PRESCRIPTION DRUG STEP THERAPY GUIDE

Transcription

1 PRESCRIPTION DRUG STEP THERAPY GUIDE What is Step Therapy? Step therapy encourages safe and cost-effective medication use. Under our Step Therapy program, a step approach is required to receive coverage for certain higher-cost medications. This means to receive coverage you first need to try a proven, cost-effective medication before using a more costly one. How does Step Therapy Work? Step Therapy requires that you try one or more Prerequisite drugs before we will cover the Restricted (Step Therapy) drug. The Prerequisite drugs are Federal Drug Administration (FDA) approved, treat the same condition, and may be available to you at a lower copay or coinsurance amount. The Restricted drugs (Step Therapy drugs) are less-preferred or sometimes more costly. Who decides which drugs are included in the Step Therapy program? Our delegated Pharmacy & Therapeutics committee developed our Step Therapy program based on guidance and direction from independent licensed doctors, pharmacists, other medical experts and the FDA. They review the most current research on drugs tested and approved by the FDA for safety and effectiveness then make recommendations for specific drugs. What drugs are included in the Step Therapy program? You may reference the Assurant Health Prescription Drug Guide to identify drugs that are included in the Step Therapy program. Drugs marked with ST in the Prescription Drug Guide are Restricted drugs that require a trial of one or more Prerequisite drugs first. TIME INSURANCE COMPANY

2 You may reference this guide ( Prescription Drug Step Therapy Guide ) to determine which Prerequisite drugs are required before a Restricted drug will be covered. Show this list to your prescriber so he or she will know which drugs are Restricted and which are Prerequisite. Please consult this guide often as information is subject to change. Brand-name drugs are capitalized (e.g., Differin) and generic drugs are listed in lowercase italics (e.g., adapalene). Don t more expensive drugs work better? A higher-cost drug does not necessarily mean a drug is better. For example, a brand drug may have a less-expensive generic or brand alternative. Generic and brand drugs must meet the same standards set by the FDA for safety and effectiveness. Work with your prescriber to find the most cost-effective medication for you. What happens if I use a brand-name drug when a generic is available? Some of the brand-name Restricted drugs in the Step Therapy program have generic equivalents available. If you are approved to receive these brand-name Restricted drugs through the Step Therapy program, you will be responsible for paying the brand-name cost-sharing amount, such as deductibles or copays. You will also be responsible for paying the difference in cost between the brand-name drug and its generic or bio-similar equivalent (this is called an ancillary charge). The ancillary charge will not be reimbursed by Assurant Health, nor does it count toward satisfying any coinsurance, deductible or other out-of-pocket limit. Not applicable in all states. Drugs in which an ancillary charge may apply are marked in this guide with ANC. The Assurant Health Step Therapy Prescription Drug Guide provides summary information. For a complete listing of benefits, exclusions, and limitations, please refer to the certificate of insurance. In the event there are discrepancies with the information in this brochure, the terms and conditions of the coverage documents will govern. Plan design, benefits, optional features, provisions, and exclusions may vary by state. Please note that not all drugs listed in this guide are covered by all pharmacy benefit programs. Check your benefit materials or contact Assurant Health by calling the customer service number on the back of your medical identification card to determine if a drug is covered. TIME INSURANCE COMPANY 2

3 Definitions of abbreviations used throughout this guide: ADHD = attention deficit hyperactivity disorder ANC = ancillary charge may apply COPD = chronic obstructive pulmonary disease CR = controlled release CD = controlled release capsule ER = extended release LA = long acting mg = milligram NSAID = nonsteroidal anti inflammatory drug Rx = prescription drug XL = extended release (24 hour) XR = extended release To quickly find a specific drug, use the search feature available in Adobe Acrobat Reader (PC keyboard shortcut: Ctrl+F; Mac keyboard shortcut: Cmd+F) Assurant Health Step Therapy Guide Drug class Restricted drug Prerequisite drugs (try first) Acne products topical Tretin X topical tretinoin OR Retin A Micro must try Veltin AND 1 of: Atralin adapalene Retin A ANC clindamycin/benzoyl peroxide gel Fabior foam Ziana benzoyl peroxide topical clindamycin topical erythromycin erythromycin/benzoyl peroxide gel sulfacetamide Sulfacetamide/sulfur Benzefoam Ultra ANC benzoyl peroxide foam 9.8% Riax aerosol foam benzoyl peroxide foam (any strength) TIME INSURANCE COMPANY 3

4 Acne products topical, continued Acanya Benzaclin ANC Benzamycin ANC Benzamycin pak Duac ANC Onexton gel Differin cream ANC Differin lotion ANC Differin gel ANC Plexion liquid ANC Plexion cream ANC Plexion cloth pad Plexion lotion ANC clindamycin/benzoyl peroxide OR erythromycin/benzyol peroxide adapalene cream, gel, lotion sulfacetamide/sulfur Soolantra cream sulfacetamide/sulfur OR metronidazole topical gel, cream, lotion Mirvaso gel sulfacetamide/sulfur AND metronidazole topical gel, cream, lotion Acne oral Acticlate doxycycline TIME INSURANCE COMPANY 4

5 ADHD stimulant Adderall ANC, Adderall XR ANC Any 3 of: Aptensio XR amphetamine/dextroamphetamine, Concerta ANC amphetamine/dextroamphetamine SR, Daytrana patch Desoxyn ANC Dexedrine CR ANC Evekeo Focalin ANC, Focalin XR ANC Metadate CD ANC Methylin chewable ANC, Methylin solution ANC ProCentra ANC Quillivant XR Ritalin ANC, Ritalin LA ANC, Ritalin SR ANC dexmethylphenidate, dextroamphetamine, methamphetamine, methylphenidate, methylphenidate ER, methylphenidate SR, Strattera, Vyvanse ADHD nonstimulant Intuniv ANC Any 3 of: Kapvay ANC clonidine, clonidine ER, guanfacine, amphetamine/dextroamphetamine, amphetamine/dextroamphetamine SR, dexmethylphenidate, dextroamphetamine, methamphetamine, methylphenidate, methylphenidate ER, methylphenidate SR, Strattera, Vyvanse Analgesic NSAID Pennsaid Any 1 generic NSAID: Vimovo Examples: naproxen, ibuprofen (400mg, 600mg, 800mg), meloxicam, diclofenac, nabumetone, Zorvolex etodolac, indomethacin, sulindac Analgesic opioid Exalgo ANC morphine sulfate CR Anaphylaxis Adrenaclick Auvi Q OR EpiPen OR EpiPen Jr. TIME INSURANCE COMPANY 5

6 Androgens Androderm AndroGel OR Testim Axiron Anticoagulation Fortesta Natesto Striant Vogelxo Savaysa Eliquis AND Xarelto Anticonvulsant Lyrica Any 3 of: duloxetine, gabapentin, tramadol, cyclobenzaprine, carisoprodol, chlorzoxazone, metaxolone, orphenadrine, tizanadine, baclofen, methocarbamol, citalopram, escitalopram, fluoxetine, fluvoxamine, fluvoxamine ER, paroxetine, paroxetine ER, sertraline, venflaxine, venlafaxine ER, Savella, tricyclic antidepressant (e.g., amitriptyline, nortriptyline) Antidepressant Brintellix Any 3 of: Desvenlafaxine ER tablet budeprion SR, bupropion, bupropion SR, bupropion XL, citalopram, duloxetine, escitalopram, Fetzima, Fetzima titration pack fluoxetine, fluoxetine weekly, fluoxetine (PMDD), Irenka fluvoxamine, fluovoxamine ER, Khedezla paroxetine, paroxetine ER, Pristiq mirtazepine, sertraline, venlafaxine,venlafaxine ER Viibryd, Viibryd kit TIME INSURANCE COMPANY 6

7 Antidepressant, continued Aplenzin Any 1 of: Forfivo XL budeprion SR, bupropion, bupropion SR, bupropion XL, citalopram, duloxetine, escitalopram, Fluoxetine 60mg tablet fluoxetine, fluoxetine weekly, fluoxetine (PMDD), Pexeva Venlafaxine ER tablet Oleptro trazodone Antipsychotic Abilify tablet ANC (18 years & older) Any 1 of: Abilify solution (18 years & older) Fanapt Geodon ANC Invega Saphris Risperdal ANC Seroquel immediate release tablet ANC Zyprexa ANC, Zyprexa Zydis ANC Versacloz fluvoxamine, fluovoxamine ER, paroxetine, paroxetine ER, mirtazepine, sertraline, venlafaxine,venlafaxine ER aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone AND Latuda clozapine Antiviral Sitavig acyclovir oral or topical Asthma/COPD Pulmicort Flexhaler Any 1 of: Anoro Ellipta Incruse Ellipta Tudorza Arcapta Brovana Perforomist TIME INSURANCE COMPANY 7 Asmanex, Flovent, Qvar Spiriva HandiHaler or Respimat Foradil AND Serevent

8 Asthma/COPD, continued Breo Ellipta Advair AND Dulera AND Symbicort Arnuity Ellipta Daliresp Striverdi Respimat Maxair Autohaler Proventil HFA Asmanex OR Qvar Any 1 of: albuterol/ipratropium, ipratropium inhalation solution,combivent Respimat, Spiriva, Symbicort Foradil OR Serevent ProAir HFA/ProAir Respiclick AND Ventolin HFA Xopenex HFA Bisphosphonate Binosto alendronate AND risedronate or Atelvia ANC Diabetes injectable Tanzeum Bydureon AND Victoza Toujeo Lantus OR Levemir Diabetes oral Afrezza Any 1 of: Humulin, Humulin mix or Humalog Farxiga metformin (single or combination product) Glyxambi Invokana Invokamet Jardiance Kazano metformin AND Invokana/Invokamet AND Januvia or Onglyza or Tradjenta metformin (single or combination product) metformin (single or combination product) metformin (single or combination product) Jentadueto AND Kombiglyze AND either Janumet or Janumet XR Nesina Oseni Xigduo XR metformin (single or combination product) AND Januvia AND Onglyza AND Tradjenta metformin (single or combination product) AND pioglitazone in combination with one month Januvia AND Onglyza AND Tradjenta metformin (single or combination product) TIME INSURANCE COMPANY 8

9 Diagnostic tests Blood Glucose Test Strips All nonpreferred blood glucose test strips Enzyme replacement Pertzye Any 2 of: Ultresa Preferred blood glucose test strip by Johnson & Johnson OR Abbott Laboratories (One Touch Ultra, One Touch Verio, FreeStyle, FreeStyle Lite, FreeStyle InsuLinx, Precision Xtra) Creon, Ultrase, Ultrase MT, Zenpep Viokace Fibric acid derivatives Antara Any 1 of: Fenoglide tab ANC fenofibrate capsule Fibricor ANC Lipofen ANC Lofibra cap ANC Lofibra tab ANC Tricor ANC Triglide Trilipix ANC fenofibrate micronized capsule fenofibrate tablet gemfibrozil choline fenofibrate fenofibric acid Lopid ANC gemfibrozil AND fenofibrate or fenofibric acid Gastrointestinal Glycate glycopyrrolate Azulfidine ANC Any 1 of: Azulfidine EN ANC Apriso, Asacol, Asacol HD, Delzicol, Lialda, Pentasa Colazal ANC Dipentum Giazo Uceris rectal aerosol Any 1 of: Asacol HD, Delzicol, Lialda, Pentasa Glaucoma Rescula latanoprost OR bimatoprost AND Travatan Z Xalatan ANC Zioptan Glucocorticoid Rayos prednisone Gout Mitigare Colcrys TIME INSURANCE COMPANY 9

10 Heart Failure Corlanor Any 1 of: generic angiotensin converting enzyme (ACE) inhibitor (e.g., enalapril, fosinopril, lisinopril, perindopril, ramipril, trandolapril) OR angiotensin II receptor antagonist (ARB) (e.g., candesartan, losartan, valsartan) AND Any 1 of: beta blocker (e.g., bisoprolol, bisoprolol/hctz, carvedilol, carvedilol CR, metoprolol succinate, metoprolol succinate/hctz, Bystolic) Hormonal contraceptives All brand name hormonal Any 1 preferred generic hormonal contraceptive Hyperlipidemia HMG CoA reductase inhibitors contraceptives including oral and topical patch ANC Altoprev Lescol ANC, Lescol XL Lipitor ANC Livalo (example oral or xulane patch) lovastatin Any 1 of: atorovastatin, fluvastatin, lovastatin, pravastatin, simvastatin Hyperlipidemia/Hypertension Caduet ANC amlodipine/atorvastatin HMG CoA reductase inhibitors and calcium channel blocker combinations Hypertension Vecamyl Triple drug combination from the preferred alternatives from these drug classes (selection of three medications must each be from a different class): diuretics, angiotensin converting enzyme (ACE) inhibitor, angiotensin II receptor antagonist (ARB), beta blocker (BB), calcium channel blocker (CaB) Inderal XL propranolol ER Diovan ANC Any 3 of: single entity or hydrochlorothiazide (hctz) combination product: candesartan, eprosartan, irbesartan, losartan, valsartan, telmisartan TIME INSURANCE COMPANY 10

11 Hypertension, continued Azor Any 2 of: Twynsta ANC Benicar Edarbi Micardis ANC Benicar HCT Diovan HCT ANC candesartan, eprosartan, irbesartan, losartan, telmisartan in combination with amlodipine OR amlodipine/valsartan OR telmisartan/amlodipine OR Exforge Any 3 of: single entity or hydrochlorothiazide (hctz) combination product: candesartan, eprosartan, irbesartan, losartan, telmisartan Any 3 of: candesartan/hctz, eprosartan/hctz, Edarbyclor Micardis HCT ANC Tribenzor Nexiclon XR irbesartan/hctz, losartan/hctz, valsartan/hctz, telmisartan/hctz Any 2 of: Insulin Novolin 70/30 Humulin 70/30 Relion 70/30 Candesartan hctz, eprosartan hctz, Irbesartan hctz, losartan hctz, valsartan hctz in combination with amlodipine OR amlodipinevalsartan hctz OR Exforge HCT ANC clonidine Novolin R Relion R Novolin N Relion N Humulin R Humulin N TIME INSURANCE COMPANY 11

12 Migraine Alsuma Any 3 of: Axert ANC naratriptan, rizatriptan/mlt, Frova Relpax Sumavel Zomig nasal spray Treximet sumatriptan, zolmitriptan/odt naproxen must try AND 3 of: naratriptan, rizatriptan/mlt, sumatriptan, zolmitriptan/odt Muscle relaxant Amrix cyclobenzaprine or cyclobenzaprine ER must try Fexmid Nasal steroids Beconase AQ Any 2 of: Rhinocort Zetonna AND 1 of: baclofen, carisoprodol, carisoprodol with aspirin, carisoprodol with codeine, chlorzoxazone metaxalone, methocarbamol, orphenadrine ER, orphenadrine compound, tizanidine budesonide nasal spray, flunisolide nasal spray, Nasonex, Veramyst Narcotic partial opioid Bunavail buccal film buprenorphine/naloxone sublingual tablet Zubsolv sublingual tablet Oncology Purixan suspension mercaptopurine Ophthalmics miscellaneous Patanol Pataday Phosphate binder Renagel Renvela Velphoro buprenorphine/naloxone sublingual tablet AND Suboxone sublingual film Any 1 of: calcium acetate, Fosrenol, Phoslyra, Renvela TIME INSURANCE COMPANY 12

13 Post Herpetic Neuralgia (PHN) Gralise gabapentin Horizant Any 1 of: cabergoline, gabapentin, pramipexole Proton Pump Inhibitors Prilosec 10mg ANC Must try all 5: Prilosec 20mg Rx ANC Dexilant AND lansoprazole AND Prilosec 40mg ANC esomeprazole 40mg capsule AND pantoprazole AND Prilosec powder omeprazole sodium or omeprazole *Nexium 20mg capsules no longer covered under Rx benefit available over the counter (OTC)* Zegerid ANC AcipHex ANC, AcipHex sprinkle Nexium 40mg ANC Protonix ANC Protonix packet Prevacid 30mg ANC Prevacid SoluTab ANC Esomeprazole strontium Sedative/Hypnotic Edluar zolpidem OR zolpidem ER Intermezzo Rozerem Sonata ANC Zolpimist spray Belsomra Lunesta ANC Silenor Any 1 of: eszopiclone, zaleplon, zolpidem/er eszopiclone OR zolpidem OR zolpidem ER doxepin AND zolpidem OR zolpidem ER TIME INSURANCE COMPANY 13

14 Urinary antispasmodics Detrol ANC, Detrol LA ANC Any 1 of: Overactive bladder (OAB) Ditropan XL ANC trospium/er, tolterodine/er Gelnique OR Oxytrol (Rx) males Enablex*, Myrbetriq*, Vesicare* Sanctura ANC, Sanctura XR ANC (*must try trospium/er, tolterodine/er first) Toviaz Enablex trospium/er OR tolterodine/er Myrbetriq Vesicare The Assurant Health Step Therapy Prescription Drug Guide provides summary information. For a complete listing of benefits, exclusions, and limitations, please refer to the certificate of insurance. In the event there are discrepancies with the information in this brochure, the terms and conditions of the coverage documents will govern. Plan design, benefits, optional features, provisions, and exclusions may vary by state. Please note that not all drugs listed in this guide are covered by all pharmacy benefit programs. Check your benefit materials or contact Assurant Health by calling the customer service number on the back of your medical identification card to determine if a drug is covered. TIME INSURANCE COMPANY 14