Microsoft word - 2010 step therapy requirements.doc

2010 Step Therapy Criteria
Effective January 1, 2010
Step Therapy Group Description Step Therapy Criteria
Requires member has filled at least a 60-day supply of a step 1 drug (i.e. long-acting beta agonist, Spiriva or inhaled corticosteroid) in the last 120 days before Advair will be covered
Requires member must have a documented 60-day trial
of either Antabuse or naltrexone before Campral will
be covered
Requires patient has tried and failed at least a 30 day
trial on step 1 drug (i.e. fexofenadine, fluticasone nasal,
Astelin or Astepro) within the last 120 days before
Clarinex, Clarinex D, Patanase or Singulair will be
Requires patient have a prescription history demonstrating at least a six week trial each of at least two preferred step 1 drugs (i.e. citalopram, fluoxetine, bupropion, sertraline, paroxetine, fluvoxamine or venlafaxine) before non-preferred agent will be covered Requires patient has a prescription history demonstrating trial of risperdal and Seroquel before step Requires member must have filled a 30-day supply of lamotrigine, valproate, topiramate or Felbatol in the last Requires member has filled a prescription for at least 2 preferred generic antibiotics in the last 30-days Requires member has filled at least two prescriptions for step one drugs (i.e. generic equivalents) in the last 180 Requires patient has filled a prescription for generic hydrocodone/APAP or hydrocodone/IBU in the last 120-days Requires member has filled a prescription for a macrolide in the last 30-days Requires member hs filled a prescription for at least two non-COX 2 selective NSAIDs in the last 120-days Requires member has flled a prescription for a sulfonylurea, metformin (or combo agent), Actos, ActoPlus Met, or Duetact within the last 120-days Requires member has filled a prescription for morphine sulfate sustained-release or Opana ER in the last 120- 2010 Step Therapy Criteria
Effective January 1, 2010
Requires member has filled a prescription for a protease-inhibitor, NRTI or NNRTI in the last 180-days Requires member has filled a prescription for preferred PPI agent(s) in the last 150-days Requires member has filled a prescription for zolpidem before Lunesta or Rozerem will be covered
Requires member has filled a prescription for a long-
acting stimulant and a short-acting stimulant within the
last 120-days Requires member has filled at least a 60-day supply of a step 1 drug (i.e. long-acting beta agonist, Spiriva or inhaled corticosteroid) in the last 120 days before Symbicort will be covered Requires member has filled a prescription for a mealtime insulin in the last 120-days, and continues to file meal-time insulin while on Symlin Member has filled a prescription for Vectical ointment in the previous 120-days Requires member has filled 2 consecutive months of allopurinol at maximum dose of 600mg per day Requires member has filled a prescription for

Source: http://www.healthplanofnevada.com/documents/2010%20Step%20Therapy%20Requirements.pdf