Effective date:

University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
STEP THERAPY GROUP DESCRIPTION
GLP-1 ANALOGS
DRUG NAME
BYDUREON
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.
University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
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.
University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
STEP THERAPY GROUP DESCRIPTION
ALZHEIMER'S DRUGS
DRUG NAME
EXELON
STEP THERAPY CRITERIA
IF THE PATIENT HAS TRIED A STEP 1 DRUG, THEN AUTHORIZATION FOR A STEP 2
DRUG MAY BE GIVEN. STEP 1 DRUG(S): DONEPEZIL HCL, GALANTAMINE
HYDROBROMIDE, GALANTAMINE HBR, RIVASTIGMINE. STEP 2 DRUG(S): EXELON
ORAL SOLUTION, EXELON PATCH. AUTHORIZATION MAY BE GIVEN FOR A STEP 2
DRUG IF THE PATIENT IS CURRENTLY TAKING (OR HAS TAKEN IN THE PAST) THE
REQUESTED AGENT. AUTHORIZATION FOR EXELON PATCH MAY BE GIVEN IF THE
PATIENT HAS DIFFICULTY SWALLOWING OR CANNOT SWALLOW. THIS STEP
THERAPY PROGRAM APPLIES TO NEW UTILIZERS ONLY.
University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
STEP THERAPY GROUP DESCRIPTION
ANTIDEPRESSANTS- SSRI
DRUG NAME
PAXIL | VIIBRYD
STEP THERAPY CRITERIA
IF THE PATIENT HAS TRIED TWO STEP 1 DRUGS, THEN AUTHORIZATION FOR A
STEP 2 DRUG MAY BE GIVEN. STEP 1 DRUG(S): CITALOPRAM, CITALOPRAM HBR,
FLUOXETINE DR, ESCITALOPRAM, FLUOXETINE HCL, FLUVOXAMINE MALEATE,
PAROXETINE HCL, PAROXETINE ER, RAPIFLUX, SERTRALINE HCL. STEP 2 DRUG(S):
VIIBRYD, PAXIL ORAL SUSPENSION. PATIENTS WHO HAVE TAKEN A STEP 2 SSRI AT
ANY TIME IN THE PAST AND DISCONTINUED ITS USE MAY RECEIVE
AUTHORIZATION TO RESTART THE STEP 2 SSRI (WHICHEVER THEY USED IN THE
PAST). AUTHORIZATION MAY BE GIVEN FOR A STEP 2 SSRI IF THE PATIENT IS
CURRENTLY TAKING THE REQUESTED AGENT. AUTHORIZATION MAY BE GIVEN
FOR A STEP 2 DRUG IF THE PATIENT IS A CHILD OR ADOLESCENT AGED 18 YEARS
OR LESS OR HAS SUICIDAL IDEATION. THIS STEP THERAPY PROGRAM APPLIES TO
NEW UTILIZERS ONLY.
University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
STEP THERAPY GROUP DESCRIPTION
DRUG NAME
AZOR | BENICAR | BENICAR HCT | DIOVAN | EXFORGE | EXFORGE HCT | MICARDIS |
MICARDIS HCT | TRIBENZOR | TWYNSTA
STEP THERAPY CRITERIA
IF THE PATIENT HAS TRIED A STEP 1 DRUG, THEN AUTHORIZATION FOR A STEP 2
DRUG MAY BE GIVEN. STEP 1 DRUG(S): AMLODIPINE BESYLATE-BENAZEPRIL,
BENAZEPRIL HCL, BENAZEPRIL-HYDROCHLOROTHIAZIDE, CANDESARTAN-
HYDROCHLOROTHIAZIDE, CAPTOPRIL, CAPTOPRIL-HYDROCHLOROTHIAZIDE,
ENALAPRIL MALEATE, ENALAPRIL-HYDROCHLOROTHIAZIDE, EPROSARTAN,
FOSINOPRIL SODIUM, FOSINOPRIL-HYDROCHLOROTHIAZIDE, IRBESARTAN,
IRBESARTAN-HYDROCHLOROTHIAZIDE, LISINOPRIL, LISINOPRIL-
HYDROCHLOROTHIAZIDE, LOSARTAN POTASSIUM, LOSARTAN-
HYDROCHLOROTHIAZIDE, MOEXIPRIL HCL, MOEXIPRIL-
HYDROCHLOROTHIAZIDE, PERINDOPRIL ERBUMINE, QUINAPRIL HCL, QUINAPRIL-
HYDROCHLOROTHIAZIDE, RAMIPRIL, TRANDOLAPRIL. STEP 2 DRUG(S): AZOR,
BENICAR, BENICAR HCT, DIOVAN, EXFORGE, EXFORGE HCT, MICARDIS, MICARDIS
HCT, TRIBENZOR, TWYNSTA. AUTHORIZATION MAY BE GIVEN FOR A STEP 2
PRODUCT, WITHOUT A TRIAL OF A STEP 1 AGENT, IF THE PATIENT WAS RECENTLY
HOSPITALIZED AND DISCHARGED WITHIN THE PREVIOUS 30 DAYS FOR A
CARDIOVASCULAR EVENT (E.G., MYOCARDIAL INFARCTION, HYPERTENSIVE
EMERGENCY, DECOMPENSATED HEART FAILURE) AND HAS ALREADY BEEN
STARTED AND STABILIZED ON THE AGENT.
University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
STEP THERAPY GROUP DESCRIPTION
BISPHOSPHONATES ORAL
DRUG NAME
BONIVA
STEP THERAPY CRITERIA
IF THE PATIENT HAS TRIED A STEP 1 DRUG, THEN AUTHORIZATION FOR A STEP 2
DRUG MAY BE GIVEN. STEP 1 DRUG(S): ALENDRONATE SODIUM, IBANDRONATE
SODIUM. STEP 2 DRUG(S): BONIVA. AUTHORIZATION MAY BE GIVEN FOR BONIVA, IF
THE PATIENT HAS TRIED ALENDRONATE SODIUM (BRAND OR GENERIC) OR
IBANDRONATE SODIUM.
University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
STEP THERAPY GROUP DESCRIPTION
BRAND NSAIDS
DRUG NAME
VOLTAREN
STEP THERAPY CRITERIA
IF THE PATIENT HAS TRIED TWO STEP 1 DRUGS, THEN AUTHORIZATION FOR A
STEP 2 DRUG MAY BE GIVEN. STEP 1 DRUG(S): DICLOFENAC POTASSIUM,
DICLOFENAC SODIUM, ETODOLAC, FENOPROFEN CALCIUM, FLURBIPROFEN,
IBUPROFEN, INDOMETHACIN, KETOPROFEN, KETOROLAC TROMETHAMINE,
MECLOFENAMATE SODIUM, MEFENAMIC ACID, MELOXICAM, NABUMETONE,
NAPROXEN, NAPROXEN SODIUM, OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN
SODIUM. STEP 2 DRUG(S): VOLTAREN GEL. AUTHORIZATION MAY BE GIVEN FOR
VOLTAREN GEL FOR PATIENTS WITH DIFFICULTY SWALLOWING OR CANNOT
SWALLOW. AUTHORIZATION MAY BE GIVEN FOR VOLTAREN GEL FOR PATIENTS
WITH A CHRONIC MUSCULOSKELETAL PAIN CONDITION (EG, OSTEOARTHRITIS) IN
3 OR FEWER JOINTS/SITES (IE, HAND, WRIST, ELBOW, KNEE, ANKLE, OR FOOT EACH
COUNT AS 1 JOINT/SITE) WHO ARE AT RISK OF NSAID-ASSOCIATED TOXICITY (EG,
PREVIOUS GASTROINTESTINAL [GI] BLEED, HISTORY OF PEPTIC ULCER DISEASE,
IMPAIRED RENAL FUNCTION, CARDIOVASCULAR DISEASE, HYPERTENSION, HEART
FAILURE, ELDERLY PATIENTS WITH IMPAIRED HEPATIC FUNCTION, OR THOSE
TAKING CONCOMITANT ANTICOAGULANTS).
University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
STEP THERAPY GROUP DESCRIPTION
DRUG NAME
CELEBREX
STEP THERAPY CRITERIA
IF THE PATIENT HAS TRIED TWO STEP 1 DRUGS, THEN AUTHORIZATION FOR A
STEP 2 DRUG MAY BE GIVEN. STEP 1 DRUG(S): DICLOFENAC POTASSIUM,
DICLOFENAC SODIUM, ETODOLAC, FENOPROFEN CALCIUM, FLURBIPROFEN,
IBUPROFEN, INDOMETHACIN, KETOPROFEN, KETOROLAC TROMETHAMINE,
MECLOFENAMATE SODIUM, MEFENAMIC ACID, MELOXICAM, NABUMETONE,
NAPROXEN, NAPROXEN SODIUM, OXAPROZIN, PIROXICAM, SULINDAC, TOLMETIN
SODIUM. STEP 2 DRUG(S): CELEBREX. AUTHORIZATION FOR CELEBREX MAY BE
GIVEN IF THE PATIENT HAS TRIED TWO ORAL PRESCRIPTION STRENGTH NSAIDS
(BRAND OR GENERIC) FOR THE CURRENT CONDITION. THIS STEP THERAPY
PROGRAM WILL EXCLUDE PARTICIPANTS WITH A CLAIMS HISTORY OF WARFARIN
(COUMADIN) WITHIN THE LAST 130 DAYS. AUTHORIZATION FOR CELEBREX MAY
BE GIVEN FOR PATIENTS WHO ARE CURRENTLY TAKING CHRONIC SYSTEMIC
CORTICOSTEROID THERAPY, WARFARIN (COUMADIN), CLOPIDOGREL (PLAVIX),
PRASUGREL (EFFIENT), TICAGRELOR (BRILINTA), RIVAROXABAN (XARELTO),
DABIGATRAN (PRADAXA), CHRONIC ASPIRIN THERAPY, OR LOW MOLECULAR
WEIGHT HEPARINS.
University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
STEP THERAPY GROUP DESCRIPTION
FENOFIBRATE
DRUG NAME
LIPOFEN
STEP THERAPY CRITERIA
IF THE PATIENT HAS TRIED A STEP 1 DRUG, THEN AUTHORIZATION FOR A STEP 2
DRUG MAY BE GIVEN. STEP 1 DRUG(S): FENOFIBRATE. STEP 2 DRUG(S): LIPOFEN.
University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
STEP THERAPY GROUP DESCRIPTION
HMG RULE 1
DRUG NAME
CRESTOR
STEP THERAPY CRITERIA
IF THE PATIENT HAS TRIED A STEP 1 DRUG, THEN AUTHORIZATION FOR A STEP 2
DRUG MAY BE GIVEN. STEP 1 DRUG(S): ATORVASTATIN, FLUVASTATIN,
LOVASTATIN, PRAVASTATIN SODIUM, SIMVASTATIN. STEP 2 DRUG(S): CRESTOR 5
MG. AUTHORIZATION MAY BE GIVEN FOR A STEP 2 DRUG, IF THE PATIENT HAS
TRIED ATORVASTATIN (BRAND OR GENERIC), FLUVASTATIN (BRAND OR GENERIC),
LOVASTATIN (BRAND OR GENERIC), PRAVASTATIN SODIUM (BRAND OR GENERIC),
OR SIMVASTATIN (BRAND OR GENERIC). AUTHORIZATION FOR A STEP 2 DRUG
WILL GIVEN ON AN INDIVIDUAL BASIS FOR DRUG-DRUG INTERACTIONS.
University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
STEP THERAPY GROUP DESCRIPTION
LONG ACTING OPIOIDS
DRUG NAME
OPANA ER
STEP THERAPY CRITERIA
IF THE PATIENT HAS TRIED A STEP 1 DRUG, THEN AUTHORIZATION FOR A STEP 2
DRUG MAY BE GIVEN. STEP 1 DRUG(S): MORPHINE SULFATE, MORPHINE SULFATE
ER, OXYMORPHONE ER. STEP 2 DRUG(S): OPANA ER, OXYCONTIN. AUTHORIZATION
MAY BE GIVEN FOR OXYCONTIN IF THE PATIENT IS UNABLE TO TOLERATE OR HAS
A DRUG ALLERGY NOTED WITH MORPHINE SULFATE. AUTHORIZATION MAY BE
GIVEN FOR OXYCONTIN IF THE PATIENT HAS RENAL INSUFFICIENCY.
AUTHORIZATION MAY BE GIVEN FOR OXYCONTIN IF THE PATIENT IS PREGNANT.
University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
STEP THERAPY GROUP DESCRIPTION
OPHTHALMIC PROSTAGLANDINS
DRUG NAME
TRAVATAN Z
STEP THERAPY CRITERIA
IF THE PATIENT HAS TRIED A STEP 1 DRUG, THEN AUTHORIZATION FOR A STEP 2
DRUG MAY BE GIVEN. STEP 1 DRUG(S): LATANOPROST. STEP 2 DRUG(S): TRAVATAN
Z. AUTHORIZATION FOR TRAVATAN Z MAY BE GIVEN IF THE PATIENT HAS A
KNOWN BENZALKONIUM CHLORIDE (BAK) SENSITIVITY OR SENSITIVITY TO
OTHER OPHTHALMIC PRESERVATIVES.
University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
STEP THERAPY GROUP DESCRIPTION
OVERACTIVE BLADDER
DRUG NAME
ENABLEX | SANCTURA XR
STEP THERAPY CRITERIA
IF THE PATIENT HAS TRIED A STEP 1 DRUG, THEN AUTHORIZATION FOR A STEP 2
DRUG MAY BE GIVEN. STEP 1 DRUG(S): OXYBUTYNIN CHLORIDE, OXYBUTYNIN
CHLORIDE ER, TROSPIUM CHLORIDE. STEP 2 DRUG(S): ENABLEX, SANCTURA XR.
University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
STEP THERAPY GROUP DESCRIPTION
PROTON PUMP INHIBITORS
DRUG NAME
NEXIUM
STEP THERAPY CRITERIA
IF THE PATIENT HAS TRIED A STEP 1 DRUG, THEN AUTHORIZATION FOR A STEP 2
DRUG MAY BE GIVEN. STEP 1 DRUG(S): LANSOPRAZOLE, OMEPRAZOLE,
OMEPRAZOLE-SODIUM BICARBONATE, PANTOPRAZOLE SODIUM. STEP 2 DRUG(S):
NEXIUM. AUTHORIZATION FOR NEXIUM MAY BE GIVEN IN PATIENTS LESS THAN 1
YEAR OF AGE.
University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
STEP THERAPY GROUP DESCRIPTION
SEDATIVE HYPNOTICS
DRUG NAME
ROZEREM
STEP THERAPY CRITERIA
IF THE PATIENT HAS TRIED A STEP 1 DRUG, THEN AUTHORIZATION FOR A STEP 2
DRUG MAY BE GIVEN. STEP 1 DRUG(S): ZALEPLON, ZOLPIDEM TARTRATE. STEP 2
DRUG(S): ROZEREM. ROZEREM WILL BE COVERED FOR MEMBERS EQUAL TO OR
OVER THE AGE OF 65 YEARS. FOR THOSE UNDER 65 YEARS OF AGE, THE STEP
THERAPY WILL APPLY. AUTHORIZATION FOR ROZEREM MAY BE GIVEN IF THE
PATIENT HAS A DOCUMENTED HISTORY OF ADDICTION TO CONTROLLED
SUBSTANCES.
University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
STEP THERAPY GROUP DESCRIPTION
TEKTURNA
DRUG NAME
AMTURNIDE | TEKAMLO | TEKTURNA | TEKTURNA HCT
STEP THERAPY CRITERIA
IF THE PATIENT HAS TRIED A STEP 1 DRUG, THEN AUTHORIZATION FOR A STEP 2
DRUG MAY BE GIVEN. STEP 1 DRUG(S): AMLODIPINE BESYLATE-BENAZEPRIL,
AZOR, BENICAR, BENICAR HCT, BENAZEPRIL HCL, BENAZEPRIL-
HYDROCHLOROTHIAZIDE, CANDESARTAN-HYDROCHLOROTHIAZIDE, CAPTOPRIL,
CAPTOPRIL-HYDROCHLOROTHIAZIDE, DIOVAN, ENALAPRIL MALEATE,
ENALAPRIL-HYDROCHLOROTHIAZIDE, EPROSARTAN, EXFORGE, EXFORGE HCT,
FOSINOPRIL SODIUM, FOSINOPRIL-HYDROCHLOROTHIAZIDE, IRBESARTAN,
IRBESARTAN-HYDROCHLOROTHIAZIDE, LISINOPRIL, LISINOPRIL-
HYDROCHLOROTHIAZIDE, LOSARTAN POTASSIUM, LOSARTAN-
HYDROCHLOROTHIAZIDE, MICARDIS, MICARDIS HCT, MOEXIPRIL HCL,
MOEXIPRIL-HYDROCHLOROTHIAZIDE, PERINDOPRIL ERBUMINE, QUINAPRIL HCL,
QUINAPRIL-HYDROCHLOROTHIAZIDE, RAMIPRIL, TRANDOLAPRIL, TRIBENZOR,
TWYNSTA. STEP 2 DRUG(S): AMTURNIDE, TEKAMLO, TEKTURNA, TEKTURNA HCT.
AUTHORIZATION FOR A STEP 2 DRUG MAY BE GIVEN IF THE PATIENT TRIED AN
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ACE INHIBITOR
COMBINATION PRODUCT IN THE PAST. AUTHORIZATION FOR A STEP 2 DRUG MAY
BE GIVEN IF THE PATIENT TRIED AN ANGIOTENSIN RECEPTOR BLOCKER (ARB) OR
ARB COMBINATION PRODUCT IN THE PAST THEY ARE NOT REQUIRED TO HAVE A
TRIAL WITH AN ACE INHIBITOR.
University Care Advantage (HMO SNP)
Step Therapy Webfile
EFFECTIVE DATE: 04/01/2013
STEP THERAPY GROUP DESCRIPTION
DRUG NAME
ULORIC
STEP THERAPY CRITERIA
IF THE PATIENT HAS TRIED A STEP 1 DRUG, THEN AUTHORIZATION FOR A STEP 2
DRUG MAY BE GIVEN. STEP 1 DRUG(S): ALLOPURINOL. STEP 2 DRUG(S): ULORIC.
AUTHORIZATION MAY BE GIVEN FOR ULORIC IF THE PATIENT HAS TRIED
ALLOPURINOL (BRAND OR GENERIC) AT ANY TIME IN THE PAST. AUTHORIZATION
MAY BE GIVEN FOR ULORIC IF THE PATIENT HAS RENAL INSUFFICIENCY OR
DECREASED RENAL FUNCTION. AUTHORIZATION MAY BE GIVEN FOR ULORIC IF
THE PATIENT IS RECEIVING CONCOMITANT MEDICATIONS THAT HAVE
SIGNIFICANT DRUG-DRUG INTERACTIONS WITH ALLOPURINOL, WHICH ARE NOT
NOTED WITH ULORIC (EG, CYCLOSPORINE, CHLORPROPAMIDE).

Source: http://www.universitycareadvantage.com/Admin/ContentDocuments/STEPWEB_File_UOA_13042_02282013_162500_EFF_04012013_WEB.pdf