2018 Step Therapy Criteria
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- Jasmine Burns
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1 2018 Step Therapy Criteria ANGIOTENSIN RECEPTOR BLOCKERS... 2 ANTIDEPRESSANTS... 3 ANTIDEPRESSANTS, MISCELLANEOUS... 4 ANTIDEPRESSANTS, OTHER... 5 ANTIDIABETIC AGENTS... 6 ANTIGOUT AGENTS... 7 ANTIHYPERTENSIVE AGENTS... 8 ATYPICAL ANTIPSYCHOTICS... 9 BISPHOSPHONATES DYSLIPIDEMICS INVOKAMET NONSTEROIDAL ANTI-INFLAMMATORY AGENTS OPHTHALMIC ANTIGLAUCOMA AGENTS OPHTHALMIC ANTIGLAUCOMA AGENTS, OTHER PROTON PUMP INHIBITORS SMOKING CESSATION AGENTS XIGDUO XR Updated: 4/2018 1
2 ANGIOTENSIN RECEPTOR BLOCKERS amlodipine/valsartan benazepril benazepril/amlodipine besylate benazepril/hctz captopril captopril/hctz enalapril enalapril maleate/hctz fosinopril fosinopril/hctz irbesartan irbesartan/hctz lisinopril lisinopril/hctz losartan losartan /hctz moexipril moexipril/hctz perindopril erbumine quinapril quinapril/hctz ramipril trandolapril valsartan valsartan/hctz amlodipine/olmesartan amlodipine/valsartan/hctz olmesartan olmesartan/hctz The use of at least one Step 1 drug is required prior to the use of Step 2 drugs. A look back period for claims review for Step 1 drugs is 130 days. Updated: 4/2018 2
3 ANTIDEPRESSANTS citalopram escitalopram oxalate fluoxetine paroxetine sertraline venlafaxine ir/er DESVENLAFAXINE ER desvenlafaxine succinate er FETZIMA FETZIMA TITRATION PACK KHEDEZLA This Step Therapy Group is applicable to new starts. The use of at least one Step 1 drug is required prior to the use of Step 2 drugs. A look back period for claims review for Step 1 drugs is 365 days. Updated: 4/2018 3
4 ANTIDEPRESSANTS, MISCELLANEOUS citalopram duloxetine escitalopram fluoxetine paroxetine sertraline venlafaxine ir/er TRINTELLIX This Step Therapy Group is applicable to new starts. The use of at least two Step 1 drugs is required prior to the use of a Step 2 drug. A look back period for claims review for Step 1 drugs is 365 days. Updated: 4/2018 4
5 ANTIDEPRESSANTS, OTHER citalopram escitalopram oxalate fluoxetine paroxetine sertraline VIIBRYD VIIBRYD STARTER PACK This Step Therapy Group is applicable to new starts. The use of at least two Step 1 drugs is required prior to the use of a Step 2 drug. A look back period for claims review for Step 1 drugs is 365 days. Updated: 4/2018 5
6 ANTIDIABETIC AGENTS metformin metformin er FARXIGA INVOKANA The use of at least one Step 1 drug is required prior to the use of Step 2 drugs. A look back period for claims review for a Step 1 drug is 130 days. Updated: 4/2018 6
7 ANTIGOUT AGENTS allopurinol ULORIC The use of a Step 1 drug is required prior to the use of a Step 2 drug. A look back period for claims review for a Step 1 drug is 130 days. Updated: 4/2018 7
8 ANTIHYPERTENSIVE AGENTS amlodipine/valsartan benazepril benazepril/amlodipine besylate benazepril/hctz captopril captopril/hctz enalapril enalapril maleate/hctz fosinopril fosinopril/hctz irbesartan irbesartan/hctz lisinopril lisinopril/hctz losartan losartan /hctz moexipril moexipril/hctz perindopril erbumine quinapril quinapril/hctz ramipril trandolapril valsartan valsartan/hctz TEKTURNA HCT TEKTURNA The use of at least one Step 1 drug is required prior to the use of Step 2 drugs. A look back period for claims review for Step 1 drugs is 130 days. Updated: 4/2018 8
9 ATYPICAL ANTIPSYCHOTICS olanzapine/odt quetiapine fumarate risperidone/odt ziprasidone oral aripiprazole/odt FANAPT FANAPT TITRATION PACK LATUDA paliperidone er quetiapine fumarate er REXULTI SAPHRIS SEROQUEL XR VRAYLAR TM This Step Therapy Group is applicable to new starts. The use of at least one Step 1 drug is required prior to the use of Step 2 drugs. A look back period for claims review for Step 1 drugs is 365 days. A trial of at least one step 1 drug is not required if Aripiprazole ODT or Aripiprazole tabs or Quetiapine ER or Seroquel XR or Rexulti will be used as an adjunctive treatment for major depression (this process will be automated: the member's claims history will be utilized). A trial of at least one step 1 drug is not required if Aripiprazole ODT or Aripiprazole tabs will be used for the treatment of Tourette's disorder (this process will be automated: the member's claims history will be utilized). Updated: 4/2018 9
10 BISPHOSPHONATES alendronate ibandronate oral risedronate oral The use of at least one Step 1 drug is required prior to the use of Step 2 drugs. A look back period for claims review for Step 1 drugs is 130 days. Updated: 4/
11 DYSLIPIDEMICS atorvastatin simvastatin rosuvastatin The use of at least one Step 1 drug is required prior to the use of a Step 2 drug. A look back period for claims review for Step 1 drugs is 130 days. Updated: 4/
12 INVOKAMET INVOKANA metformin metformin ER INVOKAMET INVOKAMET XR The use of at least one Step 1 drug is required prior to the use of Step 2 drugs. A look back period for claims review for Step 1 drugs is 130 days. Updated: 4/
13 NONSTEROIDAL ANTI-INFLAMMATORY AGENTS diclofenac potassium diclofenac sodium ec/er diflunisal etodolac/er ibuprofen meloxicam nabumetone naproxen/ec naproxen sodium piroxicam sulindac celecoxib The use of at least two Step 1 drugs is required prior to the use of a Step 2 drug. A look back period for claims review for Step 1 drugs is 180 days. A trial of two generic NSAIDs is not required if celecoxib will be used in patients on any of the following: warfarin, Coumadin, Jantoven, Pradaxa, Eliquis or Xarelto (this process will be automated: the members claims history will be utilized). Updated: 4/
14 OPHTHALMIC ANTIGLAUCOMA AGENTS brimonidine tartrate carteolol levobunolol metipranolol timolol soln COMBIGAN The use of at least one Step 1 drug is required prior to the use of a Step 2 drug. A look back period for claims review for Step 1 drugs is 130 days. Updated: 4/
15 OPHTHALMIC ANTIGLAUCOMA AGENTS, OTHER latanoprost LUMIGAN The use of a Step 1 drug is required prior to the use of a Step 2 drug. A look back period for claims review for a Step 1 drug is 130 days. Updated: 4/
16 PROTON PUMP INHIBITORS lansoprazole omeprazole pantoprazole esomeprazole magnesium caps The use of at least one Step 1 drug is required prior to the use of a Step 2 drug. A look back period for claims review for Step 1 drugs is 130 days. Updated: 4/
17 SMOKING CESSATION AGENTS bupropion SR 150 mg CHANTIX CHANTIX STARTING PACK CHANTIX CONTINUING PACK The use of a Step 1 drug is required prior to the use of Step 2 drugs. A look back period for claims review for a Step 1 drug is 130 days. Updated: 4/
18 XIGDUO XR FARXIGA metformin metformin ER XIGDUO XR The use of at least one Step 1 drug is required prior to the use of a Step 2 drug. A look back period for claims review for Step 1 drugs is 130 days. Updated: 4/
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