Step Therapy Program Precision Formulary Physician Guidelines Failure of previous steps in the Step Therapy Program: For most therapies, Magellan Rx Management will review the most recent 180 days of claim history available. Historical review timeframe may change based on therapy class or client request. (OR) Access the appropriate Magellan Rx Management Prior Authorization (PA) form online to begin the Step Therapy process: https://magellanrx.com/provider/. Note: Step Therapy Guidelines may be updated on an ongoing basis due to changes in the pharmacy industry. Failure to accurately complete the PA form or submit required documentation may result in a delay in the member s therapy. Step Therapy Categories ACNE: ADOXA Doxycycline Adoxa ANDROGENS: NATESTO Androgel Natesto ANTI-DEPRESSANTS: FETZIMA Two preferred SNRSs Fetzima ANTI-EMETICS: METOZOLV metoclopramide (Reglan generic) Metozolv ODT ANTIFUNGALS: CRESEMBA voriconazole Cresemba BPH: CARDURA XL (Flomax) Tamsulosin -- a. Cardura b. Hytrin Cardura XL BPH: RAPAFLO (Flomax) Tamsulosin -- a. Cardura b. Hytrin Rapaflo BRONCHODILATORS: AEROSPAN Flovent AND Pulmicort Flexhaler Aerospan BRONCHODILATORS: EPINEPHRINE Any Epipen product Epinephrine CARDIO: AMTURNIDE a. ACE inhibitor b. ACE inhibitor c. Angiotensin II Receptor d. Angiotensin II Receptor e. Losartan f. Losartan/HCTZ Tekturna OR Tekturna HCT Amturnide CARDIO: COREG CR Cavedilol OR Coreg Coreg CR CARDIO: CORLANOR Any Beta Corlanor CARDIO: EXFORGE Any ONE of the following : ) f. amlodipine/ valsartan Exforge CARDIO: EXFORGE HCT ) f. amlodipine/ valsartan HCT Exforge HCT 1
CARDIO: PRESTALIA amlodipine OR perindopril AND tribenzor OR Azor Prestalia CARDIO: TEKTURNA ) f. ARB/CCB g. ARB/CCB/HCTZ Tekturna CARDIO: TEKTURNA HCT ) f. ARB/CCB g. ARB/CCB/HCTZ Tekturna HCT CARDIO: TWYNSTA a. Azor b. Exforge/ Exforge HCT Twynsta CARDIO-ACE/ARB COMBO: EDARBI Edarbi CARDIO-ACE/ARB COMBO: EDARBYCLOR a. Benicar/ Benicar HCT b. Diovan/ Diovan HCT c. Micardis OR Micardis HCT Edarbyclor CHOLESTEROL: MICARDIS HCT Micardis HCT CHOLESTEROL: SIMCOR a. Any Formulary Statin b. Advicor c. Vytorin Simcor CHOLESTEROL: ZETIA Any statin Zetia CNS ALZHEIMER S: NAMENDA XR Namenda Namenda XR CNS STIMULANTS: ADDERALL XR Any TWO formulary CNS stimulants Brand OR Generic Adderall XR CNS STIMULANTS: ADZENYS XR-ODT Any TWO generic CNS stimulants Adzenys XR-ODT CNS STIMULANTS: CONCERTA Any ONE formulary CNS stimulant Concerta CNS STIMULANTS: DAYTRANA Any ONE formulary CNS stimulant CNS STIMULANTS: DESOXYN Any TWO formulary CNS stimulant Desoxyn CNS STIMULANTS: DYANAVEL XR Any TWO generic CNS stimulants Dyanavel XR CNS STIMULANTS: EVEKEO dextroamphetamine amphetamine salts Evekeo CNS STIMULANTS: FOCALIN XR Any ONE formulary CNS stimulant Focalin XR CNS STIMULANTS: KAPVAY Any TWO formulary CNS stimulant Kapvay CNS STIMULANTS: METADATE CD Any ONE formulary CNS stimulant Metadate CD CNS STIMULANTS: PROCENTRA Any TWO formulary CNS stimulant Procentra CNS STIMULANTS: QUILLICHEW ER Any TWO generic CNS stimulants Quillichew ER CNS STIMULANTS: QUILLIVANT Any TWO formulary CNS stimulant Quillivant CNS STIMULANTS: RITALIN LA Any TWO formulary CNS stimulant Ritalin LA 2
DEPRESSION: SAVELLA a. amitriptyline b. cyclobenzaprine c. Cymbalta Savella DERM: ELIDEL FIn patients > 2 years of age with: Any medium to very high potency Corticosteroid (topical) tacrolimus Elidel DERM: FINACEA PLUS (KIT) Finacea Gel (non-kit) Finacea Plus Kit DERM: PICATO Topical fluorouracil OR imiquimod Picato DERM: PROTOPIC In patients > 2 years of age with: Any medium to very high potency Corticosteroid (topical) tacrolimus Protopic DERM: TOLAK Trial and failure two preferred formulary alternatives including of generic lower strength fluorouracil (0.5%, 2%), Carac, OR Fluoroplex Tolak (fluorouracil 4%) DIABETES: INVOKANA Metformin AND one of the following: sulfonylurea, pioglitazone, DPP4, GLP, or insulin Invokana DIABETES: JANUMET XR Janumet Janumet XR DIABETES: JARDIANCE Invokana Jardiance DIABETES: JENTADUETO Any one of the following: Jentadueto DIABETES: KOMBIGLYZE Any one of the following: Jentadueto Kombiglyze DIABETES: PRECOSE Metformin Precose/Acarbose DIABETES: STARLIX Metformin Starlix OR Nateglinide DIABETES: TOUJEO Lantus Levemir Toujeo DIABETES: TRESIBA Lantus Tresiba STRIPS): BAYER Bayer STRIPS): FREESTYLE Freestyle STRIPS): GLUCOCARD Glucocard STRIPS): PRECISION Precision STRIPS): PRODIGY Prodigy STRIPS): TRUERESULT Trueresult STRIPS): TRUETRACK TrueTRACK EPILEPSY: GRALISE Gabapentin Gralise GI (IBS): AMITIZA For patients than 18 years old Polyethylene glycol OR lactulose Amitiza GI (IBS): LINZESS For patients than 18 years old Polyethylene glycol OR lactulose Linzess GOUT: MITIGARE Colcrys Mitigare GOUT: ULORIC allopurinol Uloric MIGRAINE: ONZETRA XSAIL Trial and failure of two preferred serotonin 5HT1 Agonists Treximet MIGRAINE: TREXIMET Sumatriptan Treximet MIGRAINE: ZEMBRACE SYMTOUCH Trial and failure of two preferred serotonin 5HT1 Agonists Zembrace 3
OPHTHALMIC: LASTACAFT Patanol OR Pataday OR Optivar Lastacaft OSTEOPORISIS: ATELVIA alendronate OR alendronate soln Atelvia PAIN: OPANA ER Oxymorphone ER OR Oxycodone ER OR Morphine ER sulfate OR Hydromorphone ER Opana ER PAIN: OXYCONTIN a. Morphine Sulfate SR b. MS Contin c. Oramorph SR Oxycontin PAIN: NUCYNTA Generic Ultram (tramadol) OR generic Ultracet (tramadol/acetaminophen) oxycodone immediate-release (e.g., OxyIR) OR morphine immediaterelease (eg, MSIR) or Dilaudid (hydromorphone immediate-release) Nucynta PARKINSON S DISEASE/RESTLESS LEG SYNDROME: MIRAPEX ER ropinorole OR pramipexole Mirapex ER PARKINSON S DISEASE/ RESTLESS LEG SYNDROME: REQUIP XL (ROPINIROLE XL) PPI: ACIPHEX ropinorole OR pramipexole Requip XL (Ropinirole Xl) OTC Zegerid Aciphex PPI: DEXILANT Dexilant PPI: NEXIUM Nexium PPI: PREVACID Prevacid PPI: PREVACID STB Prevacid STB PPI: PRILOSEC Prilosec PPI: PROTONIX Protonix PPI: ZEGERID (OMEPRAZOLE - BICARBONATE) Omeprazole (rx), OR OTC Omeprazole, OTC Prilosec, OTC Prevacid, Zegerid (Omeprazole - Bicarbonate) PSYCH: ARICEPT 23MG At least 10 mg of Aricept/Aricept ODT (generic) Note: At least 10 mg of Aricept/ Aricept ODT (brand) will also meet ST1 requirement Aricept 23 mg PSYCH: FANAPT Fanapt PSYCH: FETZIMA Two preferred SNRI Fetzima PSYCH: GEODON (ZIPRASIDONE) PSYCH: INVEGA Geodon (Ziprasidone) d. Seroquel XsR Invega PSYCH: INVEGA SUST a. Olanzapine b. Quetiapine Invega Sust PSYCH: SAPHRIS Saphris PSYCH: TRINTELLIX Two preferred SSRI, SNRI, bupropion, mirtazapine Trintellix RESPIRATORY: ARCAPTA a. Inhaled corticosteroid b. Anticholinergic c. Theophylline Foradil AND Serevent Arcapta RESPIRATORY: FORADIL For management of asthma or COPD with ONE of the following: a. Inhaled corticosteroid b. Anticholinergic c. Theophylline Foradil 4
RESPIRATORY: STIOLTO RESPIMAT Spiriva Stiolto Respimat RESPIRATORY: STRIVERDI RESPIMAT Serevent Foradil Striverdi Respimat UROLOGICS: MYRBETRIQ Any oxybutynin IR/ER, tolterodine IR/ER, Gelnique, Vesicare Myrbetriq SLEEP: BELSOMRA zolpidem OR zaleplon OR Belsomra SLEEP: EDLUAR SUB Zolpidem OR Ambien Edluar SLEEP: AMBIEN -- Ambien SLEEP: AMBIEN CR -- Ambien CR SLEEP: INTERMEZZO SUB Zolpidem OR Ambien Edluar SLEEP: LUNESTA Lunesta SLEEP: ROZEREM -- Rozerem SLEEP: SONATA -- Sonata 5