Lovelacemedicareplan.com

Medicare Part D Step Therapy Protocal
CURRENT AS OF 6/1/2011
CMS Approval Date 5/25/2011
CMS Marketing Materials Id Number H3251-1288_CMS approved 07182010
Step Therapy
Algorithm
Adrenergic_Vasopre Midodrine--Indicated for symptomatic orthostatic hypotension-- Requires prior use of fludrocortisone acetate (Florinef) within the Step 2: midodrine 10 mg Tab, midodrine 2.5 mg Tab, last six months. midodrine 5 mg Tab, ProAmatine 10 mg Tab, ProAmatine 2.5 mg Tab, ProAmatine 5 mg Tab Medicare Part D Step Therapy Protocal
CURRENT AS OF 6/1/2011
CMS Approval Date 5/25/2011
CMS Marketing Materials Id Number H3251-1288_CMS approved 07182010
Step Therapy
Algorithm
Angiotensin_II_rece All Angiotensin II Receptor Antagonists as a sole product or in Step 1: Accupril 10 mg Tab, Accupril 20 mg Tab, combination have step therapy. Our pharmacy claims processor, Accupril 40 mg Tab, Accupril 5 mg Tab, Accuretic 10 looks back 6 months for a previous fill of an Angiotensin- mg-12.5 mg Tab, Accuretic 20 mg-12.5 mg Tab, Converting Enzyme Inhibitor to determine if the Angiotensin II Accuretic 20 mg-25 mg Tab, Aceon 2 mg Tab, Aceon 4 Receptor Antagonist claim should pay. An exception can be mg Tab, Aceon 8 mg Tab, Altace 1.25 mg Cap, Altace 1.25 mg Tab, Altace 10 mg Cap, Altace 10 mg Tab, Altace 2.5 mg Cap, Altace 2.5 mg Tab, Altace 5 mg Cap, Altace 5 mg Tab, benazepril 10 mg Tab, benazepril 20 mg Tab, benazepril 20 mg Tab, benazepril 40 mg Tab, benazepril 5 mg Tab, benazepril-hydrochlorothiazide 10 mg-12.5 mg Tab, benazepril-hydrochlorothiazide 20 mg-12.5 mg Tab, benazepril-hydrochlorothiazide 20 mg-25 mg Tab, benazepril-hydrochlorothiazide 5 mg-6.25 mg Tab, captopril 100 mg Tab, captopril 12.5 mg Tab, captopril 25 mg Tab, captopril 50 mg Tab, captopril-hydrochlorothiazide 25 mg-15 mg Tab, captopril-hydrochlorothiazide 25 mg-25 mg Tab, captopril-hydrochlorothiazide 50 mg-15 mg Tab, captopril-hydrochlorothiazide 50 mg-25 mg Tab, enalapril maleate 10 mg Tab, enalapril maleate 2.5 mg Tab, enalapril maleate 20 mg Tab, enalapril maleate 5 mg Tab, enalapril-hydrochlorothiazide 10 mg-25 mg Tab, enalapril-hydrochlorothiazide 5 mg-12.5 mg Tab, fosinopril 10 mg Tab, fosinopril 20 mg Tab, fosinopril 40 mg Tab, fosinopril-hydrochlorothiazide 10 mg-12.5 mg Tab, fosinopril-hydrochlorothiazide 20 mg-12.5 mg Tab, lisinopril 10 mg Tab, lisinopril 2.5 mg Tab, lisinopril 20 mg Tab, lisinopril 30 mg Tab, lisinopril 40 mg Tab, LISINOPRIL 5 MG ORAL TABLET, lisinopril 5 mg Medicare Part D Step Therapy Protocal
CURRENT AS OF 6/1/2011
CMS Approval Date 5/25/2011
CMS Marketing Materials Id Number H3251-1288_CMS approved 07182010
Step Therapy
Algorithm
Tab, lisinopril-hydrochlorothiazide 10 mg-12.5 mg Tab, lisinopril-hydrochlorothiazide 20 mg-12.5 mg Tab, lisinopril-hydrochlorothiazide 20 mg-25 mg Tab, Lotensin 10 mg Tab, Lotensin 20 mg Tab, Lotensin 40 mg Tab, Lotensin 5 mg Tab, Lotensin HCT 10 mg-12.5 mg Tab, Lotensin HCT 20 mg-12.5 mg Tab, Lotensin HCT 20 mg-25 mg Tab, Lotensin HCT 5 mg-6.25 mg Tab, Mavik 1 mg Tab, Mavik 2 mg Tab, Mavik 4 mg Tab, moexipril 15 mg Tab, moexipril 7.5 mg Tab, moexipril-hydrochlorothiazide 15 mg-12.5 mg Tab, moexipril-hydrochlorothiazide 15 mg-25 mg Tab, moexipril-hydrochlorothiazide 7.5 mg-12.5 mg Tab, Monopril 10 mg Tab, Monopril 40 mg Tab, perindopril erbumine 2 mg Tab, perindopril erbumine 4 mg Tab, perindopril erbumine 8 mg Tab, Prinivil 10 mg Tab, Prinivil 20 mg Tab, Prinivil 5 mg Tab, Prinivil 5 mg Tab, Prinzide 10 mg-12.5 mg Tab, Prinzide 20 mg-12.5 mg Tab, quinapril 10 mg Tab, quinapril 20 mg Tab, quinapril 40 mg Tab, quinapril 5 mg Tab, quinapril-hydrochlorothiazide 10 mg-12.5 mg Tab, quinapril-hydrochlorothiazide 20 mg-12.5 mg Tab, quinapril-hydrochlorothiazide 20 mg-25 mg Tab, ramipril 1.25 mg Cap, ramipril 10 mg Cap, ramipril 2.5 mg Cap, ramipril 5 mg Cap, Tarka 1 mg-240 mg 24 hr Tab, Tarka 2 mg-180 mg 24 hr Tab, Tarka 2 mg-240 mg 24 hr Tab, Tarka 4 mg-240 mg 24 hr Tab, trandolapril 1 mg Tab, trandolapril 2 mg Tab, trandolapril 4 mg Tab, Uniretic 15 mg-12.5 mg Tab, Uniretic 15 mg-25 mg Tab, Uniretic 7.5 mg-12.5 mg Tab, Univasc 15 mg Tab, Univasc 7.5 mg Tab, Vaseretic Medicare Part D Step Therapy Protocal
CURRENT AS OF 6/1/2011
CMS Approval Date 5/25/2011
CMS Marketing Materials Id Number H3251-1288_CMS approved 07182010
Step Therapy
Algorithm
10 mg-25 mg Tab, Vasotec 10 mg Tab, Vasotec 2.5 mg Tab, Vasotec 20 mg Tab, Vasotec 5 mg Tab, Zestoretic 10 mg-12.5 mg Tab, Zestoretic 20 mg-12.5 mg Tab, Zestoretic 20 mg-25 mg Tab, Zestril 10 mg Tab, Zestril 2.5 mg Tab, Zestril 20 mg Tab, Zestril 30 mg Tab, Zestril 40 mg Tab, Zestril 5 mg Tab Step 2: Atacand 16 mg Tab, Atacand 32 mg Tab, Atacand 4 mg Tab, Atacand 8 mg Tab, Atacand HCT 16 mg-12.5 mg Tab, Atacand HCT 32 mg-12.5 mg Tab, Atacand HCT 32 mg-25 mg Tab, Avalide 150 mg-12.5 mg Tab, Avalide 300 mg-12.5 mg Tab, Avalide 300 mg-25 mg Tab, Avapro 150 mg Tab, Avapro 300 mg Tab, Avapro 75 mg Tab, Azor 10 mg-20 mg Tab, Azor 10 mg-40 mg Tab, Azor 5 mg-20 mg Tab, Azor 5 mg-40 mg Tab, Benicar 20 mg Tab, Benicar 40 mg Tab, Benicar 5 mg Tab, Benicar HCT 20 mg-12.5 mg Tab, Benicar HCT 40 mg-12.5 mg Tab, Benicar HCT 40 mg-25 mg Tab, Cozaar 100 mg Tab, Cozaar 25 mg Tab, Cozaar 50 mg Tab, Diovan 160 mg Tab, Diovan 320 mg Tab, Diovan 40 mg Tab, Diovan 80 mg Tab, Diovan HCT 160 mg-12.5 mg Tab, Diovan HCT 160 mg-25 mg Tab, Diovan HCT 320 mg-12.5 mg Tab, Diovan HCT 320 mg-25 mg Tab, Diovan HCT 80 mg-12.5 mg Tab, Edarbi 40 mg Tab, Edarbi 80 mg Tab, Exforge 10 mg-160 mg Tab, Exforge 10 mg-320 mg Tab, Exforge 5 mg-160 mg Tab, Exforge 5 mg-320 mg Tab, Exforge HCT 10 mg-160 mg-12.5 mg Tab, Exforge HCT 10 mg-160 mg-25 mg Tab, Exforge HCT 10 mg-320 mg-25 mg Tab, Exforge HCT 5 mg-160 mg-12.5 mg Tab, Exforge HCT 5 mg-160 mg-25 mg Tab, Medicare Part D Step Therapy Protocal
CURRENT AS OF 6/1/2011
CMS Approval Date 5/25/2011
CMS Marketing Materials Id Number H3251-1288_CMS approved 07182010
Step Therapy
Algorithm
Hyzaar 100 mg-12.5 mg Tab, Hyzaar 100 mg-25 mg Tab, Hyzaar 50 mg-12.5 mg Tab, losartan 100 mg Tab, losartan 25 mg Tab, losartan 50 mg Tab, losartan-hydrochlorothiazide 100 mg-12.5 mg Tab, losartan-hydrochlorothiazide 100 mg-25 mg Tab, losartan-hydrochlorothiazide 50 mg-12.5 mg Tab, Micardis 20 mg Tab, Micardis 40 mg Tab, Micardis 80 mg Tab, Micardis HCT 40 mg-12.5 mg Tab, Micardis HCT 80 mg-12.5 mg Tab, Micardis HCT 80 mg-25 mg Tab, Teveten 400 mg Tab, Teveten 600 mg Tab, Teveten HCT 600 mg-12.5 mg Tab, Teveten HCT 600 mg-25 mg Tab, Tribenzor 20 mg-5 mg-12.5 mg Tab, Tribenzor 40 mg-10 mg-12.5 mg Tab, Tribenzor 40 mg-10 mg-25 mg Tab, Tribenzor 40 mg-5 mg-12.5 mg Tab, Tribenzor 40 mg-5 mg-25 mg Tab, Twynsta 40 mg-10 mg Tab, Twynsta 40 mg-5 mg Tab, Twynsta 80 mg-10 mg Tab, Twynsta 80 mg-5 mg Tab Medicare Part D Step Therapy Protocal
CURRENT AS OF 6/1/2011
CMS Approval Date 5/25/2011
CMS Marketing Materials Id Number H3251-1288_CMS approved 07182010
Step Therapy
Algorithm
Diabetic_Step_Ther Current treatment guidelines for the management of Diabetes Step 1: Fortamet 1,000 mg 24 hr Tab Ctrl Rel, Fortamet requires the use of metformin before other classes of 500 mg 24 hr Tab Ctrl Rel, Glucophage 1,000 mg Tab, medications. The plan requires a trial of metformin before Glucophage 500 mg Tab, Glucophage 850 mg Tab, authorizing use of the following medication classes: Incretin Glucophage XR 500 mg 24 hr Tab, Glucophage XR 750 Mimetics, Biguanides, Thiazolidinediones, and DPP-4 Inhibitors mg 24 hr Tab, Glumetza 500 mg 24 hr Tab, metformin 1,000 mg Tab, metformin 500 mg Tab, metformin 850 mg Tab, metformin ER 500 mg 24 hr Tab, metformin ER 750 mg 24 hr Tab, RIOMET 500 mg/5 mL Oral Soln Step 2: Actoplus MET 15 mg-500 mg Tab, Actoplus MET 15 mg-850 mg Tab, Actos 15 mg Tab, Actos 30 mg Tab, Actos 45 mg Tab, AVANDAMET 2 mg-1,000 mg Tab, AVANDAMET 2 mg-500 mg Tab, AVANDAMET 4 mg-1,000 mg Tab, AVANDAMET 4 mg-500 mg Tab, Avandaryl 4 mg-1 mg Tab, Avandaryl 4 mg-2 mg Tab, Avandaryl 4 mg-4 mg Tab, Avandaryl 8 mg-2 mg Tab, Avandaryl 8 mg-4 mg Tab, Avandia 2 mg Tab, Avandia 4 mg Tab, Avandia 8 mg Tab, Byetta 10 mcg/0.04 mL per dose Sub-Q Pen Injector, Byetta 5 mcg/0.02 mL per dose Sub-Q Pen Injector, DUETACT 30 mg-2 mg Tab, DUETACT 30 mg-4 mg Tab, Janumet 50 mg-1,000 mg Tab, Janumet 50 mg-500 mg Tab, Januvia 100 mg Tab, Januvia 25 mg Tab, Januvia 50 mg Tab, Kombiglyze XR 2.5 mg-1,000 mg 24 hr Tab, Kombiglyze XR 5 mg-1,000 mg 24 hr Tab, Kombiglyze XR 5 mg-500 mg 24 hr Tab, Onglyza 2.5 mg Tab, Onglyza 5 mg Tab, Victoza 0.6 mg/0.1 mL (18 mg/3 mL) Sub-Q Pen Injector Medicare Part D Step Therapy Protocal
CURRENT AS OF 6/1/2011
CMS Approval Date 5/25/2011
CMS Marketing Materials Id Number H3251-1288_CMS approved 07182010
Step Therapy
Algorithm
The plan step therapy requires that there has been prior use of Step 1: omeprazole 10 mg Cap, Delayed Release, omeprazole (prescription only generic) documented in the omeprazole 20 mg Cap, Delayed Release, omeprazole 20 member medication profile before paying for any other proton mg Cap, Delayed Release, omeprazole 40 mg Cap, Delayed Release Step 2: Aciphex 20 mg Tab, Dexilant 30 mg Capsule, Dexilant 60 mg Capsule, lansoprazole 15 mg Cap, Delayed Release, lansoprazole 15 mg Rapid Dissolve Tab, Delayed Release, lansoprazole 30 mg Cap, Delayed Release, lansoprazole 30 mg Rapid Dissolve Tab, Delayed Release, Nexium 20 mg Cap, Nexium 40 mg Cap, Nexium IV 20 mg Solution, Nexium IV 40 mg Solution, Nexium Packet 10 mg Oral Susp, Nexium Packet 20 mg Oral Susp, Nexium Packet 40 mg Oral Susp, omeprazole-sodium bicarbonate 20 mg-1.1 gram Cap, omeprazole-sodium bicarbonate 40 mg-1.1 gram Cap, pantoprazole 20 mg Tab, Delayed Release, pantoprazole 40 mg Tab, Delayed Release, Prevacid 15 mg Cap, Prevacid 30 mg Cap, Prevacid SoluTab 15 mg Rapid Dissolve, Prevacid SoluTab 30 mg Rapid Dissolve, Prilosec 10 mg Cap, Prilosec 20 mg Cap, Prilosec 40 mg Cap, Protonix 20 mg Tab, Protonix 40 mg IV Solution, Protonix 40 mg Oral Susp, Protonix 40 mg Tab, Zegerid 20 mg-1,680 mg Oral Packet, Zegerid 20 mg-1.1 gram Cap, Zegerid 40 mg-1,680 mg Oral Packet, Zegerid 40 mg-1.1 gram Cap Medicare Part D Step Therapy Protocal
CURRENT AS OF 6/1/2011
CMS Approval Date 5/25/2011
CMS Marketing Materials Id Number H3251-1288_CMS approved 07182010
Step Therapy
Algorithm
Aliskiren--Indicated for hypertension treatment--The plan step Step 1: Accupril 10 mg Tab, Accupril 20 mg Tab, therapy requires that there has been use of an ACE Inhibitor or Accupril 40 mg Tab, Accupril 5 mg Tab, Accuretic 10 mg-12.5 mg Tab, Accuretic 20 mg-12.5 mg Tab, Accuretic 20 mg-25 mg Tab, Aceon 2 mg Tab, Aceon 4 mg Tab, Aceon 8 mg Tab, Altace 1.25 mg Cap, Altace 1.25 mg Tab, Altace 10 mg Cap, Altace 10 mg Tab, Altace 2.5 mg Cap, Altace 2.5 mg Tab, Altace 5 mg Cap, Altace 5 mg Tab, Atacand 16 mg Tab, Atacand 32 mg Tab, Atacand 4 mg Tab, Atacand 8 mg Tab, Atacand HCT 16 mg-12.5 mg Tab, Atacand HCT 32 mg-12.5 mg Tab, Atacand HCT 32 mg-25 mg Tab, Avalide 150 mg-12.5 mg Tab, Avalide 300 mg-12.5 mg Tab, Avalide 300 mg-25 mg Tab, Avapro 150 mg Tab, Avapro 300 mg Tab, Avapro 75 mg Tab, Azor 10 mg-20 mg Tab, Azor 10 mg-40 mg Tab, Azor 5 mg-20 mg Tab, Azor 5 mg-40 mg Tab, benazepril 10 mg Tab, benazepril 20 mg Tab, benazepril 20 mg Tab, benazepril 40 mg Tab, benazepril 5 mg Tab, benazepril-hydrochlorothiazide 10 mg-12.5 mg Tab, benazepril-hydrochlorothiazide 20 mg-12.5 mg Tab, benazepril-hydrochlorothiazide 20 mg-25 mg Tab, benazepril-hydrochlorothiazide 5 mg-6.25 mg Tab, Benicar 20 mg Tab, Benicar 40 mg Tab, Benicar 5 mg Tab, Benicar HCT 20 mg-12.5 mg Tab, Benicar HCT 40 mg-12.5 mg Tab, Benicar HCT 40 mg-25 mg Tab, captopril 100 mg Tab, captopril 12.5 mg Tab, captopril 25 mg Tab, captopril 50 mg Tab, captopril-hydrochlorothiazide 25 mg-15 mg Tab, captopril-hydrochlorothiazide 25 mg-25 mg Tab, captopril-hydrochlorothiazide 50 mg-15 mg Tab, captopril- Medicare Part D Step Therapy Protocal
CURRENT AS OF 6/1/2011
CMS Approval Date 5/25/2011
CMS Marketing Materials Id Number H3251-1288_CMS approved 07182010
Step Therapy
Algorithm
hydrochlorothiazide 50 mg-25 mg Tab, Cozaar 100 mg Tab, Cozaar 25 mg Tab, Cozaar 50 mg Tab, Diovan 160 mg Tab, Diovan 320 mg Tab, Diovan 40 mg Tab, Diovan 80 mg Tab, Diovan HCT 160 mg-12.5 mg Tab, Diovan HCT 160 mg-25 mg Tab, Diovan HCT 320 mg-12.5 mg Tab, Diovan HCT 320 mg-25 mg Tab, Diovan HCT 80 mg-12.5 mg Tab, enalapril maleate 10 mg Tab, enalapril maleate 2.5 mg Tab, enalapril maleate 20 mg Tab, enalapril maleate 5 mg Tab, enalapril-hydrochlorothiazide 10 mg-25 mg Tab, enalapril-hydrochlorothiazide 5 mg-12.5 mg Tab, Exforge 10 mg-160 mg Tab, Exforge 10 mg-320 mg Tab, Exforge 5 mg-160 mg Tab, Exforge 5 mg-320 mg Tab, Exforge HCT 10 mg-160 mg-12.5 mg Tab, Exforge HCT 10 mg-160 mg-25 mg Tab, Exforge HCT 10 mg-320 mg-25 mg Tab, Exforge HCT 5 mg-160 mg-12.5 mg Tab, Exforge HCT 5 mg-160 mg-25 mg Tab, fosinopril 10 mg Tab, fosinopril 20 mg Tab, fosinopril 40 mg Tab, fosinopril-hydrochlorothiazide 10 mg-12.5 mg Tab, fosinopril-hydrochlorothiazide 20 mg-12.5 mg Tab, Hyzaar 100 mg-12.5 mg Tab, Hyzaar 100 mg-25 mg Tab, Hyzaar 50 mg-12.5 mg Tab, lisinopril 10 mg Tab, lisinopril 2.5 mg Tab, lisinopril 20 mg Tab, lisinopril 30 mg Tab, lisinopril 40 mg Tab, LISINOPRIL 5 MG ORAL TABLET, lisinopril 5 mg Tab, lisinopril-hydrochlorothiazide 10 mg-12.5 mg Tab, lisinopril-hydrochlorothiazide 20 mg-12.5 mg Tab, lisinopril-hydrochlorothiazide 20 mg-25 mg Tab, losartan 100 mg Tab, losartan 25 mg Tab, losartan 50 mg Tab, losartan-hydrochlorothiazide 100 mg-12.5 mg Tab, Medicare Part D Step Therapy Protocal
CURRENT AS OF 6/1/2011
CMS Approval Date 5/25/2011
CMS Marketing Materials Id Number H3251-1288_CMS approved 07182010
Step Therapy
Algorithm
losartan-hydrochlorothiazide 100 mg-25 mg Tab, losartan-hydrochlorothiazide 50 mg-12.5 mg Tab, Lotensin 10 mg Tab, Lotensin 20 mg Tab, Lotensin 40 mg Tab, Lotensin 5 mg Tab, Lotensin HCT 10 mg-12.5 mg Tab, Lotensin HCT 20 mg-12.5 mg Tab, Lotensin HCT 20 mg-25 mg Tab, Lotensin HCT 5 mg-6.25 mg Tab, Mavik 1 mg Tab, Mavik 2 mg Tab, Mavik 4 mg Tab, Micardis 20 mg Tab, Micardis 40 mg Tab, Micardis 80 mg Tab, Micardis HCT 40 mg-12.5 mg Tab, Micardis HCT 80 mg-12.5 mg Tab, Micardis HCT 80 mg-25 mg Tab, moexipril 15 mg Tab, moexipril 7.5 mg Tab, moexipril-hydrochlorothiazide 15 mg-12.5 mg Tab, moexipril-hydrochlorothiazide 15 mg-25 mg Tab, moexipril-hydrochlorothiazide 7.5 mg-12.5 mg Tab, Monopril 10 mg Tab, Monopril 40 mg Tab, perindopril erbumine 2 mg Tab, perindopril erbumine 4 mg Tab, perindopril erbumine 8 mg Tab, Prinivil 10 mg Tab, Prinivil 20 mg Tab, Prinivil 5 mg Tab, Prinivil 5 mg Tab, Prinzide 10 mg-12.5 mg Tab, Prinzide 20 mg-12.5 mg Tab, quinapril 10 mg Tab, quinapril 20 mg Tab, quinapril 40 mg Tab, quinapril 5 mg Tab, quinapril-hydrochlorothiazide 10 mg-12.5 mg Tab, quinapril-hydrochlorothiazide 20 mg-12.5 mg Tab, quinapril-hydrochlorothiazide 20 mg-25 mg Tab, ramipril 1.25 mg Cap, ramipril 10 mg Cap, ramipril 2.5 mg Cap, ramipril 5 mg Cap, Tarka 1 mg-240 mg 24 hr Tab, Tarka 2 mg-180 mg 24 hr Tab, Tarka 2 mg-240 mg 24 hr Tab, Tarka 4 mg-240 mg 24 hr Tab, Teveten 400 mg Tab, Teveten 600 mg Tab, Teveten HCT 600 mg-12.5 mg Tab, Teveten Medicare Part D Step Therapy Protocal
CURRENT AS OF 6/1/2011
CMS Approval Date 5/25/2011
CMS Marketing Materials Id Number H3251-1288_CMS approved 07182010
Step Therapy
Algorithm
HCT 600 mg-25 mg Tab, trandolapril 1 mg Tab, trandolapril 2 mg Tab, trandolapril 4 mg Tab, Tribenzor 20 mg-5 mg-12.5 mg Tab, Tribenzor 40 mg-10 mg-12.5 mg Tab, Tribenzor 40 mg-10 mg-25 mg Tab, Tribenzor 40 mg-5 mg-12.5 mg Tab, Tribenzor 40 mg-5 mg-25 mg Tab, Twynsta 40 mg-10 mg Tab, Twynsta 40 mg-5 mg Tab, Twynsta 80 mg-10 mg Tab, Twynsta 80 mg-5 mg Tab, Uniretic 15 mg-12.5 mg Tab, Uniretic 15 mg-25 mg Tab, Uniretic 7.5 mg-12.5 mg Tab, Univasc 15 mg Tab, Univasc 7.5 mg Tab, Vaseretic 10 mg-25 mg Tab, Vasotec 10 mg Tab, Vasotec 2.5 mg Tab, Vasotec 20 mg Tab, Vasotec 5 mg Tab, Zestoretic 10 mg-12.5 mg Tab, Zestoretic 20 mg-12.5 mg Tab, Zestoretic 20 mg-25 mg Tab, Zestril 10 mg Tab, Zestril 2.5 mg Tab, Zestril 20 mg Tab, Zestril 30 mg Tab, Zestril 40 mg Tab, Zestril 5 mg Tab Step 2: Amturnide 150 mg-5 mg-12.5 mg Tab, Amturnide 300 mg-10 mg-12.5 mg Tab, Amturnide 300 mg-10 mg-25 mg Tab, Amturnide 300 mg-5 mg-12.5 mg Tab, Amturnide 300 mg-5 mg-25 mg Tab, Tekamlo 150 mg-10 mg Tab, Tekamlo 150 mg-5 mg Tab, Tekamlo 300 mg-10 mg Tab, Tekamlo 300 mg-5 mg Tab, Tekturna 150 mg Tab, Tekturna 300 mg Tab, Tekturna HCT 150 mg-12.5 mg Tab, Tekturna HCT 150 mg-25 mg Tab, Tekturna HCT 300 mg-12.5 mg Tab, Tekturna HCT 300 mg-25 mg Tab, Valturna 150 mg-160 mg Tab, Valturna 300 mg-320 mg Tab Medicare Part D Step Therapy Protocal
CURRENT AS OF 6/1/2011
CMS Approval Date 5/25/2011
CMS Marketing Materials Id Number H3251-1288_CMS approved 07182010
Step Therapy
Algorithm
Tiagabine--Indicated for adjunctive therapy of partial seizure Step 1: carbamazepine 100 mg Chewable Tab, disorder--The plan step therapy requires that there has been use carbamazepine 200 mg Tab, carbamazepine 200 mg/10 of phenytoin (Dilantin), carbamazepine (Tegretol), valproic acid mL Oral Susp, Depakene 250 mg Cap, Depakene 250 (Depakene), or Depakote within the past 180 days. mg/5 mL Syrup, Depakote 125 mg Tab, Depakote 250 mg Tab, Depakote 500 mg Tab, Depakote ER 250 mg 24 hr Tab, Depakote ER 500 mg 24 hr Tab, Depakote Sprinkles 125 mg sprinkle Cap, Dilantin Extended 100 mg Cap, Dilantin Infatabs 50 mg Chewable, Dilantin-125 125 mg/5 mL Oral Susp, divalproex 125 mg sprinkle Cap, divalproex ER 250 mg 24 hr Tab, divalproex ER 500 mg 24 hr Tab, Epitol 200 mg Tab, Phenytek 200 mg Cap, Phenytek 300 mg Cap, phenytoin 125 mg/5 mL Oral Susp, phenytoin sodium 50 mg/mL IV, phenytoin sodium extended 100 mg Cap, Tegretol 100 mg Chewable Tab, Tegretol 100 mg/5 mL Oral Susp, Tegretol 200 mg Tab, Tegretol XR 100 mg 12 hr Tab, Tegretol XR 200 mg 12 hr Tab, Tegretol XR 400 mg 12 hr Tab, valproic acid (as sodium salt) 250 mg/5 mL Syrup, valproic acid 250 mg Cap Step 2: Gabitril 12 mg Tab, Gabitril 16 mg Tab, Gabitril 2 mg Tab, Gabitril 4 mg Tab Medicare Part D Step Therapy Protocal
CURRENT AS OF 6/1/2011
CMS Approval Date 5/25/2011
CMS Marketing Materials Id Number H3251-1288_CMS approved 07182010

Index
Accupril 10 mg Tab . 2, 8
Depakote 250 mg Tab . 12 Depakote 500 mg Tab . 12 Medicare Part D Step Therapy Protocal
CURRENT AS OF 6/1/2011
CMS Approval Date 5/25/2011
CMS Marketing Materials Id Number H3251-1288_CMS approved 07182010
Medicare Part D Step Therapy Protocal
CURRENT AS OF 6/1/2011
CMS Approval Date 5/25/2011
CMS Marketing Materials Id Number H3251-1288_CMS approved 07182010
Medicare Part D Step Therapy Protocal
CURRENT AS OF 6/1/2011
CMS Approval Date 5/25/2011
CMS Marketing Materials Id Number H3251-1288_CMS approved 07182010

Source: http://www.lovelacemedicareplan.com/medicare-nm/docs/Lovelace%20Medicare%20Plan%20Step%20Therapy%20Guide.pdf