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2013 Medicare High Performance 4 Tier Step Therapy Criteria
ALZHEIMER'S DRUGS . 6
omeprazole/sodium bicarbonat . 18 ALZHEIMER'S DRUGS
Affected Drugs
STEP 1 DRUGS
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, Galantamine Hbr, 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 utilizers only. ANTIDEPRESSANTS- SSRI
Affected Drugs
STEP 1 DRUGS
fluvoxamine paroxetine sertraline If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Citalopram, Citalopram Hbr, Fluoxetine Dr, Escitalopram, Fluoxetine Hcl, Fluvoxamine Maleate, Paroxetine Hcl, Paroxetine ER, Rapiflux, Sertraline Hcl. Step 2 Drug(s): Viibryd, Paxil oral suspension. Patients who have taken a step 2 SSRI [Selective Serotonin Reuptake Inhibitor] at any time in the past and discontinued its use may receive authorization to restart the step 2 SSRI [Selective Serotonin Reuptake Inhibitor] (whichever they used in the past). Authorization may be given for a step 2 SSRI [Selective Serotonin Reuptake Inhibitor] if the patient is currently taking the requested agent. Authorization may be given for a step 2 drug 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. ARB
Affected Drugs
STEP 1 DRUGS
BILE ACID SEQUESTRANTS
Affected Drugs
STEP 1 DRUGS
BISPHOSPHONATES ORAL
Affected Drugs
STEP 1 DRUGS
BRAND NSAIDS
Affected Drugs
STEP 1 DRUGS
etodolac fenoprofen flurbiprofen ibuprofen indomethacin ketoprofen ketorolac meclofenamate mefenamic acid meloxicam nabumetone naproxen naproxen sodium oxaprozin piroxicam sulindac tolmetin 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, Etodolac, Fenoprofen Calcium, Flurbiprofen, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac Tromethamine, Meclofenamate Sodium, Mefenamic Acid, Meloxicam, Nabumetone, Naproxen, Naproxen Sodium, Oxaprozin, Piroxicam, Sulindac, Tolmetin Sodium. Step 2 Drug(s): Voltaren Gel. Authorization may be given for Voltaren Gel for patients with difficulty swallowing or cannot swallow. Authorization may be given for 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 anticoagulants). COX-2
Affected Drugs
STEP 1 DRUGS
etodolac fenoprofen flurbiprofen ibuprofen indomethacin ketoprofen ketorolac meclofenamate mefenamic acid meloxicam nabumetone naproxen naproxen sodium oxaprozin piroxicam sulindac tolmetin 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, Etodolac, Fenoprofen Calcium, Flurbiprofen, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac Tromethamine, Meclofenamate Sodium, Mefenamic Acid, Meloxicam, Nabumetone, Naproxen, Naproxen Sodium, Oxaprozin, Piroxicam, Sulindac, Tolmetin Sodium. Step 2 Drug(s): Celebrex. Authorization for Celebrex may be given if the patient has tried two oral prescription strength NSAIDs [Non-steroidal anti-inflammatory drugs] (brand or generic) for the current condition. This step therapy program will exclude participants with a claims history of warfarin (Coumadin) within the last 130 days. Authorization for Celebrex may be given for patients who are currently taking chronic systemic corticosteroid therapy, warfarin (Coumadin), clopidogrel (Plavix), prasugrel (Effient), ticagrelor (Brilinta), rivaroxaban (Xarelto), dabigatran (Pradaxa), chronic aspirin therapy, or low molecular weight heparins. FENOFIBRATE
Affected Drugs
STEP 1 DRUGS
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): Lipofen. HMG RULE 1
Affected Drugs
STEP 1 DRUGS
LONG ACTING OPIOIDS
Affected Drugs
STEP 1 DRUGS
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, morphine sulfate ER, oxymorphone 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. OPHTHALMIC PROSTAGLANDINS
Affected Drugs
STEP 1 DRUGS
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): Travatan Z. Authorization for Travatan Z may be given if the patient has a known benzalkonium chloride (BAK) sensitivity or sensitivity to other ophthalmic preservatives. OVERACTIVE BLADDER
Affected Drugs
STEP 1 DRUGS
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Oxybutynin Chloride, Oxybutynin Chloride Er, Trospium Chloride. Step 2 Drug(s): Enablex, Sanctura XR. PROTON PUMP INHIBITORS
Affected Drugs
STEP 1 DRUGS
omeprazole/sodium bicarbonat pantoprazole If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Lansoprazole, Omeprazole, Omeprazole-Sodium Bicarbonate, Pantoprazole Sodium. Step 2 Drug(s): Nexium. Authorization for Nexium may be given in patients less than 1 year of age. SEDATIVE HYPNOTICS
Affected Drugs
STEP 1 DRUGS
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): Rozerem. 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 substances. TEKTURNA
Affected Drugs
STEP 1 DRUGS
THIAZOLIDINEDIONE
Affected Drugs
STEP 1 DRUGS
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Glipizide-metformin, Glyburide-metformin Hcl, Janumet, Janumet XR, Kombiglyze XR, Metformin Hcl, Metformin Hcl Er, Riomet. Step 2 Drug(s): Actoplus Met, Actoplus Met Xr, Actos, Duetact. Authorization may be given for a step 2 drug if the patient has tried metformin or a metformin-containing combination product in the past. Authorization may be given for a step 2 drug if the patient is already started on the requested step 2 drug. Authorization may be given for Actos or Duetact without a trial of metformin in patients with renal insufficiency or renal disease. Authorization may be given for Actos or Duetact without a trial of metformin in patients with cardiomyopathy, heart failure, unstable angina, or who have experienced a myocardial infarction. Authorization may be given for Actos or Duetact without a trial of metformin in patients with a condition (not already noted above) that could potentially increase the risk of hypoperfusion, hypoxemia, or dehydration. Authorization may be given for Actos or Duetact without a trial of metformin if the patient has hepatic impairment or is alcohol dependent. Authorization may be given for Actos or Duetact without a trial of metformin if the patient has chronic metabolic acidosis. ULORIC
Affected Drugs
STEP 1 DRUGS
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 (brand or generic) 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). diclofenac potassium, 11, 12

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