2018 STEP THERAPY CRITERIA UCare Connect (SNBC)

MinnesotaCare Prepaid Medical Assistance Program (PMAP)

Minnesota Senior Care Plus (MSC+) In some cases, UCare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, UCare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, UCare will then cover Drug B. This is a list of drugs that require these steps for us to provide coverage.

UCare PMAP, MinnesotaCare, and MSC+ members with questions should call UCare Customer Services at 1-800-203-7225 toll free. UCare Connect members with questions should call 1-877-903-0061 toll free. TTY machine users can call 1-800-688-2534. Hours of operation are 8 a.m. - 5 p.m., Monday-Friday.

PMAP MnCare MSC+ SNBC_102617_2 DHS Approved (11032017) Updated 11/2017

U6428 (11/17)

American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For enrollees age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your primary care provider prior to the referral.

BISPHOSPHONATES

Products Affected• ibandronate 150 mg tabletDetails

Criteria If a patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given. Step 1 drug(s): alendronate, etidronate. Step 2 drug(s): ibandronate.

1

BPH Step Therapy

Products Affected• dutasteride 0.5 mg capsule• dutasteride 0.5 mg-tamsulosin er 0.4 mg

capsule ext.release 24hr mphas

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given.

Step 1 Drug(s) include: Finasteride

Step 2 Drug(s) include: dutasteride, dutasteride-tamsulosin.

Number of days for retrospective claims review for Step 1 drugs: 180 days.

This step therapy program applies to new utilizers only.

2

Colcrys

Products Affected• COLCRYS 0.6 MG TABLETDetails

Criteria If the patient has tried one Step 1 product (Mitigare), authorization for a Step 2 (Colcrys) product may be given.

Exceptions can be made for a step 2 drug (without a trial of a step 1 drug) for the treatment of Familial Mediterranean Fever and for the treatment of gout flares (i.e, prophylaxis of gout flares requires a trial of a step 1 drug)

3

COX-2 Step Therapy

Products Affected• celecoxib 100 mg capsule• celecoxib 200 mg capsule

• celecoxib 400 mg capsule• celecoxib 50 mg capsule

Details

Criteria If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given.

Step 1 Drug(s) include: diclofenac, diclofenac ER, diclofenac potassium, etodolac, etodolac er, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketoprofen ER, ketorolac, meclofenamate, meloxicam, nabumetone, naproxen, naproxen ec, naproxen sodium, nabumetone, oxaprozin, piroxicam, sulindac, tolmetin.

Step 2 Drug(s) include: celecoxib, Celebrex.

This step therapy program will exclude participants with a claims history of warfarin (Coumadin) or dabigatran (Pradaxa) within the last 180 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, fondaparinux (Arixtra), apixaban (Eliquis) or low molecular weight heparins.

Authorization for Celebrex may be given for patients aged greater than 75 years who are requesting Celebrex for a chronic condition.

Number of days for claims review for Step 1 drugs: 180 days.

This step therapy program applies to new utilizers only.

4

Novel Antipsychotics Step Therapy

Products Affected• aripiprazole 1 mg/ml oral solution• aripiprazole 10 mg disintegrating tablet• aripiprazole 10 mg tablet• aripiprazole 15 mg disintegrating tablet• aripiprazole 15 mg tablet• aripiprazole 2 mg tablet• aripiprazole 20 mg tablet• aripiprazole 30 mg tablet• aripiprazole 5 mg tablet• LATUDA 120 MG TABLET• LATUDA 20 MG TABLET• LATUDA 40 MG TABLET• LATUDA 60 MG TABLET• LATUDA 80 MG TABLET• olanzapine 10 mg disintegrating tablet• olanzapine 15 mg disintegrating tablet• olanzapine 20 mg disintegrating tablet

• olanzapine 5 mg disintegrating tablet• quetiapine er 150 mg tablet,extended

release 24 hr• quetiapine er 200 mg tablet,extended

release 24 hr• quetiapine er 300 mg tablet,extended

release 24 hr• quetiapine er 400 mg tablet,extended

release 24 hr• quetiapine er 50 mg tablet,extended

release 24 hr• risperidone 0.25 mg disintegrating tablet• risperidone 0.5 mg disintegrating tablet• risperidone 1 mg disintegrating tablet• risperidone 2 mg disintegrating tablet• risperidone 3 mg disintegrating tablet• risperidone 4 mg disintegrating tablet

Details

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given.

Step 1 Drug(s) include: olanzapine, risperidone, ziprasidone and quetiapine IR.

Step 2 Drug(s) include: aripiprazole, Latuda, quetiapine ER.

Authorization for the following drugs may be given without a trial of a Step 1 drug: quetiapine ER (if the patient has a diagnosis of major depressive disorder and currently on an antidepressant), aripiprazole (if patient has a diagnosis of Major Depressive Disorder and receiving antidepressants).

Patients under the age of 18 are excluded from step therapy requirements.

Number of days for retrospective claims review for Step 1 drugs: 180 days.

This step therapy program applies to new utilizers only.

5

Oxycontin

Products Affected• OXYCODONE ER 10 MG

TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR

• OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR

• OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR

• OXYCODONE ER 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12

HR• OXYCONTIN 10 MG TABLET,CRUSH

RESISTANT,EXTENDED RELEASE• OXYCONTIN 15 MG TABLET,CRUSH

RESISTANT,EXTENDED RELEASE• OXYCONTIN 20 MG TABLET,CRUSH

RESISTANT,EXTENDED RELEASE• OXYCONTIN 30 MG TABLET,CRUSH

RESISTANT,EXTENDED RELEASE• OXYCONTIN 40 MG TABLET,CRUSH

RESISTANT,EXTENDED RELEASE• OXYCONTIN 60 MG TABLET,CRUSH

RESISTANT,EXTENDED RELEASE• OXYCONTIN 80 MG TABLET,CRUSH

RESISTANT,EXTENDED RELEASEDetails

Criteria If the patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given.

Step 1 Drug(s) include: Morphine ER (or provide a medical reason why they cannot take the alternative medication).

Number of days for claims review for first line drugs: 180 days.

This step therapy program applies to new utilizers only.

6

Rosuvastatin

Products Affected• rosuvastatin 10 mg tablet• rosuvastatin 20 mg tablet

• rosuvastatin 40 mg tablet• rosuvastatin 5 mg tablet

Details

Criteria If patient has tried a Step 1 drug, then authorization for a Step 2 drug may be given.

Step 1 drug(s): atorvastatin, lovastatin, pravastatin, simvastatin Step 2 drug(s): rosuvastatin

7

Sedative Hypnotic

Products Affected• eszopiclone 1 mg tablet• eszopiclone 2 mg tablet

• eszopiclone 3 mg tablet

Details

Criteria If the patient has tried two Step 1 drugs, then authorization for a Step 2 drug may be given.

Step 1 Drug(s) include: zolpidem IR (Ambien), zolpidem ER (Ambien CR) or zaleplon (Sonata)

Step 2 Drug(s) include : eszopiclone (Lunesta)

Number of days for retrospective claims review for Step 1 drugs: 180 days.

This step therapy program applies to new utilizers only.

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Index

aripiprazole 1 mg/ml oral solution............5aripiprazole 10 mg disintegrating tablet...5aripiprazole 10 mg tablet......................... 5aripiprazole 15 mg disintegrating tablet...5aripiprazole 15 mg tablet......................... 5aripiprazole 2 mg tablet........................... 5aripiprazole 20 mg tablet......................... 5aripiprazole 30 mg tablet......................... 5aripiprazole 5 mg tablet........................... 5celecoxib 100 mg capsule....................... 4celecoxib 200 mg capsule....................... 4celecoxib 400 mg capsule....................... 4celecoxib 50 mg capsule......................... 4COLCRYS 0.6 MG TABLET....................3dutasteride 0.5 mg capsule..................... 2dutasteride 0.5 mg-tamsulosin er 0.4 mg capsule ext.release 24hr mphas........2eszopiclone 1 mg tablet...........................8eszopiclone 2 mg tablet...........................8eszopiclone 3 mg tablet...........................8ibandronate 150 mg tablet.......................1LATUDA 120 MG TABLET...................... 5LATUDA 20 MG TABLET........................ 5LATUDA 40 MG TABLET........................ 5LATUDA 60 MG TABLET........................ 5LATUDA 80 MG TABLET........................ 5olanzapine 10 mg disintegrating tablet.... 5olanzapine 15 mg disintegrating tablet.... 5olanzapine 20 mg disintegrating tablet.... 5olanzapine 5 mg disintegrating tablet...... 5OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR...................................................... 6OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR...................................................... 6OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR...................................................... 6

OXYCODONE ER 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR...................................................... 6OXYCONTIN 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE...... 6OXYCONTIN 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE...... 6OXYCONTIN 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE...... 6OXYCONTIN 30 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE...... 6OXYCONTIN 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE...... 6OXYCONTIN 60 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE...... 6OXYCONTIN 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE...... 6quetiapine er 150 mg tablet,extended release 24 hr............................................5quetiapine er 200 mg tablet,extended release 24 hr............................................5quetiapine er 300 mg tablet,extended release 24 hr............................................5quetiapine er 400 mg tablet,extended release 24 hr............................................5quetiapine er 50 mg tablet,extended release 24 hr............................................5risperidone 0.25 mg disintegrating tablet........................................................5risperidone 0.5 mg disintegrating tablet...5risperidone 1 mg disintegrating tablet......5risperidone 2 mg disintegrating tablet......5risperidone 3 mg disintegrating tablet......5risperidone 4 mg disintegrating tablet......5rosuvastatin 10 mg tablet........................ 7rosuvastatin 20 mg tablet........................ 7rosuvastatin 40 mg tablet........................ 7rosuvastatin 5 mg tablet.......................... 7

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