Step Therapy Medications

Transcription

1 Step Therapy Medications Step Therapy (ST PA ) is an automated form of prior authorization. It encourages the use of therapies that should be tried first, before other treatments are covered, based on clinical practice guidelines and cost-effectiveness. Medications on Step 1 the lowest step are usually covered without authorization. We have noted the few exceptions, which may require your provider to submit a request to Tufts Health Plan for coverage. Medications on Step 2 or higher are automatically authorized at the point-of-sale if you have taken the required prerequisite drugs. However, if your provider prescribes a medication on a higher step, and you have not yet taken the required medication(s) on a lower step, or if you are a new Tufts Health Plan member and do not have any prescription drug claims history, we will consider coverage of the medication only if your provider submits a request for coverage to Tufts Health Plan. ARAVA (LEFUNOMIDE) } methotrexate } Rheumatrex } Trexall 2 drug within the previous 120 days before these will be covered } leflunomide } Arava ATTENTION DEFICIT HYPERACTIVITY DISORDER } amphetamine/salt combo } amphetamine/dextroamphetamine mixed salts ER } dexmethylphenidate ext-rel 15 mg and 30 mg } dexmethylphenidate HCl } dextroamphetamine sulfate } Metadate ER 20 mg } methamphetamine } Methylin Chewable tablets } methylphenidate } methylphenidate ER 20 mg } methylphenidate ext-rel } methylphenidate SR BISPHOSPHONATES before these will be covered } Adderall } Adderall XR } Concerta } Daytrana } Focalin XR } Metadate CD } Methylin Oral Solution } Procentra } Quillivant XR } Ritalin LA } Ritalin-SR } Vyvanse without authorization Step 2, or one (1) Step 3 drug within the previous 180 days before these will be covered } alendronate } ibandronate tablet } Actonel You must have had a trial of one (1) Step 2, or one (1) Step 3 drug within the previous 180 days before these will be covered } Boniva tablet

2 DEPRESSION without authorization } budeprion SR } budeprion XL } bupropion HCl } bupropion SR } bupropion XL } citalopram HBr } duloxetine } escitalopram } fluoxetine delayed release } fluoxetine HCl } fluvoxamine } paroxetine HCl } paroxetine ER } sertraline } venlafaxine } venlafaxine ER Step 2, or one (1) Step 3 drug within the previous 180 days before these will be covered or if the Member is below 18 years of age } Pristiq } Viibryd ELIDEL (PIMECROLIMUS) & PROTOPIC (TACROLIMUS) You must have had a trial of one (1) Step 2, or one (1) Step 3 drug within the previous 180 days before these will be covered or if the member is below 18 years of age } Aplenzin } Cymbalta } Emsam } Forfivo XL } Lexapro } Oleptro ER } Pexeva } Sarafem } Venlafaxine OSM 24hr ER tablet } amcinonide cream, lotion, ointment 0.1% } augmented betamethasone dipropionate cream, ointment 0.05% } betamethasone benzoate cream, gel, lotion 0.025% } betamethasone dipropionate cream, ointment 0.05% } betamethasone dipropionate lotion 0.05% } betamethasone valerate cream, ointment 0.1% } clocortolone pivalate cream 0.1% } clobetasol propionate cream, ointment 0.05% } desoximetasone cream, gel 0.05% } desoximetasone cream, ointment 0.25% } diflorasone diacetate cream, ointment (emollient base) 0.05% } diflorasone diacetate ointment 0.05% } fluocinolone acetonide cream, ointment 0.025% } fluocinonide cream, ointment, gel 0.05% } flurandrenolide cream, ointment 0.025% } flurandrenolide cream, ointment, lotion 0.05% } flurandrenolide Tape 4 mcg/cm2 You must have tried at least two (2) Step 1 drugs covered } Elidel } Protopic

3 ELIDEL (PIMECROLIMUS) & PROTOPIC (TACROLIMUS) You must have tried at least two (2) Step 1 drugs covered } fluticasone propionate cream 0.05% } fluticasone propionate ointment 0.005% } halcinonide cream, ointment 0.1% } halobetasol propionate cream,ointment 0.05% } hydrocortisone butyrate ointment, solution 0.1% } hydrocortisone valerate cream, ointment 0.2% } mometasone furoate cream, ointment 0.1% } triamcinolone acetonide cream, ointment 0.5% INSOMNIA. } zaleplon } zolpidem tartrate Step 2 drug within the previous 180 days before these will be covered. Quantity limitation applies to all drugs in this } Intermezzo } Lunesta } Rozerem } Zolpimist } zolpidem ext-rel INSPRA (EPLERENONE). } spironolactone spironolactone/ hydrochlorothiazide before these will be covered. } eplerenone } Inspra LYRICA (PREGABALIN) You must have had a trial of one (1) Step 1 drug covered. } gabapentin } Lyrica

4 MIGRAINE MEDICATIONS. } naratriptan } rizatriptan } rizatriptan soluble tablet } sumatriptan } zolmitriptan } zolmitriptan soluble tablet before these will be covered. Quantity limitation applies to all drugs in this } Alsuma } Amerge } Axert } Frova } Imitrex } Maxalt } Maxalt MLT } Relpax } Sumavel } Zomig } Zomig ZMT OVERACTIVE BLADDER MEDICATIONS } Ditropan XL } Enablex } flavoxate } Gelnique } oxybutynin } oxybutynin ext-rel } Oxytrol } Sanctura } Sanctura XR } tolterodine } trospium } trospium ER } Vesicare PROVIGIL (MODAFINIL) unless noted with * as requiring Step Therapy Prior Authorization. } amphetamine salt combo } amphetamine/dextroamphetamine } mixed salts ER } dextroamphetamine sulfate ext-rel } methlyphenidate } methlyphenidate ER will be covered } Detrol } Detrol LA } Myrbetriq before these will be covered. } modafinil } Nuvigil

5 PULMICORT RESPULES (BUDESONIDE INHALATION SUSPENSION) FOR MEMBERS OVER THE AGE OF 18. } Advair Diskus } Advair HFA } Alvesco } Asmanex } Flovent Diskus } Flovent HFA } Pulmicort Flexhaler } QVAR } Symbicort will be covered. Quantity limitation applies to all drugs in this } budesonide inhalation susp 0.25mg/2ml & 0.5mg/2ml } Pulmicort Respules SAVELLA (MILNACIPRAN HCL) } gabapentin } Savella ULORIC (FEBUXOSTAT) one (1) Step 2 drug or you have had a trial of cymbalta or lyrica within the previous 180 days before these will be covered. You must have had a trial of one (1) Step 1 drug covered. } allupurinol } Uloric XOPENEX (LEVALBUTEROL HCL) INHALATION SOLUTION. } AccuNeb inhalation solution } albuterol inhalation solution } DuoNeb inhalation solution } ipratropium/albuterol inhalation solution } Ventolin inhalation solution } Xopenex HFA inhalation aerosol will be covered. Quantity limitation applies to all drugs in this } levalbuterol inhalation solution } Xopenex inhalation solution 12/13