX 75-25(U-100)INSULN



HUMALOG U-100 INSULIN



HUMULIN 70/30 U-100 INSULIN



HUMULIN 70/30 U-100 KWIKPEN



HUMULIN N NPH INSULIN KWIKPEN



HUMULIN N NPH U-100 INSULIN



HUMULIN R REGULAR U-100 INSULN



hydrocodone bitartrate

Criteria Details An automatic approval will be given to members who have had a trial of at least two of the following long acting opioid products: fentanyl patch, morphine ER tab, Xtampza ER, buprenorphine transdermal patch, Belbuca.


hydromorphone



HYSINGLA ER



imiquimod

Criteria Details The member has had previous treatment, or intolerance to generic imiquimod 5% cream.


IMPEKLO



INSULIN LISPRO



INSULIN LISPRO PROTAMIN-LISPRO



INVELTYS



ivermectin



KADIAN



KAPSPARGO SPRINKLE

Criteria Details The member has had previous treatment with at least TWO of the following generic beta blockers: carvedilol tablet, atenolol tablet, metoprolol (tartrate OR succinate).


lanthanum



LASTACAFT



LESCOL



LESCOL XL



levalbuterol tartrate

Criteria Details An automatic approval will be given to members who have had previous treatment with generic albuterol HFA and Ventolin HFA.


levorphanol tartrate

Criteria Details The member has had a trial, intolerance, or contraindication to TWO of the following agents: immediate release formulations of oxycodone, hydromorphone, or morphine sulfate, one of which must have been used within the past 12 months.


LIALDA



LIVALO

Criteria Details An automatic approval will be given to members who have had previous treatment with both of the following: Zypitamag and ezetimibe.


LORZONE



LOTEMAX



loteprednol etabonate



luliconazole

Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months, contraindication, or intolerance to two of the following: clotrimazole cream, ciclopirox 0.77% cream/gel/suspension, or ketoconazole cream.


LUXIQ



LUZU



LYUMJEV KWIKPEN U-100 INSULIN



LYUMJEV KWIKPEN U-200 INSULIN



LYUMJEV U-100 INSULIN



LYVISPAH



MAXIDEX



mesalamine



metformin



METROGEL



MICARDIS



MICARDIS HCT



minocycline



MINOLIRA ER



MIRAPEX

Criteria Details An automatic approval will be given to members who have had previous treatment with Pramipexole IR AND Ropinirole IR.


MIRAPEX ER



MIRVASO



mometasone



mondoxyne nl



MONODOX



morgidox



MORPHABOND ER



morphine



MOVIPREP



MOXEZA



moxifloxacin



mupirocin calcium

Criteria Details The member has had previous treatment within the past 12 months or intolerance with mupirocin topical ointment.


naftifine



NAFTIN



NALFON



NAPRELAN CR



naproxen sodium



NASONEX



NEVANAC



NORITATE



NORLIQVA

Criteria Details Pending CMS Review


NUCYNTA

Criteria Details An automatic approval will be given to members who have had previous treatment within the past 12 months, contraindication, or intolerance to at least two (2) of the following agents: oxycodone IR, hydromorphone, morphine sulfate IR.


NUCYNTA ER



NULYTELY LEMON-LIME



NULYTELY WITH FLAVOR PACKS



okebo



olopatadine



OMECLAMOX-PAK



omeprazole-sodium bicarbonate

Criteria Details An approval will be given to members who have had previous treatment or intolerance to omeprazole AND pantoprazole. For the diagnosis of reduction of risk of upper GI bleeding in critically ill patients, pantoprazole therapy is not required.


OMNARIS



ONZETRA XSAIL



ORACEA



OSMOPREP



OXTELLAR XR

Criteria Details An automatic approval will be given to members who have had prior therapy with immediate release oxcarbazepine.


oxymorphone



OXYTROL



PANCREAZE

Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to Creon AND Zenpep.


PATANASE



peg3350-sod sul-nacl-kcl-asb-c



PENTASA



PERTZYE



PHOSLYRA



PLENVU



pramipexole



PRED FORTE



PRED MILD



PREPOPIK



PROAIR DIGIHALER



PROAIR HFA



PROAIR RESPICLICK



PROLENSA



PROVENTIL HFA



PULMICORT FLEXHALER



QNASL



QVAR REDIHALER



ramelteon

Criteria Details The member has had previous treatment, intolerance or contraindication with Belsomra or trazodone.


RELAFEN



RELAFEN DS



RELPAX



RENAGEL



REQUIP XL



RHOFADE



RHOPRESSA

Criteria Details An automatic approval will be given to members who have had previous treatment, contraindication, or intolerance to a prostaglandin analog.


ROCKLATAN

Criteria Details An automatic approval will be given to members who have had previous treatment, contraindication, or intolerance to a prostaglandin analog.


ropinirole



rosadan



ROSZET



ROZEREM

Criteria Details The member has had previous treatment, intolerance or contraindication with Belsomra or trazodone.


RYTARY

Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to an immediate-release or extended-release Carbidopa-Levodopa containing product.


sevelamer hcl



SEYSARA



SIMBRINZA



SOAANZ

Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: furosemide tablet, bumetanide table, or torsemide tablet.


SOLODYN



SOOLANTRA



SORILUX



SPRITAM

Criteria Details An automatic approval will be given to members who have had prior therapy with levetiracetam and one of the following: lamotrigine, carbamazepine, topiramate, divalproex, or phenytoin.


sumatriptan-naproxen



TALICIA



TARGADOX



TEKTURNA HCT



telmisartan-hydrochlorothiazid



TIMOPTIC



TIMOPTIC OCUDOSE (PF)



TIVORBEX



tizanidine



TOSYMRA



tramadol

Criteria Details An automatic approval will be given to members who have had a trial with immediate release tramadol AND extended release tramadol tablets.


TRAVATAN Z

Criteria Details An automatic approval will be given to members who have had previous treatment with two of the following: latanoprost, travaprost, Lumigan, Rocklatan, or Vyzulta.


TREXIMET



TRINTELLIX

Criteria Details An automatic approval will be given to members who have had prior therapy, intolerance, or contraindication with a generic SSRI, SNRI, a generic bupropion product (75mg/100mg IR, 100mg/150mg/200mg SR, or 150mg/300mg XL) or mirtazapine.


ULORIC

Criteria Details An automatic approval will be given to members who have had previous treatment with Allopurinol.


VALSARTAN



VECTICAL



VELPHORO



VIBRAMYCIN (CALCIUM)



VIBRAMYCIN (MONO)



VIOKACE



VOQUEZNA DUAL PAK



VOQUEZNA TRIPLE PAK



XELPROS



XIMINO



XOPENEX HFA



ZANAFLEX



ZEGERID

Criteria Details An approval will be given to members who have had previous treatment or intolerance to omeprazole AND pantoprazole. For the diagnosis of reduction of risk of upper GI bleeding in critically ill patients, pantoprazole therapy is not required.


ZEMBRACE SYMTOUCH



ZETONNA



zileuton

Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to montelukast AND zafirlukast.


ZIOPTAN (PF)



ZIPSOR



ZOHYDRO ER



zolmitriptan



ZOMIG



ZOMIG ZMT



ZORVOLEX



ZYCLARA

Criteria Details The member has had previous treatment, or intolerance to generic imiquimod 5% cream.


ZYFLO

Criteria Details An automatic approval will be given to members who have had previous treatment or intolerance to montelukast AND zafirlukast.


ZYMAXID



ZYPITAMAG

Criteria Details An automatic approval will be given to members who have had previous treatment with one of the following statins: simvastatin, pravastatin, lovastatin, atorvastatin or rosuvastatin.


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policies:Discrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618If you need help filing a grievance, call 877-320-1235 (TTY: 711).

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