MEDCARE PLUS MEDICARE PART D FORMULARY STEP EDIT RESTRICTIONS
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS ALPHA 1-PROTEINASE INHIBITOR . 3 ANALGESICS, NARCOTICS . 4 ANTIBACTERIALS (EENT) . 5 ANTIDIABETIC AGENTS – INSULINS. 6 ANTIULCER AGENTS . 7 B VERSUS D ADMINISTRATIVE STEP . 8 COPD .10 DIPEPTIDYL PEPTIDASE-4 ENZYME INHIBITORS.11 DUTASTRIDE AND TAMSULOSIN .12 GABAPENTIN SR .13 HYPERURICEMIC AGENTS .14 KETOLIDES .15 MULTIPLE SCLEROSIS AGENTS .16 NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPE .17 OPHTHALMIC ANTIHISTAMINES .18 ORAL INHALED CORTICOSTEROIDS .19 RENIN ANGIOTENSIN SYSTEM INHIBITORS .20 THIAZOLIDINEDIONES .21 TOPICAL NSAID THERAPY AGENTS.22 TRAZODONE, EXTENDED RELEASE* .23
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS ALPHA 1-PROTEINASE INHIBITOR Step edit may or may not apply to your formulary. ¹ Drug not available on closed formularies.Use formulary alternative. Generic Name:
STEP EDIT DESCRIPTION
Prior claim for Aralast NP, Prolastin, Prolastin C, or Zemaira within the past 120 days. Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS ANALGESICS, NARCOTICS ¹ Drug not available on closed formularies.Use formulary alternative.
Morphine sulfate, CPMP 24-hour capsule¹
STEP EDIT DESCRIPTION
Prior claim for morphine sulfate sustained action tablet (MS Contin) within the past 120 days. Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS ANTIBACTERIALS (EENT) ¹ Drug not available on P2TC formulary. Use formulary alternative. Generic Name:
STEP EDIT DESCRIPTION Prior claim for ciprofloxacin ophthalmic drops or ofloxacin ophthalmic drops within the last 120 days. Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS ANTIDIABETIC AGENTS – INSULINS
STEP EDIT DESCRIPTION
Prior claim for Insulin Glargine (Lantus or Lantus Solostar) within the past 120 days.
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS ANTIULCER AGENTS ¹ Drug not available on closed formularies.Use formulary alternative. ³ Brand not available on closed formularies.
Lansoprazole (Prevacid³, Prevacid Solutab³)
STEP EDIT DESCRIPTION: Prior claim for generic omeprazole or pantoprazole within the past 120 days. ____________________________________________________________________________ Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS B VERSUS D ADMINISTRATIVE STEP
³ Brand not available on closed formularies.
Generic Name:
Cyclophosphamide (Oral) Methotrexate (Oral)
STEP EDIT DESCRIPTION
Prior claim for a rheumatoid arthritis drug within the past 120 days. Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS
STEP EDIT DESCRIPTION Prior claim for inhaled tiotropium (Spiriva) AND an inhaled long acting beta agonist or an inhaled long acting beta agonist combination within the last 365 days.
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS DIPEPTIDYL PEPTIDASE-4 ENZYME INHIBITORS ¹ Drug not available on closed formularies.Use formulary alternative. Generic Name:
STEP EDIT DESCRIPTION
Prior claim for metformin (Glucophage), metformin ER, glyburide/metformin (Glucovance) or glipizide/metformin (Metaglip) within the past 180 days. Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS DUTASTERIDE AND TAMSULOSIN Step edit may or may not apply to your formulary. ¹ Drug not available on closed formularies.Use formulary alternative.
STEP EDIT DESCRIPTION
Prior claim for generic tamsulosin, finasteride, or dutasteride within the past 120 days. Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS GABAPENTIN SR Step edit may or may not apply to your formulary. ¹ Drug not available on closed formularies.Use formulary alternative. Generic Name :
STEP EDIT DESCRIPTION
Prior claim for Lyrica in the past 120 days. Part D Effective 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS HYPERURICEMIC AGENTS
STEP EDIT DESCRIPTION Prior claim for allopurinol or colchicine within the past 120 days. Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS KETOLIDES
STEP EDIT DESCRIPTION
Prior claim for a macrolide within the past 120 days. Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS MULTIPLE SCLEROSIS AGENTS STEP EDIT DESCRIPTION
Prior claim for Rebif (Interferon Beta-1A) or Avonex (Interferon Beta-1A) or Copaxone (Glatiramer Acetate) within the past 120 days. ____________________________________________________________________________ Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPE
STEP EDIT DESCRIPTION
Prior claim for one oral non-steroidal anti-inflammatory agent within the past 120 days. Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS OPHTHALMIC ANTIHISTAMINES ¹ Branded drug with generic formulary alternative and/or drug not available on closed formularies. Use formulary alternative. ² Drug not available on P2TC formulary. Use formulary alternative. * Federal Legend only, not OTC
Generic Name:
STEP EDIT DESCRIPTION:
For plans that cover OTC: Prior claim for OTC loratadine, loratadine D, cetirizine, cetirizine D, or generic ketotifen eye drops (Alaway) or prescription fexofenadine*, levocetirizine, or cromolyn sodium eye drops within the past 120 days. For plans that do not cover OTC: Prior claim for fexofenadine*, levocetirizine, or cromolyn sodium eye drops within the past 120 days. Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS ORAL INHALED CORTICOSTEROIDS
Step edit may or may not apply to your formulary. ¹ Drug not available on closed formularies.Use formulary alternative. Generic Name:
STEP EDIT DESCRIPTION
Prior claim for QVAR within the past 120 days. Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS RENIN ANGIOTENSIN SYSTEM INHIBITORS ¹ Branded drug with generic formulary alternative and/or drug not available on closed formularies. Use formulary alternative. ² Drug not available on P2TC formulary. Use formulary alternative.
STEP EDIT DESCRIPTION
Prior claim for an angiotensin converting enzyme inhibitor (ACE inhibitor), or ACE inhibitor combination, or a generic angiotensin receptor blocker (ARB), or generic ARB combination within the past 120 days. Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS THIAZOLIDINEDIONES
Pioglitazone HCL/ Glimepiride Pioglitazone/metformin
Actos Duetact Actoplus Met/Actoplus Met XR
STEP EDIT DESCRIPTION
Prior claim for metformin (Glucophage), metformin ER, glyburide/metformin (Glucovance), glipizide/metformin (Metaglip) or a formulary oral sulfonylurea (e.g., glyburide, glipizide) within the past 120 days. Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS TOPICAL NSAID THERAPY AGENTS ¹ Drug not available on closed formularies. Use formulary alternative. ² Drug not available on P2TC formulary. Use formulary alternative. STEP EDIT DESCRIPTION:
Prior claim for an oral non-steroidal anti-inflammatory agent (e.g., ibuprofen, naprosyn) within the past 120 days.
Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
[Contract numbers] [Organization name] [Organization Types]
MEDCARE PLUS STEP EDIT RESTRICTIONS TRAZODONE, EXTENDED RELEASE* Step edit may or may not apply to your formulary. ¹ Drug not available on closed formularies. Use formulary alternative. ² Drug not available on P2TC formulary. Use formulary alternative. * This step therapy will apply to NEW STARTS ONLY and will not affect stabilized
STEP EDIT DESCRIPTION:
Prior claim for generic immediate release trazodone tablets within the past 120 days. Part D Effective: 01/01/12
Copyright 2011 MedImpact, Inc. All rights reserved.
The documentation and information contained herein is: Confidential and proprietary to MedImpact; may contain material MedImpact considers Trade Secrets; must be maintained in strict confidence; and may not be reproduced, transmitted, published or disclosed to others without MedImpact's express prior written authorization. If authorization is granted, it may only be used for the purpose of evaluating MedImpact services and programs and may not be used for any other purpose and may only be shared with the recipient’s employees, officers, agents, consultants or contractors who need to have access to this documentation for the purpose of evaluating MedImpact's services or programs, who are informed of these obligations, and who agree to these obligations.
Telephone (305) 412-6004 ● Fax (305) 412-3007 PRENATAL CARE AND GUIDELINES Congratulations! We are thrilled to be able to care for you during this very exciting time in your lives! Pregnancy is a time of many changes, both physical and emotional, and close prenatal care is an essential part of maintaining a healthy pregnancy. Our goal is first and foremost to achieve a healthy mother
CULMINATING ACTIVITY: TRAVELING TO EXPONENTIA This culminating task addresses all standards in the unit and is designed to serve as an assessment task. Some parts of the items below are very explicit in order to assess student mastery of particular topics. However, in general, the questions do not give the same level of guidance as the learning tasks. In the learning tasks, students are g