2015 Cigna-Healthspring Step Therapy Criteria (Updated March 2015)

2015 Cigna-Healthspring Step Therapy Criteria
(Updated March 2015)
Step Therapy Group
Step Therapy Criteria
ANTICONVULSANTS,
The member must have tried a 30 day supply or more of at least two StepADJUNCT THERAPY (Cigna- 1 medications within the same step therapy group within the previous 365
HealthSpring Rx Secure (PDP) days as evidenced by a previous paid claim under the prescription benefit
and Cigna-HealthSpring Rx
or by physician documented use. Step-1 medications are Carbamazepine,
Secure-XTRA (PDP) ONLY) Divalproex Sodium, Lamotrigine, Oxcarbazepine, Phenytoin, Topiramate,
Valproic Acid and Peganone. Step-2 medications are Aptiom, Fycompa,
Gabitril, Tiagabine and Vimpat. Medications on Step-2 are not covered
unless the above step therapy criteria are met.
Trade Name
Step Therapy Part D Step Number
Type Description
APTIOM
Step Therapy Applies
to New Starts Only
2
FYCOMPA
Step Therapy Applies
to New Starts Only
2
GABITRIL
Step Therapy Applies
to New Starts Only
2
TIAGABINE HYDROCHLORIDE
Step Therapy Applies
to New Starts Only
2
VIMPAT
Step Therapy Applies
to New Starts Only
2
CARBAMAZEPINE
Step Therapy Applies to
New Starts Only
1
CARBAMAZEPINE ER
Step Therapy Applies to
New Starts Only
1
DIVALPROEX SODIUM
Step Therapy Applies to
New Starts Only
1
DIVALPROEX SODIUM DR
Step Therapy Applies to
New Starts Only
1
DIVALPROEX SODIUM ER
Step Therapy Applies to
New Starts Only
1
LAMOTRIGINE
Step Therapy Applies to
New Starts Only
1
LAMOTRIGINE ER
Step Therapy Applies to
New Starts Only
1
OXCARBAZEPINE
Step Therapy Applies to
New Starts Only
1
PEGANONE
Step Therapy Applies to
New Starts Only
1
PHENYTOIN
Step Therapy Applies to
New Starts Only
1
PHENYTOIN INFATABS
Step Therapy Applies to
New Starts Only
1
PHENYTOIN SODIUM
Step Therapy Applies to
New Starts Only
1
PHENYTOIN SODIUM EXTENDED
Step Therapy Applies to
New Starts Only
1
TOPIRAMATE
Step Therapy Applies to
New Starts Only
1
VALPROATE SODIUM
Step Therapy Applies to
New Starts Only
1
VALPROIC ACID
Step Therapy Applies to
New Starts Only
1
Step Therapy Applies
to New Starts Only
2
Step Therapy Applies
to New Starts Only
2
Step Therapy Applies
to New Starts Only
2
Step Therapy Applies
to New Starts Only
2
Step Therapy Applies
to New Starts Only
2
Step Therapy Applies to
New Starts Only
1
BUDEPRION XL
Step Therapy Applies to
New Starts Only
1
BUPROPION HCL
Step Therapy Applies to
New Starts Only
1
BUPROPION HCL ER
Step Therapy Applies to
New Starts Only
1
BUPROPION HCL SR
Step Therapy Applies to
New Starts Only
1
BUPROPION HCL XL
Step Therapy Applies to
New Starts Only
1
CITALOPRAM HYDROBROMIDE
Step Therapy Applies to
New Starts Only
1
ESCITALOPRAM OXALATE
Step Therapy Applies to
New Starts Only
1
FLUOXETINE DR
Step Therapy Applies to
New Starts Only
1
FLUOXETINE HCL
Step Therapy Applies to
New Starts Only
1
FLUVOXAMINE MALEATE
Step Therapy Applies to
New Starts Only
1
FLUVOXAMINE MALEATE ER
Step Therapy Applies to
New Starts Only
1
ANTIDEPRESSANTS,
The member must have tried a 30 day supply or more of at least two StepBRINTELLIX
SEROTONIN/NOREPINEPHRI 1 medications within the same step therapy group within the previous 90
NE REUPTAKE INHIBITORS days as evidenced by a previous paid claim under the prescription benefit
FETZIMA
or by physician documented use. For the Antidepressants,
Serotonin/Norepinephrine The member must have tried a 30 day supply
or more of at least two Step-1 medications within the same step therapy
FETZIMA TITRATION PACK
group within the previous 90 days as evidenced by a previous paid claim
under the prescription benefit or by physician documented use. For the
Antidepressants, Serotonin/Norepinephrine Reuptake Inhibitors Step
PRISTIQ (Cigna-HealthSpring Rx Secure (PDP)
Group, Step-1 medications are Bupropion, Citalopram, Escitalopram,
and Rx Secure-XTRA (PDP) ONLY)
Fluoxetine, Fluvoxamine, Mirtazapine, Paroxetine, Paxil suspension,
VIIBRYD
Sertraline, Trazodone and Venlafaxine. For the Antidepressants,
Serotonin/Norepinephrine Reuptake Inhibitors Step Group, Step-2
medications are Brintellix, Fetzima, Viibryd and Pristiq. Medications on
BUDEPRION SR
Step-2 are not covered unless the above step therapy criteria are met.
MIRTAZAPINE
Step Therapy Applies to
New Starts Only
1
MIRTAZAPINE ODT
Step Therapy Applies to
New Starts Only
1
PAROXETINE HCL
Step Therapy Applies to
New Starts Only
1
PAROXETINE HCL ER
Step Therapy Applies to
New Starts Only
1
PAXIL
Step Therapy Applies to
New Starts Only
1
SERTRALINE HCL
Step Therapy Applies to
New Starts Only
1
TRAZODONE HCL
Step Therapy Applies to
New Starts Only
1
VENLAFAXINE HCL
Step Therapy Applies to
New Starts Only
1
VENLAFAXINE HCL ER
Step Therapy Applies to
New Starts Only
1
ATYPICAL ANTIPSYCHOTIC The member must have tried a 30 day supply or more of at least one Step1 medication within the same step therapy group within the previous 180
days as evidenced by a previous paid claim under the prescription benefit
or by physician documented use. For the Atypical Antipsychotic Step
Therapy Group, Step-1 medications include olanzapine, risperidone,
quetiapine and ziprasidone. For the Atypical Antipsychotic Step Therapy
Group, Step-2 medications include Abilify, Fanapt, Fazaclo, Invega,
Latuda, and Saphris. Medications on Step-2 are not covered unless the
above step therapy criteria are met or unless the diagnosis is
Schizoaffective disorder in which case step therapy for Invega does not
apply, or unless the diagnosis is acute treatment of agitation in
Schizophrenia, in which case step therapy for Abilify injection does not
apply.
ABILIFY
Step Therapy Applies
to New Starts Only
2
ABILIFY DISCMELT
Step Therapy Applies
to New Starts Only
2
FANAPT
Step Therapy Applies
to New Starts Only
2
FANAPT TITRATION PACK
Step Therapy Applies
to New Starts Only
2
FAZACLO
Step Therapy Applies
to New Starts Only
2
INVEGA
Step Therapy Applies
to New Starts Only
2
LATUDA
Step Therapy Applies
to New Starts Only
2
SAPHRIS
Step Therapy Applies
to New Starts Only
2
OLANZAPINE
Step Therapy Applies to
New Starts Only
1
OLANZAPINE ODT
Step Therapy Applies to
New Starts Only
1
QUETIAPINE FUMARATE
Step Therapy Applies to
New Starts Only
1
RISPERIDONE
Step Therapy Applies to
New Starts Only
1
RISPERIDONE M-TAB
Step Therapy Applies to
New Starts Only
1
RISPERIDONE ODT
Step Therapy Applies to
New Starts Only
1
ZIPRASIDONE HCL
Step Therapy Applies to
New Starts Only
1
CARDIOVASCULAR AGENTS The member must have tried a 30 day supply or more of at least one StepMISC. ANTIANGINAL
1 medication within the same step therapy group within the previous 180
AGENTS
days as evidenced by a previous paid claim under the prescription benefit
or by physician documented use. For the Cardiovascular Agents Misc.
Antianginal Agents Step Group, Step-1 Medications include beta
blockers, calcium channel blockers and nitrates. Step-2 medication is
Ranexa.
RANEXA
Step Therapy Applies
2
ACEBUTOLOL HCL
Step Therapy Applies
1
AFEDITAB CR
Step Therapy Applies
1
AMLODIPINE BESYLATE
Step Therapy Applies
1
AMLODIPINE BESYLATE/BENAZEPRIL
HYDROCHLORIDE
Step Therapy Applies
1
AMLODIPINE BESYLATE/VALSARTAN
Step Therapy Applies
1
AMLODIPINE BESYLATE/VALSARTAN/HCTZ
Step Therapy Applies
1
ATENOLOL
Step Therapy Applies
1
ATENOLOL/CHLORTHALIDONE
Step Therapy Applies
1
BETAXOLOL HCL
Step Therapy Applies
1
BISOPROLOL FUMARATE
Step Therapy Applies
1
BISOPROLOL
FUMARATE/HYDROCHLOROTHIAZIDE
Step Therapy Applies
1
CARTIA XT
Step Therapy Applies
1
CARVEDILOL
Step Therapy Applies
1
COREG CR
Step Therapy Applies
1
DILT-CD
Step Therapy Applies
1
DILTIAZEM CD
Step Therapy Applies
1
DILTIAZEM HCL
Step Therapy Applies
1
DILTIAZEM HCL ER
Step Therapy Applies
1
DILT-XR
Step Therapy Applies
1
DILTZAC
Step Therapy Applies
1
EXFORGE (non-formulary for Cigna-HealthSpring
Rx Secure (PDP))
Step Therapy Applies
1
EXFORGE HCT (non-formulary for CignaHealthSpring Rx Secure (PDP))
Step Therapy Applies
1
FELODIPINE ER
Step Therapy Applies
1
ISOCHRON
Step Therapy Applies
1
ISODITRATE ER
Step Therapy Applies
1
ISOSORBIDE DINITRATE
Step Therapy Applies
1
ISOSORBIDE DINITRATE ER
Step Therapy Applies
1
ISOSORBIDE MONONITRATE
Step Therapy Applies
1
ISOSORBIDE MONONITRATE ER
Step Therapy Applies
1
ISRADIPINE
Step Therapy Applies
1
LABETALOL HCL
Step Therapy Applies
1
MATZIM LA
Step Therapy Applies
1
METOPROLOL SUCCINATE ER
Step Therapy Applies
1
METOPROLOL TARTRATE
Step Therapy Applies
1
METOPROLOL/HYDROCHLOROTHIAZIDE
Step Therapy Applies
1
MINITRAN
Step Therapy Applies
1
NADOLOL
Step Therapy Applies
1
NADOLOL/BENDROFLUMETHIAZIDE
Step Therapy Applies
1
NICARDIPINE HCL
Step Therapy Applies
1
NIFEDIAC CC
Step Therapy Applies
1
NIFEDICAL XL
Step Therapy Applies
1
NIFEDIPINE ER
Step Therapy Applies
1
NIMODIPINE
Step Therapy Applies
1
NISOLDIPINE
Step Therapy Applies
1
NISOLDIPINE ER
Step Therapy Applies
1
NITROGLYCERIN
Step Therapy Applies
1
NITROGLYCERIN LINGUAL (Cigna-HealthSpring
Rx Secure (PDP) ONLY)
Step Therapy Applies
1
NITROGLYCERIN TRANSDERMAL
Step Therapy Applies
1
NITROSTAT
Step Therapy Applies
1
PINDOLOL
Step Therapy Applies
1
PROPRANOLOL HCL
Step Therapy Applies
1
PROPRANOLOL HCL ER
Step Therapy Applies
1
PROPRANOLOL/HYDROCHLOROTHIAZIDE
Step Therapy Applies
1
TAZTIA XT
Step Therapy Applies
1
TIMOLOL MALEATE
Step Therapy Applies
1
VERAPAMIL HCL
Step Therapy Applies
1
VERAPAMIL HCL ER
Step Therapy Applies
1
FOSRENOL
NSAID COX-2: For CignaHealthSpring Rx Secure (PDP)
and Cigna-HealthSpring Rx
Secure-XTRA (PDP): Celecoxib
Step Therapy does not apply,
and Celebrex is non-formulary.
The member must have tried a 30 day supply or more of a Step 1
medication within the previous 180 days as evidenced by a previous paid
claim under the prescription benefit or by physician documented use. For
the Fosrenol Step Group, Step-1 Medication is Renvela. Step-2
medication is Fosrenol.
FOSRENOL
Step Therapy Applies
2
RENVELA
Step Therapy Applies
1
The member must have tried a 30 day supply or more of at least one Step1 medication (oral NSAIDs) within the same step therapy group within
the previous 180 days as evidenced by a previous paid claim under the
prescription benefit or by physician documented use, OR has tried a 30
day supply or more of warfarin (or Coumadin or Jantoven). In addition,
a member that has filled Celebrex or Celecoxib within the previous 180
days, or has a history of GI bleed or is post-endoscopy will be able to
bypass step therapy requirements.
CELEBREX
Step Therapy Applies
2
CELECOXIB
Step Therapy Applies
2
COUMADIN
Step Therapy Applies
1
JANTOVEN
Step Therapy Applies
1
WARFARIN SODIUM
Step Therapy Applies
1
DICLOFENAC POTASSIUM
Step Therapy Applies
1
DICLOFENAC SODIUM DR
Step Therapy Applies
1
DICLOFENAC SODIUM ER
Step Therapy Applies
1
DIFLUNISAL
Step Therapy Applies
1
ETODOLAC
Step Therapy Applies
1
ETODOLAC ER
Step Therapy Applies
1
FENOPROFEN CALCIUM
Step Therapy Applies
1
FLURBIPROFEN
Step Therapy Applies
1
IBUPROFEN
Step Therapy Applies
1
KETOPROFEN
Step Therapy Applies
1
KETOPROFEN ER
Step Therapy Applies
1
MECLOFENAMATE SODIUM
Step Therapy Applies
1
MELOXICAM
Step Therapy Applies
1
OPHTHALMIC ANTIVIRALS
The member must have tried a 30 day supply or more of one Step-1
medication within the same step therapy group within the previous 180
days as evidenced by a previous paid claim under the prescription benefit
or by physician documented use. Step-1 medication is Trifluridine, Step-2
medication is Zirgan. Step-2 medications are not covered unless the above
step therapy criteria are met.
OPHTHALMIC CARBONIC
The member must have tried a 30 day supply or more of at least one StepANHYDRASE INHIBITORS
1 medication within the same step therapy group within the previous 365
(Cigna-HealthSpring Rx Secure days as evidenced by a previous paid claim under the prescription benefit
(PDP) and Cigna-HealthSpring or by physician documented use. Step-1 medications include dorzolamide
Rx Secure-XTRA (PDP) ONLY) and dorzolamide/timolol. Step-2 medication is Azopt. Step-2 medication
is not covered unless the above step therapy criteria is met
NABUMETONE
Step Therapy Applies
1
NAPROXEN
Step Therapy Applies
1
NAPROXEN DR
Step Therapy Applies
1
NAPROXEN SODIUM
Step Therapy Applies
1
OXAPROZIN
Step Therapy Applies
1
PIROXICAM
Step Therapy Applies
1
SULINDAC
Step Therapy Applies
1
TOLMETIN SODIUM
Step Therapy Applies
1
ZIRGAN
Step Therapy Applies
2
TRIFLURIDINE
Step Therapy Applies
1
AZOPT
Step Therapy Applies
2
DORZOLAMIDE HCL
Step Therapy Applies
1
DORZOLAMIDE HCL/TIMOLOL MALEATE
Step Therapy Applies
1
OPHTHALMIC STEROIDS
The member must have tried a 30 day supply or more of at least one StepZYLET
(Cigna-HealthSpring Rx Secure 1 medication within the same step therapy group within the previous 365
(PDP) and Cigna-HealthSpring days as evidenced by a previous paid claim under the prescription benefit
NEOMYCIN/POLYMYXIN/DEXAMETHASONE
Rx Secure-XTRA (PDP) ONLY)
or by physician documented use. Step-1 medications include
neomycin/polymyxin B sulfate/dexamethasone susp, sulfacetamide
sodium/prednisolone sodium phosphate, tobramycin/dexamethasone, or
PRED-G
Pred-G. Step-2 medication is Zylet. Step-2 medication is not covered
unless the above step therapy criteria is met
SULFACETAMIDE SODIUM
OPTHALMIC
PROSTAGLANDIN ANALOGS
(Cigna-HealthSpring Rx Secure
(PDP) and Cigna-HealthSpring
Rx Secure-XTRA (PDP) ONLY)
Step1 agent - Latanoprost. Step 2 agent - Travatan Z.
PICATO
The member must have tried a 30 day supply or more of imiquimod
within the previous 180 days as evidenced by a previous paid claim under
the prescription benefit or by physician documented use. Picato is not
covered unless the above step therapy criteria are met
PROLIA
Step Therapy Applies
2
Step Therapy Applies
1
Step Therapy Applies
1
Step Therapy Applies
1
SULFACETAMIDE SODIUM/PREDNISOLONE
SODIUM PHOSPHATE
Step Therapy Applies
1
TOBRAMYCIN/DEXAMETHASONE
Step Therapy Applies
1
TRAVATAN Z
Step Therapy Applies
2
LATANOPROST
Step Therapy Applies
1
PICATO
Step Therapy Applies
to New Starts Only
2
IMIQUIMOD
Step Therapy Applies to
New Starts Only
1
Step Therapy Applies
2
Step Therapy Applies
1
Step Therapy Applies
1
Step Therapy Applies
1
RISEDRONATE (non-formulary for CignaHealthSpring Rx Secure (PDP))
Step Therapy Applies
1
AMTURNIDE
Step Therapy Applies
2
BENICAR
Step Therapy Applies
2
BENICAR HCT
Step Therapy Applies
2
TEKAMLO
Step Therapy Applies
2
The member must have tried a 30 day supply or more of at least one StepPROLIA
1 medication within the same step therapy group within the previous 180
days as evidenced by a previous paid claim under the prescription benefit
or by physician documented use. For the Prolia Step Therapy Group, for ACTONEL (non-formulary for Cigna-HealthSpring
Rx Secure (PDP))
diagnosis of postmenopausal osteoporosis, Step-1 medications include oral
bisphosphonates. Step-2 medications include Prolia. Medications on StepALENDRONATE SODIUM
2 are not covered unless the above step therapy criteria are met or unless
the diagnosis is specific to Prolia such as Breast Cancer Osteopenia in
women receiving aromatase inhibitor therapy or osteopenia in men
IBANDRONATE SODIUM
receiving androgen deprivation therapy for nonmetastatic prostate cancer
RENIN INHIBITORS AND
The member must have tried a 30 day supply or more of at least one StepNON-PREFERRED ARBS (ST2 1 medication within the same step therapy group within the previous 180
medications are non-formulary days as evidenced by a previous paid claim under the prescription benefit
for Cigna-HealthSpring Rx
or by physician documented use. For the Renin Inhibitors Step Therapy
Secure (PDP))
Group, Step-1 medications include oral angiotension converting enzyme
(ACE) inhibitors, ACE combination products , Angiotensin II Receptor
Blockers (ARB), and ARB combination products. For the Renin
Inhibitors Step Therapy Group, Step-2 medications include Amturnide,
Tekamlo, Tekturna, Tekturna HCT, Benicar, and Benicar HCT.
Medications on Step-2 are not covered unless the above step therapy
criteria are met.
Medications on Step-2 are not covered unless the above step therapy
criteria are met.
TEKTURNA
Step Therapy Applies
2
TEKTURNA HCT
Step Therapy Applies
2
AMLODIPINE/VALSARTAN
Step Therapy Applies
1
BENAZEPRIL HCL
Step Therapy Applies
1
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE
Step Therapy Applies
1
CANDESARTAN CILEXETIL
Step Therapy Applies
1
CANDESARTAN
CILEXETIL/HYDROCHLOROTHIAZIDE
Step Therapy Applies
1
CAPTOPRIL
Step Therapy Applies
1
CAPTOPRIL/HYDROCHLOROTHIAZIDE
Step Therapy Applies
1
ENALAPRIL MALEATE
Step Therapy Applies
1
ENALAPRIL
MALEATE/HYDROCHLOROTHIAZIDE
Step Therapy Applies
1
FOSINOPRIL SODIUM
Step Therapy Applies
1
FOSINOPRIL
SODIUM/HYDROCHLOROTHIAZIDE
Step Therapy Applies
1
IRBESARTAN
Step Therapy Applies
1
IRBESARTAN/HYDROCHLOROTHIAZIDE
Step Therapy Applies
1
LISINOPRIL
Step Therapy Applies
1
LISINOPRIL/HYDROCHLOROTHIAZIDE
Step Therapy Applies
1
LOSARTAN POTASSIUM
Step Therapy Applies
1
LOSARTAN
POTASSIUM/HYDROCHLOROTHIAZIDE
Step Therapy Applies
1
MOEXIPRIL HCL
Step Therapy Applies
1
TOPICAL NSAIDS
The member must have tried a 30 day supply or more of at least one Step1 medication within the same step therapy group within the previous 365
days as evidenced by a previous paid claim under the prescription benefit
or by physician documented use. For the Topical NSAIDs Step Therapy
Group, Step-1 medications include oral NSAIDs. For the Topical NSAIDs
Step Therapy Group, Step-2 medication is Voltaren Topical Gel. Step-2
medication is not covered unless the above step therapy criteria are met
MOEXIPRIL/HYDROCHLOROTHIAZIDE
Step Therapy Applies
1
PERINDOPRIL ERBUMINE
Step Therapy Applies
1
QUINAPRIL HCL
Step Therapy Applies
1
QUINAPRIL/HYDROCHLOROTHIAZIDE
Step Therapy Applies
1
RAMIPRIL
Step Therapy Applies
1
TELMISARTAN
Step Therapy Applies
1
TELMISARTAN/AMLODIPINE
Step Therapy Applies
1
TELMISARTAN/HYDROCHLOROTH
Step Therapy Applies
1
TELMISARTAN/HYDROCHLOROTHIAZIDE
Step Therapy Applies
1
TRANDOLAPRIL
Step Therapy Applies
1
VALSARTAN
Step Therapy Applies
1
VALSARTAN/HYDROCHLOROTHIAZIDE
Step Therapy Applies
1
VOLTAREN
Step Therapy Applies
2
DICLOFENAC POTASSIUM
Step Therapy Applies
1
DICLOFENAC SODIUM DR
Step Therapy Applies
1
DICLOFENAC SODIUM ER
Step Therapy Applies
1
DIFLUNISAL
Step Therapy Applies
1
ETODOLAC
Step Therapy Applies
1
ETODOLAC ER
Step Therapy Applies
1
FENOPROFEN CALCIUM
Step Therapy Applies
1
ULORIC
The member must have tried a 30 day supply or more of a step 1
medication within the previous 180 days as evidenced by a previous paid
claim under the prescription benefit or by physician documented use.
Step-1 Medication is allopurinol. Step-2 medication is Uloric.
FLURBIPROFEN
Step Therapy Applies
1
IBUPROFEN
Step Therapy Applies
1
KETOPROFEN
Step Therapy Applies
1
KETOPROFEN ER
Step Therapy Applies
1
MECLOFENAMATE SODIUM
Step Therapy Applies
1
MELOXICAM
Step Therapy Applies
1
NABUMETONE
Step Therapy Applies
1
NAPROXEN
Step Therapy Applies
1
NAPROXEN DR
Step Therapy Applies
1
NAPROXEN SODIUM
Step Therapy Applies
1
OXAPROZIN
Step Therapy Applies
1
PIROXICAM
Step Therapy Applies
1
SULINDAC
Step Therapy Applies
1
TOLMETIN SODIUM
Step Therapy Applies
1
ULORIC
Step Therapy Applies
2
ALOPRIM
Step Therapy Applies
1
ALLOPURINOL
Step Therapy Applies
1
ALLOPURINOL SODIUM
Step Therapy Applies
1