Microsoft word - 2010 platinum web st file 2010_plat.doc
The Step Therapy drug will be dispensed if the drug has been dispensed within 120
days of current fill or if alternative (Step 1) drugs have been used first. If the member’s
prescription claim fails the Step Therapy edit, a prior authorization will be needed.
Prior Authorization phone lines provide quicker decisions:
1-800-711-4555 (Physician) or 1-866-815-5332 (Member)
STEP THERAPY ALGORITHMS – Golden State Health Plan Platinum Formulary Treatment Group Description Step 1: One Tier 1 or Tier 2 Proton Pump Inhibitor
Step 2: Aciphex Step 1: One of the following: metformin or thiazolidinedione
Step 2: Actoplus Met Step 1: One of the following: metformin or thiazolidinedione
Step 2: Actoplus Met XR Step 1: One of the following:
a. metformin b. sulfonylurea c. insulin d. Byetta
Step 2: Actos Step 1: One of the following:
b. Long-acting beta agonist c. Inhaled anticholinergic agent d. theophylline
Step 2: Advair Diskus or Advair HFA Step 1: cetirizine syrup
Step 2 Allegra suspension Treatment Group Description Step 1: fexofenadine
Step 2: Allegra-D Step 1: Any two of the following: metformin, sulfonylurea, thiazolidinedione (TZD), insulin,
Step 2: Glyset or Precose (including acarbose) Step 1: zolpidem
Step 2: Ambien CR Step 1: One of the following: Step 2: Amitiza Step 1: One of the following:
b. ACE inhibitor/hydrochlorothiazide combination c. ACE inhibitor/calcium channel blocker combination
Step 2: Micardis or Micardis HCT Step 1: One of the following:
b. ACE inhibitor/hydrochlorothiazide combination
c. ACE inhibitor/calcium channel blocker combination
Step 2: Benicar or Benicar HCT or Diovan or Diovan HCT or Losartan or Losartan/HCTZ Step 3: Atacand or Atacand HCT or Avapro or Avalide or Teveten or Teveten HCT Step 1: One of the following Tier 1 or Tier 2 antidepressants:
a. SSRI b. SNRI c. bupropion d. mirtazapine
Step 2: Emsam or Pexeva Treatment Group Description Step 1: One of the following:
Step 2: Actos Step 3: Avandamet Step 1: One of the following:
Step 2: Actos Step 3: Avandaryl Step 1: One of the following:
Step 2: Actos Step 3: Avandia Step 1: One of the following:
b. ACE inhibitor/hydrochlorothiazide combination
c. ACE inhibitor/calcium channel blocker combination
Step 2: Azor Step 1: Beta blocker (generic) or Beta blocker/Diuretic combination product
Step 2: Bystolic Treatment Group Description Step 1: ofloxacin otic
Step 2: Cetraxal Step 1: pilocarpine
Step 2: Evoxac Step 1: cetirizine syrup
Step 2 Clarinex Syrup Step 1: fexofenadine Step 2: Clarinex tablets or Clarinex RDT or Clarinex-D tablets Step 1: One of the following:
b. dextroamphetamine c. dexmethylphenidate d. methylphenidate
Step 2: Strattera Step 1: carvedilol
Step 2: Coreg CR
Dipeptidyl Peptidase 4 Inhibitor Therapy
Step 1: Any two of the following: metformin, sulfonylurea, thiazolidinedione (TZD), insulin,
Step 2: Januvia or Onglyza
Dipeptidyl Peptidase 4 Inhibitor/ Metformin
Step 1: Any two of the following: metformin, sulfonylurea, thiazolidinedione (TZD), insulin,
Step 2: Janumet Step 1: sulfonylurea or thiazolidinedione
Step 2: Duetact Treatment Group Description Step 1: One of the following
a. Inhaled corticosteroid b. Long-acting beta agonist c. Inhaled anticholinergic agent d. Theophylline.
Step 2: Dulera Step 1: calcium acetate 667mg Step 2: Eliphos Step 1: One of the following:
b. ACE inhibitor/hydrochlorothiazide combination
c. ACE inhibitor/calcium channel blocker combination
Step 2: Exforge or Exforge HCT Step 1: One of the following atypical antipsychotics: Step 2: Fanapt
Genitourinary Smooth Muscle Relaxant Therapy
Step 1: Oxybutynin or Oxybutynin ER
One of the following: Detrol, Detrol LA, Enablex, or Oxytrol
Step 2: Vesicare or Toviaz Step 1: One of the following:
b. sulfonylurea c. insulin d. thiazolidinedione
Step 2: Byetta Step 3: Victoza Treatment Group Description Step 1: One tier 1 or tier 2 inhaled corticosteroid Step 2: Aerobid/Aerobid-M or Asmanex or Azmacort or Alvesco or Flovent Diskus Step 1: Any one formulary ADHD stimulant Step 2: Intuniv Step 1: Avodart or tamsulosin Step 2: Jalyn Step 1: One of the following:
c. Formulary Inhaled Beta-agonist/Corticosteroid combination d. Formulary Oral Corticosteroid
Step 2: Singulair Step 3: Accolate or Zyflo CR Step 1: Intranasal Steroid or Prescription Second-Generation Antihistamine
Step 2: Singulair Step 1: zolpidem
Step 2: Lunesta Step 1: One of the following:
a. fluvoxamine b. paroxetine c. sertraline
Step 2: Luvox CR Step 1: Any two of the following: metformin, sulfonylurea, thiazolidinedione (TZD), insulin,
Step 2: Prandin or Starlix Treatment Group Description Step 1: metoclopramide Step 2: Metozolv Step 1: Ropinorole or Pramipexole Step 2: Mirapex ER Step 1: One of the following:
Step 2: Bepreve, Elestat, or Emadine Step 1: One of the following:
Step 2: Xalatan Step 1: Ophthalmic prednisolone acetate Step 2: FML Forte or Vexol Step 1: Any two of the following: metformin, sulfonylurea, thiazolidinedione (TZD), insulin,
Step 2: Prandimet Step 1: One of the following:
b. Beta-blocker c. Calcium-channel blocker
Step 2: Ranexa Step 1: ropinorole or Mirapex Step 2: Requip XL Treatment Group Description Step 1: tramadol or tramadol/acetaminophen Step 2: Ryzolt Step 1: One of the following:
Step 2: Sarafem or Selfemra Step 1: One of the following:
a. Advicor b. Vytorin c. Any formulary statin
Step 2: Simcor Step 1: cyclobenzaprine (immediate-release)
Step 2: Amrix or Fexmid Step 1: carbidopa/levodopa AND Comtan Step 2: Stalevo Step 1: One of the following:
a. simvastatin b. lovastatin c. pravastatin d. Lipitor
Step 2: Altoprev or Lescol or Lescol XL Step 1: Lipitor or Crestor
Step 2: Vytorin Treatment Group Description Step 1: Two of the following:
a. simvastatin b. lovastatin c. pravastatin d. Lipitor
Step 2: Livalo Step 1: sumatriptan injection Step 2: Sumavel Step 1: One of the following:
b. Long-acting beta agonist c. Inhaled anticholinergic agent d. theophylline
Step 2: Symbicort Step 1: One of the following:
c. Angiotensin II receptor blocker d. Angiotensin II receptor blocker combination
Step 2: Tekturna or Tekturna HCT Step 1: Topical Corticosteroid
Step 2: Elidel or Protopic Step 1: One of the following:
a. naratriptan b. sumatriptan c. Maxalt d. Maxalt MLT
Step 2: Treximet Treatment Group Description Step 1: One of the following:
b. ACE inhibitor/hydrochlorothiazide combination c. ACE inhibitor/calcium channel blocker combination
Step 2: Tribenzor Step 1: naratriptan or sumatriptan
Step 2: Axert or Frova or Relpax Step 1: ACEI, ACEI containing product, Azor, Exforge, Exforge HCT, or Tribenzor Step 2: Twynsta Step 1: allopurinol
Step 2: Uloric Step 1: One of the following:
c. Angiotensin II receptor blocker d. Angiotensin II receptor blocker combination
Step 2: Valturna Step 1: Both of the following:
a. One oral NSAID b. One Tier 1 or Tier 2 PPI
Step 2: Vimovo Step 1: albuterol (nebulizer)
NIMH · Science News from 2008 · Maintenance Treatment Crucial for Teens’ Recovery from De. Page 1 of 2Back to: NIMH Home » Science News » 2008 Maintenance Treatment Crucial for Teens’ NIMH Press Office 301-443-4536 NIMHPress@nih.gov Long-term maintenance treatment is likely to sustain improvement and prevent recurrence amo
Printed on Uncoated Permanent Printing PaperFor sale by the U. S. Government Printing OfficeSuperintendent of Documents, Mail Stop: SSOP, Washington, DC 20402-9328 J U S T I C E S S U P R E M E C O U R T WILLIAM H. REHNQUIST, Chief Justice. JOHN PAUL STEVENS, Associate Justice. SANDRA DAY O’CONNOR, Associate Justice. ANTHONY M. KENNEDY, Associate Justice. RUTH BADER GINSBURG, Associa
The Step Therapy drug will be dispensed if the drug has been dispensed within 120
days of current fill or if alternative (Step 1) drugs have been used first. If the member’s
prescription claim fails the Step Therapy edit, a prior authorization will be needed.
Prior Authorization phone lines provide quicker decisions:
1-800-711-4555 (Physician) or 1-866-815-5332 (Member)
STEP THERAPY ALGORITHMS – Golden State Health Plan Platinum Formulary