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Ucare 2013 st criteria

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 - glimepiride pioglitazone – 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.

Source: https://www.ucare.org/SiteCollectionDocuments/HealthPlans/UFS/2014/U4510AUFS2014StepTherapyCriteriaCVPER.pdf

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