Step therapy criteria

Step Therapy Criteria Paramount Medicare Formulary 2013 FID 13084, Version #24. CMS Approved 10/22/2013. Last Update 10/2013.
ALZHEIMER'S DEMENTIA_2013
Products Affected
Criteria
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, 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 ANTIDEPRESSANTS - BUPROPION_2013
Products Affected
Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Budeprion Sr, Budeprion Xl, Bupropion Hcl Sr. Step 2 Drug(s): Aplenzin. Authorization may be given for a Step 2 drug if the patient is currently taking the requested agent. This step therapy program applies to new utilizers only. ANTIDEPRESSANTS - BUPROPION_2013_REVISED 05-01-
2013
Products Affected
Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Budeprion Sr, Budeprion Xl, Bupropion Hcl Sr, Bupropion XL. Step 2 Drug(s): Aplenzin. Authorization may be given for a Step 2 drug if the patient is currently taking the requested agent. This step therapy program applies to new utilizers only. ANTIDEPRESSANTS - SARAFEM_2013
Products Affected
Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Fluoxetine DR, Fluoxetine Hcl, Rapiflux, Selfemra. Step 2 Drug(s): Sarafem. Authorization may be given for step 2 Sarafem if the patient is currently taking the requested agent. This step therapy program applies to new utilizers only. ANTIDEPRESSANTS - SNRI_2013
Products Affected
Criteria
If the patient has tried a Step 1 drug, then authorization for a drug in Step 2 drug may be given. Step 1 Drug(s): Venlafaxine Hcl, Venlafaxine Hcl ER. Step 2 Drug(s): Pristiq. Patients who have taken a Step 2 SNRI at any time in the past and discontinued its use may receive authorization to restart the Step 2 SNRI, without a trial of a Step 1 agent. Authorization may be given for a Step 2 SNRI if the patient is currently taking the requested agent. Authorization may be given for Step 2 SNRI,without a trial of a Step 1 agent, if the patient is a child or adolescent aged 18 years or less, or the patient has symptoms of suicidal ideation. This step therapy program applies to new utilizers only. ANTIDEPRESSANTS - SNRI_2013_REVISED 07-01-2013
Products Affected
Criteria
If the patient has tried a Step 1 drug, then authorization for a drug in Step 2 drug may be given. Step 1 Drug(s): Venlafaxine Hcl, Venlafaxine Hcl ER. Step 2 Drug(s): Desvenlafaxine, Pristiq. Patients who have taken a Step 2 SNRI at any time in the past and discontinued its use may receive authorization to restart the Step 2 SNRI, without a trial of a Step 1 agent. Authorization may be given for a Step 2 SNRI if the patient is currently taking the requested agent. Authorization may be given for Step 2 SNRI,without a trial of a Step 1 agent, if the patient is a child or adolescent aged 18 years or less, or the patient has symptoms of suicidal ideation. This step therapy program applies to new utilizers only. ANTIDEPRESSANTS - SSRI_2013
Products Affected
Criteria
If the patient has tried two Step 1 drugs, then authorization for a drug in Step 2 drug may be given. Step 1 Drug(s): Citalopram HBr, Fluoxetine DR, Fluoxetine Hcl, Fluvoxamine Maleate, Paroxetine Hcl, Paroxetine Hcl ER, Rapiflux, Selfemra, Sertraline Hcl. Step 2 Drug(s): Luvox CR, Viibryd. Patients who have taken Luvox CR, or Viibryd at any time in the past and discontinued its use may receive authorization to restart Luvox CR, or Viibryd (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 Luvox CR 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. ANTIHISTAMINE THERAPY_2013
Products Affected
Criteria
OTCs: "LORATADINE", "LORATADINE HIVES RELIEF", "CETIRIZINE HCL", "CETIRIZINE SYRUP", "LORATADINE-D 12HR" or "24HR", "CETIRIZINE HCL/PSEUDOEPHEDRINE HCL ER", "CETIRIZINE HCL CHILDRENS ALLERGY". If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): OTC. Step 2 Drug(s): Levocetirizine. BISPHOSPHONATES_2013
Products Affected
Criteria
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. Step 2 Drug(s): Actonel. Authorization may be given for Actonel for use in the management of Paget’s disease if the patient has already started therapy BRANDED NSAID THERAPY_2013
Products Affected
Criteria
If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Diclofenac Potassium, Diclofenac Sodium, Diclofenac Sodium DR, EC, ER, and XR, Diflunisal, Etodolac, Etodolac ER, Fenoprofen Calcium, Flurbiprofen, Ibuprofen, Indomethacin, Indomethacin ER, Ketoprofen, Ketorolac Tromethamine, Meclofenamate Sodium, Mefenamic Acid, Meloxicam, Nabumetone, Naproxen, Naproxen DR, Naproxen Sodium, Oxaprozin, Piroxicam, Sulindac, Tolmetin Sodium. Step 2 Drug(s): Arthrotec 50, Arthrotec 75, Flector, Pennsaid, Voltaren Gel. Authorization for a step 2 drug, may be given if the patient has tried two unique generic prescription strength non- steroidal anti-inflammatory drugs (NSAIDs) for the current condition. Authorization may be given for Flector, Pennsaid, or Voltaren Gel for patients with difficulty swallowing or cannot swallow. Authorization may be given for Pennsaid or 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 FENOFIBRATE_2013
Products Affected
Criteria
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): Tricor, INTRANASAL STEROIDS_2013
Products Affected
Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Flunisolide, Fluticasone Propionate. Triamcinolone. Step 2 Drug(s): Nasonex. Authorization may be given for Nasonex if it is being used in the prevention of nasal symptoms associated with seasonal allergic rhinitis or for the treatment of nasal LEUKOTRIENE INHIBITOR THERAPY_2013
Products Affected
Criteria
OTCs: "LORATADINE", "LORATADINE HIVES RELIEF", "CETIRIZINE HCL", "CETIRIZINE SYRUP", "LORATADINE-D 12HR" OR "24HR", "CETIRIZINE HCL/PSEUDOEPHEDRINE HCL ER", "CETIRIZINE HCL CHILDRENS ALLERGY". If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Intranasal flunisolide, fluticasone propionate, triamcinolone, Nasonex, plus either OTC cetirzine, OTC loratadine, or levocetirizine. Step 2 Drug(s): Singulair, Zafirlukast This step therapy program will exclude participants with a claims history of inhaled Beta 2 Agonists or inhaled corticosteroids within the last 130 days. LEUKOTRIENE INHIBITOR THERAPY_2013_REVISED 04-
01-2013
Products Affected
Criteria
OTCs: "LORATADINE", "LORATADINE HIVES RELIEF", "CETIRIZINE HCL", "CETIRIZINE SYRUP", "LORATADINE-D 12HR" OR "24HR", "CETIRIZINE HCL/PSEUDOEPHEDRINE HCL ER", "CETIRIZINE HCL CHILDRENS ALLERGY". If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Intranasal flunisolide, fluticasone propionate, triamcinolone, Nasonex, plus either OTC cetirzine, OTC loratadine, levocetirizine, or montelukast. Step 2 Drug(s): Singulair, Zafirlukast This step therapy program will exclude participants with a claims history of inhaled Beta 2 Agonists or inhaled corticosteroids within the last 130 LONG ACTING OPIOIDS_2013
Products Affected
Criteria
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 ER. Oxymorphine 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. Authorization may be given for Embeda if the patient cannot swallow or has difficulty swallowing. OPHTHALMIC PROSTAGLANDINS_2013
Products Affected
Criteria
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): Lumigan, OPHTHALMIC PROSTAGLANDINS_2013_REVISED 07-01-
2013
Products Affected
Criteria
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): Lumigan, PPI THERAPY_2013
Products Affected
Criteria
OTCs: "OMEPRAZOLE" and "LANSOPRAZOLE". If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): OTC, Pantoprazole Sodium. Step 2 Drug(s): Dexilant, Lansoprazole, Omeprazole, Omeprazole-Sodium Bicarbonate. Authorization may be given for Lansoprazole (ODT tablets) for patients with a feeding tube (eg, nasogastric tube, gastric tube). Authorization may be given for a Step 2 agent for children less than 2 years old. SEDATIVE HYPNOTICS_2013
Products Affected
Criteria
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): Lunesta, Rozerem, Zolpidem ER. 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 TEKTURNA_2013
Products Affected
Criteria
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, Avalide, Avapro, Benazepril Hcl, Benazepril-hydrochlorothiazide, Captopril, Captopril-hydrochlorothiazide, Diovan, Diovan HCT, Enalapril Maleate, Enalapril-hydrochlorothiazide, Eprosartan, Fosinopril Sodium, Fosinopril- hydrochlorothiazide, Lisinopril, Lisinopril-hydrochlorothiazide, Losartan Potassium, Losartan-Hydrochlorothiazide, Moexipril Hcl, Moexipril- hydrochlorothiazide, Perindopril erbumine, Quinapril Hcl, Quinapril- hydrochlorothiazide, Ramipril, Trandolapril. Step 2 Drug(s): 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 TEKTURNA_2013_REVISED 04-01-2013
Products Affected
Criteria
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, Avalide, Avapro, Benazepril Hcl, Benazepril-hydrochlorothiazide, Captopril, Captopril-hydrochlorothiazide, Diovan, Diovan HCT, Enalapril Maleate, Enalapril-hydrochlorothiazide, Eprosartan, Fosinopril Sodium, Fosinopril- hydrochlorothiazide, 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): 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 ULORIC_2013
Products Affected
Criteria
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 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). ZETIA_2013
Products Affected
Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Advicor, Atorvastatin, Crestor, Juvisync, Lovastatin, Pravastatin Sodium, Simcor, Simvastatin. Step 2 Drug(s): Vytorin 10 mg, Vytorin 20 mg, Zetia. Authorization for Zetia may be given if the patient is taking or will be taking a medication that has a significant drug interaction with any of the HMG-CoA reductase inhibitors [statins] (eg, cyclosporine, fibrates, niacin more than 1 g/day, itraconazole, ketoconazole, erythromycin, clarithromycin, HIV protease inhibitors, nefazodone, amiodarone, and verapamil). Authorization of Zetia may be given if the patient has severe renal impairment (creatinine clearance of 30 mL/minute or less). Authorization of Zetia may be given if for management of homozygous familial sitosterolemia. Authorization of Zetia may be given for use in pregnant woman. Authorization of Zetia may be given if the patient has active liver disease or unexplained persistent elevations of serum transaminases. Exceptions are NOT recommended for Zetia for use in patients with moderate or severe hepatic insufficiency. Authorization for Zetia may be given for use in patients who have been previously diagnosed with myopathy or rhabdomyolysis (either medication-related or not medication related) OR the patient has an underlying muscle/muscle-metabolism-related disorder (eg, myositis, A
Antidepressants - Bupropion_2013_revised 05-01- M
Antidepressants - Snri_2013 . 5 Antidepressants - Snri_2013_revised 07-01-2013 6 N
Antihistamine Therapy_2013 . 8 Aplenzin . 2, 3 O
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