Step Therapy CareOregon 2018 Last Updated: 07/27/2018 ATYPICAL ANTIPSYCHOTICS Fanapt Fanapt Titration Pack Paliperidone Er Vraylar The following criteria applies to members who newly start on the drug: Prescription claim or medical record documentation of failure of or intolerance to two of the following oral atypical antipsychotics: risperidone, olanzapine, ziprasidone, quetiapine IR, or aripiprazole. 1
CLONIDINE PATCH Clonidine Hcl PTWK Claims history in last 365 days or documentation of inability to take clonidine tablets. 2
CLOZAPINE ODT Clozapine Odt Prescription claim or medical record documentation of failure of or intolerance to clozapine tablets. 3
CYCLOSET Cycloset Prescription claim in the past 365 days or medical record documentation of failure of or intolerance to 1) metformin (includes antidiabetic combination drugs that contain metformin such as Janumet, Kombiglyze, or glipizide/metformin) and pioglitazone or 2) pioglitazone-metformin or Actoplus Met XR (pioglitazone-metformin XR). 4
DESLORATADINE Desloratadine Prescription claim in the past 365 days or medical record documentation of failure of or intolerance to levocetirizine. 5
EPLERENONE Eplerenone Prescription claim in the past 365 days or medical record documentation of failure of or intolerance to spironolactone or spironolactonehydrochlorothiazide. 6
ESOMEPRAZOLE Esomeprazole Magnesium Claims history in last 365 days or documentation of failure of or intolerance to two of the following: omeprazole, pantoprazole, lansoprazole or rabeprazole 7
IV ESOMEPRAZOLE Esomeprazole Sodium Prescription claim in the past 365 days or medical record documentation of failure of or intolerance to IV pantoprazole. 8
MYRBETRIQ Myrbetriq Claims history in last 365 days or documentation of failure of or intolerance to two of the following: oxybutynin, tolterodine or trospium. 9
OLMESARTAN Olmesartan Medoxomil TABS Olmesartan Medoxomil/hydrochlorothiazide Claims history in last 365 days or documentation of failure of two different types of angiotensin receptor blockers: 1) losartan or losartanhctz, 2) irbesartan or irbesartan-hctz, 3) valsartan, or valsartan-hctz, 4) candesartan or candesartan-hctz 5) eprosartan, 6) telmisartan, telmisartanamlodipine, or telmisartan-hctz. 10
PHOSPHATE BINDERS Fosrenol PACK Lanthanum Carbonate Renagel TABS 800MG Sevelamer Carbonate The following criteria is not required for members who are stable on medication: prescription claim in the past 365 days or medical record documentation of failure of, intolerance to or contraindication to calcium acetate. 11
QUETIAPINE ER Quetiapine Fumarate Er The following criteria applies to members who newly start on the drug: Prescription claim or medical record documentation of failure of or intolerance to aripiprazole. 12
RASAGILINE Rasagiline Mesylate TABS Prescription claim in the past 365 days or medical record documentation of failure of or intolerance to oral selegiline. 13
RISEDRONATE Risedronate Sodium Prescription claim in the past 365 days or medical record documentation of failure of or intolerance to alendronate and ibandronate. 14
ROZEREM Rozerem Step therapy required for members age 64 and younger. Claims history in the past 365 days or documentation of failure of or intolerance to zolpidem and zaleplon. 15
SAPHRIS Saphris The following criteria applies to members who newly start on the drug: Prescription claim or medical record documentation of failure of or intolerance to two of the following: risperidone ODT, olanzapine ODT, aripiprazole ODT. 16
SHORT-ACTING BETA AGONIST INHALERS Levalbuterol Tartrate Hfa Proventil Hfa Ventolin Hfa Prescription claim in the past 365 days or medical record documentation of failure of or intolerance to ProAir HFA. 17
SILENOR Silenor Step therapy required for members age 64 and younger. Claims history in the past 365 days or documentation of failure of or intolerance to zolpidem and zaleplon. 18
TINIDAZOLE Tinidazole TABS does not apply to giardiasis. Prescription claim in the past 30 days or medical record documentation of failure of or intolerance to oral metronidazole. 19
TOLCAPONE Tolcapone Prescription claim in the past 365 days or medical record documentation of failure of or intolerance to entacapone. 20
TOLTERODINE ER Tolterodine Tartrate Er Prescription claim in the past 365 days or medical record documentation of failure of, intolerance to or contraindication to immediate release tolterodine. 21
TRAVATAN Z Travatan Z Prescription claim in the past 365 days or medical record documentation of failure of or intolerance to latanoprost. 22
TRELEGY ELLIPTA Trelegy Ellipta Prescription claim in the past 365 days or medical record documentation of failure of or intolerance to 1) a inhaled corticosteroid/long-acting beta agonist combination such as fluticasone-salmeterol, Breo or Dulera or 2) an inhaled corticosteroid such as Qvar or Flovent combined with a longacting beta agonist such as Serevent or Brovana or a combination product such as Stiolto or Anoro Ellipta. 23
TROSPIUM ER Trospium Chloride Er Prescription claim in the past 365 days or medical record documentation of failure of, intolerance to or contraindication to immediate release trospium. 24
ULORIC Uloric Claims history in the past 365 days or documentation of failure of or intolerance to allopurinol. 25
ZOLMITRIPTAN Zolmitriptan TABS Zolmitriptan Odt Claims history in last 365 days or documentation of failure of or intolerance to 1) sumatriptan and 2) naratriptan or rizatriptan. 26
INDEX A Atypical Antipsychotics... 1 C Clonidine Hcl... 2 Clonidine Patch... 2 Clozapine Odt... 3 Cycloset... 4 D Desloratadine... 5 E Eplerenone... 6 Esomeprazole... 7 Esomeprazole Magnesium... 7 Esomeprazole Sodium... 8 F Fanapt... 1 Fanapt Titration Pack... 1 Fosrenol... 11 I IV Esomeprazole... 8 L Lanthanum Carbonate... 11 Levalbuterol Tartrate Hfa... 17 M Myrbetriq... 9 O Olmesartan... 10 Olmesartan Medoxomil... 10 Olmesartan Medoxomil/hydrochlorothiazide... 10 P Paliperidone Er... 1 Phosphate Binders... 11 Proventil Hfa... 17 Q Quetiapine Er... 12 Quetiapine Fumarate Er... 12 R Rasagiline... 13 Rasagiline Mesylate... 13 Renagel... 11 Risedronate... 14 Risedronate Sodium... 14 Rozerem... 15 S Saphris... 16 Sevelamer Carbonate... 11 Short-acting Beta Agonist Inhalers... 17 Silenor... 18 T Tinidazole... 19 Tolcapone... 20 Tolterodine Er... 21 Tolterodine Tartrate Er... 21 Travatan Z... 22 Trelegy Ellipta... 23 Trospium Chloride Er... 24 Trospium Er... 24 U Uloric... 25 V Ventolin Hfa... 17 27
Vraylar... 1 Z Zolmitriptan... 26 Zolmitriptan Odt... 26 28