2015 Medicare Part D Step Therapy Requirements. Effective: November 01, 2015
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1 2015 Medicare Part D Step Therapy Requirements Effective: November 01, 2015 Formulary ID 15293, Version 17 Last Updated: 10/27/2015
2 BISPHOSPHONATE THERAPY ACTONEL 30 MG TABLET ACTONEL 35 MG TABLET ACTONEL 5 MG TABLET FOSAMAX PLUS D 70 MG-2,800 UNIT TABLET FOSAMAX PLUS D 70 MG-5,600 UNIT TABLET risedronate 150 mg tablet risedronate 30 mg tablet risedronate 35 mg tablet risedronate 5 mg tablet PRIOR USE OF GENERIC ALENDRONATE WITHIN THE PREVIOUS 12 MONTHS. 1
3 COREG CR COREG CR 10 MG CAPSULE, EXTENDED RELEASE COREG CR 20 MG CAPSULE, EXTENDED RELEASE COREG CR 40 MG CAPSULE, EXTENDED RELEASE COREG CR 80 MG CAPSULE, EXTENDED RELEASE PRIOR USE OF GENERIC CARVEDILOL REGULAR RELEASE WITHIN THE PREVIOUS 12 MONTHS. 2
4 INVOKANA INVOKAMET 150 MG-1,000 MG TABLET INVOKAMET 150 MG-500 MG TABLET INVOKAMET 50 MG-1,000 MG TABLET INVOKAMET 50 MG-500 MG TABLET INVOKANA 100 MG TABLET INVOKANA 300 MG TABLET PRIOR USE OF GENERIC METFORMIN, METFORMIN/GLIPIZIDE, OR JENTADUETO WITHIN THE PREVIOUS 12 MONTHS. 3
5 JARDIANCE JARDIANCE 10 MG TABLET JARDIANCE 25 MG TABLET PRIOR USE OF GENERIC METFORMIN, METFORMIN/GLIPIZIDE, OR JENTADUETO WITHIN THE PREVIOUS 12 MONTHS. 4
6 LEVEMIR LEVEMIR 100 UNIT/ML SUBCUTANEOUS SOLUTION LEVEMIR FLEXTOUCH 100 UNIT/ML (3 ML) SUBCUTANEOUS INSULIN PEN PRIOR USE OF LANTUS WITHIN THE PREVIOUS 12 MONTHS. 5
7 LIDOCAINE PATCH lidocaine 5 % (700 mg/patch) adhesive patch PRIOR USE OF GABAPENTIN WITHIN THE PREVIOUS 12 MONTHS. 6
8 OMEGA-3-ACID ETHYL ESTERS omega-3 acid ethyl esters 1 gram capsule PRIOR USE OF GEMFIBROZIL OR A FORMULARY FENOFIBRATE WITHIN THE PREVIOUS 12 MONTHS. 7
9 PROTON PUMP INHIBITORS lansoprazole 15 mg capsule,delayed release lansoprazole 30 mg capsule,delayed release PRIOR USE OF GENERIC PRESCRIPTION OMEPRAZOLE OR PANTOPRAZOLE WITHIN THE PREVIOUS 12 MONTHS. 8
10 RENIN INHIBITOR THERAPY amlodipine 10 mg-valsartan 160 mg tablet amlodipine 10 mg-valsartan 160 mg-hydrochlorothiazide 12.5 mg tablet amlodipine 10 mg-valsartan 160 mg-hydrochlorothiazide 25 mg tablet amlodipine 10 mg-valsartan 320 mg tablet amlodipine 10 mg-valsartan 320 mg-hydrochlorothiazide 25 mg tablet amlodipine 5 mg-valsartan 160 mg tablet amlodipine 5 mg-valsartan 160 mg-hydrochlorothiazide 12.5 mg tablet amlodipine 5 mg-valsartan 160 mg-hydrochlorothiazide 25 mg tablet amlodipine 5 mg-valsartan 320 mg tablet PRIOR USE OF A FORMULARY ACE INHIBITOR (SUCH AS BENAZEPRIL, CAPTOPRIL, ENALAPRIL, LISINOPRIL, RAMIPRIL, BENAZEPRIL-HCTZ OR LISINOPRIL-HCTZ) OR OF A GENERIC FORMULARY ARB (SUCH AS LOSARTAN, LOSARTAN HCTZ, IRBESARTAN, IRBESARTAN-HCTZ) WITHIN THE PREVIOUS 12 MONTHS. 9
11 ULORIC ULORIC 40 MG TABLET ULORIC 80 MG TABLET PRIOR USE OF ALLOPURINOL WITHIN THE PREVIOUS 12 MONTHS. 10
12 VASCEPA VASCEPA 1 GRAM CAPSULE PRIOR USE OF GEMFIBROZIL OR A FORMULARY FENOFIBRATE WITHIN THE PREVIOUS 12 MONTHS. 11
13 ZOLPIDEM CR zolpidem er 12.5 mg tablet,extended release,multiphase zolpidem er 6.25 mg tablet,extended release,multiphase PRIOR USE OF GENERIC ZOLPIDEM REGULAR RELEASE WITHIN THE PREVIOUS 12 MONTHS. 12
14 Index xedni ACTONEL 30 MG TABLET... 1 ACTONEL 35 MG TABLET... 1 ACTONEL 5 MG TABLET... 1 amlodipine 10 mg-valsartan 160 mg tablet... 9 amlodipine 10 mg-valsartan 160 mg-hydrochlorothiazide 12.5 mg tablet... 9 amlodipine 10 mg-valsartan 160 mg-hydrochlorothiazide 25 mg tablet... 9 amlodipine 10 mg-valsartan 320 mg tablet... 9 amlodipine 10 mg-valsartan 320 mg-hydrochlorothiazide 25 mg tablet... 9 amlodipine 5 mg-valsartan 160 mg tablet... 9 amlodipine 5 mg-valsartan 160 mg-hydrochlorothiazide 12.5 mg tablet... 9 amlodipine 5 mg-valsartan 160 mg-hydrochlorothiazide 25 mg tablet... 9 amlodipine 5 mg-valsartan 320 mg tablet... 9 COREG CR 10 MG CAPSULE, EXTENDED RELEASE... 2 COREG CR 20 MG CAPSULE, EXTENDED RELEASE... 2 COREG CR 40 MG CAPSULE, EXTENDED RELEASE... 2 COREG CR 80 MG CAPSULE, EXTENDED RELEASE... 2 FOSAMAX PLUS D 70 MG-2,800 UNIT TABLET... 1 FOSAMAX PLUS D 70 MG-5,600 UNIT TABLET... 1 INVOKAMET 150 MG-1,000 MG TABLET... 3 INVOKAMET 150 MG-500 MG TABLET... 3 INVOKAMET 50 MG-1,000 MG TABLET... 3 INVOKAMET 50 MG-500 MG TABLET... 3 INVOKANA 100 MG TABLET... 3 INVOKANA 300 MG TABLET... 3 JARDIANCE 10 MG TABLET... 4 JARDIANCE 25 MG TABLET... 4 lansoprazole 15 mg capsule,delayed release... 8 lansoprazole 30 mg capsule,delayed release... 8 LEVEMIR 100 UNIT/ML SUBCUTANEOUS SOLUTION... 5 LEVEMIR FLEXTOUCH 100 UNIT/ML (3 ML) SUBCUTANEOUS INSULIN PEN... 5 xedni lidocaine 5 % (700 mg/patch) adhesive patch... 6 omega-3 acid ethyl esters 1 gram capsule... 7 risedronate 150 mg tablet... 1 risedronate 30 mg tablet... 1 risedronate 35 mg tablet... 1 risedronate 5 mg tablet... 1 ULORIC 40 MG TABLET ULORIC 80 MG TABLET VASCEPA 1 GRAM CAPSULE zolpidem er 12.5 mg tablet,extended release,multiphase zolpidem er 6.25 mg tablet,extended release,multiphase
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ALENDRONATE SOD TAB 35MG (max 1 per week) $37.00 $70.00 ALENDRONATE SOD TAB 70MG (max 1 per week) $37.00 $70.00 ALLOPURINOL TAB 100MG $20.00 $38.00 ALLOPURINOL TAB 300MG $20.00 $38.00 AMITRIPTYLINE TAB
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