Download 2014 AlohaCare Advantage (HMO) and AlohaCare Advantage Plus

2014 AlohaCare Advantage (HMO) and AlohaCare Advantage Plus Formulary (HMO SNP)
Drugs with Step Therapy Requirements
AlohaCare requires you to first try one drug to treat your medical condition before we will cover another drug for that condition. Below is the list of
drugs with step therapy requirements.
Drug Name
glipizide-metformin
glyburide-metformin
Janumet
Janumet XR
Jentadueto
Kazano
Kombiglyze XR
metformin
metformin ER
Prandimet
RIOMET
Actoplus MET
Actoplus Met XR
Actos
DUETACT
Oseni
pioglitazone
candesartan
eprosartan
losartan
losartan-hydrochlorothiazide
valsartan-hydrocholorothiazide
Cozaar
Diovan
Diovan HCT
Edarbi
Hyzaar
Step Therapy Group
Actos Family of Drugs
Angiotensin Receptor Antagonist (ARBs)
H5969_501502_1 CMS Approved 07222011
Step Number
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
1
1
1
1
1
2
2
2
2
2
Description
First-line agents are metformin,
metformin/glipizide, metformin/glyburide,
metformin/repaglinide, metformin/sitagliptin,
metformin/saxagliptin, metformin/linagliptan, or
metformin/alogliptin combination products. If
any first line agents have been tried in the last
180 days then Actos, pioglitazone, Duetact,
ActoPlus Met, pioglitazone/metformin,
ActoPlus Met XR, or Oseni can be used as
2nd-line agents.
Generic ARBs and generic ARB combination
products are First Line Agents. Brand ARBs
and brand ARB combination products on the
formulary are Second Line Agents.
Updated 10/1/2013
Actoplus MET
Actoplus Met XR
glipizide-metformin
glyburide-metformin
metformin
metformin ER
pioglitazone
Prandimet
RIOMET
Janumet
Janumet XR
Jentadueto
Kazano
Kombiglyze XR
Januvia
Nesina
Onglyza
Tradjenta
Byetta
Victoza
Bydureon XR
Advicor XR
lovastatin
pravastatin
simvastatin
Vytorin
atorvastatin
Crestor
Dipeptidyl Peptidase IV Inhibitors
Glucagon-Like Peptide-1 (GLP-1) Receptor
Agonists
HMG CoA Reductase Inhibitors (Statins)
H5969_501502_1 CMS Approved 07222011
1
1
1
1
1
1
1
1
1
2
2
2
2
2
3
3
3
3
1
1
2
1
1
1
1
1
2
3
Metformin, metformin/glyburide,
metformin/glipizide, metformin/repaglinide,
metformin/pioglitazone, or metformin/alogliptin
combination products must be used as first
line agents. If a first line agent was tried then
2nd-line agents Janumet, Janumet XR,
Kombiglyze XR, Jentadueto, or Kazano may
be used. Januvia, Onglyza, Tradjenta, and
Nesina should only be used as 3rd line agents.
Exenatide and liraglutide are first-line agents.
Exenatide ER should be used as a second line
agent if first-line agents have been tried.
First line agents are simvastatin, lovastatin,
pravastatin, or any combination simvastatin or
lovastatin product. 2nd line agent is
atorvastatin. 3rd line agent is Crestor.
Updated 10/1/2013
cetirizine
cetirizine oral solution
levocetirizine
Levocetirizine oral solution
OTC-PRODUCT
desloratadine
desloratadine disintegrating
Clarinex
Clarinex disintergrating
Clarinex oral solution
Xyzal
Xyzal oral solution
alendronate
Boniva
ibandronate
Actonel
Atelvia
Fosamax Plus D
omeprazole
OTC-PRODUCT
lansoprazole
pantoprazole
Dexilant
allopurinol
Aloprim
Uloric
Non-Sedating/Low-Sedating Antihistamines
(NS/LSA)
Oral Bisphosphonate Agents
Proton Pump Inhibitors (PPIs)
Uricosuric Agents
1
1
1
1
1
1
1
2
2
2
2
2
1
1
1
2
2
2
1
1
2
2
3
The first-line NS/LSA drugs are OTC
loratadine, prescription generic loratadine,
prescription generic desloratadine, OTC
fexofenadine, prescription generic
fexofenadine, OTC cetirizine, or prescription
generic cetirizine. Brand NS/LSA drugs will be
covered as 2nd-line agents where OTC
loratadine, prescription generic loratadine,
prescription generic desloratadine, OTC
fexofenadine, prescription generic
fexofenadine, OTC cetirizine, or prescription
generic cetirizine have been tried.
1
1
2
Must have tried and failed allopurinol first then
Uloric may be used as a 2nd line agent.
First-line Oral Bisphosphonate is alendronate
or Boniva. Must have tried alendronate or
Boniva in the last 180 days before using other
formulary Oral Bisphosphonate agents.
First-line PPI's are Prilosec OTC, Prevacid
24Hr, or generic omeprazole. If Prilosec OTC,
Prevacid 24Hr, or generic omeprazole have
been tried within the last 180 days then
pantoprazole or lansoprazole can be used as
2nd-line agents. Dexilant can be used as a
3rd-line agent if either pantoprazole or
lansoprazole is tried wihtin the last 180 days.
If you have any questions about the step therapy requirements, contact Customer Service at 973-6395 or toll free at 1-866-973-6395, 8 a.m. to 8
p.m., 7 days a week. TTY users call 1-877-447-5990.
AlohaCare Advantage is a health plan with a Medicare contract. AlohaCare Advantage Plus is a Coordinated Care plan with a Medicare Advantage
contract but without a contract with the Hawaii Medicaid program.
Call 1-866-973-6395 to receive material in an alternate format or language.
H5969_501502_1 CMS Approved 07222011
Updated 10/1/2013