Cy14mnpopeneast_stcriteriamemberfile_20130927t104916

Step  Therapy  Criteria  
CY  14  MNP  Open   -­‐  East  
Last  Updated:  09/27/2013  
 
ALPHA BLOCKERS
Products Affected

Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): alfuzosin Er, doxazosin, tamsulosin, terazosin. Step 2 Drug(s): Cardura, Cardura XL, Flomax, Rapaflo, UroXatral. ANTIDEPRESSANTS - SSRI
Products Affected

Criteria
If the patient has tried two Step 1 drugs, then authorization for a drug in Step 2 drug may be given. Step 1 Drug(s): Citalopram, Citalopram Hbr, Escitalopram, Fluoxetine Dr, Fluoxetine Hcl, Fluvoxamine Maleate, Paroxetine Hcl, Paroxetine ER, Sertraline Hcl. Step 2 Drug(s): Celexa, Fluoxetine 60 mg tablet, Lexapro, Luvox Cr, Paxil, Paxil Cr, Pexeva, Prozac, Prozac Weekly, Viibryd, Zoloft. Patients who have taken Luvox Cr, Pexeva, or Viibryd at any time in the past and discontinued its use may receive authorization to restart Luvox Cr, Pexeva or Viibryd (whichever they used in the past). Authorization may be given for a step 2 SSRI if the patient is currently taking the requested agent. Authorization may be given for Luvox Cr, Pexeva, or Viibryd if the patient is a child or adolescent aged 18 years or less, or has suicidal ideation. This step therapy program applies to new utilizers only. BILE ACID SEQUESTRANTS
Products Affected

Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Cholestyramine Light, Colestipol Hcl, Prevalite. Step 2 Drug(s): Colestid, Questran, Welchol. Authorization may be given for Welchol if patients have a drug-drug interaction with cholestyramine or colestipol. Authorization may be given for Welchol in patients who are pregnant. Authorization may be given for Welchol in patients with type 2 diabetes who are also using other antidiabetic agents (eg, insulin, metformin, sulfonylurea). Authorization may be given for Welchol in patients less than 18 years of age. BRAND NSAIDS
Products Affected

Criteria
If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug other than Vimovo or Duexis may be given. Step 1 Drug(s): Diclofenac-misoprostol, Diclofenac Potassium, Diclofenac Sodium, Etodolac, Fenoprofen Calcium, Flurbiprofen, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac Tromethamine, Lansoprazole, Meclofenamate Sodium, Mefenamic Acid, Meloxicam, Omeprazole, Nabumetone, Naproxen, Naproxen Sodium, Oxaprozin, Pantoprazole Sodium, Piroxicam, Sulindac, Tolmetin Sodium. Step 2 Drug(s): Anaprox, Anaprox Ds, Arthrotec 50, Arthrotec 75, Cambia, Cataflam, Daypro, Duexis, Ec-naprosyn, Feldene, Flector, Indocin, Mobic, Nalfon, Naprelan, Naprosyn, Pennsaid, Ponstel, Sprix, Vimovo, Voltaren, Voltaren-XR. Authorization for Vimovo may be given if the patient has claims history for both omeprazole or lansoprazole or pantoprazole sodium and a prescription naproxen or naproxen sodium product. Authorization may be given for Flector, Pennsaid, Sprix, or Voltaren Gel for patients with difficulty swallowing or cannot swallow. Authorization may be given for Pennsaid or Voltaren Gel for patients with a chronic musculoskeletal pain condition (eg, osteoarthritis) in 3 or fewer joints/sites (ie, hand, wrist, elbow, knee, ankle, or foot each count as 1 joint/site) who are at risk of NSAID-associated toxicity (eg, previous gastrointestinal [GI] bleed, history of peptic ulcer disease, impaired renal function, cardiovascular disease, hypertension, heart failure, elderly patients with impaired hepatic function, or those taking concomitant anticoagulants). Authorization for Duexis may be given if there is a claims history for both a generic H2RA (famotidine, cimetidine, nizatidine, ranitidine) and ibuprofen (brand or generic). These must be in the claims history. Coverage of Duexis is not recommended if the patient has only tried OTC ibuprofen, other NSAIDs besides ibuprofen, or a COX-2 inhibitor (Celebrex). Authorization may be given for Voltaren Gel or Pennsaid for patients greater than or equal to 75 years of age with hand or knee osteoarthritis. CCB - DIHYDROPYRIDINES
Products Affected

Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Afeditab Cr, Amlodipine Besylate, Amlodipine Besylate-benazepril, Felodipine Er, Isradipine, Nicardipine Hcl, Nifediac Cc, Nifedical Xl, Nifedipine Er, Nisoldipine. Step 2 Drug(s): Adalat Cc, Norvasc, Procardia XL, Sular. CCB - VERAPAMIL
Products Affected

Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Verapamil Er, Verapamil Er Pm, Verapamil Hcl. Step 2 Drug(s): Calan, Calan Sr, Verelan, Verelan PM. Products Affected

Criteria
DOPAMINE AGONISTS
Products Affected

Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Pramipexole Dihydrochloride, Ropinirole Hcl. Step 2 Drug(s): Mirapex, Mirapex Er, Neupro, Requip, Requip Xl. Authorization may be given for Mirapex ER or Neupro if the patient is currently taking (or has taken in the past) the requested agent. Authorization for Neupro may be given if the patient cannot swallow or has difficulty swallowing. ENHANCED ARB
Products Affected

Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug may be given. Step 1 Drug(s): Amlodipine Besylate-benazepril, Benazepril Hcl, Benazepril-hydrochlorothiazide, Candesartan-hydrochlorothiazide, Captopril, Captopril-hydrochlorothiazide, Enalapril Maleate, Enalapril-hydrochlorothiazide, eprosartan, Fosinopril Sodium, Fosinopril-hydrochlorothiazide, Irbesartan, Irbesartan-hydrochlorothiazide, Lisinopril, Lisinopril-hydrochlorothiazide, Losartan Potassium, Losartan-Hydrochlorothiazide, Moexipril Hcl, Moexipril-hydrochlorothiazide, Perindopril erbumine, Quinapril Hcl, Quinapril-hydrochlorothiazide, Ramipril, Trandolapril, Valsartan-hydrochlorothiazide. Step 2 Drug(s): Azor, Benicar, Benicar Hct, Exforge, Exforge Hct, Tribenzor. Step 3 Drug(s): Atacand, Atacand Hct, Avalide, Avapro, Cozaar, Diovan, Diovan Hct, Edarbi, Edarbyclor, Hyzaar, Micardis, Micardis Hct, Teveten, Teveten Hct, Twynsta. Authorization may be given for a step 2 or step 3 angiotensin receptor blocker (ARB) or ARB-containing combination product, without a trial of a step 1 or 2 agent, if the patient was recently hospitalized and discharged within the previous 30 days for a cardiovascular event (eg, myocardial infarction, hypertensive emergency, decompensated heart failure) and has already been started and stabilized on the requested agent. Authorization may be given for Atacand in children aged less than 6 years but greater than or equal to 1 year. ENHANCED BISPHOSPHONATES ORAL
Products Affected

Criteria
ENHANCED OPHTHALMIC PROSTAGLANDINS
Products Affected

Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug may be given. Step 1 Drug(s): latanoprost, travoprost. Step 2 Drug(s): Lumigan, Travatan Z. Step 3 Drug(s): Rescula, Xalatan, Zioptan. Authorization for Travatan Z or Zioptan may be given if the patient has a known benzalkonium chloride (BAK) sensitivity or sensitivity to other ophthalmic preservatives. ENHANCED OVERACTIVE BLADDER
Products Affected

Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug may be given. Step 1 Drug(s): Oxybutynin Chloride, Oxybutynin Chloride Er, Tolterodine, Trospium Chloride, Trospium Er. Step 2 Drug(s): Enablex, Gelnique. Step 3 Drug(s): Detrol, Detrol La, Ditropan Xl, Myrbetriq, Oxytrol, Sanctura, Sanctura XR,Toviaz, Vesicare. Authorization for Gelnique may be given for patients who cannot swallow or who have difficulty swallowing. ENHANCED SEDATIVE HYPNOTICS
Products Affected

Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug may be given. A specific trial duration is not required as reasons for discontinuation are patient specific. The definiton of an adequate trial is best determined by the patient's prescriber. Step 1 Drug(s): Zaleplon, Zolpidem Tartrate. Step 2 Drug(s): Lunesta, Rozerem. Step 3 Drug(s): Ambien, Ambien Cr, Edluar, Silenor, Sonata, Zolpimist. Rozerem will be covered for members equal to or over the age of 65 years. For those under 65 years of age, the step therapy will apply. Authorization for Rozerem or Silenor may be given if the patient has a documented history of addiction to controlled substances. Authorization for Edluar or Zolpimist may be given if the patient has difficulty swallowing or cannot swallow tablets. FENOFIBRATE
Products Affected

Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug may be given. Step 1 Drug(s): Fenofibrate. Step 2 Drug(s): Tricor, Trilipix, Antara, Fenoglide, Fibricor, Lipofen, Lofibra. HIGH RISK MEDICATIONS - LONG ACTING
SULFONYLUREAS
Products Affected

Criteria
HIGH RISK MEDICATIONS - SEDATIVE HYPNOTICS
Products Affected

Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Rozerem, Silenor, trazodone. Step 2 Drug(s): Ambien, Ambien Cr, Edluar, Lunesta, Sonata, Zaleplon, Zolpidem, Zolpidem Er, Zolpimist. This step therapy program applies to chronic utilizers greater than 64 years of age only. Authorization for Edluar or Zolpimist may be given if the patient has difficulty swallowing or cannot swallow tablets. Authorization for zolpidem or zolpidem Er (brand or generic) may be given if being used for an indication other than insomnia. Authorization for a step 2 drug may be given in patients aged less than 65 years. HMG RULE 1
Products Affected

Criteria
If the patient has tried a Step 1 drug (brand or generic), then authorization for a Step 2 drug may be given. A specific trial duration is not required as reasons for discontinuation are patient specific. The definiton of an adequate trial is best determined by the patient's prescriber. Step 1 Drug(s): Atorvastatin, Fluvastatin, Lovastatin, Pravastatin Sodium, Simvastatin. Step 2 Drug(s): Crestor. HMG RULE 2
Products Affected

Criteria
If the patient has tried a Step 1 Group A (brand or generic) and a Step 1 Group B drug, then authorization for a Step 2 drug may be given. Step 1 Group A Drug(s): Atorvastatin, Fluvastatin, Lovastatin, Pravastatin Sodium, Simvastatin. Step 1 Group B Drug(s): Crestor. Step 2 Drug(s): Altoprev, Caduet, Lescol, Lescol Xl, Lipitor, Livalo, Mevacor, Pravachol, Vytorin, Zocor. INFLAMMATORY BOWEL
Products Affected

Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Asacol, Asacol HD, balsalazide, Delzicol, Lialda, Pentasa, sulfasalazine, sulfazine EC. Step 2 Drug(s): Apriso, Azulfidine, Azulfidine Entab, Colazal, Dipentum, Giazo. LONG ACTING OPIOIDS
Products Affected

Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): morphine sulfate ER, oxymorphone ER. Step 2 Drug(s): Avinza, Exalgo, Kadian, MS Contin, Nucynta ER,Opana Er, Oxycontin. Authorization may be given for Exalgo, OxyContin, or Nucynta ER if the patient is unable to tolerate or has a drug allergy noted with morphine sulfate. Authorization may be given for Exalgo, OxyContin, or Nucynta ER if the patient has renal insufficiency. Authorization may be given for OxyContin if the patient is pregnant. METFORMIN
Products Affected

Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Metformin Hcl, Metformin Hcl Er. Step 2 Drug(s): Fortamet, Glucophage, Glucophage Xr, Glumetza, Riomet. Participant must have 30 days of generic metformin or generic metformin ER in claims history. Authorization may be given for Riomet patients who are unable to swallow or have difficulty swallowing tablets containing metformin. PPI ENHANCED
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Criteria
TETRACYCLINES (ORAL)
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Criteria
THIAZOLIDINEDIONE
Products Affected

Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Glimepiride-pioglitazone, Metformin-pioglitazone, Pioglitazone. Step 2 Drug(s): Actoplus Met, Actoplus Met Xr, Actos, Avandamet, Avandaryl, Avandia, Duetact, Oseni. Authorization may be given for a step 2 drug if the patient has tried a step 1 drug in the past. TOPICAL CORTICOSTEROIDS
Products Affected

Criteria
If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Ala-cort, Alclometasone Dipropionate, Amcinonide, Betamethasone Dipropionate, Betamethasone Valerate, Clobetasol Emollient, Clobetasol Propionate, Desonide, Desoximetasone, Diflorasone Diacetate, Fluocinolone Acetonide, Fluocinonide, Fluocinonide Emollient, Fluticasone Propionate, Halobetasol Propionate, Hydrocortisone, Hydrocortisone Butyrate, Hydrocortisone Valerate, Mometasone Furoate, Prednicarbate, Triamcinolone Acetonide, Triderm. Step 2 Drug(s): Ala-scalp Hp, Capex, Carmol Hc, Clobex, Cloderm, Cordran, Cutivate, Derma Smoothe FS, Dermatop, Desonate, Desowen, Diprolene, Diprolene Af, Elocon, Halog, Kenalog, Locoid, Locoid Lipocream, Lokara, Luxiq, Olux-e, Pandel, Synalar,Temovate, Topicort, Topicort Lp, U-cort, Ultravate, Vanos, Verdeso, Westcort. Authorization for a step 2 drug may be given if the patient has tried two step 1 drugs for the current condition. Authorization may be given for Verdeso foam or Capex shampoo without a trial of two step 1 drugs for the treatment of dermatoses of the scalp. Authorization may be given for Derma-Smoothe FS scalp oil without a trial of two step 1 drugs for the treatment of psoriasis of the scalp. TRAMADOL
Products Affected

Criteria
Products Affected

Criteria
If the patient has tried a Step 1 drug (brand or generic), then authorization for a Step 2 drug may be given. Step 1 Drug(s): Allopurinol, Zyloprim. Step 2 Drug(s): Uloric. Authorization may be given for Uloric if the patient has renal insufficiency or decreased renal function. Authorization may be given for Uloric if the patient is receiving concomitant medications that have significant drug-drug interactions with allopurinol, which are not noted with Uloric (eg, cyclosporine, chlorpropamide). A  
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High Risk Medications - Sedative Hypnotics . 17 I  
Enhanced Arb . 10 Enhanced Bisphosphonates Oral . 11 K  
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Opana Er (crush Resistant) . 21 Oracea . 24 T  
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Prevacid Solutab . 23 Prilosec . 23 Procardia XL . 6  
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Source: http://truelifeadvantage.amidacareny.org/Collateral/Documents/English-US/StepTherapyCriteria_SNP.pdf