Step Therapy Criteria

Transcription

1 Tier 5 Formulary Step Therapy 2016 Updated: 05/24/2016 Effective: 06/01/2016 What is Step Therapy? Some prescription drugs require step therapy (ST). In some cases, the plan requires you to first try certain drugs to treat your medical condition before we cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. Why is Step Therapy required? Trying a similar formulary drug first, which is generally a less costly generic drug instead of a more expensive brand, helps guide appropriate use of certain drugs. How do I request an exception to the coverage rules? You can ask us to make an exception to our coverage rules. For specific types of exceptions that you can ask us to make, please refer to your Comprehensive Formulary. When you are requesting a utilization restriction exception, including Step Therapy, you should submit a statement from your doctor supporting your request along with a completed Request for Medicare Prescription Drug Coverage Determination* Formulary ID: ; Version 12 Y0020_ST16_2_ Page 1 of 23

2 form. Generally, we must make our decision within 72 hours of getting your prescriber s or prescribing doctor s supporting statement. You can request expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber s or prescribing doctor s supporting statement. *Please note You cannot use this form for Medicare non-covered drugs: fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations). Please call our Member Services number at 1(844) for a complete drug list or if you have questions. TTY users should call 711. From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday Friday from 8 a.m. to 8 p.m. Alternate technologies, such as voice mail, will be used after hours, on the weekends, and holidays from February 15 through September 30. Voice messages are reviewed and responded to within one business day. Benefits may change on January 1 of each year. The Formulary may change at any time. You will receive notice when necessary. Trillium Community Health Plan is an HMO and a PPO plan with a Medicare contract. Enrollment in Trillium Community Health Plan depends on contract renewal. This information is available for free in other languages. Please call our Member Services number at 1(844) TTY users should call 711. From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday Friday from 8 a.m. to 8 p.m. Alternate technologies, such as voice mail, will be used after hours, on the weekends, and holidays from February 15 through September 30. Voice messages are reviewed and responded to within one business day. Member Services also has free language interpreter services available for non-english speakers. Page 2 of 23

3 Drug Category Page # ADHD STIMULANTS-S5TR...4 ANTIDEPRESSANTS-S5TR...5 ANTIFUNGAL-S5TR...6 ANTISPASMODICS - R5TR...7 ARB-R5TR...8 ATOPIC DERMATITIS-S5TR...9 ATYPICAL ANTIPSYCHOTICS-S5TR BISPHOSPHONATES-S5TR DIFICID-S DPP4 INHIBITORS - R5TR GLP1 AGONIST - R5TR ICS/LABA - R5TR...15 NASAL STEROIDS -S5TR NEUPRO-S5TR PPI-S5TR...18 SGLT2 - R5TR...19 STATINS-R5TR TRIPTANS-R5TR Page 3 of 23

4 ADHD STIMULANTS-S5TR Daytrana Strattera Patient needs to have a paid claim for two generic formulary ADHD stimulant medications. Page 4 of 23

5 ANTIDEPRESSANTS-S5TR Aplenzin Brintellix Desvenlafaxine Er Fetzima Fetzima Titration Pack Forfivo XL Pexeva Pristiq Trintellix Viibryd Viibryd Starter Pack Patient needs to have a paid claim for TWO of the following formulary products: bupropion, mirtazapine, generic SSRI, generic SNRI, or Paxil suspension. Page 5 of 23

6 ANTIFUNGAL-S5TR Exelderm Mentax Naftin CREA 2% Naftin GEL Oxistat Patient needs to have a paid claim for one formulary generic topical antifungal agent Page 6 of 23

7 ANTISPASMODICS - R5TR Enablex Patient needs to have a paid claim for one generic formulary antispasmodic agent or Gelnique, Myrbetriq, Oxytrol, Toviaz, or Vesicare Page 7 of 23

8 ARB-R5TR Edarbi Edarbyclor Patient needs to have a paid claim for two generic formulary ARBs or ARB-diuretic combinations or Benicar or Benicar HCT Page 8 of 23

9 ATOPIC DERMATITIS-S5TR Elidel Patient needs to have a paid claim for one formulary topical corticosteroid Page 9 of 23

10 ATYPICAL ANTIPSYCHOTICS-S5TR Abilify ORAL SOLN Abilify Discmelt Abilify Maintena Fanapt Fanapt Titration Pack Invega Latuda Rexulti Saphris Versacloz Vraylar Patient needs to have a paid claim for one generic formulary atypical antipsychotic agent Page 10 of 23

11 BISPHOSPHONATES-S5TR Fosamax Plus D Patient needs to have a paid claim for one generic formulary oral bisphosphonate agent Page 11 of 23

12 DIFICID-S Dificid Patient needs to have a paid claim for one Step 1 drug (vancomycin (oral) (gen)) prior to filling a Step 2 drug(dificid). Page 12 of 23

13 DPP4 INHIBITORS - R5TR Jentadueto Tradjenta Patient needs to have a paid claim for Januvia, Janumet, Janumet XR, Kombiglyze, or Onglyza Page 13 of 23

14 GLP1 AGONIST - R5TR Victoza Patient needs to have a paid claim for Byetta or Bydureon Page 14 of 23

15 ICS/LABA - R5TR Advair Diskus Advair Hfa Breo Ellipta Patient needs to have a paid claim for Dulera or Symbicort Page 15 of 23

16 NASAL STEROIDS -S5TR Dymista Nasonex Veramyst Patient needs to have a paid claim for one generic formulary intranasal corticosteroid agent Page 16 of 23

17 NEUPRO-S5TR Neupro Patient needs to have a paid claim for one generic formulary dopamine agonist agent Page 17 of 23

18 PPI-S5TR Dexilant Patient needs to have a paid claim for one generic formulary proton pump inhibitor Page 18 of 23

19 SGLT2 - R5TR Jardiance Xigduo Xr Patient needs to have a paid claim for Invokana, Invokamet, or Synjardy Page 19 of 23

20 STATINS-R5TR Lescol XL Livalo Simcor Vytorin TABS 10MG; 10MG, 10MG; 20MG, 10MG; 40MG Patient needs to have a paid claim for two generic formulary HMG-CoA reductase inhibitors (statin) Page 20 of 23

21 TRIPTANS-R5TR Axert Frova Zomig SOLN 2.5MG Zomig Nasal Spray Patient needs to have a paid claim for one generic formulary serotonin 5- HT1 receptor antagonist (triptans) or Relpax Page 21 of 23

22 INDEX A Abilify Abilify Discmelt Abilify Maintena Adhd Stimulants-s5tr... 4 Advair Diskus Advair Hfa Antidepressants-s5tr... 5 Antifungal-s5tr... 6 Antispasmodics - R5tr... 7 Aplenzin... 5 Arb-r5tr... 8 Atopic Dermatitis-s5tr... 9 Atypical Antipsychotics-s5tr Axert B Bisphosphonates-s5tr Breo Ellipta Brintellix... 5 D Daytrana... 4 Desvenlafaxine Er... 5 Dexilant Dificid Dificid-s Dpp4 Inhibitors - R5tr Dymista E Edarbi... 8 Edarbyclor... 8 Elidel... 9 Enablex... 7 Exelderm... 6 F Fanapt Fanapt Titration Pack Fetzima... 5 Fetzima Titration Pack... 5 Forfivo XL... 5 Fosamax Plus D Frova G Glp1 Agonist - R5tr I Ics/laba - R5tr Invega J Jardiance Jentadueto L Latuda Lescol XL Livalo M Mentax... 6 N Naftin... 6 Nasal Steroids -s5tr Nasonex Neupro Neupro-s5tr O Oxistat... 6 Page 22 of 23

23 P Pexeva... 5 Ppi-s5tr Pristiq... 5 R Rexulti S Saphris Sglt2 - R5tr Simcor Statins-r5tr Strattera... 4 T Tradjenta Trintellix... 5 Triptans-r5tr V Veramyst Versacloz Victoza Viibryd... 5 Viibryd Starter Pack... 5 Vraylar Vytorin X Xigduo Xr Z Zomig Zomig Nasal Spray Page 23 of 23