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SmartD Rx (PDP) Step Therapy Program
Rules and Coverage Criteria
Step Therapy
Algorithm
Byetta Step Therapy Patients who have never tried the Step-2 Medication such as Step 1: Actoplus MET 15 mg-500 mg tablet, Actoplus Byetta and Bydureon being requested: Step-1 medications are MET 15 mg-850 mg tablet, Avandamet 2 mg-1,000 mg covered at the point of service. These include Actoplus MET, tablet, Avandamet 2 mg-500 mg tablet, Avandamet 4 mg- Avandamet, Janumet, Metformin and Metformin ER. Step-2 1,000 mg tablet, Avandamet 4 mg-500 mg tablet, Janumet medications require the prior use of at least one Step-1 50 mg-1,000 mg tablet, Janumet 50 mg-500 mg tablet, medication within the same step therapy group within the metformin 1,000 mg tablet, metformin 500 mg tablet, previous 180 days as evidenced by a previous paid claim under metformin 850 mg tablet, metformin ER 500 mg the prescription benefit administered by BeneCard or by tablet,extended release 24 hr, metformin ER 750 mg physician documented use. Patients who have tried the Step-2 Medication being requested: Members that have taken the same Step 2: Bydureon 2 mg SubQ suspension,extended Step-2 medication that is being requested within the last 180 days release, Byetta 10 mcg/0.04 mL per dose Sub-Q Pen can receive the medication without trial and failure of a Step-1 Injector, Byetta 5 mcg/0.02 mL per dose Sub-Q Pen medication. Medications on Step-2 are not covered unless the Page 1 of 3 SmartD Rx SM PDP is a Federally-Qualified Medicare Contracting Prescription Drug Plan offered by Smart Insurance Company in all 50 states, the District of Columbia and Puerto Rico. S0064 SmartD Rx (PDP) Step Therapy Program
Rules and Coverage Criteria
Step Therapy
Algorithm
Step-1 medications are covered at the point of service. Step-2 Step 1: alendronate 10 mg tablet, alendronate 35 mg medications require the prior use of at least one Step-1 tablet, alendronate 5 mg tablet, alendronate 70 mg tablet, medication within the same step therapy group within the previous 180 days as evidenced by a previous paid claim under Step 2: Prolia 60 mg/mL Sub-Q Syringe, Reclast 5 the prescription benefit administered by BeneCard or by physician documented use. Medications on Step-2 are not covered unless the above step therapy criteria are met. For Osteoporosis Step Therapy Group, Step-1 is alendronate sodium, ibandronate sodium. For Osteoporosis Step Therapy Group, Step-2 is Prolia. Alendronate sodium 40mg will not have step therapy requirements since it is mainly used for the treatment of Pagets Disease. In addition, members with breast cancer-osteopenia (women receiving aromatase inhibitor therapy) or nonmetastatic prostate cancer osteopenia (men receiving androgen deprivation therapy) will be approved for Prolia without trying a step 1 drug ibandronate or alendronate. Page 2 of 3 SmartD Rx SM PDP is a Federally-Qualified Medicare Contracting Prescription Drug Plan offered by Smart Insurance Company in all 50 states, the District of Columbia and Puerto Rico. S0064 SmartD Rx (PDP) Step Therapy Program
Rules and Coverage Criteria
Index
Name of Medication Page Name of Medication Page Name of Medication Page

Actoplus MET 15 mg-500 mg
Page 3 of 3 SmartD Rx SM PDP is a Federally-Qualified Medicare Contracting Prescription Drug Plan offered by Smart Insurance Company in all 50 states, the District of Columbia and Puerto Rico. S0064

Source: http://www.smartdrxpbf.com/resources/documents/Step-Therapy-Coverage-Rules.pdf