Std step therapy drugs 20121204 '2012'.doc

STANDARD Stepped Therapy Agents ~ 2012
The following drugs will require prior authorization if the condition is not met when the pharmacist would attempt to transmit a prescription claim. Your doctor will coordinate this approval for you. If the prescription is approved, Coventry Health Care will cover the cost. You will be responsible for the copayment. If the request is not approved, it does not mean your doctor cannot prescribe the medicine for you. It means that you are responsible for paying the prescription in full. Self-administered injectable agents also require prior authorization and can be found on a separate list. Condition
Abilify (aripiprazole) ODT or solution Trial & failure of Abilify oral tablet Trial & failure of metformin/ER (at least 1500mg/d) ActoPLUS Met* (pioglitazone / metformin) Trial & failure of metformin/ER (at least 1500mg/d) ActoPLUS Met XR (pioglitazone / metformin ext rel) Trial & failure of metformin/ER (at least 1500mg/d) Ambien CR* (zolpidem extended release) Trial & failure of Ambien* or Sonata* Trial & failure of Lactulose* or Miralax* Apidra (insulin glulisine) vial, pen Trial of Aricept 10mg QD for at least 3 months Trial & failure of Flonase* or Nasalide*, AND Nasonex Trial & failure of a Imitrex* or Amerge* Trial & failure of 2: Claritin OTC*, Zyrtec OTC*, Allegra OTC Coreg CR (carvedilol extended rel) Cosopt PF (dorzolamide / timolol) preservative free Trial & failure of Mevacor*, Pravachol*, Zocor* or Lipitor* Trial & failure of Abreva or oral acyclovir Detrol / Detrol LA (tolterodine / extended release) Trial & failure of Ditropan* or Sanctura*/Sanctura XL Dovonex cream, ointment, solution (calcipotriene) Trial & failure of a medium to high potency topical steroid Trial & failure of metformin/ER (at least 1500mg/d) Trial & failure of Ditropan* or Sanctura*/Sanctura XL Epiduo gel (adapalene/benzoyl peroxide) Trial & failure of 2: Risperdal*, Seroquel*, Geodon* Trial & failure of metformin/ER (at least 1500mg/d) Gelnique (oxybutynin topical gel) Trial & failure of Ditropan* or Sanctura*/Sanctura XL Trial & failure of metformin/ER (at least 1500mg/d) For Post-Herpetic Neuralgia: trial & failure of Neurontin* For Restless Leg Syndrome: Trial & failure of 2: Neurontin*, Requip*, Mirapex* * indicates generic available Italics indicate Non-Formulary agents # indicates Step Therapy required for age 18yr and under This is the most current list at the time of printing and is subject to change. Last update December 4, 2012 STANDARD Stepped Therapy Agents ~ 2012
The following drugs will require prior authorization if the condition is not met when the pharmacist would attempt to transmit a prescription claim. Your doctor will coordinate this approval for you. If the prescription is approved, Coventry Health Care will cover the cost. You will be responsible for the copayment. If the request is not approved, it does not mean your doctor cannot prescribe the medicine for you. It means that you are responsible for paying the prescription in full. Self-administered injectable agents also require prior authorization and can be found on a separate list. Condition
For Post-Herpetic Neuralgia: trial & failure of Neurontin* For Restless Leg Syndrome: Trial & failure of 2: Neurontin*, Requip*, Mirapex* Trial & failure of 2: Risperdal*, Seroquel*, Geodon* Trial & failure of metformin/ER (at least 1500mg/d) Janumet XR (sitagliptin / metformin ext rel) Trial & failure of metformin/ER (at least 1500mg/d) Trial & failure of metformin/ER (at least 1500mg/d) Trial & failure of metformin/ER (at least 1500mg/d) Trial & failure of metformin/ER (at least 1500mg/d), AND Jentadueto (linagliptin / metformin) Trial & failure of metformin/ER (at least 1500mg/d) Trial & failure of Levemir vial or pen Trial & failure of 2: Risperdal*, Seroquel*, Geodon* Lescol* / Lescol XL (fluvastatin) Trial & failure of Mevacor*, Pravachol*, Zocor* or Lipitor* AND Crestor Trial & failure of Apriso, Asacol or Asacol HD Trial & failure of Lactulose* or Miralax* Trial & failure of Mevacor*, Pravachol*, Zocor* or Lipitor* AND Crestor Trial & failure of Ambien* or Sonata* Luvox CR (fluvoxamine extended release) Trial & failure of Ditropan* or Sanctura*/Sanctura XL Trial & failure of Lotrimin* and Spectazole* Trial & failure of Flonase* or Nasalide*, AND Nasonex Trial & failure of 2: Neurontin*, Requip*, Mirapex* (covered without * indicates generic available Italics indicate Non-Formulary agents # indicates Step Therapy required for age 18yr and under This is the most current list at the time of printing and is subject to change. Last update December 4, 2012 STANDARD Stepped Therapy Agents ~ 2012
The following drugs will require prior authorization if the condition is not met when the pharmacist would attempt to transmit a prescription claim. Your doctor will coordinate this approval for you. If the prescription is approved, Coventry Health Care will cover the cost. You will be responsible for the copayment. If the request is not approved, it does not mean your doctor cannot prescribe the medicine for you. It means that you are responsible for paying the prescription in full. Self-administered injectable agents also require prior authorization and can be found on a separate list. Drug
Condition
Trial & failure of Flonase* or Nasalide*, AND Nasonex Trial & failure of metformin/ER (at least 1500mg/d) Trial & failure of Ditropan* or Sanctura*/Sanctura XL Paxil CR* (paroxetine extended release) Trial & failure of Flonase* or Nasalide*, AND Nasonex Trial & failure of Flonase* or Nasalide*, AND Nasonex Trial & failure of Risperdal* oral tablet Trial & failure of 2: Risperdal*, Seroquel*, Geodon* Seroquel XR (quetiapine extended release) Trial & failure of 2: Risperdal*, Seroquel*, Geodon* Symbyax (olanzapine / fluoxetine) Trial & failure of 2: Risperdal*, Seroquel*, Geodon* Taclonex (calcipotriene/betamethasone dip) Trial & failure of Dovonex AND a medium to high potency topical steroid Trial & failure of Retin-A Micro (covered without trials for psoriasis) Trial & failure of Ditropan* or Sanctura*/Sanctura XL Trial & failure of metformin/ER (at least 1500mg/d), AND Tretin-X 0.0375% cream (Combo pack not covered) Ultram ER* (tramadol extended release) Trial & failure of 2 medium to high potency topical steroids Trial & failure of a medium to high potency topical steroid Veltin gel (tretinoin/clindamycin) Trial & failure of Flonase* or Nasalide*, AND Nasonex Trial & failure of Ditropan* or Sanctura*/Sanctura XL Vytorin (simvastatin/ezetimibe) 10/10, 10/20, 10/40 Trial & failure of Mevacor*, Pravachol*, Zocor* or Lipitor* AND Crestor * indicates generic available Italics indicate Non-Formulary agents # indicates Step Therapy required for age 18yr and under This is the most current list at the time of printing and is subject to change. Last update December 4, 2012 STANDARD Stepped Therapy Agents ~ 2012
The following drugs will require prior authorization if the condition is not met when the pharmacist would attempt to transmit a prescription claim. Your doctor will coordinate this approval for you. If the prescription is approved, Coventry Health Care will cover the cost. You will be responsible for the copayment. If the request is not approved, it does not mean your doctor cannot prescribe the medicine for you. It means that you are responsible for paying the prescription in full. Self-administered injectable agents also require prior authorization and can be found on a separate list. Drug
Condition
Trial & failure of 2: Claritin OTC*, Zyrtec OTC*, Allegra OTC Trial & failure of Flonase* or Nasalide*, AND Nasonex Ziana gel (tretinoin/clindamycin) Trial & failure of Abreva or oral acyclovir, AND Denavir Trial & failure of 2: Risperdal*, Seroquel*, Geodon* * indicates generic available Italics indicate Non-Formulary agents # indicates Step Therapy required for age 18yr and under This is the most current list at the time of printing and is subject to change. Last update December 4, 2012

Source: http://metracomp.com/web/groups/public/@cvty_regional/documents/webcontent/c064526.pdf