Emblem MMP 2016 Part D Step Therapy Criteria 2
User Manual: Part-D-Step-Therapy-Criteria-2
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2016 Step Therapy (ST) Criteria Some drugs require step therapy pre-approval. This means that your doctor must have you first try a different drug to treat your medical condition before we will cover a drug that needs step therapy pre-approval. Below you will find a table of drugs that require step therapy pre-approval. If you find your drug on this list, talk to your doctor about what other drugs you could try first. To see if your drug is on the list refer to the index located at the end of this document for the medication you are looking for. ANTIDIABETICS Products Affected Step 2: Actoplus Met XR 15 mg-1,000 mg tablet,extended release Actoplus Met XR 30 mg-1,000 mg tablet,extended release Cycloset 0.8 mg tablet Details Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of Metformin, Metformin ER, Pioglitazone/Metformin, then the member has met the criteria for coverage of Cycloset and/or ACTOPLUS MET XR at the applicable copayment/coinsurance. Updated: 05/2016 H0811_GN131_Web ST Protocol_GN Review Approved 1 COREG CR Products Affected Step 2: Coreg CR 10 mg capsule, extended release Coreg CR 20 mg capsule, extended release Coreg CR 40 mg capsule, extended release Coreg CR 80 mg capsule, extended release Details Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of generic Carvedilol, then the member has met the criteria for coverage of Brand Coreg CR at the applicable copayment/coinsurance. Updated: 05/2016 H0811_GN131_Web ST Protocol_GN Review Approved 2 ELIDEL Products Affected Step 2: Elidel 1 % topical cream Details Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of one topical generic Corticosteroid, then the member has met the criteria for coverage of Elidel at the applicable copayment/coinsurance. Updated: 05/2016 H0811_GN131_Web ST Protocol_GN Review Approved 3 IMMUNOMODULATORS Products Affected Step 2: Actemra 200 mg/10 mL (20 mg/mL) intravenous solution Actemra 400 mg/20 mL (20 mg/mL) intravenous solution Actemra 80 mg/4 mL (20 mg/mL) intravenous solution Cimzia 400 mg/2 mL (200 mg/mL x 2) subcutaneous syringe kit Cimzia Powder for Recon 400 mg (200 mg x 2 vials) subcutaneous kit Cosentyx 150 mg/mL subcutaneous syringe Cosentyx Pen 150 mg/mL subcutaneous Orencia (with maltose) 250 mg intravenous solution Details Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of Humira, then the member has met the criteria for coverage of Actemra, Cimzia, Cosentyx at the applicable copayment/coinsurance. Updated: 05/2016 H0811_GN131_Web ST Protocol_GN Review Approved 4 OPHTALMIC ANTIHISTAMINES Products Affected Step 2: Pataday 0.2 % eye drops Details Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of Epinastine solution, Lastacaft solution, then the member has met the criteria for coverage of Pataday solution at the applicable copayment/coinsurance. Updated: 05/2016 H0811_GN131_Web ST Protocol_GN Review Approved 5 OVERACTIVE BLADDER Products Affected Step 2: Gelnique 10 % (100 mg/gram) transdermal gel packet Details Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of one of the following OXYBUTYNIN CHLORIDE, OXYBUTYNIN CHLORIDE ER, TOLTERODINE TARTRATE ER, TOLTERODINE TARTRATE, TROSPIUM CHLORIDE ER, or TROSPIUM CHLORIDE, then the member has met the criteria for coverage of Gelnique, at the applicable copayment/coinsurance. Updated: 05/2016 H0811_GN131_Web ST Protocol_GN Review Approved 6 VOLTAREN GEL Products Affected Step 2: Voltaren 1 % topical gel Details Criteria As per the protocol, the member's electronic medication profile will be reviewed over the prior 90 days. If the profile shows that the member has had previous history of one generic oral NSAID, then the member has met the criteria for coverage of Voltaren gel at the applicable copayment/coinsurance. Updated: 05/2016 H0811_GN131_Web ST Protocol_GN Review Approved 7 Index A Actemra 200 mg/10 mL (20 mg/mL) intravenous solution ................................ 4 Actemra 400 mg/20 mL (20 mg/mL) intravenous solution ................................ 4 Actemra 80 mg/4 mL (20 mg/mL) intravenous solution ................................ 4 Actoplus Met XR 15 mg-1,000 mg tablet,extended release ............................ 1 Actoplus Met XR 30 mg-1,000 mg tablet,extended release ............................ 1 C Cimzia 400 mg/2 mL (200 mg/mL x 2) subcutaneous syringe kit ......................... 4 Cimzia Powder for Recon 400 mg (200 mg x 2 vials) subcutaneous kit ...................... 4 Coreg CR 10 mg capsule, extended release 2 Coreg CR 20 mg capsule, extended release 2 Coreg CR 40 mg capsule, extended release 2 Coreg CR 80 mg capsule, extended release 2 Cosentyx 150 mg/mL subcutaneous syringe ................................................................. 4 Cosentyx Pen 150 mg/mL subcutaneous .... 4 Cycloset 0.8 mg tablet................................. 1 E Elidel 1 % topical cream ............................. 3 G Gelnique 10 % (100 mg/gram) transdermal gel packet ................................................ 6 O Orencia (with maltose) 250 mg intravenous solution.................................................... 4 P Pataday 0.2 % eye drops ............................. 5 V Voltaren 1 % topical gel ............................. 7 Updated: 05/2016 H0811_GN131_Web ST Protocol_GN Review Approved 8 GuildNet Gold Plus FIDA Plan is a managed care plan that contracts with both Medicare and New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. Beneficiaries must use network pharmacies to access their premium and/or copayment/coinsurance may change on January 1, 2017. This document includes GuildNet Gold Plus FIDA Plan’s partial formulary as of May 1, 2016. For a complete, updated formulary, please visit our website at www.guildnetny.org or call 1-800815-0000 (TTY 1-800-662-1220). For alternative formats or language, please call Participant Services toll free at: 1-800-815-0000, Monday through Sunday from 8am to 8pm. TTY/TDD users should call 1-800-662-1220. You can get this information for free in other languages. Call 1-800-815-0000 and TTY/TDD 1800-662-1220 during 8am to 8pm. The call is free. Usted puede obtener esta información en otros idiomas gratis. Llame al 1-800-815-0000 o TTY/TDD al 1-800-662-1220, de lunes a domingo de 8am a 8pm. La llamada es gratis. Queste informazioni sono disponibili gratuitamente in altre lingue. Chiamare il numero verde 1800-815-0000 o 1-800-662-1220 mediante un telefono testuale per non udenti (TTY/TDD), da lunedì a domenica, dalle 8 alle 20. La chiamata è gratuita. 您可以免費獲得本信息的其他語言版本。請撥打 1-800-815-0000 或聽障／語障人士專線 (TTY/TDD) 1-800-662-1220，星期一至星期日上午 8 時至晚上 8 時。撥打該電話免費。 Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang. Rele nimewo 1-800-815-0000 oswa TTY/TDD 1-800-662-1220, lendi jiska dimanch, depi 8am jiska 8pm. Koutfil la gratis. 다른 언어로 작성된 이 정보를 무료로 얻으실 수 있습니다. 월요일 - 일요일 오전 8시부터 오후 8시 사이에 1-800-815-0000번이나 TTY/TDD 1-800-662-1220번으로 전화주세요. 통화는 무료입니다. Вы можете бесплатно получить эту информацию на других языках. Позвоните по телефону 1-800-815-0000 и TTY/TDD 1-800-662-1220. Служба работает с понедельника по воскресенье с 08:00 до 20:00 ч. Звонок бесплатный. The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by GuildNet Gold Plus FIDA Plan. ICAN may be reached toll-free at 1-844614-8800 or online at icannys.org. 16143 v10 Updated: 05/2016 H0811_GN131_Web ST Protocol_GN Review Approved 9
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