2017 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements
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1 2017 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for that condition. Below is the list of drugs with step therapy requirements. H5969_501510_17 Last Updated 09/30/2016
2 ALZHEIMER'S DRUGS EXELON 1.5 MG CAPSULE, EXELON 3 MG CAPSULE, EXELON 4.5 MG CAPSULE, EXELON 4.6 MG/24HR PATCH, EXELON 6 MG CAPSULE, EXELON 9.5 MG/24HR PATCH Step 1: donepezil, glanatamine Hbr, rivastigmine Step 2: Exelon, Exelon patches PAGE 1 LAST UPDATED 09/30/2016
3 ANGIOTENSIN RECEPTOR ANTAGONIST (ARBS) EDARBI, EDARBYCLOR Generic ARBs and generic ARB combination products are First Line Agents. Brand ARBs and brand ARB comboination products on the formulary are Second Line Agents. PAGE 2 LAST UPDATED 09/30/2016
4 GLUCAGON-LIKE PEPTIDE-1 (GLP-1) RECEPTOR AGONISTS BYDUREON Exenatide and liraglutide are first-line agents. Exenatide ER should be used as a second line agent if first-line agents have been tried. PAGE 3 LAST UPDATED 09/30/2016
5 HIGH RISK MEDICATIONS- LONG ACTING SULFONYLUREAS CHLORPROPAMIDE, GLYBURIDE 1.25 MG TABLET, GLYBURIDE 2.5 MG TABLET, GLYBURIDE 5 MG TABLET, GLYBURIDE MICRONIZED, GLYBURIDE-METFORMIN HCL First line agents are glipizide, glipizide/metformin, glimeperide, and tolbutamide. If any of these first line agents have been tried then glyburide, glyburide micronized, glyburide/metformin, or chlorpropamide can be used as second line agents. PAGE 4 LAST UPDATED 09/2016
6 NON-SEDATING/LOW-SEDATING ANTIHISTAMINES (NSA/LSA) CLARINEX 0.5 MG/ML (2.5 MG/5) First-line NS/LSA drugs are OTC loratadine, prescription generic desloratadine, OTC fexofenadine, prescription generic levocetirizine, OTC cetirizine, prescription generic cetirizine, OTC cetirizine hcl/pseudoephedrine, OTC fexofenadine/pseudoephedrine, OTC loratadine/pseudoephedrine, or desloratadine/pseudoephedrine. Brand NS/LSA drugs will be covered as 2nd-line agents. PAGE 5 LAST UPDATED 09/30/2016
7 ORAL BISPHOSPHONATE AGENTS ATELVIA, FOSAMAX PLUS D, RISEDRONATE SODIUM, RISEDRONATE SODIUM DR First-line Bisphosphonates are alendronate, ibandronate (oral or injectable), or Boniva. Must have tried alendronate or Boniva in the last 180 days before using other formulary Oral Bisphosphonate agents. PAGE 6 LAST UPDATED 09/30/2016
8 PROTON PUMP INHIBITORS (PPIS) DEXILANT, ESOMEPRAZOLE MAG DR 40 MG CAP, KAPIDEX, LANSOPRAZOLE DR 15 MG CAPSULE, LANSOPRAZOLE DR 30 MG CAPSULE, PANTOPRAZOLE SOD DR 20 MG TAB, PANTOPRAZOLE SOD DR 40 MG TAB, RABEPRAZOLE SODIUM First-line PPI's are Prilosec OTC, OTC omeprazole magnesium, generic Rx/OTC omeprazole, Prevacid 24Hr(OTC), or OTC lansoprazole. If Prilosec OTC, OTC omeprazole magnesium, generic Rx/OTC omeprazole, Prevacid 24Hr(OTC), or OTC lansoprazole have been tried within the last 180 days then pantoprazole, lansoprazole, esomeprazole, or rabeprazole can be used as 2nd-line agents. Dexilant can be used as a 3rd-line agent if either pantoprazole, lansoprazole, esomeprazole, or rabeprazole have been tried wihtin the last 180 days. PAGE 7 LAST UPDATED 09/30/2016
9 SGLT 2 INHIBITORS FARXIGA, INVOKAMET, INVOKANA, JARDIANCE step 1: metformin AND one DPP-4 inhibitor or DPP-4 inhibitor combination product OR one GLP-1 receptor agonist. step 2: SGLT2 inhibitor or SGLT2 inhibitor combination product PAGE 8 LAST UPDATED 09/30/2016
10 URICOSURIC AGENTS ULORIC Must have tried allopurinol first, then Uloric may be used as a 2nd line agent PAGE 9 LAST UPDATED 09/30/2016
11 PAGE 10 LAST UPDATED 09/30/2016
12 If you have any questions about the step therapy requirements, contact Member Services at or toll free at , 8 a.m. to 8 p.m., 7 days a week. TTY users call AlohaCare Advantage Plus is an HMO plan with a Medicare contract and a contract with the Hawaii Medicaid program. Enrollment in AlohaCare Advantage Plus depends on contract renewal. AlohaCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PAKDAAR: Nu saritaem ti Ilocano, ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Awagan ti (TTY: ). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ).
2017 AlohaCare Advantage Plus Formulary (HMO SNP) Drugs with Step Therapy Requirements
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