2013 Step Therapy (ST) Criteria

Transcription

1 2013 Step Therapy (ST) Criteria Some drugs require step therapy pre-approval. This means that your doctor must have you first try a different drug to treat your medical condition before we will cover a drug that needs step therapy preapproval. Below you will find a table of drugs that require step therapy pre-approval. If you find your drug on this list, talk to your doctor about what other drugs you could try first. To see if your drug is on the list, refer to the table of contents below for the step therapy criteria you are looking for, or refer to the index located at the end of this document for the medication you are looking for. TABLE OF CONTENTS ALZHEIMER'S DRUGS donepezil galantamine rivastigmine tartrate EXELON ANTIDEPRESSANTS- SSRI citalopram escitalopram oxalate Updated: 06/2013 Y0026_ Approved 09/25/2012 Page 1 of 31 Group Health Incorporated (GHI), GHI HMO Select, Inc. (GHI HMO), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies, EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

2 fluoxetine fluvoxamine paroxetine sertraline PAXIL VIIBRYD ARB benazepril benazepril/amlodipine besylate benazepril/hctz candesartan cilexetil/hctz captopril captopril/hctz enalapril enalapril maleate/hctz eprosartan mesylate fosinopril fosinopril/hctz hctz/valsartan irbesartan irbesartan/hctz lisinopril lisinopril/hctz losartan losartan /hctz Page 2 of 31

3 moexipril moexipril/hctz perindopril erbumine quinapril quinapril/hctz ramipril trandolapril DIOVAN EXFORGE HCT EXFORGE MICARDIS HCT MICARDIS TWYNSTA BILE ACID SEQUESTRANTS cholestyramine/aspartame colestipol WELCHOL BISPHOSPHONATES ORAL alendronate ibandronate BONIVA BRAND NSAIDS diclofenac potassium diclofenac sodium diclofenac sodium/misoprostol Page 3 of 31

4 etodolac fenoprofen flurbiprofen ibuprofen indomethacin ketoprofen ketorolac meclofenamate mefenamic acid meloxicam nabumetone naproxen naproxen sodium oxaprozin piroxicam sulindac tolmetin VOLTAREN COX diclofenac potassium diclofenac sodium diclofenac sodium/misoprostol etodolac fenoprofen flurbiprofen Page 4 of 31

5 ibuprofen indomethacin ketoprofen ketorolac meclofenamate mefenamic acid meloxicam nabumetone naproxen naproxen sodium oxaprozin piroxicam sulindac tolmetin CELEBREX FENOFIBRATE fenofibrate LIPOFEN HMG RULE atorvastatin calcium fluvastatin lovastatin pravastatin simvastatin CRESTOR Page 5 of 31

6 LONG ACTING OPIOIDS morphine oxymorphone OPANA ER OXYCONTIN OPHTHALMIC PROSTAGLANDINS latanoprost TRAVATAN Z OVERACTIVE BLADDER oxybutynin tolterodine tartrate trospium chloride ENABLEX SANCTURA XR PROTON PUMP INHIBITORS lansoprazole omeprazole omeprazole/sodium bicarbonat pantoprazole NEXIUM SEDATIVE HYPNOTICS zaleplon zolpidem ROZEREM TEKTURNA Page 6 of 31

7 benazepril benazepril/amlodipine besylate benazepril/hctz candesartan cilexetil/hctz captopril captopril/hctz DIOVAN enalapril enalapril maleate/hctz eprosartan mesylate EXFORGE HCT EXFORGE fosinopril fosinopril/hctz hctz/valsartan irbesartan irbesartan/hctz lisinopril lisinopril/hctz losartan losartan /hctz MICARDIS HCT MICARDIS moexipril moexipril/hctz Page 7 of 31

8 perindopril erbumine quinapril quinapril/hctz ramipril trandolapril TWYNSTA AMTURNIDE TEKAMLO TEKTURNA HCT TEKTURNA THIAZOLIDINEDIONE glipizide/metformin hcl glyburide/metformin hcl JANUMET XR JANUMET KOMBIGLYZE XR metformin pioglitazone hcl pioglitazone hcl/metformin hc pioglitazone/glimepiride RIOMET ACTOPLUS MET XR ACTOPLUS MET ACTOS DUETACT Page 8 of 31

9 ULORIC allopurinol ULORIC Page 9 of 31

10 ALZHEIMER'S DRUGS donepezil galantamine rivastigmine tartrate EXELON If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Donepezil Hcl, Galantamine Hydrobromide, Galantamine Hbr, Rivastigmine. Step 2 Drug(s): Exelon oral solution, Exelon patch. Authorization may be given for a Step 2 drug if the patient is currently taking (or has taken in the past) the requested agent. Authorization for Exelon Patch may be given if the patient has difficulty swallowing or cannot swallow. This step therapy program applies to new utilizers only. Page 10 of 31

11 ANTIDEPRESSANTS- SSRI citalopram escitalopram oxalate fluoxetine fluvoxamine paroxetine sertraline PAXIL VIIBRYD If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Citalopram, Citalopram Hbr, Fluoxetine Dr, Escitalopram, Fluoxetine Hcl, Fluvoxamine Maleate, Paroxetine Hcl, Paroxetine ER, Rapiflux, Sertraline Hcl. Step 2 Drug(s): Viibryd, Paxil oral suspension. Patients who have taken a step 2 SSRI at any time in the past and discontinued its use may receive authorization to restart the step 2 SSRI (whichever they used in the past). Authorization may be given for a step 2 SSRI if the patient is currently taking the requested agent. Authorization may be given for a step 2 drug if the patient is a child or adolescent aged 18 years or less or has suicidal ideation. This step therapy program applies to new utilizers only. Page 11 of 31

12 ARB benazepril benazepril/amlodipine besylate benazepril/hctz candesartan cilexetil/hctz captopril captopril/hctz enalapril enalapril maleate/hctz eprosartan mesylate fosinopril fosinopril/hctz hctz/valsartan irbesartan irbesartan/hctz lisinopril lisinopril/hctz losartan losartan /hctz moexipril moexipril/hctz perindopril erbumine quinapril quinapril/hctz ramipril trandolapril DIOVAN EXFORGE HCT EXFORGE MICARDIS HCT MICARDIS TWYNSTA If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Amlodipine Besylate-benazepril, Benazepril Hcl, Benazeprilhydrochlorothiazide, Candesartan-hydrochlorothiazide, Captopril, Captoprilhydrochlorothiazide, Enalapril Maleate, Enalapril-hydrochlorothiazide, eprosartan, Fosinopril Sodium, Fosinopril-hydrochlorothiazide, Irbesartan, Irbesartanhydrochlorothiazide, Lisinopril, Lisinopril-hydrochlorothiazide, Losartan Potassium, Losartan-Hydrochlorothiazide, Moexipril Hcl, Moexipril-hydrochlorothiazide, Perindopril erbumine, Quinapril Hcl, Quinapril-hydrochlorothiazide, Ramipril, Trandolapril, Valsartan-hydrochlorothiazide. Step 2 Drug(s): Exforge, Exforge Hct, Micardis, Micardis Hct, Twynsta, Diovan. Authorization may be given for a Step 2 product, without a trial of Page 12 of 31

13 a step 1 agent, if the patient was recently hospitalized and discharged within the previous 30 days for a cardiovascular event (e.g., myocardial infarction, hypertensive emergency, decompensated heart failure) and has already been started and stabilized on the agent. Page 13 of 31

14 BILE ACID SEQUESTRANTS cholestyramine/aspartame colestipol WELCHOL If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Cholestyramine Light, Colestipol Hcl, Prevalite. Step 2 Drug(s): Welchol. Authorization may be given for Welchol if patients have a drug-drug interaction with cholestyramine or colestipol. Authorization may be given for Welchol in patients who are pregnant. Authorization may be given for Welchol in patients with type 2 diabetes who are also using other antidiabetic agents (eg, insulin, metformin, sulfonylurea). Authorization may be given for Welchol in patients less than 18 years of age. Page 14 of 31

15 BISPHOSPHONATES ORAL alendronate ibandronate BONIVA If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Alendronate Sodium, Ibandronate Sodium. Step 2 Drug(s): Boniva. Authorization may be given for Boniva, if the patient has tried alendronate sodium (brand or generic) or ibandronate sodium. Page 15 of 31

16 BRAND NSAIDS diclofenac potassium diclofenac sodium diclofenac sodium/misoprostol etodolac fenoprofen flurbiprofen ibuprofen indomethacin ketoprofen ketorolac meclofenamate mefenamic acid meloxicam nabumetone naproxen naproxen sodium oxaprozin piroxicam sulindac tolmetin VOLTAREN If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Diclofenac-misoprostol, Diclofenac Potassium, Diclofenac Sodium, Etodolac, Fenoprofen Calcium, Flurbiprofen, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac Tromethamine, Meclofenamate Sodium, Mefenamic Acid, Meloxicam, Nabumetone, Naproxen, Naproxen Sodium, Oxaprozin, Piroxicam, Sulindac, Tolmetin Sodium. Step 2 Drug(s): Voltaren Gel. Authorization may be given for Voltaren Gel for patients with difficulty swallowing or cannot swallow. Authorization may be given for Voltaren Gel for patients with a chronic musculoskeletal pain condition (eg, osteoarthritis) in 3 or fewer joints/sites (ie, hand, wrist, elbow, knee, ankle, or foot each count as 1 joint/site) who are at risk of NSAID-associated toxicity (eg, previous gastrointestinal [GI] bleed, history of peptic ulcer disease, impaired renal function, cardiovascular disease, hypertension, heart failure, elderly patients with impaired hepatic function, or those taking concomitant anticoagulants). Page 16 of 31

17 COX-2 diclofenac potassium diclofenac sodium diclofenac sodium/misoprostol etodolac fenoprofen flurbiprofen ibuprofen indomethacin ketoprofen ketorolac meclofenamate mefenamic acid meloxicam nabumetone naproxen naproxen sodium oxaprozin piroxicam sulindac tolmetin CELEBREX If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Diclofenac-misoprostol, Diclofenac Potassium, Diclofenac Sodium, Etodolac, Fenoprofen Calcium, Flurbiprofen, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac Tromethamine, Meclofenamate Sodium, Mefenamic Acid, Meloxicam, Nabumetone, Naproxen, Naproxen Sodium, Oxaprozin, Piroxicam, Sulindac, Tolmetin Sodium. Step 2 Drug(s): Celebrex. Authorization for Celebrex may be given if the patient has tried two oral prescription strength NSAIDs (brand or generic) for the current condition. This step therapy program will exclude participants with a claims history of warfarin (Coumadin) within the last 130 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, or low molecular weight heparins. Page 17 of 31

18 FENOFIBRATE fenofibrate LIPOFEN If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Fenofibrate. Step 2 Drug(s): Lipofen. Page 18 of 31

19 HMG RULE 1 atorvastatin calcium fluvastatin lovastatin pravastatin simvastatin CRESTOR If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Atorvastatin, Fluvastatin, Lovastatin, Pravastatin Sodium, Simvastatin. Step 2 Drug(s): Crestor 5 mg. Authorization may be given for a step 2 drug, if the patient has tried atorvastatin (brand or generic), fluvastatin (brand or generic), lovastatin (brand or generic), pravastatin sodium (brand or generic), or simvastatin (brand or generic). Authorization for a step 2 drug will given on an individual basis for drug-drug interactions. Page 19 of 31

20 LONG ACTING OPIOIDS morphine oxymorphone OPANA ER OXYCONTIN If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Morphine sulfate, morphine sulfate ER, oxymorphone ER. Step 2 Drug(s): Opana Er, Oxycontin. Authorization may be given for OxyContin if the patient is unable to tolerate or has a drug allergy noted with morphine sulfate. Authorization may be given for OxyContin if the patient has renal insufficiency. Authorization may be given for OxyContin if the patient is pregnant. Page 20 of 31

21 OPHTHALMIC PROSTAGLANDINS latanoprost TRAVATAN Z If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): latanoprost. Step 2 Drug(s): Travatan Z. Authorization for Travatan Z may be given if the patient has a known benzalkonium chloride (BAK) sensitivity or sensitivity to other ophthalmic preservatives. Page 21 of 31

22 OVERACTIVE BLADDER oxybutynin tolterodine tartrate trospium chloride ENABLEX SANCTURA XR If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Oxybutynin Chloride, Oxybutynin Chloride Er, Tolterodine, Trospium Chloride, Trospium Er. Step 2 Drug(s): Enablex, Sanctura XR. Page 22 of 31

23 PROTON PUMP INHIBITORS lansoprazole omeprazole omeprazole/sodium bicarbonat pantoprazole NEXIUM If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Lansoprazole, Omeprazole, Omeprazole-Sodium Bicarbonate, Pantoprazole Sodium. Step 2 Drug(s): Nexium. Authorization for Nexium may be given in patients less than 1 year of age. Page 23 of 31

24 SEDATIVE HYPNOTICS zaleplon zolpidem ROZEREM If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Zaleplon, Zolpidem Tartrate. Step 2 Drug(s): Rozerem. Rozerem will be covered for members equal to or over the age of 65 years. For those under 65 years of age, the step therapy will apply. Authorization for Rozerem may be given if the patient has a documented history of addiction to controlled substances. Page 24 of 31

25 TEKTURNA benazepril benazepril/amlodipine besylate benazepril/hctz candesartan cilexetil/hctz captopril captopril/hctz DIOVAN enalapril enalapril maleate/hctz eprosartan mesylate EXFORGE HCT EXFORGE fosinopril fosinopril/hctz hctz/valsartan irbesartan irbesartan/hctz lisinopril lisinopril/hctz losartan losartan /hctz MICARDIS HCT MICARDIS moexipril moexipril/hctz perindopril erbumine quinapril quinapril/hctz ramipril trandolapril TWYNSTA AMTURNIDE TEKAMLO TEKTURNA HCT TEKTURNA If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Amlodipine Besylate-benazepril, Benazepril Hcl, Benazeprilhydrochlorothiazide, Candesartan-hydrochlorothiazide, Captopril, Captoprilhydrochlorothiazide, Diovan, Enalapril Maleate, Enalapril-hydrochlorothiazide, Page 25 of 31

26 eprosartan, Exforge, Exforge Hct, Fosinopril Sodium, Fosinopril-hydrochlorothiazide, Irbesartan, Irbesartan-hydrochlorothiazide, Lisinopril, Lisinopril-hydrochlorothiazide, Losartan Potassium, Losartan-Hydrochlorothiazide, Micardis, Micardis Hct, Moexipril Hcl, Moexipril-hydrochlorothiazide, Perindopril erbumine, Quinapril Hcl, Quinaprilhydrochlorothiazide, Ramipril, Trandolapril, Twynsta, Valsartan-hydrochlorothiazide. Step 2 Drug(s): Amturnide, Tekamlo, Tekturna, Tekturna Hct. Authorization for a step 2 drug may be given if the patient tried an angiotensin converting enzyme (ACE) inhibitor or ACE inhibitor combination product in the past. Authorization for a step 2 drug may be given if the patient tried an angiotensin receptor blocker (ARB) or ARB combination product in the past they are not required to have a trial with an ACE inhibitor. Page 26 of 31

27 THIAZOLIDINEDIONE glipizide/metformin hcl glyburide/metformin hcl JANUMET XR JANUMET KOMBIGLYZE XR metformin pioglitazone hcl pioglitazone hcl/metformin hc pioglitazone/glimepiride RIOMET ACTOPLUS MET XR ACTOPLUS MET ACTOS DUETACT If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Glimepiride-pioglitazone, Glipizide-metformin, Glyburidemetformin Hcl, Janumet, Janumet XR, Kombiglyze XR, Metformin Hcl, Metformin Hcl Er, Metformin-pioglitazone, Pioglitazone, Riomet. Step 2 Drug(s): Actoplus Met, Actoplus Met Xr, Actos, Duetact. Authorization may be given for a step 2 drug if the patient has tried a step 1 drug in the past. Authorization may be given for a step 2 drug if the patient is already started on the requested step 2 drug. Authorization may be given for Actos or Duetact without a trial of metformin in patients with renal insufficiency or renal disease. Authorization may be given for Actos or Duetact without a trial of metformin in patients with cardiomyopathy, heart failure, unstable angina, or who have experienced a myocardial infarction. Authorization may be given for Actos or Duetact without a trial of metformin in patients with a condition (not already noted above) that could potentially increase the risk of hypoperfusion, hypoxemia, or dehydration. Authorization may be given for Actos or Duetact without a trial of metformin if the patient has hepatic impairment or is alcohol dependent. Authorization may be given for Actos or Duetact without a trial of metformin if the patient has chronic metabolic acidosis. Page 27 of 31

28 ULORIC allopurinol ULORIC If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Allopurinol. Step 2 Drug(s): Uloric. Authorization may be given for Uloric if the patient has tried allopurinol (brand or generic) at any time in the past. Authorization may be given for Uloric if the patient has renal insufficiency or decreased renal function. Authorization may be given for Uloric if the patient is receiving concomitant medications that have significant drug-drug interactions with allopurinol, which are not noted with Uloric (eg, cyclosporine, chlorpropamide). Page 28 of 31

29 ACTOPLUS MET XR, 27 ACTOPLUS MET, 27 ACTOS, 27 alendronate, 15 allopurinol, 28 AMTURNIDE, 25 atorvastatin calcium, 19 benazepril, 12, 25 benazepril/amlodipine besylate, 12, 25 benazepril/hctz, 12, 25 BONIVA, 15 candesartan cilexetil/hctz, 12, 25 captopril, 12, 25 captopril/hctz, 12, 25 CELEBREX, 17 cholestyramine/aspartame, 14 citalopram, 11 colestipol, 14 CRESTOR, 19 diclofenac potassium, 16, 17 diclofenac sodium, 16, 17 diclofenac sodium/misoprostol, 16, 17 DIOVAN, 12, 25 donepezil, 10 DUETACT, 27 ENABLEX, 22 enalapril, 12, 25 enalapril maleate/hctz, 12, 25 eprosartan mesylate, 12, 25 escitalopram oxalate, 11 etodolac, 16, 17 EXELON, 10 EXFORGE HCT, 12, 25 EXFORGE, 12, 25 fenofibrate, 18 fenoprofen, 16, 17 fluoxetine, 11 flurbiprofen, 16, 17 fluvastatin, 19 fluvoxamine, 11 fosinopril, 12, 25 fosinopril/hctz, 12, 25 galantamine, 10 glipizide/metformin hcl, 27 glyburide/metformin hcl, 27 hctz/valsartan, 12, 25 ibandronate, 15 ibuprofen, 16, 17 indomethacin, 16, 17 irbesartan, 12, 25 irbesartan/hctz, 12, 25 JANUMET XR, 27 JANUMET, 27 ketoprofen, 16, 17 ketorolac, 16, 17 KOMBIGLYZE XR, 27 lansoprazole, 23 latanoprost, 21 LIPOFEN, 18 lisinopril, 12, 25 lisinopril/hctz, 12, 25 losartan, 12, 25 losartan /hctz, 12, 25 lovastatin, 19 meclofenamate, 16, 17 mefenamic acid, 16, 17 meloxicam, 16, 17 metformin, 27 MICARDIS HCT, 12, 25 MICARDIS, 12, 25 moexipril, 12, 25 moexipril/hctz, 12, 25 morphine, 20 nabumetone, 16, 17 naproxen, 16, 17 naproxen sodium, 16, 17 NEXIUM, 23 omeprazole, 23 Page 29 of 31

30 omeprazole/sodium bicarbonat, 23 OPANA ER, 20 oxaprozin, 16, 17 oxybutynin, 22 OXYCONTIN, 20 oxymorphone, 20 pantoprazole, 23 paroxetine, 11 PAXIL, 11 perindopril erbumine, 12, 25 pioglitazone hcl, 27 pioglitazone hcl/metformin hc, 27 pioglitazone/glimepiride, 27 piroxicam, 16, 17 pravastatin, 19 quinapril, 12, 25 quinapril/hctz, 12, 25 ramipril, 12, 25 RIOMET, 27 rivastigmine tartrate, 10 ROZEREM, 24 SANCTURA XR, 22 sertraline, 11 simvastatin, 19 sulindac, 16, 17 TEKAMLO, 25 TEKTURNA HCT, 25 TEKTURNA, 25 tolmetin, 16, 17 tolterodine tartrate, 22 trandolapril, 12, 25 TRAVATAN Z, 21 trospium chloride, 22 TWYNSTA, 12, 25 ULORIC, 28 VIIBRYD, 11 VOLTAREN, 16 WELCHOL, 14 zaleplon, 24 zolpidem, 24 Page 30 of 31

31 HIP Health Plan of New York (HIP) is a Medicare Advantage organization with a Medicare contract. Group Health Incorporated (GHI) is a Medicare Advantage organization and a standalone prescription drug plan with a Medicare contract. HIP and GHI are EmblemHealth companies. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their premium and/or copayment/coinsurance may change on January 1, This document includes EmblemHealth Medicare PDP partial formulary as of June 1, For a complete, updated formulary, please visit our Web site at or call the Customer Service number below. For alternative formats or language, please call Customer Service toll free at: EmblemHealth Medicare HMO: , Monday through Sunday, 8 am to 8 pm. EmblemHealth Medicare PPO: , Monday through Sunday, 8 am to 8 pm. EmblemHealth Medicare PDP: , Monday through Sunday, 8 am to 8 pm. TTY/TDD users should call v11 Page 31 of 31