2016 STEP THERAPY CRITERIA

Transcription

1 2016 STEP THERAPY CRITERIA Diamante Choice Platino, Diamante Extra Platino, Diamante Excel Platino, Supremo, Único Extra, Elite Ultra, Elite Excel, ELA Relax Oro, ELA Plus Plata, ELA Flex Bronce ST Criteria ( , ) 2016 MMM-PHA-ST E Updated: September

2 ANTIDEPRESSANTS-SNRI Affected Drugs: PRISTIQ ER 50 MG & 100 MG TAB FETZIMA ER 24 HOUR 20 MG, 40 MG, 80 MG, 120 MG FETZIMA 20 & 40 MG TITRATION PACK If the patient has tried TWO Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug: generic antidepressants SNRI/SSRI Step 2 Drug: brand antidepressants SNRI 130 days for claims review for select or first line drugs. History effective date: 130 days prior to effective date. Grandfathering: Access to second-line drug will be granted for patients who have a history of use within the past 130 days. 2

3 ANTIDEPRESSANTS-SSRI Affected Drugs: PAXIL 10 MG/5 ML SUSPENSION VIIBRYD 10 MG, 20 MG, & 40 MG TABLET VIIBRYD STARTER PACK 10/20 30 DAY PACK TRINTELLIX ORAL TAB 5MG, 10MG, 20MG If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given. Step 1 Drug: generic antidepressants SSRI Step 2 Drug: brand antidepressants - SSRI Patients who have taken a Step 2 SSRI at any time in the past and discontinued its use may receive authorization to restart the Step 2 SSRI (whichever they used in the past). Authorization may be given for a Step 2 SSRI if the patient is currently taking the requested agent. 130 days for claims review for select or first line drugs. History effective date: 130 days prior to effective date. Grandfathering: Access to second-line drug will be granted for patients who have a history of use within the past 130 days. 3

4 ANTIHYPERTENSIVES Affected Drugs: TEKTURNA ORAL TAB 150 MG, 300 MG BENICAR ORAL TAB 5MG, 20 MG BENICAR HCT MG, MG, MG AZOR ORAL TAB 5-20 MG, MG, 5-40 MG, MG If the patient has tried one Generic ACE inhibitor, or Generic ACE inhibitor-hctz combo- AND one Generic ARB or Generic ARB-hctz combo, Generic ACE inhibitor-ccb combo, then authorization for a Step 2 drug may be given. Step 1 Drug: Generic ACE inhibitor, or Generic ACE inhibitor-hctz combo- AND one Generic ARB or Generic ARB-hctz combo, Generic ACE inhibitor-ccb combo. Step 2 Drug: TEKTURNA ORAL TAB 150 MG, 300 MG, BENICAR ORAL TAB 5MG, 20 MG, BENICAR HCT MG, MG, MG, AZOR ORAL TAB 5 20 MG, MG, 5-40 MG, MG Number of days for claims review for select or first line drugs: 90 days. History effective date: 180 days prior to effective date. Grandfathering: Access to second-line drug will be granted for patients who have a history of use within the past 180 days. 4

5 DIFICID Affected Drug: DIFICID ORAL TAB 200 MG Patient needs to have a paid claim for one Step 1 drug (vancomycin (oral) (gen)) prior to filling a Step 2 drug (Dificid) Step 1 Drug: Vancomycin Oral Cap 125 mg, 250 mg Step 2 Drugs: DIFICID ORALT TAB 200 MG Members without Prior History of medication in claims, MD shall provide documentation of medical record or pharmacy claims processing thru another benefit to comply with previous utilization. 5

6 HMG-COA REDUCTASE INHIBITOR Affected Drugs: CRESTOR ORAL TAB 5 MG, 10 MG, 20 MG, 40 MG If the patient has tried one Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug: generic high dose simvastatin, or generic atorvastatin Step 2 Drugs: CRESTOR Number of days for claims review cumulative day supply to 90 days within past 180 day look back of Step 1 drug utilization. Members without Prior History of medication in claims, MD shall provide documentation of medical record or pharmacy claims processing thru another benefit to comply with previous utilization. 6

7 OVERACTIVE BLADDER Affected Drug: MYRBETRIQ ER ORAL TAB 25 MG, 50 MG VESICARE ORAL TAB 5 MG, 10 MG If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug: generic anticholinergic antispasmodics Step 2 Drugs: brand anticholinergic antispasmodics Numbers of days for claims review cumulative day supply to 90 days within past 180 days look back of Step 1 drug utilization. Members without Prior History of medication in claims, MD shall provide documentation of medical record or pharmacy claims processing thru another benefit to comply with previous utilization. 7

8 SILENOR Affected Drug: SILENOR ORAL TAB 3 MG, 6 MG If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug: Temazepam or estazolam Step 2 Drugs: SILENOR Number of days for claims review cumulative day supply to 30 days within past 180 day look back of Step 1 drug utilization. Members without Prior History of medication in claims, MD shall provide documentation of medical record or pharmacy claims processing thru another benefit to comply with previous utilization Authorization for Silenor may be given if the patient has a documented history of addiction to controlled substances. 8

9 ZETIA Affected Drugs: ZETIA 10 MG If the patient has tried one Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug: generic statins Step 2 Drugs: Zetia Approve Zetia without requiring trial and failure to Step 1 drugs if: sitosterolemia, Homozygous familial. Number of days for claims review cumulative day supply to 30 days within past 180 day look back of Step 1 drug utilization Members without Prior History of medication in claims, MD shall provide documentation of medical record or pharmacy claims processing thru another benefit to comply with previous utilization. 9

10 Index: AZOR ORAL TAB...4 BENICAR HCT...4 BENICAR ORAL TAB...4 CRESTOR ORAL TAB...6 DIFICID ORAL TAB...5 FETZIMA 20 & 40 MG TITRATION PACK...2 FETZIMA ER...2 MYRBETRIQ ER ORAL TAB...7 PAXIL 10 MG/5 ML SUSPENSION...3 PRISTIQ ER... 2 SILENOR ORAL TAB 3 MG, 6 MG... 8 TEKTURNA ORAL TAB... 4 TRINTELLIX... 3 VESICARE ORAL TAB... 7 VIIBRYD 10 MG, 20 MG, & 40 MG TABLET3 VIIBRYD STARTER PACK... 3 ZETIA 10 MG