Effective date:

Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
ANALGESICS, NARCOTICS
DRUG NAME
KADIAN | MORPHINE SULFATE ER
STEP THERAPY CRITERIA
PRIOR CLAIM FOR MORPHINE SULFATE SUSTAINED ACTION TABLET (MS CONTIN)
WITHIN THE PAST 120 DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
ANTIBACTERIALS (EENT)
DRUG NAME
BESIVANCE
STEP THERAPY CRITERIA
PRIOR CLAIM FOR CIPROFLOXACIN OPHTHALMIC DROPS, CIPROFLOXACIN
OPHTHALMIC OINTMENT, OR OFLOXACIN OPHTHALMIC DROPS WITHIN THE LAST
120 DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
ANTIDIABETIC AGENTS - INSULINS
DRUG NAME
LEVEMIR | LEVEMIR FLEXPEN
STEP THERAPY CRITERIA
PRIOR CLAIM FOR INSULIN GLARGINE (LANTUS OR LANTUS SOLOSTAR) WITHIN
THE PAST 120 DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
ANTIDIABETIC AGENTS - MISCELLANEOUS
DRUG NAME
INVOKANA
STEP THERAPY CRITERIA
PRIOR CLAIM FOR METFORMIN, METFORMIN ER, A SULFONYLUREA, A
COMBINATION OF SULFONYLUREA AND METFORMIN, PIOGLITAZONE, OR
COMBINATION PIOGLITAZONE AND METFORMIN WITHIN THE PAST 120 DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
ANTIPSYCHOTIC AGENTS
DRUG NAME
FANAPT | FAZACLO | INVEGA | LATUDA | SAPHRIS
STEP THERAPY CRITERIA
PRIOR CLAIM FOR A GENERIC ANTIPSYCHOITIC SUCH AS RISPERIDONE TABLET,
RISPERIDONE DISINTEGRATING TABLET, CLOZAPINE TABLET, CLOZAPINE ORAL
DISINTEGRATING TABLET, OLANZAPINE TABLET, OLANZAPINE ORAL
DISINTEGRATING TABLET, IMMEDIATE RELEASE QUETIAPINE FUMARATE, OR
ZIPRASIDONE, AND ABILIFY WITHIN THE PAST 365 DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
ANTIULCER AGENTS
DRUG NAME
LANSOPRAZOLE
STEP THERAPY CRITERIA
PRIOR CLAIM FOR GENERIC FEDERAL LEGEND OMEPRAZOLE OR PANTOPRAZOLE
WITHIN THE PAST 120 DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
ARIPIPRAZOLE
DRUG NAME
ABILIFY | ABILIFY DISCMELT
STEP THERAPY CRITERIA
PRIOR CLAIM FOR A GENERIC ATYPICAL ANTIPSYCHOTIC SUCH AS RISPERIDONE
TABLET, RISPERIDONE DISINTEGRATING TABLET, CLOZAPINE TABLET,
CLOZAPINE ORAL DISINTEGRATING TABLET, OLANZAPINE TABLET, OLANZAPINE
ORAL DISINTEGRATING TABLET, IMMEDIATE RELEASE QUETIAPINE FUMARATE,
OR ZIPRASIDONE OR AN SSRI OR SNRI SUCH AS CITALOPRAM, FLUOXETINE,
PAROXETINE, SERTRALINE, OR VENLAFAXINE WITHIN THE PAST 120 DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
B VERSUS D ADMINISTRATIVE STEP
DRUG NAME
CYCLOPHOSPHAMIDE | METHOTREXATE | TREXALL
STEP THERAPY CRITERIA
PRIOR CLAIM FOR A RHEUMATOID ARTHRITIS DRUG WITHIN THE PAST 120 DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
BUDESONIDE-FORMOTEROL FUMERATE
DRUG NAME
SYMBICORT
STEP THERAPY CRITERIA
PRIOR CLAIM FOR ADVAIR OR DULERA WITHIN THE PAST 120 DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
DRUG NAME
DALIRESP
STEP THERAPY CRITERIA
PRIOR CLAIM FOR ONE COPD AGENT (LAMA, LABA, SAMA, SAMA/SABA) SUCH AS
ATROVENT, COMBIVENT, SPIRIVA, ARCAPTA, SEREVENT, OR FORADIL WITHIN THE
LAST 120 DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
GLP-1 ANALOGS
DRUG NAME
BYDUREON | BYETTA
STEP THERAPY CRITERIA
PRIOR CLAIM FOR EITHER METFORMIN, METFORMIN ER, A SULFONYLUREA
AGENT (E.G. GLYBURIDE, GLIPIZIDE), COMBINATION OF A SULFONYLUREA AND
METFORMIN, A THIAZOLIDINEDIONE (E.G. PIOGLITAZONE, ROSIGLITAZONE), OR A
COMBINATION THIAZOLIDINEDIONE AND METFORMIN WITHIN THE PAST 120
DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
HYPERURICEMIC AGENTS
DRUG NAME
ULORIC
STEP THERAPY CRITERIA
PRIOR CLAIM FOR ALLOPURINOL OR COLCHICINE WITHIN THE PAST 120 DAYS
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
KETOLIDES
DRUG NAME
KETEK
STEP THERAPY CRITERIA
PRIOR CLAIM FOR A MACROLIDE WITHIN THE PAST 120 DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
MULTIPLE SCLEROSIS AGENTS
DRUG NAME
AVONEX | AVONEX ADMINISTRATION PACK | BETASERON | EXTAVIA
STEP THERAPY CRITERIA
PRIOR CLAIM FOR REBIF (INTERFERON BETA-1A) OR COPAXONE (GLATIRAMIR
ACETATE) WITHIN THE PAST 120 DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPE
DRUG NAME
CELEBREX
STEP THERAPY CRITERIA
PRIOR CLAIM FOR ONE (1) NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
WITHIN THE PAST 120 DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
OPHTHALMIC ANTIHISTAMINES
DRUG NAME
BEPREVE | PATADAY | PATANOL
STEP THERAPY CRITERIA
PRIOR CLAIM FOR LEVOCETIRIZINE OR CROMOLYN SODIUM EYE DROPS WITHIN
THE PAST 120 DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
QUETIAPINE FUMARATE EXTENDED RELEASE
DRUG NAME
SEROQUEL XR
STEP THERAPY CRITERIA
PRIOR CLAIM FOR A GENERIC ATYPICAL ANTIPSYCHOTIC SUCH AS RISPERIDONE
TABLET, RISPERIDONE DISINTEGRATING TABLET, CLOZAPINE TABLET,
CLOZAPINE ORAL DISINTEGRATING TABLET, OLANZAPINE TABLET, OLANZAPINE
ORAL DISINTEGRATING TABLET, IMMEDIATE RELEASE QUETIAPINE FUMARATE,
OR ZIPRASIDONE OR AN SSRI OR SNRI SUCH AS CITALOPRAM, FLUOXETINE,
PAROXETINE, SERTRALINE, OR VENLAFAXINE AND ABILIFY WITHIN THE PAST 365
DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
RENIN ANGIOTENSION SYSTEM INHIBITORS
DRUG NAME
AMTURNIDE | AZOR | BENICAR | BENICAR HCT | DIOVAN | EXFORGE | EXFORGE HCT |
MICARDIS | MICARDIS HCT | TEKAMLO | TEKTURNA | TEKTURNA HCT | TEVETEN |
TEVETEN HCT | TRIBENZOR
STEP THERAPY CRITERIA
PRIOR CLAIM FOR AN ANGIOTENSIN CONVERTING ENZYME INHIBITOR (ACE
INHIBITOR), OR ACE INHIBITOR COMBINATION OR A GENERIC ANGIOTENSIN
RECEPTOR BLOCKER (ARB), OR GENERIC ARB COMBINATION WITHIN THE PAST 120
DAYS.
Carilion Clinic Medicare Health Plan
Step Therapy Requirements
Effective Date: 10/01/2013
STEP THERAPY GROUP DESCRIPTION
ROTIGOTINE
DRUG NAME
NEUPRO
STEP THERAPY CRITERIA
PRIOR CLAIM FOR IMMEDIATE RELEASE PRAMIPEXOLE OR IMMEDIATE RELEASE
ROPINIROLE WITHIN THE PAST 120 DAYS.

Source: http://www.carilionmedicare.com/2013/documents/2013_CCMHP_ST.pdf