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AARP MedicareRx Preferred (PDP) plan
STEP THERAPY ALGORITHMS
Treatment Group
Description
Step 1: Metformin

Step 2: Actoplus Met
Step 1: Metformin

Step 2: Actos
Step 1: One of the following:

Step 2
: Amitiza
Step 1: One of the following Tier 1 or Tier 2 antidepressants:
a. SSRI b. SNRI c. Bupropion d. Mirtazepine
Step 2: Emsam
Step 1: Fomepizole 1 gm/mL injection (generic)
Step 2: Antizol 1 gm/mL injection (brand)
Step 1: Pamidronate disodium injection (generic)
Step 2: Aredia 30 mg or Aredia 90 mg injection (brand)
Treatment Group
Description
Step 1: Metformin

Step 2: Avandamet
Step 1: Metformin

Step 2: Avandaryl
Step 1: Metformin

Step 2
: Avandia
Step 1: One Tier 1 or Tier 2 bisphosphonate

Step 2: Fosamax Oral Solution
Step 1: Irinotecan 20 mg/mL injection (generic)
Step 2: Camptosar 20 mg/mL injection (brand)
Step 1: Ofloxacin otic

Step 2: Cetraxal
Step 1: One of the following sulfonylurea products:
a. Glyburide b. Glipizide c. Glimepiride
Step 2: Diabinese (chlorpropamide)
Step 1: One of the following:
b. Dextroamphetamine c. Dexmethylphenidate d. Methylphenidate
Step 2: Strattera
Step 1: Colistimethate sodium 150 mg injection (generic)
Step 2: Coly-Mycin 150 mg injection
Treatment Group
Description
Step 1: Dihydroergotamine mesylate 1 mg/mL injection (generic)
Step 2:
D.H.E. 1 mg/mL injection (brand)
Step 1: Desmopressin acetate 4 mcg/mL injection (generic)

Step 2:
DDAVP 4 mcg/mL injection (brand)
Dipeptidyl Peptidase-4 Inhibitor Therapy Step 1: Metformin

Step 2: Januvia or Onglyza
Dipeptidyl Peptidase-4 Inhibitor/ Metformin Step 1: Metformin
Step 2: Janumet
Step 1: Metformin

Step 2: Duetact
Step 1: Epirubicin Injection (generic)
Step 2
: Ellence Injection (brand)
Step 1: Amifostine Injection (generic)
Step 2
: Ethyol Injection (brand)
Step 1: One of the following atypical antipsychotics:
a. Geodon b. Risperidone c. Seroquel/Seroquel Step 2: Fanapt
Step 1: Idarubicin injection (generic)

Step 2: Idamycin PFS injection (brand)
Step 1: Metformin

Step 2: Byetta
Treatment Group
Description
Step 1: One Tier 1 or Tier 2 inhaled corticosteroid
Step 2: Aerobid, Aerobid-M, Asmanex, Azmacort, or Alvesco
Step 1: One of the following atypical antipsychotics:
Step 2: Invega
Step 1: Singulair

Step 2: Accolate or Zyflo CR
Step 1: One of the following:

Step 2: Foradil or Serevent
Step 1: One of the following formulary opioid products

Step 2: Demerol (meperidine)
Step 1: Morphine sulfate ER (generic)
Step 2: MS Contin 200 mg (brand)
Step 1: Pentostatin injection (generic)
Step 1: Nipent injection (brand)
Novantrone injection Novantrone Therapy* Step 1: Mitoxantrone 2 mg/mL injection (generic)
Step 2: Novantrone 2 mg/mL injection (brand)
Treatment Group
Description
Step 1: One of the following:

Step 2: Xalatan
Step 1: Nortriptyline capsules
Step 2: Pamelor capsules
Step 1: One of the following formulary opioid products:
a. Hydrocodone b. Methadone c. Morphine d. Oxycodone e. Opiate/acetaminophen
Step 2: Talwin NX (pentazocine/ naloxone) or Talacen (pentazocine/ acetaminophen)
Step 1: One of the following:
b. Beta-blocker c. Calcium-channel blocker
Step 2: Ranexa
Step 1: One of the following:

Step 2: Selfemra
Step 1: Sumatriptan injection

Step 2
: Sumavel
Treatment Group
Description
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: Allopurinol

Step 2: Uloric
Step 1: Albuterol (nebulizer)

Step 2: Xopenex Nebulizer
Step 1: Ondansetron Injection (generic)
Step 2: Zofran Injection (brand)

*Step therapy applies to new starts only

Source: http://www.q1medicare.com/2011/content/includes/pdpPlanMaterials/AARP-2011_PDP_StepTherapyCriteria_Preferred.pdf

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