Plan Year Allegian Advantage (HMO) Step Therapy Criteria (ST)

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1 Plan Year 2015 Allegian Advantage (HMO) Step Therapy (ST) Step Therapy: In some cases, Allegian Advantage 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 Allegian Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Allegian Advantage will then cover Drug B. PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT OUR STEP THERAPY CRITERIA. Allegian Health Plans is an HMO plan with a Medicare contract. Enrollment in Allegian Health Plans depends on contract renewal. H8554_ A Last updated 05/01/2015

2 2015 Allegian Advantage Medicare D Formulary Step Therapy Products Affected ACTONEL TAB Last Updated 5/1/2015 Step Therapy requires a trial of alendronate in previous 180 days. 1

3 APLENZIN TAB Step Therapy requires trial of bupropion SR or bupropion XL in previous 180 days. 2

4 ARANESP INJ. 100MCG, 150MCG, 200MCG, 300MCG, 500MCG Step Therapy requires trial of PROCRIT. 3

5 ARANESP INJ. 25MCG, 60MCG Step Therapy requires trial of PROCRIT. 4

6 ARANESP INJ. 40MCG Step Therapy requires trial of PROCRIT. 5

7 ARICEPT TAB 23MG Step Therapy requires trial of donepezil 10mg in previous 180 days. 6

8 ATELVIA TAB Step Therapy requires a trial of alendronate in previous 180 days. 7

9 AUVI-Q INJ. Step Therapy requires trial of EPIPEN in previous 180 days. 8

10 BECONASE AQ NASAL SPRAY Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 9

11 BESIVANCE OPHTH SUSP. Step Therapy requires trial of one of the following ciprofloxacin, levofloxacin, ofloxacin, VIGAMOX or MOXEZA in previous 180 days. 10

12 BONIVA INJ. Step Therapy requires a trial of alendronate in previous 180 days. 11

13 BONIVA TAB Step Therapy requires a trial of alendronate in previous 180 days. 12

14 BRINTELLIX TAB Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 13

15 budesonide nasal inhaler Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 14

16 BYETTA INJ. Step Therapy requires trial of Victoza 15

17 DESVENLAFAXINE ER TAB Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 16

18 DEXILANT CAP Step Therapy requires trial of omeprazole, lansoprazole or pantoprazole in previous 180 days. 17

19 DIFICID TAB Step Therapy requires trial of VANCOCIN. 18

20 donepezil tab 23mg Step Therapy requires trial of donepezil 10mg in previous 180 days. 19

21 EPINEPHRINE INJ Step Therapy requires trial of EPIPEN in previous 180 days. 20

22 EPOGEN INJ. 2000UNIT, 10000UNIT, 20000UNIT Step Therapy requires trial of PROCRIT in past 180 days 21

23 EPOGEN INJ. 3000UNIT, 4000UNIT Step Therapy requires trial of PROCRIT in past 180 days 22

24 EXTAVIA INJ. Step Therapy requires trial of two of the following: AVONEX, REBIF or COPAXONE 23

25 FETZIMA ER CAP Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 24

26 FETZIMA TITRATION PACK Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 25

27 fluvoxamine ER cap Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 26

28 gatifloxacin ophth soln. Step Therapy requires trial of one of the following ciprofloxacin, levofloxacin, ofloxacin, VIGAMOX or MOXEZA in previous 180 days. 27

29 guanfacine ER tab Step Therapy requires trial of guanfacine IR in previous 180 days. 28

30 ibandronate inj. Step Therapy requires a trial of alendronate in previous 180 days. 29

31 ibandronate tab Step Therapy requires a trial of alendronate in previous 180 days. 30

32 INTUNIV TAB Step Therapy requires trial of guanfacine IR in previous 180 days. 31

33 KHEDEZLA TAB Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 32

34 LUNESTA TAB Step Therapy requires trial of zolpidem or zaleplon in previous 180 days. 33

35 LUVOX CR TAB Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 34

36 METROGEL 1% Step Therapy requires trial of FINACEA. 35

37 NORITATE CREAM Step Therapy requires trial of FINACEA. 36

38 OMNARIS NASAL SPRAY Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 37

39 PANCREAZE CAP Step Therapy requires trial of CREON in previous 180 days. 38

40 PENTASA CAP Step Therapy requires trial of one of the following ASACOL, DELZICOL or LIALDA in previous 180 days. 39

41 PERTZYE CAP Step Therapy requires trial of CREON in previous 180 days. 40

42 PEXEVA TAB Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 41

43 PRISTIQ TAB Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 42

44 QNASL Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 43

45 QNASL CHILDRENS NASAL SPRAY Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 44

46 RHINOCORT AQUA NASAL Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 45

47 risedronate sodium tab Step Therapy requires a trial of alendronate in previous 180 days. 46

48 ULORIC TAB Step Therapy requires trial of allopurinol in previous 180 days. 47

49 ULTRESA CAP Step Therapy requires trial of CREON in previous 180 days. 48

50 VANCOCIN CAP 125MG Step Therapy requires trial of metronidazole in previous 180 days 49

51 VANCOCIN CAP 250MG Step Therapy requires trial of metronidazole in previous 180 days 50

52 vancomycin cap Step Therapy requires trial of metronidazole in previous 180 days 51

53 VIIBRYD TAB Step Therapy requires trial of one of the following generic SSRI's in previous 180 days: sertraline, fluoxetine, citalopram, paroxetine or fluvoxamine. 52

54 XOPENEX HFA INHALER Step Therapy requires trial of VENTOLIN HFA in previous 180 days. 53

55 ZENPEP CAP Step Therapy requires trial of CREON in previous 180 days. 54

56 ZETONNA NASAL SPRAY Patient has tried or was intolerant to TWO (2) of the following agents: flunisolide, fluticasone, VERAMYST and NASONEX. BECONASE AQ requires trial of ONE (1) of the following agents: flunisolide, fluticasone, NASONEX or VERAMYST. 55

57 ZIOPTAN OPHTH SOLN Step Therapy requires trial of latanoprost. 56

58 ZYMAXID OPHTH SOLN. Step Therapy requires trial of one of the following ciprofloxacin, levofloxacin, ofloxacin, VIGAMOX or MOXEZA in previous 180 days. 57

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