UCARE FOR SENIORS CLASSIC (HMO-POS) VALUE PLUS (HMO-POS) and ESSENTIALS RX (HMO-POS) 2014 STEP THERAPY CRITERIA In some cases, UCare for Seniors requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, UCare for Seniors may not cover Drug B unless you try Drug A first. If Drug A does not work for you, UCare for Seniors will then cover Drug B.
UCare Minnesota and UCare Health, Inc. are HMO-POS health plans with Medicare contracts. Enrollment in UCare Minnesota and UCare Health, Inc. depends on contract renewal.
H2459 H4270_101713_2 CMS Approved (10182013)
Affected Drugs STEP 1 DRUGS Step Therapy Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): Humalog, Novolog Step 2 Drug(s): Apidra Number of days for claims review for first line drugs: 120 days. This step therapy program applies to new utilizers only. ARB/TEKTURNA Affected Drugs STEP 1 DRUGS Step Therapy Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): losartan, losartan-hctz Step 2 Drug(s): eprosartan, irbesatan, irbesartan/hctz, valsartan/hctz, candesartan/hctz, candesartan Step 3 Drug(s): Azor, Benicar, Benicar HCT, Diovan, Exforge, Exforge HCT, Tekturna, Tekturna HCT Number of days for claims review for first line drugs: 120 days. This step therapy program applies to new utilizers only. BISPHOSPHONATES Affected Drugs
ACTONEL® ATELVIA® FOSAMAX® FOSAMAX PLUS D®
Step Therapy Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. If the patient has tried a Step 2 drug, then authorization for a Step 3 drug may be given. Step 1 Drug(s): alendronate Step 2 Drug(s): ibandronate Step 3 Drug(s): Actonel, Atelvia, Fosamax, Fosamax Plus D Authorization may be given for Fosamax oral solution if there is an inability to swallow tablets. Authorization may be given for a step 3 drug after a trial of only a step 1 drug (no need to try a step 2 drug) for the following indications: osteoporosis in men, glucocorticoid- induced osteoporosis and Paget's disease. Number of days for claims review for first line drugs: 120 days. This step therapy program applies to new utilizers only. BPH DRUGS Affected Drugs STEP 1 DRUGS Step Therapy Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): finasteride Step 2 Drug(s): Avodart, Jalyn Authorization may be given for a Step 2 drug if the patient has previously tried finasteride (brand or generic). Number of days for claims review for first line drugs: 120 days. This step therapy program applies to new utilizers only. Affected Drugs STEP 1 DRUGS diclofenac er etodolac etodolac er flurbiprofen ibuprofen indomethacin indomethacin er ketoprofen ketorolac meloxicam nabumetone naproxen naproxen ec naproxen sodium oxaprozin piroxicam sulindac tolmetin VOLTAREN –XR® Step Therapy 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, diclofenac er, diclofenac-misoprostal, etodolac, etodolac er, flurbiprofen, ibuprofen, indomethacin, indomethacin er, ketoprofen, ketorolac, meloxicam, nabumetone, naproxen, naproxen ec, naproxen sodium, oxaprozin, piroxicam, sulindac, tolmetin, VOLTAREN XR®. Step 2 Drug(s): Celebrex. This step therapy program will exclude participants with a claims history of warfarin (Coumadin) or dabigatran (Pradaxa) within the last 120 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, fondaparinux (Arixtra), apixaban (Eliquis) or low molecular weight
heparins. Authorization for Celebrex may be given for patients aged greater than 75 years who are requesting Celebrex for a chronic condition. Number of days for claims review for first line drugs: 180 days. This step therapy program applies to new utilizers only.
DIABETIC MEDS Affected Drugs STEP 1 DRUGS
JANUMET XR® JANUMET® JANUVIA® KOMBIGLYZE XR® KAZANO® ONGLYZA® OSENI® pioglitazone pioglitazone - glimepiridepioglitazone – metformin Step Therapy Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): metformin, metformin er, glipizide/metformin, glyburide/metformin Step 2 Drug(s): Actoplus Met, Actos, Cycloset, Duetact, Januvia, Janumet, Janumet XR, Kombiglyze XR, Kazano, Onglyza, Oseni, pioglitazone, pioglitazone – glimepiride, pioglitazone - metformin
Number of days for claims review for first line drugs: 120 days. This step therapy program applies to new utilizers only. Affected Drugs STEP 1 DRUGS simvastatin Step Therapy Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): atorvastatin, lovastatin, pravastatin, simvastatin Step 2 Drug(s): Crestor, Vytorin Number of days for claims review for first line drugs: 120 days. This step therapy program applies to new utilizers only. NASAL STEROIDS Affected Drugs STEP 1 DRUGS Step Therapy 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, triamcinolone Step 2 Drug(s): Dymista, Nasonex, Qnasl, Veramyst, Zetonna Number of days for claims review for first line drugs: 120 days. This step therapy program applies to new utilizers only. NOVEL ANTIPSYCHOTICS Affected Drugs STEP 1 DRUGS
LATUDA® olanzapine - fluoxetine SAPHRIS® SEROQUEL XR® SEROQUEL® ziprasidone Step Therapy Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): quetiapine, risperidone, olanzapine, olanzapine odt Step 2 Drug(s): olanzapine-fluoxetine, ziprasidone, Abilify, Fanapt, Invega ER, Latuda, Saphris, Seroquel, Seroquel XR Authorization for the following drugs may be given without a trial of a Step 1 drug:
Seroquel XR, if the patient has a diagnosis of major depressive disorder and
ziprasidone, if the patient has a diagnois of acute psychosis,
Invega, if the patient has a diagnosis of schizoaffective disorder;
Abilify, if patient has a diagnosis of Major Depressive Disorder and receiving
Patients under the age of 18 are excluded from this edit. Number of days for claims review for first line drugs: 120 days. This step therapy program applies to new utilizers only.
OPHTHALMIC PROSTAGLANDINS Affected Drugs STEP 1 DRUGS Step Therapy 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, Travoprost Step 2 Drug(s): Travatan-Z, Lumigan, Rescula, Zioptan Number of days for claims review for first line drugs: 120 days. This step therapy program applies to new utilizers only. TRIPTANS Affected Drugs STEP 1 DRUGS sumatriptan Step Therapy Criteria
If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 Drug(s): naratriptan, rizatriptan, sumatriptan Step 2 Drug(s): Relpax Number of days for claims review for first line drugs: 120 days. This step therapy program applies to new utilizers only.
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