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 11/2017 U6428 (11/17)

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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 BISPHOSPHONATES ibandronate 150 mg tablet 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. 1

7 BPH Step Therapy dutasteride 0.5 mg capsule dutasteride 0.5 mg-tamsulosin er 0.4 mg 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. 2

8 Colcrys COLCRYS 0.6 MG TABLET Criteria If the patient has tried one Step 1 product (Mitigare), authorization for a Step 2 (Colcrys) product may be given. Exceptions can be made for a step 2 drug (without a trial of a step 1 drug) for the treatment of Familial Mediterranean Fever and for the treatment of gout flares (i.e, prophylaxis of gout flares requires a trial of a step 1 drug) 3

9 COX-2 Step Therapy celecoxib 100 mg capsule celecoxib 200 mg capsule 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 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 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 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 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 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: olanzapine, risperidone, ziprasidone and quetiapine IR. Step 2 Drug(s) include: aripiprazole, Latuda, quetiapine 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). Patients under the age of 18 are excluded from step therapy requirements. Number of days for retrospective claims review for Step 1 drugs: 180 days. This step therapy program applies to new utilizers only. 5

11 Oxycontin OXYCODONE ER 10 MG 12 HR OXYCODONE ER 20 MG 12 HR OXYCODONE ER 40 MG 12 HR OXYCODONE ER 80 MG 12 HR OXYCONTIN 10 MG OXYCONTIN 15 MG OXYCONTIN 20 MG OXYCONTIN 30 MG OXYCONTIN 40 MG OXYCONTIN 60 MG OXYCONTIN 80 MG 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. 6

12 Rosuvastatin rosuvastatin 10 mg tablet rosuvastatin 20 mg tablet 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 7

13 Sedative Hypnotic eszopiclone 1 mg tablet eszopiclone 2 mg tablet 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. 8

14 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 COLCRYS 0.6 MG TABLET...3 dutasteride 0.5 mg capsule... 2 dutasteride 0.5 mg-tamsulosin er 0.4 mg capsule ext.release 24hr mphas...2 eszopiclone 1 mg tablet...8 eszopiclone 2 mg tablet...8 eszopiclone 3 mg tablet...8 ibandronate 150 mg tablet...1 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 12 HR... 6 OXYCODONE ER 20 MG 12 HR... 6 OXYCODONE ER 40 MG 12 HR... 6 OXYCODONE ER 80 MG 12 HR... 6 OXYCONTIN 10 MG... 6 OXYCONTIN 15 MG... 6 OXYCONTIN 20 MG... 6 OXYCONTIN 30 MG... 6 OXYCONTIN 40 MG... 6 OXYCONTIN 60 MG... 6 OXYCONTIN 80 MG... 6 quetiapine er 150 mg tablet,extended release 24 hr...5 quetiapine er 200 mg tablet,extended release 24 hr...5 quetiapine er 300 mg tablet,extended release 24 hr...5 quetiapine er 400 mg tablet,extended release 24 hr...5 quetiapine er 50 mg tablet,extended release 24 hr...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... 7 rosuvastatin 20 mg tablet... 7 rosuvastatin 40 mg tablet... 7 rosuvastatin 5 mg tablet

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