Cca 2013 version 10 step therapy criteria

Step Therapy Criteria
Commonwealth Care Alliance 2013
Last Updated: 03/2013
Effective: April 1, 2013
CCA ANTIDEPRESSANT (SNRI) ST 2013C
Products Affected
Criteria
Patient needs to have paid claims for one of the following Step 1 drugs with a day supply of at least 30 days prior to filling a Step 2 drug. Step 1 drugs: citalopram, citalopram Hbr, escitalopram, fluoxetine Dr, fluoxetine Hcl, fluvoxamine maleate, paroxetine Hcl, Rapiflux, sertraline Hcl, venlafaxine Hcl, venlafaxine Hcl Er. Step 2 Drugs: Cymbalta, Pristiq, Savella. Patients who have taken a step 2 drug at any time in the past may restart. Authorization may be given for a step 2 drug if the patient is currently taking the requested agent. Patients aged 18 years of less: approve Cymbalta or Pristiq without a trial of a step 1 agent. Symptoms of suicidal ideation: approve Cymbalta or Pristiq without a trial of a step 1 agent. Stress urinary incontinence: approve Cymbalta without a trial of a step 1 agent. Fibromyalgia: approve Cymbalta or Savella without a trial of a step 1 agent. Chronic musculoskeletal pain (eg, low back pain or pain due to osteoarthritis): approve Cymbalta without a trial of a step 1 agent. Chronic musculoskeletal pain (eg, low back pain or pain due to osteoarthritis) and Diabetic peripheral neuropathy: approve Cymbalta CCA BISPHOSPHONATES 2013S
Products Affected
Criteria
Patient needs to have a paid claim for one of the following Step 1 drugs prior to filling a Step 2 drug. Step 1 drugs: alendronate, ibandronate. Step CCA NASAL CORTICOSTERIODS ST 2013S
Products Affected
Criteria
Patient needs to have a paid claim for one of the following Step 1 drugs prior to filling a Step 2 drug. Step 1 drugs: flunisolide, fluticasone propionate, Nasonex, Rhinocort Aqua, Veramyst, triamcinolone. Step 2 CCA SEDATIVE HYPNOTICS ST 2013S
Products Affected
Criteria
Patient needs to have a paid claim for one of the following Step 1 drugs prior to filling a Step 2 drug. Step 1 drugs: generic zolpidem (including zolpidem CR) or zaleplon. Step 2 drugs: Rozerem, Edluar, Zolpimist. CCA SSRI ANTIDEPRESSANTS (SSRI) ST 2013S
Products Affected
Criteria
Patient needs to have paid claims for one of the following Step 1 drugs (must be generic) with a day supply of at least 30 days prior to filling a Step 2 drug. Step 1 drugs: citalopram hydrobromide, escitalopram, fluoxetine HCL, fluvoxamine maleate, paroxetine HCL, paroxetine ER, sertraline HCL.Step 2: Luvox CR, Viibryd. A
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Cca Bisphosphonates 2013s . 2 Cca Nasal Corticosteriods St 2013s . 3 V
Cca Ssri Antidepressants (ssri) St 2013s . 5 Cymbalta . 1 Z
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Source: http://commonwe.itg.net/downloads/Step_Therapy_Criteria_Apr2013.pdf