2017 step therapy (st) criteria - medicare coverage

2017 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 or click this [SEARCH] button and enter the name of your drug in the pop-up task pane.

Updated: 08/2017 Y0026_124334 Approved 1/12/2014

1

ANTIDIABETICS

Products Affected

Step 1: metformin 1,000 mg tablet

metformin 500 mg tablet

metformin 850 mg tablet

metformin ER 1,000 mg 24 hr

tablet,extended release

metformin ER 1,000 mg tablet,extended

release 24hr

metformin ER 500 mg 24 hr


metformin ER 500 mg tablet,extended

release 24 hr


release 24hr


release 24 hr

pioglitazone 15 mg-metformin 500 mg

tablet


tablet

Step 2: Actoplus Met XR 15 mg-1,000 mg


Actoplus Met XR 30 mg-1,000 mg


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 generic Metformin containing product, then the

member has met the criteria for coverage of Cycloset and/or ACTOPLUS

MET XR at the applicable copayment/coinsurance.


2

BRAND ARB

Products Affected

Step 1: amlodipine 10 mg-valsartan 160 mg tablet

amlodipine 10 mg-valsartan 160 mg-

hydrochlorothiazide 12.5 mg tablet


hydrochlorothiazide 25 mg tablet

amlodipine 10 mg-valsartan 320 mg tablet





hydrochlorothiazide 12.5 mg tablet




candesartan 16 mg tablet

candesartan 16 mg-hydrochlorothiazide

12.5 mg tablet


candesartan 32 mg-hydrochlorothiazide

12.5 mg tablet

candesartan 32 mg-hydrochlorothiazide 25

mg tablet



irbesartan 150 mg tablet

irbesartan 150 mg-hydrochlorothiazide

12.5 mg tablet


irbesartan 300 mg-hydrochlorothiazide

12.5 mg tablet


losartan 100 mg tablet

losartan 100 mg-hydrochlorothiazide 12.5

mg tablet

losartan 100 mg-hydrochlorothiazide 25

mg tablet




mg tablet

telmisartan 20 mg tablet


telmisartan 40 mg-hydrochlorothiazide

12.5 mg tablet


telmisartan 80 mg-hydrochlorothiazide

12.5 mg tablet

telmisartan 80 mg-hydrochlorothiazide 25

mg tablet

valsartan 160 mg tablet

valsartan 160 mg-hydrochlorothiazide

12.5 mg tablet

valsartan 160 mg-hydrochlorothiazide 25

mg tablet


valsartan 320 mg-hydrochlorothiazide

12.5 mg tablet


mg tablet



valsartan 80 mg-hydrochlorothiazide 12.5

mg tablet

Step 2: Benicar 20 mg tablet

Benicar 40 mg tablet

Benicar 5 mg tablet

Benicar HCT 20 mg-12.5 mg tablet

Benicar HCT 40 mg-12.5 mg tablet

Benicar HCT 40 mg-25 mg tablet


3

Details



had previous history of one step one agent then the member has met the

criteria for coverage of step 2 agent at the applicable

copayment/coinsurance


4

BRAND STATIN

Products Affected

Step 1: amlodipine 10 mg-atorvastatin 10 mg

tablet

amlodipine 10 mg-atorvastatin 20 mg

tablet


tablet


tablet

amlodipine 2.5 mg-atorvastatin 10 mg

tablet


tablet


tablet

amlodipine 5 mg-atorvastatin 10 mg tablet




atorvastatin 10 mg tablet




Step 2: Crestor 10 mg tablet

Crestor 20 mg tablet

Crestor 40 mg tablet

Crestor 5 mg tablet

Details







5

COREG CR

Products Affected

Step 1: carvedilol 12.5 mg tablet

carvedilol 25 mg tablet

carvedilol 3.125 mg tablet

carvedilol 6.25 mg tablet

Step 2: Coreg CR 10 mg capsule, extended release

Coreg CR 20 mg capsule, extended release



Details



had previous history of generic Carvedilol, then the member has met the

criteria for coverage of Brand Coreg CR at the applicable

copayment/coinsurance.


6

ELIDEL

Products Affected

Step 1: alclometasone 0.05 % topical cream

alclometasone 0.05 % topical ointment

amcinonide 0.1 % lotion

amcinonide 0.1 % topical cream

amcinonide 0.1 % topical ointment

betamethasone dipropionate 0.05 % lotion

betamethasone dipropionate 0.05 %

topical cream

betamethasone dipropionate 0.05 %

topical ointment

betamethasone valerate 0.1 % lotion

betamethasone valerate 0.1 % topical

cream


ointment


foam

betamethasone, augmented 0.05 % lotion

betamethasone, augmented 0.05 % topical

cream


gel


ointment

clobetasol 0.05 % lotion

clobetasol 0.05 % scalp solution

clobetasol 0.05 % shampoo

clobetasol 0.05 % topical foam

clobetasol 0.05 % topical gel

clobetasol 0.05 % topical ointment

clobetasol-emollient 0.05 % topical cream

desonide 0.05 % lotion

desonide 0.05 % topical cream

desonide 0.05 % topical ointment

desoximetasone 0.05 % topical cream

desoximetasone 0.05 % topical gel

desoximetasone 0.05 % topical ointment

desoximetasone 0.25 % topical cream

desoximetasone 0.25 % topical ointment

diflorasone 0.05 % topical cream

diflorasone 0.05 % topical ointment

fluocinolone 0.01 % topical body oil

fluocinolone 0.01 % topical cream

fluocinolone 0.01 % topical solution

fluocinolone 0.025 % topical cream

fluocinolone 0.025 % topical ointment

fluocinonide 0.05 % topical cream

fluocinonide 0.05 % topical gel

fluocinonide 0.05 % topical ointment

fluocinonide 0.05 % topical solution

fluocinonide 0.1 % topical cream

Fluocinonide-E 0.05% topical cream

fluticasone 0.005 % topical ointment

fluticasone 0.05 % lotion

fluticasone 0.05 % topical cream

halobetasol propionate 0.05 % topical

cream


ointment

hydrocortisone 1 % topical cream

hydrocortisone 1 % topical ointment

hydrocortisone 2.5 % lotion

hydrocortisone 2.5 % topical cream

hydrocortisone 2.5 % topical ointment

hydrocortisone butyrate 0.1 % topical

ointment


solution

hydrocortisone butyrate-emollient 0.1 %

topical cream

hydrocortisone valerate 0.2 % topical

cream


ointment


7

mometasone 0.1 % topical cream

mometasone 0.1 % topical ointment

mometasone 0.1 % topical solution

prednicarbate 0.1 % topical cream

prednicarbate 0.1 % topical ointment

triamcinolone acetonide 0.025 % lotion

triamcinolone acetonide 0.025 % topical

cream


ointment

triamcinolone acetonide 0.1 % lotion


cream


ointment


cream


ointment

Triderm 0.1 % topical cream

Step 2: Elidel 1 % topical cream

Details



had previous history of one topical generic Corticosteroid, then the

member has met the criteria for coverage of Elidel at the applicable



8

GLYBURIDE

Products Affected

Step 1: glimepiride 1 mg tablet

glimepiride 2 mg tablet

glimepiride 4 mg tablet

glipizide 10 mg tablet

glipizide 2.5 mg-metformin 250 mg tablet

glipizide 2.5 mg-metformin 500 mg tablet

glipizide 5 mg tablet

glipizide 5 mg-metformin 500 mg tablet

glipizide ER 10 mg tablet, extended

release 24 hr

glipizide ER 2.5 mg tablet, extended

release 24 hr

glipizide ER 5 mg tablet, extended release

24 hr

pioglitazone 30 mg-glimepiride 2 mg

tablet

pioglitazone 30 mg-glimepiride 4 mg

tablet

Step 2: glyburide 1.25 mg tablet

glyburide 1.25 mg-metformin 250 mg

tablet

glyburide 2.5 mg tablet

glyburide 2.5 mg-metformin 500 mg tablet

glyburide 5 mg tablet

glyburide 5 mg-metformin 500 mg tablet

glyburide micronized 1.5 mg tablet

glyburide micronized 3 mg tablet

glyburide micronized 6 mg tablet

Details







9

IMMUNOMODULATORS

Products Affected

Step 1: Humira 10 mg/0.2 mL subcutaneous

syringe kit

Humira 20 mg/0.4 mL subcutaneous

syringe kit

Humira 40 mg/0.8 mL subcutaneous

syringe kit

Humira Pediatric Crohn's Starter 40

mg/0.8 mL subcutaneous syringe kit

Humira Pediatric Crohn's Starter 40

mg/0.8 mL subcutaneous syringe kit (6

pack)

Humira Pen 40 mg/0.8 mL subcutaneous

Humira Pen Crohn's-Ulc Colitis-Hid Sup

Starter 40 mg/0.8 mL subcut kit

Humira Pen Psoriasis-Uveitis Starter 40

mg/0.8 mL subcutaneous kit

Step 2: Actemra 200 mg/10 mL (20 mg/mL)

intravenous solution

Actemra 400 mg/20 mL (20 mg/mL)




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

Xeljanz 5 mg tablet

Xeljanz XR 11 mg tablet,extended release

Details



had previous history of Humira, then the member has met the criteria for

coverage of Actemra, Xeljanz, Xeljanz XR or Cimzia at the applicable



10

NASAL STEROID

Products Affected

Step 1: budesonide 32 mcg/actuation nasal spray

flunisolide 25 mcg (0.025 %) nasal spray

fluticasone 50 mcg/actuation nasal

spray,suspension

mometasone 50 mcg/actuation nasal spray

Step 2: Nasonex 50 mcg/actuation Spray

Details







11

OPHTHALMIC ANTIHISTAMINES

Products Affected

Step 1: epinastine 0.05 % eye drops

Lastacaft 0.25 % eye drops

olopatadine 0.1 % eye drops

Pazeo 0.7 % eye drops

Step 2: Pataday 0.2 % eye drops

Details



had previous history of generic ophthalmic antihistamine, Lastacaft

solution, or Pazeo then the member has met the criteria for coverage of

Pataday solution at the applicable copayment/coinsurance.


12

OVERACTIVE BLADDER

Products Affected

Step 1: darifenacin ER 15 mg tablet,extended

release 24 hr

darifenacin ER 7.5 mg tablet,extended

release 24 hr

oxybutynin chloride 5 mg tablet

oxybutynin chloride 5 mg/5 mL syrup

oxybutynin chloride ER 10 mg

tablet,extended release 24 hr





tolterodine 1 mg tablet

tolterodine 2 mg tablet

tolterodine ER 2 mg capsule,extended

release 24 hr


release 24 hr

trospium 20 mg tablet

trospium ER 60 mg capsule,extended

release 24 hr

Step 2: Enablex 15 mg tablet,extended release

Enablex 7.5 mg tablet,extended release

Gelnique 10 % (100 mg/gram)

transdermal gel packet

Details







13

VOLTAREN GEL

Products Affected

Step 1: celecoxib 100 mg capsule

celecoxib 200 mg capsule



diclofenac 1 % topical gel

diclofenac 50 mg-misoprostol 200 mcg

tablet,immed.and delayed release


tablet,immediate,delayed release

diclofenac ER 100 mg tablet,extended

release 24 hr

diclofenac potassium 50 mg tablet

diclofenac sodium 25 mg tablet,delayed

release


release


release

diflunisal 500 mg tablet

etodolac 200 mg capsule

etodolac 300 mg capsule

etodolac 400 mg tablet

etodolac 500 mg tablet

etodolac ER 400 mg tablet,extended

release 24 hr


release 24 hr


release 24 hr

fenoprofen 600 mg tablet

flurbiprofen 100 mg tablet

flurbiprofen 50 mg tablet

ibuprofen 100 mg/5 mL oral suspension

ibuprofen 400 mg tablet



ketoprofen 50 mg capsule

ketoprofen 75 mg capsule

ketoprofen ER 200 mg 24 hr

capsule,extended release

meclofenamate 100 mg capsule

meclofenamate 50 mg capsule

mefenamic acid 250 mg capsule

meloxicam 15 mg tablet

meloxicam 7.5 mg tablet

nabumetone 500 mg tablet

nabumetone 750 mg tablet

Naprelan CR 750 mg tab,extended release

24 hr mphase

naproxen 125 mg/5 mL oral suspension

naproxen 250 mg tablet


naproxen 375 mg tablet,delayed release


naproxen 500 mg tablet,delayed release

naproxen sodium 275 mg tablet

naproxen sodium 550 mg tablet

naproxen sodium ER 375 mg

tablet,extended release 24hr mphase

oxaprozin 600 mg tablet

piroxicam 10 mg capsule

piroxicam 20 mg capsule

sulindac 150 mg tablet

sulindac 200 mg tablet

tolmetin 400 mg capsule

tolmetin 600 mg tablet

Step 2: Voltaren 1 % topical gel


14

Details







15

Index

A Actemra 200 mg/10 mL (20 mg/mL)

intravenous solution ................................ 9






tablet,extended release ............................ 1



alclometasone 0.05 % topical cream ....... 6, 7

alclometasone 0.05 % topical ointment .. 6, 7

amcinonide 0.1 % lotion ......................... 6, 7

amcinonide 0.1 % topical cream ............. 6, 7

amcinonide 0.1 % topical ointment ........ 6, 7


................................................................. 4


................................................................. 4


................................................................. 4


................................................................. 4

amlodipine 10 mg-valsartan 160 mg tablet 2,

3


hydrochlorothiazide 12.5 mg tablet .... 2, 3


hydrochlorothiazide 25 mg tablet ....... 2, 3

amlodipine 10 mg-valsartan 320 mg tablet 2,

3



amlodipine 2.5 mg-atorvastatin 10 mg tablet

................................................................. 4


................................................................. 4


................................................................. 4

amlodipine 5 mg-atorvastatin 10 mg tablet 4




amlodipine 5 mg-valsartan 160 mg tablet2, 3


hydrochlorothiazide 12.5 mg tablet .... 2, 3



amlodipine 5 mg-valsartan 320 mg tablet2, 3

atorvastatin 10 mg tablet ............................. 4




B Benicar 20 mg tablet ............................... 2, 3

Benicar 40 mg tablet ............................... 2, 3

Benicar 5 mg tablet ................................. 2, 3

Benicar HCT 20 mg-12.5 mg tablet ........ 2, 3

Benicar HCT 40 mg-12.5 mg tablet ........ 2, 3

Benicar HCT 40 mg-25 mg tablet ........... 2, 3

betamethasone dipropionate 0.05 % lotion 6,

7

betamethasone dipropionate 0.05 % topical

cream ................................................... 6, 7

betamethasone dipropionate 0.05 % topical

ointment .............................................. 6, 7

betamethasone valerate 0.1 % lotion ...... 6, 7

betamethasone valerate 0.1 % topical cream

............................................................. 6, 7


ointment .............................................. 6, 7

betamethasone valerate 0.12 % topical foam

............................................................. 6, 7

betamethasone, augmented 0.05 % lotion6, 7


cream ................................................... 6, 7


gel ........................................................ 6, 7


ointment .............................................. 6, 7

budesonide 32 mcg/actuation nasal spray . 10

C candesartan 16 mg tablet ......................... 2, 3


16

candesartan 16 mg-hydrochlorothiazide 12.5

mg tablet.............................................. 2, 3

candesartan 32 mg tablet ......................... 2, 3

candesartan 32 mg-hydrochlorothiazide 12.5

mg tablet.............................................. 2, 3

candesartan 32 mg-hydrochlorothiazide 25

mg tablet.............................................. 2, 3

candesartan 4 mg tablet ........................... 2, 3

candesartan 8 mg tablet ........................... 2, 3

carvedilol 12.5 mg tablet............................. 5

carvedilol 25 mg tablet................................ 5

carvedilol 3.125 mg tablet........................... 5

carvedilol 6.25 mg tablet............................. 5

celecoxib 100 mg capsule ................... 13, 14



celecoxib 50 mg capsule ..................... 13, 14

Cimzia 400 mg/2 mL (200 mg/mL x 2)

subcutaneous syringe kit ......................... 9

Cimzia Powder for Recon 400 mg (200 mg

x 2 vials) subcutaneous kit ...................... 9

clobetasol 0.05 % lotion .......................... 6, 7

clobetasol 0.05 % scalp solution ............. 6, 7

clobetasol 0.05 % shampoo..................... 6, 7

clobetasol 0.05 % topical foam ............... 6, 7

clobetasol 0.05 % topical gel .................. 6, 7

clobetasol 0.05 % topical ointment ......... 6, 7

clobetasol-emollient 0.05 % topical cream 6,

7

Coreg CR 10 mg capsule, extended release 5




Crestor 10 mg tablet .................................... 4



Crestor 5 mg tablet ...................................... 4

Cycloset 0.8 mg tablet................................. 1

D darifenacin ER 15 mg tablet,extended

release 24 hr .......................................... 12

darifenacin ER 7.5 mg tablet,extended

release 24 hr .......................................... 12

desonide 0.05 % lotion ............................ 6, 7

desonide 0.05 % topical cream ............... 6, 7

desonide 0.05 % topical ointment ........... 6, 7

desoximetasone 0.05 % topical cream .... 6, 7

desoximetasone 0.05 % topical gel ......... 6, 7

desoximetasone 0.05 % topical ointment 6, 7

desoximetasone 0.25 % topical cream .... 6, 7

desoximetasone 0.25 % topical ointment 6, 7

diclofenac 1 % topical gel ................... 13, 14


tablet,immed.and delayed release ... 13, 14


tablet,immediate,delayed release .... 13, 14

diclofenac ER 100 mg tablet,extended

release 24 hr .................................... 13, 14

diclofenac potassium 50 mg tablet ...... 13, 14


release ............................................. 13, 14


release ............................................. 13, 14


release ............................................. 13, 14

diflorasone 0.05 % topical cream ............ 6, 7

diflorasone 0.05 % topical ointment ....... 6, 7

diflunisal 500 mg tablet ...................... 13, 14

E Elidel 1 % topical cream ......................... 6, 7

Enablex 15 mg tablet,extended release ..... 12

Enablex 7.5 mg tablet,extended release .... 12

epinastine 0.05 % eye drops...................... 11

etodolac 200 mg capsule ..................... 13, 14

etodolac 300 mg capsule ..................... 13, 14

etodolac 400 mg tablet ........................ 13, 14

etodolac 500 mg tablet ........................ 13, 14

etodolac ER 400 mg tablet,extended release

24 hr ................................................ 13, 14


24 hr ................................................ 13, 14


24 hr ................................................ 13, 14

F fenoprofen 600 mg tablet .................... 13, 14

flunisolide 25 mcg (0.025 %) nasal spray . 10

fluocinolone 0.01 % topical body oil ...... 6, 7

fluocinolone 0.01 % topical cream ......... 6, 7


17

fluocinolone 0.01 % topical solution ...... 6, 7

fluocinolone 0.025 % topical cream ....... 6, 7

fluocinolone 0.025 % topical ointment ... 6, 7

fluocinonide 0.05 % topical cream ......... 6, 7

fluocinonide 0.05 % topical gel .............. 6, 7

fluocinonide 0.05 % topical ointment ..... 6, 7

fluocinonide 0.05 % topical solution ...... 6, 7

fluocinonide 0.1 % topical cream ........... 6, 7

Fluocinonide-E 0.05% topical cream ...... 6, 7

flurbiprofen 100 mg tablet .................. 13, 14

flurbiprofen 50 mg tablet .................... 13, 14

fluticasone 0.005 % topical ointment...... 6, 7

fluticasone 0.05 % lotion ........................ 6, 7

fluticasone 0.05 % topical cream ............ 6, 7

fluticasone 50 mcg/actuation nasal

spray,suspension ................................... 10

G Gelnique 10 % (100 mg/gram) transdermal

gel packet .............................................. 12

glimepiride 1 mg tablet ............................... 8



glipizide 10 mg tablet.................................. 8

glipizide 2.5 mg-metformin 250 mg tablet . 8

glipizide 2.5 mg-metformin 500 mg tablet . 8

glipizide 5 mg tablet.................................... 8

glipizide 5 mg-metformin 500 mg tablet .... 8


24 hr ........................................................ 8

glipizide ER 2.5 mg tablet, extended release

24 hr ........................................................ 8


24 hr ........................................................ 8

glyburide 1.25 mg tablet ............................. 8

glyburide 1.25 mg-metformin 250 mg tablet

................................................................. 8

glyburide 2.5 mg tablet ............................... 8

glyburide 2.5 mg-metformin 500 mg tablet 8

glyburide 5 mg tablet .................................. 8

glyburide 5 mg-metformin 500 mg tablet ... 8

glyburide micronized 1.5 mg tablet ............ 8

glyburide micronized 3 mg tablet ............... 8

glyburide micronized 6 mg tablet ............... 8

H halobetasol propionate 0.05 % topical cream

............................................................. 6, 7


ointment .............................................. 6, 7

Humira 10 mg/0.2 mL subcutaneous syringe

kit ............................................................ 9


kit ............................................................ 9


kit ............................................................ 9

Humira Pediatric Crohn's Starter 40 mg/0.8

mL subcutaneous syringe kit .................. 9

Humira Pediatric Crohn's Starter 40 mg/0.8

mL subcutaneous syringe kit (6 pack) .... 9

Humira Pen 40 mg/0.8 mL subcutaneous ... 9

Humira Pen Crohn's-Ulc Colitis-Hid Sup

Starter 40 mg/0.8 mL subcut kit ............. 9

Humira Pen Psoriasis-Uveitis Starter 40

mg/0.8 mL subcutaneous kit ................... 9

hydrocortisone 1 % topical cream ........... 6, 7

hydrocortisone 1 % topical ointment ...... 6, 7

hydrocortisone 2.5 % lotion .................... 6, 7

hydrocortisone 2.5 % topical cream........ 6, 7

hydrocortisone 2.5 % topical ointment ... 6, 7


ointment .............................................. 6, 7


solution ................................................ 6, 7

hydrocortisone butyrate-emollient 0.1 %

topical cream ....................................... 6, 7

hydrocortisone valerate 0.2 % topical cream

............................................................. 6, 7


ointment .............................................. 6, 7

I ibuprofen 100 mg/5 mL oral suspension . 13,

14

ibuprofen 400 mg tablet ...................... 13, 14



irbesartan 150 mg tablet .......................... 2, 3

irbesartan 150 mg-hydrochlorothiazide 12.5

mg tablet.............................................. 2, 3


18

irbesartan 300 mg tablet .......................... 2, 3

irbesartan 300 mg-hydrochlorothiazide 12.5

mg tablet.............................................. 2, 3

irbesartan 75 mg tablet ............................ 2, 3

K ketoprofen 50 mg capsule ................... 13, 14

ketoprofen 75 mg capsule ................... 13, 14

ketoprofen ER 200 mg 24 hr

capsule,extended release ................. 13, 14

L Lastacaft 0.25 % eye drops ....................... 11

losartan 100 mg tablet ............................. 2, 3


mg tablet.............................................. 2, 3

losartan 100 mg-hydrochlorothiazide 25 mg

tablet .................................................... 2, 3

losartan 25 mg tablet ............................... 2, 3

losartan 50 mg tablet ............................... 2, 3

losartan 50 mg-hydrochlorothiazide 12.5 mg

tablet .................................................... 2, 3

M meclofenamate 100 mg capsule .......... 13, 14

meclofenamate 50 mg capsule ............ 13, 14

mefenamic acid 250 mg capsule ......... 13, 14

meloxicam 15 mg tablet ...................... 13, 14

meloxicam 7.5 mg tablet ..................... 13, 14

metformin 1,000 mg tablet .......................... 1

metformin 500 mg tablet ............................. 1

metformin 850 mg tablet ............................. 1

metformin ER 1,000 mg 24 hr


metformin ER 1,000 mg tablet,extended

release 24hr ............................................. 1

metformin ER 500 mg 24 hr tablet,extended

release ..................................................... 1


release 24 hr ............................................ 1


release 24hr ............................................. 1


release 24 hr ............................................ 1

mometasone 0.1 % topical cream ........... 6, 7

mometasone 0.1 % topical ointment ....... 6, 7

mometasone 0.1 % topical solution ........ 6, 7

mometasone 50 mcg/actuation nasal spray 10

N nabumetone 500 mg tablet .................. 13, 14

nabumetone 750 mg tablet .................. 13, 14

Naprelan CR 750 mg tab,extended release

24 hr mphase ................................... 13, 14

naproxen 125 mg/5 mL oral suspension .. 13,

14

naproxen 250 mg tablet ....................... 13, 14


naproxen 375 mg tablet,delayed release .. 13,

14


naproxen 500 mg tablet,delayed release .. 13,

14

naproxen sodium 275 mg tablet .......... 13, 14

naproxen sodium 550 mg tablet .......... 13, 14

naproxen sodium ER 375 mg

tablet,extended release 24hr mphase13, 14

Nasonex 50 mcg/actuation Spray .............. 10

O olopatadine 0.1 % eye drops ..................... 11

oxaprozin 600 mg tablet...................... 13, 14

oxybutynin chloride 5 mg tablet ............... 12

oxybutynin chloride 5 mg/5 mL syrup...... 12


tablet,extended release 24 hr ................. 12





P Pataday 0.2 % eye drops ........................... 11

Pazeo 0.7 % eye drops .............................. 11


tablet ........................................................ 1


tablet ........................................................ 1

pioglitazone 30 mg-glimepiride 2 mg tablet 8

pioglitazone 30 mg-glimepiride 4 mg tablet 8

piroxicam 10 mg capsule .................... 13, 14

piroxicam 20 mg capsule .................... 13, 14

prednicarbate 0.1 % topical cream .......... 6, 7

prednicarbate 0.1 % topical ointment ..... 6, 7


19

S sulindac 150 mg tablet ........................ 13, 14

sulindac 200 mg tablet ........................ 13, 14

T telmisartan 20 mg tablet .......................... 2, 3

telmisartan 40 mg tablet .......................... 2, 3

telmisartan 40 mg-hydrochlorothiazide 12.5

mg tablet.............................................. 2, 3

telmisartan 80 mg tablet .......................... 2, 3

telmisartan 80 mg-hydrochlorothiazide 12.5

mg tablet.............................................. 2, 3

telmisartan 80 mg-hydrochlorothiazide 25

mg tablet.............................................. 2, 3

tolmetin 400 mg capsule ..................... 13, 14

tolmetin 600 mg tablet ........................ 13, 14

tolterodine 1 mg tablet .............................. 12

tolterodine 2 mg tablet .............................. 12


release 24 hr .......................................... 12


release 24 hr .......................................... 12

triamcinolone acetonide 0.025 % lotion . 6, 7


cream ................................................... 6, 7


ointment .............................................. 6, 7

triamcinolone acetonide 0.1 % lotion ..... 6, 7

triamcinolone acetonide 0.1 % topical cream

............................................................. 6, 7


ointment .............................................. 6, 7

triamcinolone acetonide 0.5 % topical cream

............................................................. 6, 7


ointment .............................................. 6, 7

Triderm 0.1 % topical cream .................. 6, 7

trospium 20 mg tablet ............................... 12

trospium ER 60 mg capsule,extended release

24 hr ...................................................... 12

V valsartan 160 mg tablet ........................... 2, 3


mg tablet.............................................. 2, 3


mg tablet.............................................. 2, 3

valsartan 320 mg tablet ........................... 2, 3


mg tablet.............................................. 2, 3


mg tablet.............................................. 2, 3

valsartan 40 mg tablet ............................. 2, 3

valsartan 80 mg tablet ............................. 2, 3


mg tablet.............................................. 2, 3

Voltaren 1 % topical gel ..................... 13, 14

X Xeljanz 5 mg tablet ..................................... 9

Xeljanz XR 11 mg tablet,extended release . 9


20

ConnectiCare, Inc. is an HMO/HMO-POS plan with a Medicare contract. Enrollment in

ConnectiCare depends on contract renewal.

Note to existing members: This formulary has changed since last year. Please review this

document to make sure that it still contains the drugs you take.

Beneficiaries must use network pharmacies to access their premium and/or

copayment/coinsurance may change on January 1, 2018

This document includes ConnectiCare VIP Medicare Plan’s partial formulary as of August 1,

2017. For a complete, updated formulary, please visit our website at

www.connecticare.com/Medicare or call the Member Services number below.

For alternative formats or language, please call Member Services toll free at:

1-800-CCI-CARE (1-800-224-2273) between the hours of 8:00 a.m. and 8:00 p.m., seven days a

week.

TTY/TDD users should call 1-800-842-9710.

17204 v15

2017 step therapy (st) criteria - medicare coverage

Documents