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2013 Step Therapy (ST) Criteria

Some drugs require step therapy pre-approval. This means that your doctor must have you first try a
different drug to treat your medical condition before we will cover a drug that needs step therapy pre-
approval.
Below you will find a table of drugs that require step therapy pre-approval. If you find your drug on this
list, talk to your doctor about what other drugs you could try first.
To see if your drug is on the list, refer to the table of contents below for the step therapy criteria
you are looking for, or refer to the index located at the end of this document for the medication
you are looking for.
TABLE OF CONTENTS

Updated: 06/2013 Y0026_123248 Approved 09/25/2012 Group Health Incorporated (GHI), GHI HMO Select, Inc. (GHI HMO), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies, EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. 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 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. 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. Affected Drugs
STEP 1 DRUGS
enalapril maleate/hctz eprosartan mesylate fosinopril fosinopril/hctz hctz/valsartan irbesartan irbesartan/hctz lisinopril lisinopril/hctz losartan losartan /hctz moexipril moexipril/hctz perindopril erbumine quinapril quinapril/hctz ramipril trandolapril 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, Benazepril Hcl, Benazepril-hydrochlorothiazide, Candesartan-hydrochlorothiazide, Captopril, Captopril-hydrochlorothiazide, Enalapril Maleate, Enalapril-hydrochlorothiazide, eprosartan, Fosinopril Sodium, Fosinopril-hydrochlorothiazide, Irbesartan, Irbesartan-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): Exforge, Exforge Hct, Micardis, Micardis Hct, Twynsta, Diovan. Authorization may be given for a Step 2 product, without a trial of a step 1 agent, if the patient was recently hospitalized and discharged within the previous 30 days for a cardiovascular event (e.g., myocardial infarction, hypertensive emergency, decompensated heart failure) and has already been started and stabilized on the agent. BILE ACID SEQUESTRANTS
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): Cholestyramine Light, Colestipol Hcl, Prevalite. Step 2 Drug(s): Welchol. Authorization may be given for Welchol if patients have a drug-drug interaction with cholestyramine or colestipol. Authorization may be given for Welchol in patients who are pregnant. Authorization may be given for Welchol in patients with type 2 diabetes who are also using other antidiabetic agents (eg, insulin, metformin, sulfonylurea). Authorization may be given for Welchol in patients less than 18 years of age. BISPHOSPHONATES ORAL
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): Alendronate Sodium, Ibandronate Sodium. Step 2 Drug(s): Boniva. Authorization may be given for Boniva, if the patient has tried alendronate sodium (brand or generic) or ibandronate sodium. BRAND NSAIDS
Affected Drugs
STEP 1 DRUGS
diclofenac sodium/misoprostol 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-misoprostol, 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). Affected Drugs
STEP 1 DRUGS
diclofenac sodium/misoprostol 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-misoprostol, 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 (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
lovastatin pravastatin simvastatin If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Atorvastatin, Fluvastatin, Lovastatin, Pravastatin Sodium, Simvastatin. Step 2 Drug(s): Crestor 5 mg. Authorization may be given for a step 2 drug, if the patient has tried atorvastatin (brand or generic), fluvastatin (brand or generic), lovastatin (brand or generic), pravastatin sodium (brand or generic), or simvastatin (brand or generic). Authorization for a step 2 drug will given on an individual basis for drug-drug interactions. 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, Tolterodine, Trospium Chloride, Trospium Er. 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
captopril/hctz DIOVAN® enalapril enalapril maleate/hctz eprosartan mesylate EXFORGE HCT® EXFORGE® fosinopril fosinopril/hctz hctz/valsartan irbesartan irbesartan/hctz lisinopril lisinopril/hctz losartan losartan /hctz MICARDIS HCT® MICARDIS® moexipril moexipril/hctz perindopril erbumine quinapril quinapril/hctz ramipril trandolapril TWYNSTA® 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, Benazepril Hcl, Benazepril-hydrochlorothiazide, Candesartan-hydrochlorothiazide, Captopril, Captopril-hydrochlorothiazide, Diovan, Enalapril Maleate, Enalapril-hydrochlorothiazide, eprosartan, Exforge, Exforge Hct, Fosinopril Sodium, Fosinopril-hydrochlorothiazide, Irbesartan, Irbesartan-hydrochlorothiazide, Lisinopril, Lisinopril-hydrochlorothiazide, Losartan Potassium, Losartan-Hydrochlorothiazide, Micardis, Micardis Hct, Moexipril Hcl, Moexipril-hydrochlorothiazide, Perindopril erbumine, Quinapril Hcl, Quinapril-hydrochlorothiazide, Ramipril, Trandolapril, Twynsta, Valsartan-hydrochlorothiazide. Step 2 Drug(s): Amturnide, Tekamlo, 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 an ACE inhibitor. THIAZOLIDINEDIONE
Affected Drugs
STEP 1 DRUGS
metformin pioglitazone hcl pioglitazone hcl/metformin hc pioglitazone/glimepiride RIOMET® If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Glimepiride-pioglitazone, Glipizide-metformin, Glyburide-metformin Hcl, Janumet, Janumet XR, Kombiglyze XR, Metformin Hcl, Metformin Hcl Er, Metformin-pioglitazone, Pioglitazone, 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 a step 1 drug 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. 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). benazepril/amlodipine besylate, 12, 25 candesartan cilexetil/hctz, 12, 25 diclofenac potassium, 16, 17 diclofenac sodium/misoprostol, 16, 17 enalapril maleate/hctz, 12, 25 eprosartan mesylate, 12, 25 perindopril erbumine, 12, 25 pioglitazone hcl/metformin hc, 27 HIP Health Plan of New York (HIP) is a Medicare Advantage organization with a Medicare
contract. Group Health Incorporated (GHI) is a Medicare Advantage organization and a
standalone prescription drug plan with a Medicare contract. HIP and GHI are EmblemHealth
companies.
Note to existing members: This formulary has changed since last year. Please review this
document to make sure that it still contains the drugs you take.
Beneficiaries must use network pharmacies to access their premium and/or
copayment/coinsurance may change on January 1, 2014.
This document includes EmblemHealth Medicare PDP partial formulary as of June 1, 2013. For
a complete, updated formulary, please visit our Web site at www.emblemhealth.com/medicare
or call the Customer Service number below.
For alternative formats or language, please call Customer Service toll free at:
EmblemHealth Medicare HMO: 1-877-344-7364, Monday through Sunday, 8 am to 8 pm.
EmblemHealth Medicare PPO: 1-866-557-7300, Monday through Sunday, 8 am to 8 pm.
EmblemHealth Medicare PDP: 1-877-444-7241, Monday through Sunday, 8 am to 8 pm.
TTY/TDD users should call 711.
13461 v11

Source: http://www.myemblemhealth.com/medicare/pdf/PDP_step_Therapy.pdf

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