Denver-Health-Medical-Plan Step Therapy Coverage

Febuxostat

Step 2 coverage for febuxostat

Febuxostat 40 mg/80 mg Step 2: Prior claim for the formulary version of allopurinol tablets within the past 120 days is required.120 days

Supports Step 2 placement for febuxostat 40 mg and 80 mg; see chunks 0-1

Esomeprazole (granules)

Step 2 coverage for esomeprazole magnesium granules

Esomeprazole magnesium DR granules Step 2: Prior claim for a generic formulary oral proton‑pump inhibitor (lansoprazole, esomeprazole magnesium capsule, rabeprazole, omeprazole, or pantoprazole) within the past 120 days is required.120 days

Applies to esomeprazole magnesium granules across listed strengths; see chunks 2-3

Antipsychotics Step Criteria

Step 2 coverage for selected antipsychotics

Antipsychotics Step 2 prior-claim options: Required prior-claim evidence varies by product: either claim for two formulary oral generic antipsychotics within the past 365 days (e.g., asenapine patch, cariprazine, other listed products) OR prior claim for one formulary oral antipsychotic within the past 120 days for products that specify a single-agent lookback (e.g., certain clozapine disintegrating tablets).120 or 365 days

See chunks 6, 9, and 11 for product-specific requirements and acceptable agents

AUVELITY

Step 2 coverage for AUVELITY

AUVELITY Step 2: Prior claim for TRINTELLIX and one generic antidepressant (acceptable agents listed: citalopram, escitalopram, fluoxetine, paroxetine, sertraline, desvenlafaxine, duloxetine, venlafaxine, mirtazapine, bupropion IR/SR/XL, or vilazodone) within the past 365 days is required.365 days

See chunk 13 for the qualifying antidepressant list

Dihydroergotamine

Step 2 coverage for dihydroergotamine nasal spray

Dihydroergotamine nasal spray Step 2: Prior claims for two formulary generic triptans (for example sumatriptan and rizatriptan) within the past 365 days are required.365 days

See chunk 15

DRIZALMA SPRINKLE

Step 2 coverage for DRIZALMA SPRINKLE

DRIZALMA SPRINKLE Step 2: Prior claim for a formulary generic duloxetine capsule within the past 120 days is required.120 days

See chunk 16

ELEPSIA XR

Step 2 coverage for ELEPSIA XR

ELEPSIA XR Step 2: Trial of generic levetiracetam ER tablets within the past 120 days is required for listed ER strengths.120 days

See chunk 17

Topiramate oral solution

Step 2 coverage for topiramate oral solution

Topiramate oral solution Step 2: Prior claim for generic topiramate within the past 120 days is required.120 days

See chunk 19

Step 2 coverage criteria

Covered when ALL of the following are met per listed Step 2 product:

Topiramate 25 mg/ml oral solution: Prior claim for generic topiramate within the past 120 days is required.

Eslicarbazepine 200/400/600/800 mg tablets: Prior claim for two generic anticonvulsant agents (carbamazepine, divalproex sodium, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine, topiramate, valproic acid, zonisamide, or lacosamide) within the past 365 days is required.

Omega-3 acid ethyl esters 1 g capsule: Prior claim for generic fenofibrate in the last 120 days is required.

NEXLETOL / NEXLIZET / REPATHA products: Prior 25-day trial of a formulary high-intensity statin (atorvastatin 40 or 80 mg, or rosuvastatin 20 or 40 mg) within the past 120 days is required.

Step-therapy / Prior-claim Criteria

Step-therapy and Part D payment qualification criteria based on prior pharmacy claims

Part D insulin payment qualification: A prior claim for an injectable insulin within the past 120 days will qualify for Part D payment determination.120 days

See chunk 67

KLISYRI Step 2 requirement: Prior claim for generic topical fluorouracil within the last 120 days is required for KLISYRI Step 2 coverage.120 days

See chunks 68-69

TRINTELLIX plus generic antidepressant requirement: Prior claim for TRINTELLIX and one generic antidepressant (list provided) within the past 365 days is required for specified Step 2 antidepressant products.365 days

CAPLYTA - Initial Coverage Criteria