CareAdvantage CMC 2018 Formulary Supplement II (List of Covered Drugs) Step Therapy Criteria (Criteria for Step Therapy-2 [ST-2] Drugs) Formulary ID: 00018157 Formulary Version:11 19 CMS Approved: 08/21/2018 Effective date: 09/01/2018
ALLERGIC RHINITIS-NASAL FLUNISOLIDE OTCs: "NASACORT ALLERGY 24HR", "FLUTICASONE PROP SPRAY OTC". Patient needs to have paid claims for any one of the following Step 1 drugs: NasaCort OTC, fluticasone, fluticasone OTC. Prior to filling the Step 2 drug: flunisolide. PAGE 2 LAST UPDATED 08/21/2018
ALPHA REDUCTASE INHIBITOR DUTASTERIDE Patient needs to have paid claims for any one of the following Step 1 drugs: 5 Alpha Reductase Inhibitor (finasteride). Prior to filling the Step 2 drug: 5 Alpha Reductase Inhibitor (dutasteride). PAGE 3 LAST UPDATED 08/21/2018
ANTI-MIGRAINE SUMATRIPTAN Patient needs to have paid claims for any one of the following Step 1 drugs: Rizatriptan benzoate, Naratriptan HCl, Sumatriptan (oral), Sumatriptan succinate (inj). Prior to filling the Step 2 drug: Sumatriptan (spray). PAGE 4 LAST UPDATED 08/21/2018
BPH ALFUZOSIN HCL ER Patient needs to have paid claims for any one of the following Step 1 drugs: Alpha 1 Blockers (Terazosin, Prazosin, Doxazosin, tamsulosin). Prior to filling the Step 2 drug: Alfuzosin. PAGE 5 LAST UPDATED 08/21/2018
BRILINTA BRILINTA Patient needs to have a 30 day supply paid claim for any one of the following Step 1 drug: clopidogrel. Prior to filling the Step 2 Drug: Brilinta. PAGE 6 LAST UPDATED 08/21/2018
DDP4 INHIBITORS JANUMET, JANUMET XR, JANUVIA, ONGLYZA Patient needs to have paid claims for any one of the following Step 1 drugs: metformin, metformin ER, glipizide/metformin, glyburide/metformin, canagliflozin/metformin, canagliflozin/metformin XR. Prior to filling the Step 2 Drugs: Januvia, Janumet, Onglyza. PAGE 7 LAST UPDATED 08/21/2018
DIABETES NATEGLINIDE, REPAGLINIDE Patient needs to have paid claims for any one of the following Step 1 drugs: Sulfonylureas (chlorpropamide, glimepiride, glipizide, glyburide, tolazamide, tolbutamide, glipizide ER, glipizide XL), Alpha-glucosidase inhibitors (acarbose, miglitol), metformin, metformin ER, glipizide/metformin, glyburide/metformin, Insulins (lispro, Humalog, Humalog Mix 50/50, Humalog Mix 75/25, insulin aspart, Novolog Mix 70/30, Novolog, NPH (isophane insulin susp), Humulin 70/30, Humulin N, Novolin 70/30, Novolin N, insulin glargine, insulin regular-humulin R, Novolin R), thiazolidinediones(pioglitazone, rosiglitazone), Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors (canagliflozin, canagliflozin-metformin, and canagliflozin-metformin XR). Prior to filling the Step 2 Drugs: Meglitinides (nateglinide, repaglinide). PAGE 8 LAST UPDATED 08/21/2018
INFLAMMATION CELECOXIB Patient needs to have paid claims for any two of the following Step 1 drugs: NSAIDS (diflunisal, oral diclofenac sodium, diclofenac sodium/misoprostol, diclofenac potassium, etodolac, fenoprofen, flurbiprofen, OTC ibuprofen, RX ibuprofen, indomethacin, ketorolac injection, ketoprofen, meclofenamate, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin). Prior to filling the Step 2 drug: Celecoxib. PAGE 9 LAST UPDATED 08/21/2018
LORATADINE CLARINEX 0.5 MG/ML (2.5 MG/5), CLARINEX-D 12 HOUR, DESLORATADINE, LEVOCETIRIZINE DIHYDROCHLORIDE OTCs: ALAVERT ALLERGY/SINUS, CLARITIN REDITABS, CLARITIN, CLARITIN-D 24 HOUR, CLARITIN-D 12 HOUR, CHILDRENS LORATADINE, DIPHENHYDRAMINE HCL, CETIRIZINE HCL, ZYRTEC CHILDRENS ALLERGY, ZYRTEC ALLERGY, LORATADINE-D 24HR, CETIRIZINE HCL/PSEUDOEPHEDRINE HCL ER, ALLERGY RELIEF, CETIRIZINE HCL CHILDRENS, ZYRTEC-D ALLERGY/CONGESTION, ALLEGRA ALLERGY, ALLEGRA ALLERGY CHILDRENS, ALLEGRA-D 24 HOUR ALLERGY & CONGESTION, ALLEGRA-D 12 HOUR ALLERGY & CONGESTION, LORATADINE. Patient needs to have paid claims for one of the following Step 1 drugs: Children's Zyrtec, Chrilden's Clariton, CHILDREN'S ALLEGRA ALLERGY, Allegra OTC, Allegra/pseudoephedrine combination OTC, cetirizine OTC, cetirizine/pseudoephedrine combination OTC, diphenhydramine OTC, loratadine OTC, loratadine/pseudoephedrine combination OTC. Prior to filling the Step 2 drugs: other low or nonsedating antihistamines (including pseudoephedrine combination of the following) desloratadine. PAGE 10 LAST UPDATED 08/21/2018
LYRICA LYRICA ST applies to new starts only for all medically accepted indications of gabapentin including epilepsy. postherpetic neuralgia, fibromyalgia, and diabetic peripheral neuropathy, patient needs to have paid claims for one of the following Step 1 drugs: gabapentin. Prior to filling the Step 2 drug: pregabalin. Members may request an exception and Lyrica (pregabalin) will be allowed as first line treatment for neuropathic pain associated with spinal cord injury. PAGE 11 LAST UPDATED 08/21/2018
OVERACTIVE BLADDER DARIFENACIN ER, TOLTERODINE TARTRATE ER OTCs: "OXYTROL FOR WOMEN". Patient needs to have paid claims for one of the following Step 1 drugs: Oxybutynin, Oxybutynin XL, Tolterodine, Oxytrol OTC. Prior to filling the Step 2 drug: Darifenacin ER, Tolterodine ER. PAGE 12 LAST UPDATED 08/21/2018
PATIROMER CALCIUM VELTASSA Patient needs to have paid claims for a 30 day supply for any one of the following Step 1 drug(s): sodium polystyrene sulfonate (SPS). Prior to filling the Step 2 drug: Patiromer calcium. PAGE 13 LAST UPDATED 08/21/2018
PROTON PUMP INHIBITORS RABEPRAZOLE SODIUM OTCs: "OMEPRAZOLE", "ZEGERID OTC", "OTC LANSOPRAZOLE". Patient needs to have paid claims for two of the following Step 1 drugs: omeprazole OTC, lansoprazole OTC, lansoprazole Rx, Zegerid OTC, omeprazole Rx, pantoprazole. Prior to filling the Step 2 drug: rabeprazole. PAGE 14 LAST UPDATED 08/21/2018
ROTIGOTINE NEUPRO Patient needs to have a 30 day supply paid claim for any one of the following Step 1 drug: ropinirole, pramipexole, or pramipexole ER. Prior to filling the Step 2 Drug: Neupro. PAGE 15 LAST UPDATED 08/21/2018
SKELETAL MUSCLE RELAXANT CARISOPRODOL COMPOUND, CARISOPRODOL-ASPIRIN, ORPHENADRINE ER 100 MG TABLET Patient needs to have paid claims for any one of the following oral agents: Carisoprodol, Cyclobenzaprine, Methocarbamol. Prior to filling the Step 2 drug: Orphenadrine, Carisoprodol/Aspirin. PAGE 16 LAST UPDATED 08/21/2018
TOPICAL IMMUNOMODULATORS ELIDEL, TACROLIMUS 0.03% OINTMENT, TACROLIMUS 0.1% OINTMENT Patient needs to have paid claims for two or more of the following Step 1 drugs: Topical Corticosteroids (alclometasone dipropionate, desonide, fluocinolone acetonide, betamethasone valerate, fluocinonide (-plus emollient), fluticasone propionate, prescription hydrocortisone, OTC hydrocortisone, OTC HYDROCORTISONE ACETATE, OTC hydrocortisone/aloe, hydrocortisone valerate, hydrocortisone butyrate (-plus emollient), mometasone furoate, triamcinolone acetonide, amcinonide, betamethasone dipropionate, betamethason diproprionate/prop gly, augmented betamethasone dipropionate, desoximetasone, diflorasone diacetate, clobetasol propionate (-plus emollient), halobetasol propionate, prednicarbate) Prior to filling the Step 2 drug: Topical Immunomodulators (pimecrolimus, tacrolimus). PAGE 17 LAST UPDATED 08/21/2018
ULORIC ULORIC Patient needs to have paid claims for any one of the following Step 1 drug: allopurinol. Prior to filling the Step 2 Drug: Uloric. PAGE 18 LAST UPDATED 08/21/2018
XOPENEX LEVALBUTEROL CONCENTRATE, LEVALBUTEROL HCL, LEVALBUTEROL TARTRATE HFA Patient needs to have paid claims for any one of the following Step 1 agents: albuterol inhaler, albuterol nebulization. Prior to filling the Step 2 agent: levalbuterol inhaler, levalbuterol nebulization. PAGE 19 LAST UPDATED 08/21/2018
ZETIA EZETIMIBE Patient needs to have paid claims for any one of the following Step 1 drugs: pravastatin, lovastatin, simvastatin, atorvastatin, rosuvastatin. Prior to filling the Step 2 Drug: Ezetimibe. Members may request an exception and Ezetimibe will be allowed as first line treatment for homozygous sitosterolemia. PAGE 20 LAST UPDATED 08/21/2018