2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+)

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1 2018 STEP THERAPY CRITERIA UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC+) In some cases, UCare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, UCare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, UCare will then cover Drug B. This is a list of drugs that require these steps for us to provide coverage. UCare PMAP, MinnesotaCare, and MSC+ members with questions should call UCare Customer Services at toll free. UCare Connect members with questions should call toll free. TTY machine users can call Hours of operation are 8 a.m. - 5 p.m., Monday-Friday. PMAP MnCare MSC+ SNBC_102617_2 DHS Approved ( ) Updated 10/2018 U6428 (10/18)

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5 American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For enrollees age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your primary care provider prior to the referral.

6 Antidepressants Products Affected desvenlafaxine succinate er 100 mg tablet,extended release 24 hr desvenlafaxine succinate er 25 mg tablet,extended release 24 hr desvenlafaxine succinate er 50 mg tablet,extended release 24 hr FETZIMA 120 MG CAPSULE,EXTENDED RELEASE FETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED RELEASE,24 HR,DOSE PACK FETZIMA 20 MG CAPSULE,EXTENDED RELEASE Details FETZIMA 40 MG CAPSULE,EXTENDED RELEASE FETZIMA 80 MG CAPSULE,EXTENDED RELEASE TRINTELLIX 10 MG TABLET TRINTELLIX 20 MG TABLET TRINTELLIX 5 MG TABLET VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK VIIBRYD 10 MG TABLET VIIBRYD 20 MG TABLET VIIBRYD 40 MG TABLET Criteria If the patient has tried at least two Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1: citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, paroxetine IR, paroxetine ER, sertraline, venlafaxine IR, venlafaxine ER Step 2: Desvenlafaxine ER, Viibryd, Fetzima, Trintellix 1

7 BISPHOSPHONATES Products Affected ibandronate 150 mg tablet Details Criteria If a patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 drug(s): alendronate, etidronate. Step 2 drug(s): ibandronate. 2

8 BPH Step Therapy Products Affected dutasteride 0.5 mg capsule dutasteride 0.5 mg-tamsulosin er 0.4 mg Details capsule ext.release 24hr mphas Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s) include: Finasteride Step 2 Drug(s) include: dutasteride, dutasteride-tamsulosin. Number of days for retrospective claims review for Step 1 drugs: 180 days. This step therapy program applies to new utilizers only. 3

9 COX-2 Step Therapy Products Affected celecoxib 100 mg capsule celecoxib 200 mg capsule Details celecoxib 400 mg capsule celecoxib 50 mg capsule Criteria If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s) include: diclofenac, diclofenac ER, diclofenac potassium, etodolac, etodolac er, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketoprofen ER, ketorolac, meclofenamate, meloxicam, nabumetone, naproxen, naproxen ec, naproxen sodium, nabumetone, oxaprozin, piroxicam, sulindac, tolmetin. Step 2 Drug(s) include: celecoxib, Celebrex. This step therapy program will exclude participants with a claims history of warfarin (Coumadin) or dabigatran (Pradaxa) within the last 180 days. Authorization for Celebrex may be given for patients who are currently taking chronic systemic corticosteroid therapy, warfarin (Coumadin), clopidogrel (Plavix), prasugrel (Effient), ticagrelor (Brilinta), rivaroxaban (Xarelto), dabigatran (Pradaxa), chronic aspirin therapy, fondaparinux (Arixtra), apixaban (Eliquis) or low molecular weight heparins. Authorization for Celebrex may be given for patients aged greater than 75 years who are requesting Celebrex for a chronic condition. Number of days for claims review for Step 1 drugs: 180 days. This step therapy program applies to new utilizers only. 4

10 Novel Antipsychotics Step Therapy Products Affected aripiprazole 1 mg/ml oral solution aripiprazole 10 mg disintegrating tablet aripiprazole 10 mg tablet aripiprazole 15 mg disintegrating tablet aripiprazole 15 mg tablet aripiprazole 2 mg tablet aripiprazole 20 mg tablet aripiprazole 30 mg tablet aripiprazole 5 mg tablet clozapine 100 mg disintegrating tablet clozapine 12.5 mg disintegrating tablet clozapine 25 mg disintegrating tablet LATUDA 120 MG TABLET LATUDA 20 MG TABLET LATUDA 40 MG TABLET LATUDA 60 MG TABLET LATUDA 80 MG TABLET olanzapine 10 mg disintegrating tablet olanzapine 15 mg disintegrating tablet olanzapine 20 mg disintegrating tablet olanzapine 5 mg disintegrating tablet paliperidone er 1.5 mg tablet,extended release 24 hr paliperidone er 3 mg tablet,extended release 24 hr paliperidone er 6 mg tablet,extended release 24 hr paliperidone er 9 mg tablet,extended release 24 hr quetiapine er 150 mg tablet,extended release 24 hr quetiapine er 200 mg tablet,extended release 24 hr quetiapine er 300 mg tablet,extended release 24 hr quetiapine er 400 mg tablet,extended release 24 hr quetiapine er 50 mg tablet,extended release 24 hr REXULTI 0.25 MG TABLET REXULTI 0.5 MG TABLET REXULTI 1 MG TABLET REXULTI 2 MG TABLET REXULTI 3 MG TABLET REXULTI 4 MG TABLET risperidone 0.25 mg disintegrating tablet risperidone 0.5 mg disintegrating tablet risperidone 1 mg disintegrating tablet risperidone 2 mg disintegrating tablet risperidone 3 mg disintegrating tablet risperidone 4 mg disintegrating tablet 5

11 Details 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) include: olanzapine, risperidone, ziprasidone, clozapine, haloperidol, quetiapine IR Step 2 Drug(s) include: olanzapine ODT, risperidone ODT, aripiprazole ODT, Clozapine ODT, aripiprazole, quetiapine ER, Latuda Step 3 Drug(s) include: Rexulti, paliperidone ER Authorization for the following drugs may be given without a trial of a Step 1 drug: quetiapine ER (if the patient has a diagnosis of major depressive disorder and currently on an antidepressant), aripiprazole (if patient has a diagnosis of Major Depressive Disorder and receiving antidepressants), Latuda (if the patient has morbid obesity [BMI =40] and prescriber feels step 1 medications risks would outweigh benefits). Patients under the age of 18 are excluded from step therapy requirements. Number of days for retrospective claims review for Step 1 and Step 2 drugs: 180 days. This step therapy program applies to new utilizers only. 6

12 Oxycontin Products Affected OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR OXYCODONE ER 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR OXYCONTIN 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE OXYCONTIN 15 MG TABLET,CRUSH Details RESISTANT,EXTENDED RELEASE OXYCONTIN 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE OXYCONTIN 30 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE OXYCONTIN 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE OXYCONTIN 60 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE OXYCONTIN 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s) include: Morphine ER (or provide a medical reason why they cannot take the alternative medication). Number of days for claims review for first line drugs: 180 days. This step therapy program applies to new utilizers only. 7

13 Rosuvastatin Products Affected rosuvastatin 10 mg tablet rosuvastatin 20 mg tablet Details rosuvastatin 40 mg tablet rosuvastatin 5 mg tablet Criteria If patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 drug(s): atorvastatin, lovastatin, pravastatin, simvastatin Step 2 drug(s): rosuvastatin 8

14 Sedative Hypnotic Products Affected eszopiclone 1 mg tablet eszopiclone 2 mg tablet Details eszopiclone 3 mg tablet Criteria If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s) include: zolpidem IR (Ambien), zolpidem ER (Ambien CR) or zaleplon (Sonata) Step 2 Drug(s) include : eszopiclone (Lunesta) Number of days for retrospective claims review for Step 1 drugs: 180 days. This step therapy program applies to new utilizers only. 9

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16 Index aripiprazole 1 mg/ml oral solution... 5 aripiprazole 10 mg disintegrating tablet... 5 aripiprazole 10 mg tablet... 5 aripiprazole 15 mg disintegrating tablet... 5 aripiprazole 15 mg tablet... 5 aripiprazole 2 mg tablet... 5 aripiprazole 20 mg tablet... 5 aripiprazole 30 mg tablet... 5 aripiprazole 5 mg tablet... 5 celecoxib 100 mg capsule... 4 celecoxib 200 mg capsule... 4 celecoxib 400 mg capsule... 4 celecoxib 50 mg capsule... 4 clozapine 100 mg disintegrating tablet... 5 clozapine 12.5 mg disintegrating tablet... 5 clozapine 25 mg disintegrating tablet... 5 desvenlafaxine succinate er 100 mg tablet,extended release 24 hr... 1 desvenlafaxine succinate er 25 mg tablet,extended release 24 hr... 1 desvenlafaxine succinate er 50 mg tablet,extended release 24 hr... 1 dutasteride 0.5 mg capsule...3 dutasteride 0.5 mg-tamsulosin er 0.4 mg capsule ext.release 24hr mphas...3 eszopiclone 1 mg tablet...9 eszopiclone 2 mg tablet...9 eszopiclone 3 mg tablet...9 FETZIMA 120 MG CAPSULE,EXTENDED RELEASE... 1 FETZIMA 20 MG (2)-40 MG (26) CAPSULE,EXTENDED RELEASE,24 HR,DOSE PACK...1 FETZIMA 20 MG CAPSULE,EXTENDED RELEASE... 1 FETZIMA 40 MG CAPSULE,EXTENDED RELEASE... 1 FETZIMA 80 MG CAPSULE,EXTENDED RELEASE... 1 ibandronate 150 mg tablet...2 LATUDA 120 MG TABLET... 5 LATUDA 20 MG TABLET... 5 LATUDA 40 MG TABLET... 5 LATUDA 60 MG TABLET... 5 LATUDA 80 MG TABLET... 5 olanzapine 10 mg disintegrating tablet... 5 olanzapine 15 mg disintegrating tablet... 5 olanzapine 20 mg disintegrating tablet... 5 olanzapine 5 mg disintegrating tablet... 5 OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR...7 OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR...7 OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR...7 OXYCODONE ER 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR...7 OXYCONTIN 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE... 7 OXYCONTIN 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE... 7 OXYCONTIN 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE... 7 OXYCONTIN 30 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE... 7 OXYCONTIN 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE... 7 OXYCONTIN 60 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE... 7 OXYCONTIN 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE... 7 paliperidone er 1.5 mg tablet,extended paliperidone er 3 mg tablet,extended paliperidone er 6 mg tablet,extended paliperidone er 9 mg tablet,extended quetiapine er 150 mg tablet,extended quetiapine er 200 mg tablet,extended quetiapine er 300 mg tablet,extended quetiapine er 400 mg tablet,extended 11

17 quetiapine er 50 mg tablet,extended REXULTI 0.25 MG TABLET... 5 REXULTI 0.5 MG TABLET... 5 REXULTI 1 MG TABLET... 5 REXULTI 2 MG TABLET... 5 REXULTI 3 MG TABLET... 5 REXULTI 4 MG TABLET... 5 risperidone 0.25 mg disintegrating tablet...5 risperidone 0.5 mg disintegrating tablet...5 risperidone 1 mg disintegrating tablet...5 risperidone 2 mg disintegrating tablet...5 risperidone 3 mg disintegrating tablet...5 risperidone 4 mg disintegrating tablet...5 rosuvastatin 10 mg tablet...8 rosuvastatin 20 mg tablet...8 rosuvastatin 40 mg tablet...8 rosuvastatin 5 mg tablet...8 TRINTELLIX 10 MG TABLET... 1 TRINTELLIX 20 MG TABLET... 1 TRINTELLIX 5 MG TABLET... 1 VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK...1 VIIBRYD 10 MG TABLET... 1 VIIBRYD 20 MG TABLET... 1 VIIBRYD 40 MG TABLET

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