Timeline for Step-Edit Drugs - October-December 10 by ps94506

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									                                               Timeline for Step-Edit Drugs: October-December 10

      In many cases prior authorization criteria includes a trial of one or more drugs. Step-edit logic requires prior therapy
      with at least one targeted drug or drug class. To ensure consistent evaluation of requests and consistency of
      electronic searches for step-edits, the standard definition of a drug trial is necessary. The standard timeline can be
      waived if an adverse event occurs.

      Prior Authorization Drugs
      Accretropin® (somatropin)- 90-days trial of Tev-Tropin
      Caduet® (amlodipine/atorvastatin)- 30-days trial of simvastatin and Crestor
      Cimzia® (certolizumab pegol)- 90-days trial of Enbrel or Remicade
      Crestor® (rosuvastatin)- 30-days trial of simvastatin
      Genotropin® (somatropin)- 90-days trial of Tev-Tropin
      Humatrope® (somatropin)- 90-days trial of Tev-Tropin
      Humira™ (adalimumab)- 90-days trial of Enbrel or Remicade
      Kineret® (anakinra)- 90-days trial of Enbrel
      Lescol, XL® (fluvastatin)- 30-days trial of simvastatin and Crestor
      Lipitor® (atorvastatin)- 30-days trial of simvastatin and Crestor
      Lovaza (omega-3-acid ethyl ester)- 90- days trial of fish oil
      Norditropin® (somatropin)- 90-days trial of Tev-Tropin
      Nutropin® (somatropin)- 90-days trial of Tev-Tropin
      Omnitrope® (somatropin)- 90-days trial of Tev-Tropin
      Saizen® (somatropin)- 90-days trial of Tev-Tropin
      Serostim® (somatropin)- 90-days trial of Tev-Tropin
      Simcor® (niacin and simvastatin) 30-days trial of simvastatin and Crestor
      Ulesfia (benzyl alcohol)- 10-days trial of malathion
      Vytorin™ (eztimibe/simvastatin)- 30-days trial of simvastatin and Crestor


      Step-Edit Drugs (30-days trial unless otherwise noted)
      Abilify -Trial of risperidone
      Aciphex Trial of Prilosec OTC, Omeprazole 20mg, or Omeprazole OTC
      Adderall XR -Trial of Concerta
      AllerNaze- Trial of fluticasone
      Ambien CR- Trial of temazepam or triazolam AND Ambien
      Androderm- Trial of Androgel
      Avonex- 90-days Trial of Rebif or Copaxone
      Betaseron-90-days Trial of Rebif or Copaxone
      Cardura XL- Trial of Cardura
      Concerta – (Family Care Members Only)- Trial of 1 immed release stimulant
      Coreg CR- Trial of Coreg
      Cymbalta- Trial of Effexor XR
      Daytrana-Trial of Concerta
      Edluar - Trial of temazepam or triazolam AND Ambien
      Effexor XR- Trial of one SSRI (either brand or generic)
      Focalin XR -Trial of Concerta
      Geodon- Trial of risperidone
      Invega- Trial of immediate release risperidone & and another atypical antipsychotic
      Kapidex- Trial of Prilosec OTC, Omeprazole 20mg, or Omeprazole OTC




This document is updated quarterly and is subject to change.
        *Member should be on no more than one drug at a time in the same therapeutic category.
        Ŧ
          Limitation on Transition of Care authorization

         October - December 2010
          Rev: 7/21/2010
                                               Timeline for Step-Edit Drugs: October-December 10

      Keppra XR- Trial of levetiracetam
      Lamictal ODT- Trial of lamotrigine
      Lamictal XR- Trial of lamotrigine
      Lexapro- Trial/ failure of 2 generic SSRI - OR - 1 generic SSRI and Effexor XR
      Lindane- 10-days trial of malathion
      Lunesta- Trial of temazepam or triazolam AND Ambien
      Luvox CR- Trial of 2 SSRIs or 1 SSRI and Effexor XR
      Lyrica- Trial of gabapentin
      Metadate CD- Trial of Concerta
      Nexium- Trial of Prilosec OTC, Omeprazole 20mg, or Omeprazole OTC
      Omnaris- Trial of fluticasone
      Onglyza- Trial of Januvia
      Prevacid- Trial of Prilosec OTC, Omeprazole 20mg, or Omeprazole OTC
      Prilosec (Rx version)- Trial of Prilosec OTC, Omeprazole 20mg, or Omeprazole OTC
      Pristiq- Trial of 2 of non-venlafaxine antidepressant agents
      Protonix- Trial of Prilosec OTC, Omeprazole 20mg, or Omeprazole OTC
      Risperdal (brand)- Trial of risperidone
      Ritalin LA- Trial of Concerta
      Rozerem- Trial of temazepam or triazolam AND Ambien
      Seroquel, XR- Trial of risperidone
      Savella- Trial of gabapentin
      Singulair-(OFC members)- Trial of antihistamine and nasal steroid, or Dx of Asthma
      Sonata- Trial of temazepam or triazolam AND Ambien
      Strattera- Trial of Concerta
      Testim- Trial of Androgel
      Trilipix- Trial of Tricor or any fenofibrate
      Uloric- Trial of allopurinol
      Veramyst- Trial of Flonase
      Vyvanse- Trial of Concerta
      Zegerid- Trial of Prilosec OTC, Omeprazole 20mg, or Omeprazole OTC
      Zolpimist- Trial of temazepam or triazolam AND Ambien

      Drugs requiring an ACEI/ARB Step-Edit
      Atacand HCT Avapro         Avalide                    Atacand          Azor                Benicar        Benicar HCT
      Diovan         Diovan HCT Exforge                     Exforge HCT      Micardis            Micardis HCT   Tekturna
      Tekturna HCT Teveten       Teveten HCT




This document is updated quarterly and is subject to change.
        *Member should be on no more than one drug at a time in the same therapeutic category.
        Ŧ
          Limitation on Transition of Care authorization

         October - December 2010
          Rev: 7/21/2010

								
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