CareAdvantage CMC 2017 Formulary Supplement II (List of Covered Drugs)

Step Therapy Criteria (Criteria for Step Therapy-2 [ST-2] Drugs)

Formulary ID: 00017203 CMS Approved: 07/26/2016 Last Updated: 01/01/2017 (Effective date)

ALLERGIC RHINITIS-NASAL MEDICATION(S) SUBJECT TO STEP THERAPY FLUNISOLIDE 0.025% SPRAY CRITERIA OTCs: "NASACORT ALLERGY 24HR". Patient needs to have paid claims for any one of the following Step 1 drugs: NasaCort OTC, fluticasone. Prior to filling the Step 2 drug: flunisolide.

PAGE 1

LAST UPDATED 08/2016

ALPHA REDUCTASE INHIBITOR MEDICATION(S) SUBJECT TO STEP THERAPY DUTASTERIDE CRITERIA Patient needs to have paid claims for any one of the following Step 1 drugs: 5 Alpha Reductase Inhibitor (finasteride). Prior to filling the Step 2 drug: 5 Alpha Reductase Inhibitor (dutasteride).

PAGE 2

LAST UPDATED 08/2016

ANTI-MIGRAINE MEDICATION(S) SUBJECT TO STEP THERAPY SUMATRIPTAN 20 MG NASAL SPRAY, SUMATRIPTAN 5 MG NASAL SPRAY CRITERIA Patient needs to have paid claims for any one of the following Step 1 drugs: Rizatriptan benzoate, Naratriptan HCl, Sumatriptan (oral), Sumatriptan succinate (inj). Prior to filling the Step 2 drug: Sumatriptan (spray).

PAGE 3

LAST UPDATED 08/2016

BPH MEDICATION(S) SUBJECT TO STEP THERAPY ALFUZOSIN HCL ER CRITERIA Patient needs to have paid claims for any one of the following Step 1 drugs: Alpha 1 Blockers (Terazosin, Prazosin, Doxazosin, tamsulosin). Prior to filling the Step 2 drug: Alfuzosin.

PAGE 4

LAST UPDATED 08/2016

BRILINTA MEDICATION(S) SUBJECT TO STEP THERAPY BRILINTA CRITERIA Patient needs to have a 30 day supply paid claim for any one of the following Step 1 drug: clopidogrel. Prior to filling the Step 2 Drug: Brilinta.

PAGE 5

LAST UPDATED 08/2016

DDP4 INHIBITORS MEDICATION(S) SUBJECT TO STEP THERAPY JANUMET, JANUVIA, ONGLYZA CRITERIA Patient needs to have paid claims for any one of the following Step 1 drugs: metformin, metformin ER, glipizide/metformin, glyburide/metformin. Prior to filling the Step 2 Drugs: Januvia, Janumet, Onglyza.

PAGE 6

LAST UPDATED 08/2016

DIABETES MEDICATION(S) SUBJECT TO STEP THERAPY NATEGLINIDE, REPAGLINIDE CRITERIA Patient needs to have paid claims for any one of the following Step 1 drugs: Sulfonylureas (chlorpropamide, glimepiride, glipizide, glyburide, tolazamide, tolbutamide, glipizide ER), Alphaglucosidase inhibitors (acarbose, miglitol), metformin, metformin ER, glipizide/metformin, glyburide/metformin, Insulins (lispro, Humalog, Humalog Mix 50/50, Humalog Mix 75/25, insulin aspart, Novolog Mix 70/30, Novolog, NPH (isophane insulin susp), Humulin 70/30, Humulin R, Humulin N, Novolin 70/30, Relion 70/30, Novolin R, Novolin N, insulin glargine), thiazolidinediones(pioglitazone, rosiglitazone), Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors (canagliflozin and canagliflozinmetformin). Prior to filling the Step 2 Drugs: Meglitinides (nateglinide, repaglinide).

PAGE 7

LAST UPDATED 08/2016

INFLAMMATION MEDICATION(S) SUBJECT TO STEP THERAPY CELECOXIB 100 MG CAPSULE, CELECOXIB 200 MG CAPSULE, CELECOXIB 400 MG CAPSULE, CELECOXIB 50 MG CAPSULE CRITERIA Patient needs to have paid claims for any two of the following Step 1 drugs: NSAIDS (diflunisal, diclofenac sodium, diclofenac sodium/misoprostol, diclofenac potassium, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketorolac, ketoprofen, meclofenamate, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin). Prior to filling the Step 2 drug: Celecoxib.

PAGE 8

LAST UPDATED 08/2016

LORATADINE MEDICATION(S) SUBJECT TO STEP THERAPY CLARINEX 0.5 MG/ML (2.5 MG/5), CLARINEX-D 12 HOUR, DESLORATADINE, LEVOCETIRIZINE 2.5 MG/5 ML SOL, LEVOCETIRIZINE 5 MG TABLET CRITERIA OTCs: "ALAVERT ALLERGY/SINUS", "CLARITIN REDITABS", "CLARITIN", "CLARITIN-D 24 HOUR", "CLARITIN-D 12 HOUR", "CHILDRENS LORATADINE", "DIPHENHYDRAMINE HCL", "CETIRIZINE HCL", "ZYRTEC CHILDRENS ALLERGY", "ZYRTEC ALLERGY", "LORATADINE-D 24HR", "CETIRIZINE HCL/PSEUDOEPHEDRINE HCL ER", "ALLERGY RELIEF", "CETIRIZINE HCL CHILDRENS", "ZYRTEC-D ALLERGY/CONGESTION", "ALLEGRA ALLERGY", "ALLEGRA ALLERGY CHILDRENS", "ALLEGRA-D 24 HOUR ALLERGY & CONGESTION", "ALLEGRA-D 12 HOUR ALLERGY & CONGESTION", "LORATADINE". Patient needs to have paid claims for one of the following Step 1 drugs: Allegra OTC, Allegra/pseudoephedrine combination OTC, cetirizine OTC, cetirizine/pseudoephedrine combination OTC, diphenhydramine OTC, loratadine OTC, loratadine/pseudoephedrine combination OTC. Prior to filling the Step 2 drugs: other low or nonsedating antihistamines (including pseudoephedrine combinations of the following) desloratadine or levocetirizine.

PAGE 9

LAST UPDATED 08/2016

LYRICA MEDICATION(S) SUBJECT TO STEP THERAPY LYRICA CRITERIA ST applies to new starts only. For all medically accepted indications of gabapentin including epilepsy. postherpetic neuralgia, fibromyalgia, and diabetic peripheral neuropathy, patient needs to have paid claims for one of the following Step 1 drugs: gabapentin. Prior to filling the Step 2 drug: pregabalin. Members may request an exception and Lyrica will be allowed as first line treatment for neuropathic pain associated with spinal cord injury.

PAGE 10

LAST UPDATED 08/2016

OVERACTIVE BLADDER MEDICATION(S) SUBJECT TO STEP THERAPY DARIFENACIN ER, TOLTERODINE TARTRATE ER CRITERIA OTCs: "OXYTROL FOR WOMEN". Patient needs to have paid claims for one of the following Step 1 drugs: Oxybutynin, Oxybutynin XL, Tolterodine, Oxytrol OTC. Prior to filling the Step 2 drug: Darifenacin ER, Tolterodine ER.

PAGE 11

LAST UPDATED 08/2016

PATIROMER CALCIUM MEDICATION(S) SUBJECT TO STEP THERAPY VELTASSA CRITERIA Patient needs to have paid claims for a 30 day supply for any one of the following Step 1 drug(s): sodium polystyrene sulfonate (SPS). Prior to filling the Step 2 drug: Patiromer calcium.

PAGE 12

LAST UPDATED 08/2016

PROTON PUMP INHIBITORS MEDICATION(S) SUBJECT TO STEP THERAPY RABEPRAZOLE SODIUM CRITERIA OTCs: "OMEPRAZOLE", "ZEGERID OTC", "RA LANSOPRAZOLE". Patient needs to have paid claims for two of the following Step 1 drugs: omeprazole OTC, lansoprazole OTC, Zegerid OTC, omeprazole Rx, pantoprazole. Prior to filling the Step 2 drug: rabeprazole.

PAGE 13

LAST UPDATED 08/2016

ROTIGOTINE MEDICATION(S) SUBJECT TO STEP THERAPY NEUPRO CRITERIA Patient needs to have a 30 day supply paid claim for any one of the following Step 1 drug: ropinirole, pramipexole, or pramipexole ER. Prior to filling the Step 2 Drug: Neupro.

PAGE 14

LAST UPDATED 08/2016

SKELETAL MUSCLE RELAXANT MEDICATION(S) SUBJECT TO STEP THERAPY CARISOPRODOL COMPOUND, CARISOPRODOL-ASPIRIN, ORPHENADRINE ER 100 MG TABLET CRITERIA Patient needs to have paid claims for any one of the following oral agents: Carisoprodol, Cyclobenzaprine, Methocarbamol, Baclofen, Dantrolene, tizanidine. Prior to filling the Step 2 drug: Orphenadrine, Carisoprodol/Aspirin.

PAGE 15

LAST UPDATED 08/2016

TOPICAL IMMUNOMODULATORS MEDICATION(S) SUBJECT TO STEP THERAPY ELIDEL, TACROLIMUS 0.03% OINTMENT, TACROLIMUS 0.1% OINTMENT CRITERIA Patient needs to have paid claims for two or more of the following Step 1 drugs: Topical Corticosteroids (alclometasone dipropionate, desonide, fluocinolone acetonide, betamethasone valerate, fluocinonide (-plus emollient), fluticasone propionate, hydrocortisone, hydrocortisone valerate, hydrocortisone butyrate, mometasone furoate, triamcinolone acetonide, amcinonide, betamethasone dipropionate, betamethason diproprionate/prop gly, augmented betamethasone dipropionate, desoximetasone, diflorasone diacetate, clobetasol propionate, halobetasol propionate, prednicarbate) Prior to filling the Step 2 drug: Topical Immunomodulators (pimecrolimus, tacrolimus).

PAGE 16

LAST UPDATED 08/2016

ULORIC MEDICATION(S) SUBJECT TO STEP THERAPY ULORIC CRITERIA Patient needs to have paid claims for any one of the following Step 1 drug: allopurinol. Prior to filling the Step 2 Drug: Uloric.

PAGE 17

LAST UPDATED 08/2016

XOPENEX MEDICATION(S) SUBJECT TO STEP THERAPY LEVALBUTEROL CONCENTRATE, LEVALBUTEROL 0.31 MG/3 ML SOL, LEVALBUTEROL 0.63 MG/3 ML SOL, LEVALBUTEROL 1.25 MG/3 ML SOL, XOPENEX HFA CRITERIA Patient needs to have paid claims for any one of the following Step 1 agents: albuterol inhaler, albuterol nebulization. Prior to filling the Step 2 agent: xopenex inhaler, levalbuterol nebulization.

PAGE 18

LAST UPDATED 08/2016

ZETIA MEDICATION(S) SUBJECT TO STEP THERAPY ZETIA CRITERIA Patient needs to have paid claims for any one of the following Step 1 drugs: pravastatin, lovastatin, simvastatin, atorvastatin. Prior to filling the Step 2 Drug: Zetia. Members may request an exception and Zetia will be allowed as first line treatment for homozygous sitosterolemia.

PAGE 19

LAST UPDATED 08/2016

PAGE 20

LAST UPDATED 08/2016