Std step therapy drugs 20120102 '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.
Drug
Condition
Trial & failure of Risperdal* or Seroquel Trial & failure of metformin/ER (at least 1500mg/d) 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*, AND Lunesta Trial & failure of Lactulose* or Miralax* Trial of Aricept 10mg QD for at least 3 months Trial & failure of Flonase* or Nasalide*, AND Nasonex Trial & failure of 2: Claritin OTC*, Zyrtec OTC*, Allegra OTC Coreg CR (carvedilol extended rel) Trial & failure of Mevacor*, Pravachol*, Zocor* or Lipitor* Detrol / Detrol LA (tolterodine / extended release) Trial & failure of Ditropan* or Sanctura/Sanctura XL Trial & failure of metformin/ER (at least 1500mg/d) Effexor XR* capsules (venlafaxine extended rel) Trial & failure of Ditropan* or Sanctura/Sanctura XL Epiduo gel (adapalene/benzoyl peroxide) Trial & failure of Risperdal* or Seroquel Trial & failure of metformin/ER (at least 1500mg/d) Gelnique (oxybutynin topical gel) Trial & failure of Ditropan* or Sanctura/Sanctura XL Trial & failure of Risperdal* or Seroquel Trial & failure of metformin/ER (at least 1500mg/d) Trial & failure of Neurontin* and Lidoderm Trial & failure of Risperdal* or Seroquel Janumet (sitagliptin / metformin) 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) This is the most current list at the time of printing and is subject to change. Last update January 2, 2012 Trial & failure of Levemir vial or pen Trial & failure of Risperdal* or Seroquel Trial & failure of Mevacor*, Pravachol*, Zocor* or Lipitor* AND Crestor Trial & failure of Apriso, Asacol or Asacol HD Trial & failure of Mevacor*, Pravachol*, Zocor* or Lipitor* AND Crestor Trial & failure of Ambien* or Sonata* Luvox CR (fluvoxamine extended release) Trial & failure of Flonase* or Nasalide*, AND Nasonex 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 Ambien* or Sonata*, AND Lunesta Trial & failure of Risperdal* or Seroquel Trial & failure of oral Toradol* AND one additional NSAID Symbyax (olanzapine / fluoxetine) Trial & failure of Risperdal* or Seroquel Trial & failure of Ditropan* or Sanctura/Sanctura XL Trial & failure of metformin/ER (at least 1500mg/d), AND Actos or Duetact, AND Januvia/Janumet or Onglyza/Kombiglyze Tretin-X 0.0375% cream (Combo pack not covered) Trial & failure of Retin-A Micro Ultram ER (tramadol extended release) 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 Trial & failure of 2: Claritin OTC*, Zyrtec OTC*, Allegra OTC Ziana gel (tretinoin/clindamycin) Trial & failure of Risperdal* or Seroquel * indicates generic available # indicates Step Therapy required for age 18yr and under Italics indicate non-formulary agents This is the most current list at the time of printing and is subject to change. Last update January 2, 2012

Source: http://bolerwood.com/Portals/0/Documents/Group%20Medical/2012%20Step%20Therapy%20List.pdf?fileticket=BpfHVeKHwY4%3D&tabid=81&mid=422