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Part D Step Therapy information

Drug Name: ACCOLATE | SINGULAIR | ZAFIRLUKAST

Step Therapy Group Description:
LEUKOTRIENE MODIFIERS

Step Therapy Criteria:
PRIOR CLAIM FOR INHALED CORTICOSTEROID (FLUTICASONE, BECLOMETHASONE, FLUNISOLIDE, BUDESONIDE) WITHIN THE PAST 120 DAYS.

Drug Name: ACTOS

Step Therapy Group Description:
HYPOGLYCEMICS

Step Therapy Criteria:
PRIOR CLAIM OF BIGUANIDE (METFORMIN) FOR A MINIMUM OF 15 DAYS SUPPLY WITHIN THE PAST 120 DAYS.

Drug Name: ADVAIR DISKUS | ADVAIR HFA

Step Therapy Group Description:
ORAL INHALED CORTICOSTEROIDS

Step Therapy Criteria:
PRIOR CLAIM FOR INHALED CORTICOSTEROID (FLUTICASONE, BECLOMETHASONE, FLUNISOLIDE, BUDESONIDE) WITHIN THE PAST 120 DAYS.

Drug Name: COMTAN | STALEVO 100 | STALEVO 125 | STALEVO 150 | STALEVO 200 | STALEVO 50 | STALEVO 75 | TASMAR

Step Therapy Group Description:
ANTIPARKINSON DRUGS

Step Therapy Criteria:
PRIOR CLAIM FOR CARBIDOPA/LEVODOPA FOR A MINIMUM OF 15 DAYS SUPPLY WITHIN THE PAST 120 DAYS.

Drug Name: CONCERTA | METHYLIN ER

Step Therapy Group Description:
TREATMENT FOR ATTENTION DEFICIT-HYPERACTIVITY (ADHD)/NARCOLEPSY

Step Therapy Criteria:
PRIOR CLAIM FOR GENERIC AMPHETAMINE ASP/AMPHETAMINE/D-AMPHETAMINE OR GENERIC METHYLPHENIDATE FOR A MINIMUM OF 15 DAYS SUPPLY WITHIN THE PAST 120 DAYS.

Drug Name: DETROL | DETROL LA | OXYBUTYNIN CHLORIDE ER

Step Therapy Group Description:
URINARY TRACT ANTISPASMODIC/ANTI-INCONTINENCE AGENTS

Step Therapy Criteria:
PRIOR CLAIM FOR GENERIC OXYBUTYNIN FOR A MINIMUM OF 15 DAYS SUPPLY WITHIN THE PAST 120 DAYS.

Drug Name: DEXMETHYLPHENIDATE HCL | FOCALIN XR

Step Therapy Group Description:
ADRENERGICS, AROMATIC, NON-CATECHOLAMINE

Step Therapy Criteria:
PRIOR CLAIM FOR GENERIC AMPHETAMINE ASP/AMPHETAMINE/D-AMPHETAMINE OR METHYLPHENIDATE FOR A MINIMUM OF 15 DAYS SUPPLY WITHIN THE PAST 120 DAYS.

Drug Name: IPRATROPIUM BROMIDE

Step Therapy Group Description:
IPRATROPIUM NASAL

Step Therapy Criteria:
PRIOR CLAIM OF FLUTICASONE OR FLUNISOLIDE FOR A MINIMUM OF 15 DAYS SUPPLY WITHIN THE PAST 120 DAYS.

Drug Name: KETEK

Step Therapy Group Description:
KETOLIDES

Step Therapy Criteria:
PRIOR USE OF AZITHROMYCIN OR CLARITHROMYCIN WITHIN THE PAST 30 DAYS.

Drug Name: LANSOPRAZOLE

Step Therapy Group Description:
ANTI-ULCER PREPARATIONS

Step Therapy Criteria:
PRIOR CLAIM FOR OMEPRAZOLE FOR A MINIMUM OF 15 DAYS SUPPLY WITHIN THE PAST 120 DAYS.

Drug Name: SINGULAIR

Step Therapy Group Description:
SINGULAIR

Step Therapy Criteria:
PRIOR CLAIM FOR A NASAL INHALED CORTICOSTEROIDS (FLUNISOLIDE, FLUTICASONE) AND TRIAL OF NON SEDATING ANTIHISTAMINE (LORATADINE, FEXOFENADINE) FOR A MINIMUM OF 15 DAYS SUPPLY WITH IN THE LAST 120 DAYS

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