2014 Step Therapy Criteria (List of Step Therapy Criteria)
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1 Criteria Last Updated: November 1, Step Therapy Criteria (List of Step Therapy Criteria) PLEASE READ CAREFULLY: IEHP MEDICARE DUALCHOICE (HMO SNP) REQUIRES YOU TO FIRST TRY CERTAIN DRUGS TO TREAT YOUR MEDICAL CONDITION BEFORE WE WILL COVER ANOTHER DRUG FOR THAT CONDITION. THIS DOCUMENT CONTAINS INFORMATION ABOUT THE STEP THERAPY CRITERIA THAT WE COVER IN THIS PLAN. Note to existing members: Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, of each year. IEHP Medicare DualChoice (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program. Enrollment in IEHP Medicare DualChoice (HMO SNP) depends on contract renewal. This information is available for free in other languages. Please call our customer service number at IEHP (4347), 8am 8pm (PST) 7 days a week, including holidays. TTY/TDD users should call Esta información está disponible gratis en otros idiomas. Para obtener información adicional, por favor llame a nuestro número de servicio al cliente al IEHP (4347), 8 a.m. - 8 p.m. (Hora del Pacífico), los 7 días de la semana, incluidos días festivos. Usuarios de TTY/TDD deben llamar al H5640_001_MDC_14_01857
2 COPD/Asthma Step COPD: Must first try Albuterol + Ipratropium, Ipratropium, Mometasone, beclomethasone, Budesonide or Fluticasone propionate. Asthma: Must first try Mometasone, beclomethasone, Budesonide or Fluticasone propionate. Step 1: Asmanex 120 Metered Doses AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH INHALATION, Asmanex 60 Metered Doses AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH INHALATION, Atrovent HFA AEROSOL, SOLUTION 17 MCG/ACT INHALATION, Combivent Respimat AEROSOL, SOLUTION MCG/ACT INHALATION, Flovent HFA AEROSOL 110 MCG/ACT INHALATION, Flovent HFA AEROSOL 220 MCG/ACT INHALATION, Flovent HFA AEROSOL 44 MCG/ACT INHALATION, Pulmicort Flexhaler AEROSOL POWDER, BREATH ACTIVATED 180 MCG/ACT INHALATION, Pulmicort Flexhaler AEROSOL POWDER, BREATH ACTIVATED 90 MCG/ACT INHALATION, Qvar AEROSOL, SOLUTION 40 MCG/ACT INHALATION, Qvar AEROSOL, SOLUTION 80 MCG/ACT INHALATION Step 2: Advair Diskus AEROSOL POWDER, BREATH ACTIVATED MCG/DOSE INHALATION, Advair Diskus AEROSOL POWDER, BREATH ACTIVATED MCG/DOSE INHALATION, Advair Diskus AEROSOL POWDER, BREATH ACTIVATED MCG/DOSE INHALATION, Advair HFA AEROSOL MCG/ACT INHALATION, Advair HFA AEROSOL MCG/ACT INHALATION, Advair HFA AEROSOL MCG/ACT INHALATION 1
3 COX2Therapy Must try at least one NSAID prior to the use of COX-2 inhibitor within the last 90 days Step 1: Diclofenac Potassium TABLET 50 MG ORAL, Diclofenac Sodium ER TABLET EXTENDED RELEASE 24 HR 100 MG ORAL, Diclofenac Sodium TABLET DELAYED RELEASE 25 MG ORAL, Diclofenac Sodium TABLET DELAYED RELEASE 50 MG ORAL, Diclofenac Sodium TABLET DELAYED RELEASE 75 MG ORAL, Flurbiprofen TABLET 100 MG ORAL, Flurbiprofen TABLET 50 MG ORAL, Ibuprofen SUSPENSION 100 MG/5ML ORAL, Ibuprofen TABLET 400 MG ORAL, Ibuprofen TABLET 600 MG ORAL, Ibuprofen TABLET 800 MG ORAL, Indomethacin CAPSULE 25 MG ORAL, Indomethacin CAPSULE 50 MG ORAL, Indomethacin ER CAPSULE EXTENDED RELEASE 75 MG ORAL, Meloxicam TABLET 15 MG ORAL, Meloxicam TABLET 7.5 MG ORAL, Nabumetone TABLET 500 MG ORAL, Nabumetone TABLET 750 MG ORAL, Naproxen DR TABLET DELAYED RELEASE 375 MG ORAL, Naproxen DR TABLET DELAYED RELEASE 500 MG ORAL, Naproxen SUSPENSION 125 MG/5ML ORAL, Naproxen TABLET 250 MG ORAL, Naproxen TABLET 375 MG ORAL, Naproxen TABLET 500 MG ORAL, Sulindac TABLET 150 MG ORAL, Sulindac TABLET 200 MG ORAL Step 2: CeleBREX CAPSULE 100 MG ORAL, CeleBREX CAPSULE 200 MG ORAL, CeleBREX CAPSULE 400 MG ORAL 2
4 Diabetes Must try first line of therapies such as metformin, sulfonylurea, glimepiride, glipizide, glyburide, pioglitazone (Actos), pioglitazone/metformin, or sitagliptan (Januvia), simvastatin or insulin (at least 30 days) before using second line agent. Byetta, Janumet Step 1: Glimepiride TABLET 1 MG ORAL, Glimepiride TABLET 2 MG ORAL, Glimepiride TABLET 4 MG ORAL, GlipiZIDE ER TABLET EXTENDED RELEASE 24 HR 10 MG ORAL, GlipiZIDE ER TABLET EXTENDED RELEASE 24 HR 2.5 MG ORAL, GlipiZIDE ER TABLET EXTENDED RELEASE 24 HR 5 MG ORAL, GlipiZIDE TABLET 10 MG ORAL, GlipiZIDE TABLET 5 MG ORAL, GlipiZIDE- MetFORMIN HCl TABLET MG ORAL, GlipiZIDE- MetFORMIN HCl TABLET MG ORAL, GlipiZIDE- MetFORMIN HCl TABLET MG ORAL, GlyBURIDE Micronized TABLET 1.5 MG ORAL, GlyBURIDE Micronized TABLET 3 MG ORAL, GlyBURIDE Micronized TABLET 6 MG ORAL, GlyBURIDE TABLET 1.25 MG ORAL, GlyBURIDE TABLET 2.5 MG ORAL, GlyBURIDE TABLET 5 MG ORAL, GlyBURIDE-MetFORMIN TABLET MG ORAL, GlyBURIDE-MetFORMIN TABLET MG ORAL, GlyBURIDE-MetFORMIN TABLET MG ORAL, Januvia TABLET 100 MG ORAL, Januvia TABLET 25 MG ORAL, Januvia TABLET 50 MG ORAL, MetFORMIN HCl ER TABLET EXTENDED RELEASE 24 HR 500 MG ORAL, MetFORMIN HCl ER TABLET EXTENDED RELEASE 24 HR 750 MG ORAL, MetFORMIN HCl TABLET 1000 MG ORAL, MetFORMIN HCl TABLET 500 MG ORAL, MetFORMIN HCl TABLET 850 MG ORAL, Pioglitazone HCl TABLET 15 MG ORAL, Pioglitazone HCl TABLET 30 MG ORAL, Pioglitazone HCl TABLET 45 MG ORAL, Pioglitazone HCl-Glimepiride TABLET 30-2 MG ORAL, Pioglitazone HCl-Glimepiride TABLET 30-4 MG ORAL, Pioglitazone HCl-Metformin HCl TABLET MG ORAL, Pioglitazone HCl-Metformin HCl TABLET MG ORAL 3
5 Step 2: Byetta 10 MCG Pen 10 MCG/0.04ML SUBCUTANEOUS, Byetta 5 MCG Pen 5 MCG/0.02ML SUBCUTANEOUS, Janumet TABLET MG ORAL, Janumet TABLET MG ORAL 4
6 Index Advair Diskus AEROSOL POWDER, BREATH ACTIVATED MCG/DOSE INHALATION... 1 Advair Diskus AEROSOL POWDER, BREATH ACTIVATED MCG/DOSE INHALATION... 1 Advair Diskus AEROSOL POWDER, BREATH ACTIVATED MCG/DOSE INHALATION... 1 Advair HFA AEROSOL Advair HFA AEROSOL Advair HFA AEROSOL MCG/ACT Asmanex 120 Metered Doses AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH INHALATION... 1 Asmanex 60 Metered Doses AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH INHALATION... 1 Atrovent HFA AEROSOL, SOLUTION 17 Byetta 10 MCG Pen 10 MCG/0.04ML SUBCUTANEOUS*... 4 Byetta 5 MCG Pen 5 MCG/0.02ML SUBCUTANEOUS*... 4 CeleBREX CAPSULE 100 MG ORAL... 2 CeleBREX CAPSULE 200 MG ORAL... 2 CeleBREX CAPSULE 400 MG ORAL... 2 Combivent Respimat AEROSOL, SOLUTION MCG/ACT Diclofenac Potassium TABLET 50 MG Diclofenac Sodium ER TABLET EXTENDED RELEASE 24 HR* 100 MG Diclofenac Sodium TABLET DELAYED RELEASE 25 MG ORAL... 2 Diclofenac Sodium TABLET DELAYED RELEASE 50 MG ORAL... 2 Diclofenac Sodium TABLET DELAYED RELEASE 75 MG ORAL... 2 Flovent HFA AEROSOL 110 MCG/ACT Flovent HFA AEROSOL 220 MCG/ACT Flovent HFA AEROSOL 44 MCG/ACT Flurbiprofen TABLET 100 MG ORAL... 2 Flurbiprofen TABLET 50 MG ORAL... 2 Glimepiride TABLET 1 MG ORAL... 3 Glimepiride TABLET 2 MG ORAL... 3 Glimepiride TABLET 4 MG ORAL... 3 GlipiZIDE ER TABLET EXTENDED RELEASE 24 HR* 10 MG ORAL... 3 GlipiZIDE ER TABLET EXTENDED RELEASE 24 HR* 2.5 MG ORAL... 3 GlipiZIDE ER TABLET EXTENDED RELEASE 24 HR* 5 MG ORAL... 3 GlipiZIDE TABLET 10 MG ORAL... 3 GlipiZIDE TABLET 5 MG ORAL... 3 GlipiZIDE-MetFORMIN HCl TABLET MG ORAL... 3 GlipiZIDE-MetFORMIN HCl TABLET MG ORAL... 3 GlipiZIDE-MetFORMIN HCl TABLET MG ORAL GlyBURIDE Micronized TABLET 1.5 MG GlyBURIDE Micronized TABLET 3 MG GlyBURIDE Micronized TABLET 6 MG GlyBURIDE TABLET 1.25 MG ORAL... 3 GlyBURIDE TABLET 2.5 MG ORAL... 3 GlyBURIDE TABLET 5 MG ORAL... 3 GlyBURIDE-MetFORMIN TABLET MG ORAL... 3 GlyBURIDE-MetFORMIN TABLET MG ORAL... 3 GlyBURIDE-MetFORMIN TABLET MG ORAL... 3 Ibuprofen SUSPENSION 100 MG/5ML Ibuprofen TABLET 400 MG ORAL... 2 Ibuprofen TABLET 600 MG ORAL... 2 Ibuprofen TABLET 800 MG ORAL... 2 Indomethacin CAPSULE 25 MG ORAL... 2 Indomethacin CAPSULE 50 MG ORAL... 2 Indomethacin ER CAPSULE EXTENDED RELEASE* 75 MG ORAL... 2 Janumet TABLET MG ORAL... 4 Janumet TABLET MG ORAL... 4 Januvia TABLET 100 MG ORAL... 3 Januvia TABLET 25 MG ORAL... 3 Januvia TABLET 50 MG ORAL... 3 Juvisync TABLET MG ORAL... 4 Meloxicam TABLET 15 MG ORAL... 2 Meloxicam TABLET 7.5 MG ORAL... 2 MetFORMIN HCl ER TABLET EXTENDED RELEASE 24 HR* 500 MG
7 MetFORMIN HCl ER TABLET EXTENDED RELEASE 24 HR* 750 MG MetFORMIN HCl TABLET 1000 MG MetFORMIN HCl TABLET 500 MG MetFORMIN HCl TABLET 850 MG Nabumetone TABLET 500 MG ORAL... 2 Nabumetone TABLET 750 MG ORAL... 2 Naproxen DR TABLET DELAYED RELEASE 375 MG ORAL... 2 Naproxen DR TABLET DELAYED RELEASE 500 MG ORAL... 2 Naproxen SUSPENSION 125 MG/5ML Naproxen TABLET 250 MG ORAL... 2 Naproxen TABLET 375 MG ORAL... 2 Naproxen TABLET 500 MG ORAL... 2 Pioglitazone HCl TABLET 15 MG ORAL 3 Pioglitazone HCl TABLET 30 MG ORAL 3 Pioglitazone HCl TABLET 45 MG ORAL 3 Pioglitazone HCl-Glimepiride TABLET 30-2 MG ORAL... 3 Pioglitazone HCl-Glimepiride TABLET 30-4 MG ORAL... 3 Pioglitazone HCl-Metformin HCl TABLET MG ORAL... 3 Pioglitazone HCl-Metformin HCl TABLET MG ORAL... 3 Pulmicort Flexhaler AEROSOL POWDER, BREATH ACTIVATED 180 MCG/ACT Pulmicort Flexhaler AEROSOL POWDER, BREATH ACTIVATED 90 MCG/ACT Qvar AEROSOL, SOLUTION 40 Qvar AEROSOL, SOLUTION 80 Sulindac TABLET 150 MG ORAL... 2 Sulindac TABLET 200 MG ORAL
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