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Concordia-plan-services.com

2014 Step Therapy Programs for Concordia Plan Services
Medicare Members
CONDITION TREATED
STEP ONE DRUGS
STEP TWO DRUGS
Wil deny at pharmacy without trial of step-one drug
Drug Class
within the past 130 days. Prior authorization is
required for use of step-two drug without use of step-
one drug within past 130 days.
BLOOD DISORDERSSP
Erythroid Stimulants
DEPRESSION
Other Antidepressants (bupropion
and Selective Serotonin
Norepinephrine Reuptake
Inhibitors, SNRIs)

For Savella, prior use of 2 medications (SSRI
and SNRI) in the past 130 days.
Selective Serotonin Reuptake
Inhibitors (SSRI)
DIABETES
Thiazolidinediones (TZDs)
metformin, / XR, metformin, glipizide, metformin/glyburide, metformin/repaglinide, pioglitazone, pioglitazone/metformin, pioglitazone/glimepiride, Prandimet, Riomet GASTROINTESTINAL
DISORDERS
Proton Pump Inhibitors (PPI)
Does not target patients < 2 years of age. HIGH BLOOD CHOLESTEROL
Statins
Prior use of a first line and a second line medication in the last 180 days for a non- formulary brand.
HIGH BLOOD PRESSURE AND
HEART DISEASE
Angiotensin Receptor Blockers
Contact Express Scripts 800-344-3896 with questions about specific drugs. List is subject to change.
Revision Date:
12.17.13 (to include
Page 1 of 3
2014 Step Therapy Programs for Concordia Plan Services
Medicare Members
CONDITION TREATED
STEP ONE DRUGS
STEP TWO DRUGS
Wil deny at pharmacy without trial of step-one drug
Drug Class
within the past 130 days. Prior authorization is
required for use of step-two drug without use of step-
one drug within past 130 days.
Tekturna
fosinopril / HCTZ, irbesartan / HCTZ, lisinopril / HCTZ, losartan / HCTZ, moexipril / HCTZ, perindopril, quinapril / HCTZ, ramipril, trandolapril trandolapril-verapamil INFLAMMATORY
CONDITIONSSP
Prior use of 2 first line medications in the last 180 days; prior use of second line injectable product before infused medication in last 180 days. MULTIPLE SCLEROSISSP
Injectable
Prior use of ALL first line medications in the last 180 days.
Oral
PAIN AND INFLAMMATION
Neuropathic (Nerve) Pain
Patient must use step one drug for at least 60 Nonsteroidal Anti-Inflammatory
Drugs (NSAIDs)
Patient must try 2 different first line drugs before a second line agent will be approved. For Duexis, prior use of H2RA AND Rx strength ibuprofen. For Vimovo, use of generic omeprazole, lansoprazole or pantoproazole PROSTATE / URINARY
CONDITIONS
Overactive Bladder
RESPIRATORY
Other – Alpha1 InhibitorsSP
SKIN CONDITIONS
Tetracycline
Contact Express Scripts 800-344-3896 with questions about specific drugs. List is subject to change.
Revision Date:
12.17.13 (to include
Page 2 of 3
2014 Step Therapy Programs for Concordia Plan Services
Medicare Members
CONDITION TREATED
STEP ONE DRUGS
STEP TWO DRUGS
Wil deny at pharmacy without trial of step-one drug
Drug Class
within the past 130 days. Prior authorization is
required for use of step-two drug without use of step-
one drug within past 130 days.
Topical Acne
Rule 1: Brand topical BPO, antibiotic, etc containing Prior use of first line medication in the last 130 days for Rules 1 and 2; prior use of two products in the last 130 days for Rule 3. Topical Corticosteroids
Prior use of 2 first line medication in the last hydrocortisone acetate, butyrate, or valerate mometasone, pramoxine, triamcinolone Topical Immunomodulators
Prior use of 1 first line medication in the last halobetasol, hydrocortisone, hydrocortisone acetate, butyrate, or valerate, mometasone, triamcinolone hydrocortisone acetate, butyrate, or valerate mometasone, pramoxine, triamcinolone SLEEP DISORDERS
Hypnotics
Contact Express Scripts 800-344-3896 with questions about specific drugs. List is subject to change.
Revision Date:
12.17.13 (to include
Page 3 of 3

Source: http://www.concordia-plan-services.com/graphics/assets/documents/2014_Medicare_Step_Therapy_Grid.pdf

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