Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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